FORMULA FEEDING OF CHILDREN. CLASSIFICATION AND CHARACTERISTICS OF MILK FORMULAS. GUARANTEED COW’S MILK. TECHNIQUE OF FORMULA FEEDING, CRITERIA OF ITS EFFECTIVENESS. ADDITIONAL FOOD AND FEEDING CORRECTION IN FORMULA FEEDING. CHILD’S DAILY NEED IN ENERGY, PROTEINS, FATS AND CARBOHYDRATES IN FORMULA FEEDING

FORMULA FEEDING OF CHILDREN. CLASSIFICATION AND CHARACTERISTICS OF MILK FORMULAS. GUARANTEED COW’S MILK. TECHNIQUE OF FORMULA FEEDING, CRITERIA OF ITS EFFECTIVENESS. ADDITIONAL FOOD AND FEEDING CORRECTION IN FORMULA FEEDING. CHILD’S DAILY NEED IN ENERGY, PROTEINS, FATS AND CARBOHYDRATES IN FORMULA FEEDING

 

Infant formula is a manufactured food designed and marketed for feeding to babies and infants under 12 months of age, usually prepared for bottle-feeding or cup-feeding from powder (mixed with water) or liquid (with or without additional water). The U.S. Federal Food, Drug, and Cosmetic Act (FFDCA) defines infant formula as “a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk”.

The composition of infant formula is designed to be roughly based on a human mother’s milk at approximately one to three months postpartum, although there are significant differences in the nutrient content of these products. The most commonly used infant formulas contain purified cow’s milk whey and casein as a protein source, a blend of vegetable oils as a fat source, lactose as a carbohydrate source, a vitamin-mineral mix, and other ingredients depending on the manufacturer.  In addition, there are infant formulas using soybean as a protein source in place of cow’s milk (mostly in the United States and Great Britain) and formulas using protein hydrolysed into its component amino acids for infants who are allergic to other proteins. An upswing in breastfeeding in many countries has been accompanied by a deferment in the average age of introduction of baby foods (including cow’s milk), resulting in both increased breastfeeding and increased use of infant formula between the ages of 3- and 12-months.

A 2001 World Health Organization (WHO) report found that infant formula prepared in accordance with applicable Codex Alimentarius standards was a safe complementary food and a suitable breast milk substitute. In 2003, the WHO and UNICEF published their Global Strategy for Infant and Young Child Feeding, which restated that “processed-food products for infants and young children should, when sold or otherwise distributed, meet applicable standards recommended by the Codex Alimentarius Commission”, and also warned that “lack of breastfeeding—and especially lack of exclusive breastfeeding during the first half-year of life—are important risk factors for infant and childhood morbidity and mortality”. In particular, the use of infant formula in less economically developed countries is linked to poorer health outcomes because of the prevalence of unsanitary preparation conditions, including lack of clean water and lack of sanitizing equipment.^[6] UNICEF estimates that a formula-fed child living in unhygienic conditions is between 6 and 25 times more likely to die of diarrhea and four times more likely to die of pneumonia than a breastfed child. Rarely, use of powdered infant formula (PIF) has been associated with serious illness, and even death, due to infection with Enterobacter sakazakii and other microorganisms that can be introduced to PIF during its production. Although E. sakazakii can cause illness in all age groups, infants are believed to be at greatest risk of infection. Between 1958 and 2006, there have been several dozen reported cases of E. sakazakii infection worldwide. The WHO believes that such infections are under-reported.

 

 

Evolution of Infant Formulas

 

Ø  Breastmilk alternatives have been sought after and used since the Stone Age.

Ø  Infant feeding devices have been found in ancient tombs in Greece.24

Ø  As weaning occurred, it was the common practice to give “pap”, a mixture of grain and water (recorded in the 1600’s). Other foods such as butter, raw meat juices, broth and sugar were also added to the milk mixture. Beer, wine and occasionally drugs were given as a sedative.24

Ø  In the 1700’s, sanitation practices developed and the use of cow’s milk and barley water became popular.24

Ø  In the early 1900’s, evaporated milk was used as the formula base. 24

Ø  The original “formula” often consisted of 13 oz evaporated milk + 13 oz water + 1 tablespoon cod liver oil (for the fat-soluble vitamins) + 1 tablespoon or more of orange juice and sweetener of honey or syrup.

