Mixed feeding. Technique and rules of giving new food. Schemes of mixed feeding children of the first year of life. The milk formulas which are used for additional feeding. Additional food and feeding correction in mixed feeding. Child needs in proteins, fats, carbohydrates and calories in mixed feeding..
When breastmilk is no longer enough to meet the nutritional needs of the infant, complementary foods should be added to the diet of the child. The transition from exclusive breastfeeding to family foods, referred to as complementary feeding, typically covers the period from 6 to 18-24 months of age, and is a very vulnerable period. It is the time when malnutrition starts in many infants, contributing significantly to the high prevalence of malnutrition in children under five years of age world-wide. WHO estimates that 2 out of 5 children are stunted in low-income countries.
Mix-feeding – the feeding of the babies of first 5-6 mo with human milk and formula in which the volume of formula is more than 1/5 of daily volume (or the daily volume of the human milk is less than 4/5).
There are two kinds of mix feeding:
· Mix-feeding closed to breast-feeding
- Mix-feeding close to formula feeding
Mix-feeding closed to breast-feeding – the feeding of the babies with human milk and formula in which the ratio between them in daily volume are 2:1 (or 2/3:1/3).
Mix-feeding close to formula feeding – the feeding of the babies with human milk and formula in which the ratio between them in daily volume are 1:2 (or 1/3:2/3).
Mix-feeding indication:
In causes of mother’s diseases:
1. Hypogalactia (oligogalactia);
2. Some diseases in that mother must decreased the quantity of feeding:
a. mastitis;
b. anemia of severe degree;
c. using of medicine (medicament);
d. erythroderma.
3. Human milk inferiority (fat’s, protein’s or carbohydrate’s inferiority).
In social and living conditions
1. Mother is working and can’t nurse a baby for all feeding.
2. Closed children institution in which the amount of donor human milk is not in enough quantity.
In causes of baby’s diseases:
Congenital malabsorption syndrome: hypolactasia.
HYPOGALACTIA (OLIGOGALACTIA)
Hypogalactia (oligogalactia) – is decreasing human milk secretion.
Hypogalactia is divided into primary and secondary.
Primary hypogalactia – is very rarely diseases (only 1-3 %). It is connected with neurohumoral disorders in mother’s organism or undeveloped breast or carried mastitis during previous deliveries.
Secondary hypogalactia – can appear in case of
a. not correct day regimen during pregnancy and delivery;
b. not correct carrying for breasts (nipple crack, erosion, mastitis);
c. incorrect mother’s nutrition.
There are four degree of hypogalactia:
I-st degree – deficiency of the human milk is less than 25 % of the daily requirements;
II-nd degree – deficiency of the human milk is between 25 and 50 % of the daily requirements;
III-d degree – deficiency of the human milk is between 50 and 75 % of the daily requirements;
IV-th degree – deficiency of the human milk is more than 75 % of the daily requirements.
There are two methods of mix-feeding:
· Classic method.
· Interchanging (rotate) method.
Classic method is used in babies younger than 3 mo. In this method for each feeding the formula is given.
Calculation of feeding (classic method)
For example: the child 2 mo. is in mix-feeding closed to breast-feeding. The weight at birth was 3300 g
The normal weight of the child is 3300+600+800=4700 g
Daily volume is (will use volume method of calculations)
4700/6=783 ml
Volume for one feeding is 783/6=130 ml
If the child is in mix-feeding closed to breast-feeding that the quantity of human milk must be 2/3 and formula 1/3.
So, the quantity of human milk will be 130:3´2=86 ml and formula 44 ml.
The feeding schedule (classic method)
Exemplary Menu
|
6.00 o’clock |
86 ml of human milk + 44 ml of Hipp 1 |
|
9.30 o’clock |
86 ml of human milk+ 44 ml of Hipp 1 |
|
13.00 o’clock |
86 ml of human milk+ 44 ml of Hipp 1 |
|
14.30 o’clock |
86 ml of human milk+ 44 ml of Hipp 1 |
|
20.00 o’clock |
86 ml of human milk+ 44 ml of Hipp 1 |
|
23.30 o’clock |
86 ml of human milk+ 44 ml of Hipp 1 |
Interchanging method is used in babies older than 3 mo. In this method the human milk is given for first and last feeding. In others feeding formula or human milk is given (it depend of kind of feeding).