Ø  One of the first commercial formula in the United States was SMA = “synthetic milk adapted”.

Ø  In the 1960’s the use of commercial formula was “vogue” as increased numbers of women entered the workplace.

Ø  Over the last 20 years many new formulas have been developed for use in various clinical situations, such as premature birth, fat malabsorption, metabolic disorders (i.e. PKU) or formulas with decreased electrolytes and minerals for renal disorders.

Ø  Some standard formulas today are now enriched with nucleotides, very long chain fatty acids (DHA and EPA) and all compete to have a nutrient composition “almost identical to breastmilk”.

 

 

The “standard dilution” of all infant formulas is commonly 20 calories per ounce. The standard dilution of liquid formula concentrate is 1 oz formula concentrate to 1 oz water. Powder is usually mixed as 1 scoop powder in 2 ounces water.

Tips on Formula Feeding: An Alternative to Breastfeeding

There is agreement among healthcare professionals, infant food manufacturers and mothers that breastfeeding is the best choice for feeding infants during their first four to six months of life.

But, there are several reasons why a mother may not breastfeed her baby:

• Medical or other health reasons may prevent a mother from breastfeeding.

• Working outside the home makes it more difficult to breastfeed exclusively, especially if there is no support at her workplace for her to either bring her baby or to express and store her milk.

• Choosing not to breastfeed for personal reasons, either from the birth of the baby or after breastfeeding for a short while, which is a mother’s prerogative.

If you cannot, or choose not to, breastfeed your baby, you need to find a safe alternative to breast milk. Infant formulas are an ideal choice because they are manufactured to strict standards of hygiene and formulated according to recognized international nutritional standards.

But infant formula is the safest alternative only if the mother or care giver is educated on the importance of using sterile utensils, boiling the water, washing their hands, and using the exact proportions of water and formula. Proper preparation and storage can make the difference between a healthy or sick baby and even saving a baby’s life.

To ensure that infant formula prepared at home is safe, follow these precautions:

• Choose a clean area to prepare the formula.

• Always wash your hands thoroughly with clean water and soap before handling the items required for formula preparation and when mixing formula.

• When preparing formula, always use safe, clean drinking water as well as clean and boiled bottles and utensils.

• Cool boiled water to body temperature before mixing. Prepare one bottle at a time-accordingly to label instructions-and feed immediately.

• Always start each feeding with a freshly prepared bottle of formula. Do not save unfinished bottle feeds.

In summary, you need to be consistently and meticulously careful or your baby may become ill from dirty water, bottles, nipples or unsanitary conditions in the preparation area.

Here are a few other “don’ts”:

• Do not give ordinary cow or goat’s milk to your baby for the entire first year. This milk does not meet your baby’s vitamin and mineral needs and has a high level of protein that is hard for your baby to digest, straining your baby’s immature kidneys.

• Take into consideration that evaporated, condensed and sweetened condensed milks are too strong for infant’s and need to be diluted. Also, that ordinary milks or milk powders are nutritionally unbalanced for an infant’s needs and should be mixed carefully according to your health care professional’s recommendations. * Avoid gruels made from cassava, rice, maize or other plants, which are totally unsuitable breast-milk substitutes for infants less than 4 months old. They don’t have the proper nutrition and can cause choking if there are any solids in them.

 

History of Breast-milk Substitutes

Throughout history, every generation has needed to develop an alternative to breastfeeding, either because a mother had insufficient milk or chose not to breastfeed. Scientific and historical literature tells us of centuries-old efforts to satisfy an infant’s nutritional needs and to replicate the composition and benefits of breast milk.