Calculation of feeding (interchanging method)
For example: the child 3.5 mo. is in mix-feeding closed to formula-feeding. The weight at birth was 3300 g
The normal weight of the child is 3300+600+800+800+375=5875 gm
Daily volume is (will use caloric method of calculations)
115kcal´5.875kg=676 kcal/day
700 kcal – 1000 ml of human milk
676 kcal – X ml of human milk
X=956 ml – that is the daily volume
Volume for one feeding is 956/5 = 190 ml
If the child is in the mix-feeding closed to formula-feeding, so the first and last feeding is human milk and other – formula.
The feeding schedule (interchanging method)
Exemplary Menu
|
6.00 o’clock |
190 ml of human milk |
|
10.00 o’clock |
190 Hipp 1 +20 ml apple juce |
|
14.00 o’clock |
190 ml of Hipp 2 +15 ml of apple juice |
|
18.00 o’clock |
185 ml of Hipp 1+5 ml of apple puree |
|
22.00 o’clock |
190 ml of human milk |
Feeding of Children of Different Age in Hospital.
Breast or Bottle
BREST feeding of a baby is an important time of connection.
Tips of breast feeding:
Some expectant mothers are concerned that breastfeeding will be too hard to learn.
The most important skill for them to master is getting the baby onto the breast correctly.
There are three basic breastfeeding positions.
Cradle — Hold your baby in one arm, with its head resting in the bend of your elbow.
The baby’s lower arm is tucked out of the way. Its mouth is close to your breast and the two
of you are tummy to tummy. This is the most frequently used position. This position can be
used when you are sitting up in bed with pillows supporting your back or sitting in a chair.
2. Lying down — Lie on your side with your baby also lying on his/her side. You are tummy to tummy with the baby’s mouth close to your breast. This position is ideal when you are lying in bed.
3. Football — Place the baby on a pillow at your side. Support its head with your hand. The baby’s mouth should be in front of your breast. This position is good for smaller or premature babies who might have trouble nursing.
See also: Lactation Tutorial for Nursing Students
“Latching on” is the expression breast feeding experts use to describe how a baby grasps the mother’s nipple with his/her mouth. It is a skill that a baby must learn with a little help from his/her mother.
First, get the baby to “root” for breast. Rooting is a natural reflex for babies. The baby’s mouth opens wide and its head moves quickly from side to side, searching for the nipple. To start a baby rooting, lightly touch a nipple to the baby’s lower lip. When the baby’s mouth is wide open, lift a breast to its mouth. At the same time, pull the baby close, so he/she can latch onto mother’s nipple.
Proper latching onto nipple. Wrong latching onto nipple.
For additional information goto:http://extension.usu.edu/fsne/files/uploads/lessons/Breast%20or%20Bottle/Feeding%20Infants%20-%20Breast%20or%20Bottle%20LESSON%20SCRIPT%20B&W%2010.06.pdf or https://www.ade.az.gov/health-safety/cnp/cacfp/downloads/IFANTFEEDING.pdf
BOTTLE FEEDING:
How to prepare baby’s formula:
Ø Wash your hands before you begin.
Ø Wash all bottle feeding equipment in hot, soapy water. Rinse well with hot water.
Ø 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.
Ø The water for formula should be boiled for five minutes then cooled. Use safe drinking water to prepare the formula.
Ø 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.
Ø 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:
Ø Place the bottle in a container of warm water or hold it under warm running tap water. Gently shake the bottle for even warming.
Ø 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.
Ø Never microwave formula. Microwaves heat unevenly and a baby’s mouth could be burned.
Ø Never prop a bottle. It is a choking hazard and can cause baby bottle tooth decay.
Burping:
Ø Wait until baby stops drinking.
Ø Gently rub or pat baby’s back.
Ø Rest baby on your shoulder or lap.
.
Burping the child
For detailed information go to: https://www.ade.az.gov/health-safety/cnp/cacfp/downloads/IFANTFEEDING.pdf orwww.ucc.ie/medstud/downloads/med4/feed.ppt or www.eatright.org/formulaguide.htlm
A gradual transition from breastmilk to formula is best. Learn how to transition Baby to formula and what formula options are available.
There are several formula choices currently available. To help you decide which formula is best for your baby, talk with your baby. Whether you choose to supplement breastmilk with formula or formula-feed exclusively, the closeness you share during bottle- pediatrician. No matter what formula you choose, rest assured that all iron-fortified formulas provide complete nutrition for your baby.
Milk-based formula
A milk-based formula is recommended by most doctors for healthy, full-term infants. It’s made from cow’s milk protein with added carbohydrates, fat, vitamins, and minerals. If you suspect your baby has a milk allergy, use this type of formula only under a doctor’s supervision.
Formula with DHA & ARA
Now there are formulas enriched with DHA & ARA, nutrients that are also naturally found in breastmilk. Medical studies have shown that these nutrients may play important roles in babies’ brain and eye development, and some research suggests that formula-fed babies may benefit from the added DHA & ARA in these enriched formulas.
When choosing a milk-based formula for your newborn, consider iron-fortified. It’s the only standard, milk-based formula that provides the combined benefits of easy-to-digest COMFORT PROTEINS® and DHA & ARA, nutrients found in breastmilk that support babies’ brain and eye development. Like with all GOOD START SUPREME milk-based formulas, the COMFORT PROTEINS in GOOD START SUPREME DHA & ARA are made using a patented two-step process that starts with 100% whey protein. Then, we break down this gentle protein into smaller pieces to be easy to digest. We call them COMFORT PROTEINS, and only GOOD START SUPREME milk-based formulas have them. Just look for the hearts on the can to know you’re providing your baby the very best™.
Formulas for other needs
A doctor may recommend an alternative type of formula. There are three basic categories of these formulas:
· Soy-based formulas for babies who need to avoid cow’s-milk protein or lactose, or for babies in vegetarian families.
· Older-baby and toddler formulas designed to provide nutritional insurance for babies and toddlers transitioning to solid foods. For your older baby consider milk- or soy-based. These formulas offer calcium, iron, and other important nutrients to help meet the changing nutritional needs of older babies and toddlers 9 to 24 months old-especially if there’s a gap between what they eat and what they need.
· Specialty formulas for babies with other special needs. If you feel your baby has special needs, talk with your pediatrician and decide which formula type is best for you and your baby.
Complementary feeding should be timely, meaning that all infants should start receiving foods in addition to breastmilk from 6 months onwards. It should be adequate, meaning that the nutritional value of complementary foods should parallel at least that of breastmilk. Foods should be prepared and given in a safemanner, meaning that measures are taken to minimize the risk of contamination with pathogens. And they should be given in a way that is appropriate, meaning that foods are of appropriate texture and given in sufficient quantity.
The adequacy of complementary feeding (adequacy in short for timely, adequate, safe and appropriate) not only depends on the availability of a variety of foods in the household, but also on the feeding practices of caregivers. Feeding young infants requires active care and stimulation, where the caregiver is responsive to the child clues for hunger and also encourages the child to eat. This is also referred to as active or responsive feeding.
WHO recommends that infants start receiving complementary foods at 6 months of age in addition to breastmilk, initially 2-3 times a day between 6-8 months, increasing to 3-4 times daily between 9-11 months and 12-24 months with additional nutritious snacks offered 1-2 times per day, as desired.
Inappropriate feeding practices are often a greater determinant of inadequate intakes than the availability of foods in the households. WHO has developed a that enables programme managers to identify local feeding practices, common problems associated with feeding, and adequate complementary foods. The protocol builds upon available information and proposes household trials to test improved feeding recommendations. WHO recommends that the protocol be used to design interventions for improved complementary feeding, and is included as part of adaptation process of the Integrated Management of Childhood Illness strategy.
Based oew knowledge, WHO is spearheading a global process for developing indicators to assess complementary feeding. WHO in collaboration with partners is coordinating next steps to conduct validations. It is hoped that sufficient information will be available by the end of 2003 to allow for a consensus meeting to agree a new set of global indicators for assessing complementary feeding.
Feeding your baby in the first year of life is an exciting adventure for parents and babies alike. It’s about development, nutrition, exploration, sharing and learning. You can help your baby develop a lifetime of healthy eating habits with the right start. This pamphlet will help show you when and how to introduce new foods and how to make feeding an enjoyable part of your baby’s life.
THE FIRST 6 MONTHS
For the first 6 months of life, breastfed babies will get what they need from their mother’s milk. Breast milk has the right amount and quality of nutrients to suit your baby’s first food needs. It is easiest on her digestive system, so there’s less chance of constipation or diarrhea. Breast milk also contains antibodies and other immune factors that help your baby prevent and fight off illness better.