In prehistoric cultures, infant mortality was high. Like other mammals, only the hardiest of infants, nursed by their mothers, survived. In ancient cultures, the first doctors encouraged breastfeeding. If, for some reason, the mother could not nurse, wet-nursing — substituting lactating adult women for the birth mother — was recommended for those who could afford it. Ancient art shows us that those who could not afford a wet nurse relied on the milk of domestic animals, such as donkeys, camels and goats. Clay feeding vessels, designed to transfer the milk from the animal to the baby, have been found in ancient tombs and ruins. Historians of Spartan times reported that succession to the throne was interrupted and given to a younger son because he was breastfed by his mother and his older brother was wet-nursed.

Little about infant feeding was documented between ancient times and the Renaissance. During the Middle Ages, wet nursing was the choice for a mother who could not nurse. One pediatric article on breastfeeding describes the characteristics of a good wet nurse as well as information on hiccups, diarrhea and vomiting. In the late 1500s, scientists detailed the therapeutic value of human milk not only for infants, but also for aging men and women. They also recommended the use of ass’ milk as a breast-milk substitute, should a mother need it. If the baby could not be nursed, liquid food made of diluted honey mixed with cereal flour or breadcrumbs was poured through a hollow cow’s horn. However, most efforts to replace breastfeeding were unsuccessful because of the infant’s intolerance or to bacterial contamination.

In eighteenth century Europe, unsanitary conditions were the greatest hazard for mothers and babies. The risk to babies of infection in utero from their mothers or the improper preparation of breast milk alternatives was common. Documents from that time indicate that wealthy English women chose not to nurse their infants because they thought breast-feeding aged them and ruined their figures. And, even though breastfeeding had been identified as a form of birth control, wealthy women preferred to bottle or hand feed, often having 12 to 20 babies instead.

In France during the time of Louis the XVI and Napoleon, breastfeeding – especially by the wealthy — was regarded as bourgeois and simply not done. Wet nursing, as well as animal milk and pap feeding, were the norm. French foundling homes staffed by wet nurses, which carefully regulated their diets and their activities, ensured that infants received proper nutrition.

In the 1800s, breastfeeding again became popular. For those who required an alternative, babies were fed goat or donkey milk, but this had its own drawbacks — high protein and few of the essential trace elements, plus the risk of infection from contamination. Cow’s milk — treated with additives (fat, sugar, limewater and cream) to make it more digestible and then diluted — became a common, low cost alternative. Though often used, it was not recommended because it was low protein, although thanks to the work of Louis Pasteur and Robert Koch, who discovered how to eliminate pathogenous bacteria, contamination was no longer an issue.

Urbanization and technological advances made breast-feeding less popular during the 20th century. The extended family became less of a support, and as women left the home and entered the workplace in record numbers, they tended to see breastfeeding as an unnecessary burden.

During the first half of the 20th century, scientists and physicians began in earnest to elucidate in detail the composition of mother’s milk and looking for ways of imitating it in such a way that substitutes would match more or less its digestibility and nutrient content. Success was rather slow at the beginning, however. But thanks to technological progress most manufacturers marketed bacteriologically safe and nutritionally acceptable infant foods in a powdered form already before the second World War.

The most significant breakthroughs in artificial feeding of infants have happened in the second half of the 20th century. American, Swiss and Japanese food technologists, together with pediatricians and chemists, succeeded in matching the essential nutrients of mother’s milk in formula, making it usable from the first day of a baby’s life. Improvements in the composition of infant formula, along with better sanitary conditions and standards of living helped to decrease mortality of infants who were not breastfed from around 80% to less than 2% in just a few decades.

The last 50 years have brought about the most substantial progress in improving the composition of mother’s milk substitutes ever made in history. As we enter the new millennium, infant formula manufacturers will continue to carry out efforts to develop breast milk substitutes which are closer to the gold standard of breast milk than ever before. Efforts to identify and replicate helpful trace elements, and to conduct important research regarding the addition of immunactive ingredients and enzymes that will make formula products even better, are currently under way.

Infant food manufacturers and health care professionals are united in recommending breast milk as the best way to feed a baby during the first four to six months of life. However, when a woman cannot, or chooses not to breast feed, the infant food industry makes an essential contribution to infant and young child health by offering safe and nutritious alternatives to breast milk.

 

Cow-Milk Based Formulas

Cow-Milk Based Formulas Characteristics:

–       Standard formula used when breastfeeding is not adopted or is stopped before one year of age.

–       Designed to mimic breastmilk composition. Breastmilk is approximately 60% whey and 40% casein, Cow’s milk is 80% casein and 20% whey.

–       Formulas contain at least 50% more protein/dl than breastmilk (1.5 g/100cc).

–       Formulas provide appropriate intake of essential nutrients: iron and linoleic acid.

–       Carnitine and taurine are added to most standard formulas

–       Nucleotides are added to Enfamil and Similac.

Cow-Milk Based Composition:

ü  20 calories/ounce standard dilution

ü  Protein is ideally whey-predominant (similar to breastmilk)

ü  Carbohydrate is lactose (except in Lacto-Free formula)

ü  Fat is a mixture of vegetables oils (LCT)

ü  Approximately 32 ounces of standard formula per day will meet 100% of RDA for vitamins and minerals for term infants.

ü  If infants are only fed ready to feed formula, fluoride supplement of 0.25 mg/day is necessary to meet the RDA based on American Academy of Pediatric guidelines.

Available Brands of Cow-Milk Based Formulas:

v  Enfamil with Iron (or low-iron) (Mead Johnson)

v  Similac with Iron (or low-iron) (Ross)

v  Gerber

v  Good Start (Carnation formula with 100% whey as protein)

v  Similac PM 60/40 (has decreased calcium, phosphorus and potassium content: often used in renal patients.)

 

Soy-Based Formulas

Soy-Based Formulas Indications for Use:

–       Vegetarians

–       IgE mediated reaction to cow’s milk protein

–       Lactose Intolerance or Galactosemia

–       Refeeding after chronic diarrhea (lactose-free)

Soy-Based Formulas Characteristics:

–       Increased protein content than cow-milk based formulas, since using plant source for protein (2.2 g/dl).

–       Increased vitamin and mineral content to compensate for mineral antagonists, such as phytates.

–       Additional methionine added to formula to ensure a “complete” protein

–       Taurine and cysteine added.

–       Sweeter taste than cow-milk based and lower cost.

Soy-Based Formulas Composition:

ü  20 calorie/ounce standard dilution

ü  Protein: Soy protein with added methionine

ü  Carbohydrate: Sucrose, corn syrup solids, tapioca starch

ü  Fat: Blend of vegetable oils

Available Brands of Soy Formulas:

v  Prosobee

v  Isomil

v  Isoyalac

 

Casein Hydrolysate Formulas

Casein Hydrolysate Formulas Indications for Use:

–       Milk protein or soy protein allergy

–       Complicated gastrointestinal disorders

–       Colic

–       Feeding intolerance to cow-milk or soy formulas

Casein Hydrolysate Formulas Characteristics:

–       Poor taste and expensive

–       Not recommended for long-term use in preterm infants due to inadequate vitamin and mineral content and protein source may be difficult to metabolize

–       Alimentum is only available in ready to feed

–       Pregestimil is available as a powder for the consumer, but is available in some hospitals as 20 & 24 calorie/oz ready to feed.

–       Nutramigen is available in liquid concentrate and powder to the consumer, but is available as ready to feed in the hospital setting.

Casein Hydrolysate Formulas Composition:

ü  Protein: casein hydrolysate (small peptide considered to be hypoallergenic)

ü  Carbohydrate: modified tapioca starch and glucose oligosaccharides.

ü  Fat: approximately 50% of fat is MCT oil in Alimentum and Pregestimil, and 100% of fat is corn oil in Nutramigen

Casein Hydrolysate Formulas Available Brands:

v  Nutramigen

v  Pregestimil

v  Alimentum

 

Indications for Use of Infant Formulas

 

Premature Infant Formulas

Premature Infant Formulas Characteristics:

–       Designed for premature infants with birthweight <1800 grams.

–       Major nutrient composition is partially elemental for easier digestion

–       Vitamin and mineral content is approximately 3 times that of standard formulas to meet the increased needs premature infants.

–       Available only in ready to feed in 20 or 24 calorie/ounce.

–       Designed for premature infants >1800 grams who require increased calories, protein, vitamins and minerals.

–       22 calories/ounce standard dilution

–       Available in powder commercially. Ready to feed in the hospital setting.

–       Appropriate for the first year of feeding.

Premature Infant Formulas Composition:

ü  Protein: 60% casein and 40% whey

ü  Carbohydrate: 50% lactose and 50% glucose polymers

ü  Fat: 50% Medium chain and 50% long chain triglycerides

Premature Infant Formulas Available Brands:

v  Enfamil Premature with Iron

v  Similac Special Care with Iron

v  Similac Natural Care (breastmilk fortifier)

v  Similac NeoCare

 

 

•         For infants 0 to 12 months

•         Whey proteins:casein = 60:40

•         Close to breast milk spectrum of amino acids

•         Contains taurine.

•         Milk fats – 74 % and plant fats – 26 %

•         Linoleic : α-linolenic ratio is optimal for absorption 9.9:1

•         Osmolality is equal 270 mosm/L

 

NAN nestle from 6 month

•         The level of proteins is 2.2 %

•         Whey proteins:casein = 40:60

•         Inriched with bifidum-bacteria

•         Fortified with vitamins

 

NAN sour milk

•         Biologically hydrolyzed casein and whey proteins

•         Biologically hydrolyzed lactose

•         Iron fortified (0.8 mg/100 ml)

•         Contains Bifidobacterium Lactis 2´107/1 g

•         w-6 : w-3 = 7.9:1

•         Osmolality 270 mosm/L

 

 

NAN free lactosae

•         doesn’t contain lactose

•         Only whey proteins are present, 20 % of them are amino acids

•         Contains nucleotides and selen

•         Iron and Iodine fortified

•         Contains taurine, inositol, L-karnitine.

NAN with soya

For infants with

•         Hypergalactosaemia

•         Lactose intolerance

•         Strong allergy to cow’s milk proteins

•         Vegetarian babies

 

Pre NAN

•         For premature and low-birth-weight (less than 2500 g) babies

•         Proteins – 2.3 %

•         Whey : casein ratio = 70:30

•         Proteins are particly hydrolyzed (oligopeptids)

•         Contains lysine, cystine, tryptophan, L-histidine, and taurine.

•         Polyunsaturated fatty acids (arachidonic, docosahexacnoic, linoleic, and α-linolenic) are present

 

 

NESTLE Nestogen

•         For ‘hungry’ babies

•         For infants with often regurgitation

•         Contains 77 % of casein

•         Iron, Iodine, Vit. D, A, E and C enriched.

 

Choosing a Formula

All the major manufacturers of infant formula in the United States provide appropriate nutrition for infants to grow on. Formulas are based on either cow’s milk protein, soy protein or are specially modified for infants with major digestive problems or medical conditions. Most infants do fine on the cow’s milk based formulas; the cow’s milk formulas have been modified to be appropriate for human infants. Straight cow’s milk is not appropriate. Some infants do better on soy based formulas because of a sensitivity, allergy or potential allergy to cow’s milk. Some infants are also sensitive to the lactose or sucrose used in the formula, so consult with the infant’s pediatrician if the first formula you choose does not seem to be easily digested by your infant.

There are many specialty formulas available (at a very high cost) for infants with sensitivity to both cow’s milk and to soy or with other medical or digestive conditions. If there is a strong family history of food allergy on either side of the family, it is advisable that the baby be fed solely breastmilk for the first six months of life. Research has shown that babies with a family history of allergy who are formula fed or supplemented with formula, have more food allergies than infants who are fed breastmilk alone.

Formulas come in three forms: liquid concentrate, powder and ready-to-feed. Prices vary widely and formula can be very expensive.

Ready-to-feed is usually the most expensive because you are paying for the water and more container. If you do not have a safe source of water, ready-to-feed is the only appropriate choice.

Both liquid concentrate and powder need to be mixed with water before use. Be sure to use very scrupulous sanitation practices and to follow the directions on the can carefully. Infants can run into medical and growth problems from under or over diluting the formula. Liquid concentrate is the most popular form, because all you have to do is mix with an equal amount of water. If you have well-water, or are concerned about the safety of your water, have it tested by your local health department or a reputable lab, before using it to make formula. Bottled water is not necessarily safe either, but recent legislation has improved the labeling of bottled water. Read the label carefully to determine the source of any bottled water you use. Baby bottled water is not necessary and is usually expensive. Liquid concentrate must be kept chilled (between 35 and 40 degrees) after the can is opened and/or it is mixed with water. Check the temperature of your refrigerator. All formula should be discarded twenty-four hours after opening.

Powdered formula can be very convenient, but it can be harder to mix accurately. Powdered formula is particularly appropriate for travel, because it does not have to be kept chilled until water is added. If you are going to be out on a hot day, take along bottles of water and pre-measured portions of formula and make up each bottle as needed. No need to worry about the formula going bad. Discard any unused formula after baby is finished.

You can mix and match forms of formula to meet your needs at the moment, but it is best to stick to one brand of formula. Some infants switch between brands easily, but most do not. Careful sanitation for all bottles, nipples and the kitchen where the formula is prepared is very important. Don’t forget to wash your hands before making the formula – human hands are a huge source of bacteria! And never put the nipple in your mouth before or while feeding baby!

All babies need a source of iron in their diet, so choose iron-fortified formula from the start. Some parents are afraid to use iron-fortified formulas because they think that iron will cause intestinal distress. Research shows that this is not the case, all formula fed babies experience these problems. (Pediatrics 66:168-170. 1980)

All babies also need a source of fluoride in their diet. Check with your local water supply to find out if your tap water is fluoridated. If your water is not fluoridated or if you choose to use bottled water, ask your pediatrician for a prescription for fluoride drops. Fluoride is essential for the formation of healthy bones and teeth.

Using the Bottle:

Allow the infant to tell the adult when a feeding is over. Babies have aatural ability to obtain the right amount of food if the adult will allow them that privilege. Babies will change from day to day in the amount of formula they want and need. Allow them to communicate that to the feeder. When a baby closes her mouth, turns her head away, fusses, and refuses to have the nipple replaced, consider the feeding ended and discard any formula remaining in the bottle. Formula left over after a feeding can harbor bacteria, which will grow and then be consumed by the infant if the bottle is reused.

Always hold an infant when feeding. Never prop a bottle. Infants need to be able to see the face of the person feeding them, they need to be able to communicate and enjoy the feeding and they need to be able to get the bottle out of their mouth if they are choking or gagging. None of this is possible with a propped bottle.

Never offer an infant honey or corn syrup. There have been several incidents of serious food poisoning resulting from honey and corn syrup given to infants with immature digetive systems.

Adding Solid Foods:

 

The energy and nutrient needs of the newborn to six month old infant are well met by breastmilk or commercial infant formula plus a fluoride supplement. By age six months the infant needs an additional source of carbohydrate and amore of vitamins A and C than is provided in a milk based diet alone.

Developmentally, the six month old is ready to sit upright with support, observe a spoon with food coming towards his mouth, open his mouth when ready for the food and move the food from the spoon to a swallow. The six month old is also able to communicate his rejection of the food. The digestive system is mature enough to handle new foods. The younger infant is not developmentally able to do these things and is therefore not ready to be fed solid foods.

The first solid food introduced in usually iron-fortified infant rice cereal mixed with breast milk or formula. Very few people are allergic to rice and it is easily digested, so it makes an excellent choice for a first food. Barley cereal is also an appropriate early solid. Start with just a tablespoon or so of cereal and a few teaspoons of breast milk or formula. This is a new experience and it make take a few feedings before baby is ready for a quantity of cereal

Feed baby in an upright position. Use rolled up towels or receiving blankets in a high chair if the infant needs additional support. Or have one adult hold the infant while another offers the food to baby. Do not try to feed the baby in a semi-reclined position such as an infant carrier or car seat. It is very difficult for her to swallow while reclining and difficult to see the spoon as it comes toward her mouth. It is important that the infant be able to see the spoon coming towards her mouth so that she can open her mouth in anticipation. Do not force the spoon between closed lips as this turns feeding into an unpleasant experience and can cause many feeding problems later on. Use an infant size spoon. Many babies prefer a plastic or rubber coated spoon – cold metal can be an unpleasant experience.

The baby who is developmentally ready for solids will learn to eagerly anticipate the full spoon coming towards their mouth and will be open and ready by the time it gets there. A baby who is reluctant to open and fusses and complains when the parent tries feeding for the first time may not be ready – wait a few days and then offer the food again.

Do not put infant cereal or any other solid into a bottle or infant feeder. It will interfere with the child’s natural ability to obtain the appropriate amount of energy from the milk feeds. It is simply force feeding and inappropriate.

Once the infant is developmentally ready for solids, the parents need to be ready to change quickly. Infants are capable of very fast and rapid transitions from one ability to the next during the next few months. Parents need to be ready for those changes. Trying to stick to any set routine in this stage, or trying to keep the child from progressing from one stage to another, because the parent is not ready can have detrimental results for the growing child, and his transition to mature eating patterns. Allow the child to take the lead as this chewing and swallowing ability progress. Learn to understand the child’s non-verbal communications and relax.

After the child has done well with infant cereal for several weeks, pureed or strained fruits or vegetables may be added to the diet. Experts do not agree on whether to add fruits first or vegetables first, and it probably does not matter. But babies do have an innate preference for a sweet taste, so start with sweeter vegetables such as squash, and sweet potatoes. Purchased infant foods or those made at home may be used. Baby does not need added sugar or salt. If home prepared foods are used, careful sanitation practices should be observed. Wait three to five days between each new food offered to make sure that there is not problem with a food allergy.

Watch baby’s jaw as he is offered foods. When an up and down munching motion begins to be apparent, pureed meats, beans, cooked egg yolk, tofu, cottage cheese and plain yogurt may be added to the diet.

Introducing a Cup:

The six month old, who is sitting up unsupported and is using both hands for play is developmentally ready to begin learning to drink from a cup. Start with a small amount of breast milk, or formula in the cup, hold baby on your lap and show her how to drink. Small amounts of apple, pear or other mild juice may be offered in the cup. Infants who are eating a good variety of fruits and vegetables have no nutritional need for juice, so do not offer more than four ounces a day. This is also a good time to introduce plain water.

Introducing Table Food:

By nine months old the infant should be getting himself into and out of the sitting position, playing with toys with both hands, bringing toys to his mouth, and grabbing for the spoon during feedings. Now is the time to bring the child to the table at meal time with other family members, if you have not already done so. The nine month old is eager to observe other family members and to try to do as they do. He is ready to try self-feeding with a spoon. He is ready to start soft table foods. His digestive system is ready for wheat and mixed grains. Start with small bits of soft fruit such as bananas or vegetables such as soft cooked green beans. Other good finger foods include bits of toast, arrowroot biscuits or other teething biscuits, unsalted soda crackers, cheese cubes, and other fruits and vegetables. He will be interested in what others are eating and willing to try new foods.

Understand your child’s chewing skills and help him progress as quickly as he is able, but do not push him to go too fast. Teeth are not necessary for good chewing skills or the introduction of table foods. Gagging is a good skill to have at this age. Learn the difference between gagging and choking. A parent who panics over gagging will scare the child and she may not progress as well with foods as she should. Gagging is the way a child prevents a choking incident.

As the child’s chewing and swallowing ability progresses, mashed and chopped table food from the family table may be introduced. Spices and herbs are OK. The child from nine months to twelve months is usually a good eater, interested in a variety of tastes and textures. Enjoy this stage and offer as many new foods as you and he are willing to try.

By the child’s first birthday, whole cow’s milk may be offered in the cup. Formula may be discontinued unless needed because of a medical condition. Breastfeeding may be tapered off to just “comfort feedings”; solid foods should be the main source of nutrition after one year of age – breastmilk just a supplement.

Whole eggs and egg whites may be offered after the first birthday, as well as strawberries and other potential allergens. Peanut butter appears to be a very potent allergen and should not be given until after the third birthday. The child is still developing chewing skills though, so do not offer foods which are easy to choke on such as: nuts, seeds, popcorn, raw vegetables, hot dogs, raisins, grapes, peanut butter, meat sticks, hard candies or lollipops. Children do not need fruit flavored, sweetened beverages, fruit punches, or soda. Use plain water for thirst.

Weening:

As the infant begins to walk, the parent will notice a lessening of interest in the bottle. This is the appropriate time to wean from the bottle between eleven and fourteen months. If the cup was appropriately introduced at six months, the child will be fairly proficient with it by twelve months and formula or milk may be given in the cup. The child needs 16 to 24 ounces of milk daily, this is easily obtained from a cup. The child needs four ounces or less of juice each day and this can also be given in the cup.

Length of Feeding – 20-30 minutes from the bottle.

Number of daily feedings:

First 5 months of life: 6 feedings per day every 3,5 hours with night break in 6,5 hrs.

After 6 months: 5 feedings per day every 4 hours with night break in 8 hrs.

 

WHO recommended plan of weaning in breast feeding

 

How to prepare baby’s formula:

Wash your hands before you begin.

Wash all bottle feeding equipment in hot, soapy water. Rinse well with hot water.

Sterilize bottle feeding equipment for the first three or four months of baby’s life. To sterilize, cover items completely with water and boil for five minutes. Cool and remove from water with sterile tongs.

The water for formula should be boiled for five minutes then cooled. Use safe drinking water to prepare the formula.

Mix formula according to package directions. Fill the sterilized bottles. You may prepare up to a 24-hour supply of infant formula at one time.

Store the prepared formula in the refrigerator. When away from home, store it with an ice pack in a cooler. Formula should never be left at room temperature for longer than one hour.

 

 

How to warm baby’s formula:

Place the bottle in a container of warm water or hold it under warm running tap water. Gently shake the bottle for even warming.

Check the temperature of the formula before feeding a baby. Put a few drops on the inside of your wrist. It should feel slightly cool.

Caution: Never microwave formula. Microwaves heat unevenly and a baby’s mouth could be burned.

Caution: Never prop a bottle. It is a choking hazard and can cause baby bottle tooth decay.

 

Bottles should never be given when a child is put to bed, or when the child is lying down. This is dangerous for choking and can be very detrimental to the development of healthy teeth. If you must put your baby to bed with a bottle, fill it with water only, or just offer a clean pacifier. Tooth decay can occur when any sweet liquids, as well as milk and formula are given to baby throughout the day or night. This is more of a problem if baby falls asleep while drinking these liquids. Make sure you clean baby’s teeth after eating and drinking.

 

References

а) Basic

 

1. Manual of Propaedeutic Pediatrics / S.O. Nykytyuk, N.I. Balatska, N.B. Galyash, N.O. Lishchenko, O.Y. Nykytyuk – Ternopil: TSMU, 2005. – 468 pp.

2. Kapitan T. Propaedeutics of children’s diseases and nursing of the child : [Textbook for students of higher medical educational institutions] ; Fourth edition, updated and translated in English / T. Kapitan – Vinnitsa: The State Cartographical Factory, 2010. – 808 pp.

3. Nelson Textbook of Pediatrics /edited by Richard E. Behrman, Robert M. Kliegman; senior editor, Waldo E. Nelson – 19^th ed. – W.B.Saunders Company, 2011. – 2680 p.

 

b) Additional

1. Denial Bernstein. Pediatrics for medical Students. – Second edition, 2012. – 650 p.

2. Jam W. Ball, Ruth G. Bindler Pediatric Nursing. Caring for Children. –  Third edition, 2011. – 984p.

3. Guidelines on HIV and infant feeding 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. World Health Organization, 2010.

4.  www.bookfinder.com/author/american-academy-of-pediatrics 

5. www.emedicine.medscape.com

6. http://www.nlm.nih.gov/medlineplus/medlineplus.html