Babies who are exclusively breastfed should get a daily supplement of vitamin D, which is available as drops.
If breastfeeding is not an option, use a store-bought iron-fortified infant formula for the first 9 to 12 months. The formula should be cow’s milk-based.
FEEDING SOLID FOODS
Introducing solid foods
At 6 months, most babies cannot get everything they need from breast milk or formula alone. Though you can continue to breastfeed until your baby is 2 years and beyond, at 6 months you’ll start to introduce your baby to other foods. Your baby is ready to start other foods when he:
· Seems hungry earlier than usual.
· Can sit up without support, and has good control of his neck muscles.
· Holds food in his mouth without pushing it out on his tongue right away.
· Shows interest in food when others are eating, and opens his mouth when he sees food coming his way.
· Can let you know he doesn’t want food by leaning back or turning his head away.
There are many ways to introduce solid food. The first foods usually vary from culture to culture and from family to family.
Start with foods that contain iron, which babies need for many different aspects of their development. It’s common to start with a single grain, iron-fortified infant cereal such as rice or barley. Meat, poultry, cooked egg yolk and well cooked legumes (beans, lentils, chick peas) are also good sources of iron.
· Introduce new foods one at a time, waiting about 3 to 5 days before trying another. That way, if your baby develops a reaction, you’ll have a better idea of what food might have caused it.
Feeding Techniques:
· Food is for nutrition, not for rewards, bribing or punishment
· Start with small portions
· Introduce one new food item at a time
· Wait until baby gives permission to put food in his/her mouth
· Use high chair if baby can sit
· Use appropriate utensils
· Reduce distractions
Healthy foods that your family eats are good to start with as long as they are plain, with no added salt, sugar or spices. You can also use commercial baby foods, as long as you check the label to ensure there is no added salt or sugar.
Ø Grain products. At 6 to 9 months, offer your baby up to 30 to 60 mL (2 to 4 tbsp.) of iron-fortified infant cereal, twice a day. Then try other grain products such as small pieces of dry toast or unsalted crackers. At 9 to 12 months, offer other plain cereals, whole grain bread, rice and pasta.
Ø Vegetables. At 6 to 9 months, offer your baby puried cooked vegetables-yellow, green or orange. At 9 to 12 months, progress to soft, mashed cooked vegetables.
Ø Fruits. At 6 to 9 months, offer purйed cooked fruits, very ripe mashed fruits (such as bananas). At 9 to12 months, try soft fresh fruits, peeled, seeded and diced or canned fruit, packed in water or juice (not syrup).
Ø Meat and alternatives. At 6 to 9 months, offer purйed cooked meat, fish, chicken, tofu, mashed beans, egg yolk. At 9 to 12 months, mince or dice these foods.
Ø Milk and milk products. At 9 months, you can offer dairy foods like yogurt (3.25% or higher), cottage cheese or grated hard cheese. Wait until your baby is 9 to 12 months old before introducing whole cow’s milk (3.25%). After 12 months of age, your baby should not take more than 720 mL (24 oz.) of milk products per day. Too much milk can lead to iron deficiency anemia.
Follow your baby’s cues for how much to feed. Start by offering a teaspoon or two, and don’t rush. Some babies need to try a food many times before accepting it. If she’s not hungry, she’ll turn her head and close her mouth. If she’s hungry, she’ll get excited and open up.
Never trick or coax her to eat more by playing games or offering sweetened foods. Babies who are allowed to follow their own hunger cues are much less likely to overeat later in life.
Trying foods with different textures helps babies learn how to handle foods in their mouth. So it’s important to vary both tastes and textures when serving foods.
|
Your baby’s development |
How often to feed |
Type of food |
|
Sits with support |
2-3 times a day* |
Purйed, mashed food and semisolid foods |
|
Sits on own |
2-3 times a day* |
Family foods, small amounts of soft mashed foods without lumps |
|
Crawls |
3-4 times a day* |
Family foods, ground or soft mashed foods with tiny soft lumps; crunchy foods that dissolve, such as whole grain crackers |
|
Walks |
3 meals and 2 snacks a day* |
Coarsely chopped foods; foods with more texture; toddler foods; bite-sized pieces of food; finger foods |
*Plus breast milk, formula, or whole cow’s milk, depending on your child’s age
Babies who are exclusively breastfed don’t need extra water. When your baby begins to eat other foods, you can start to offer water occasionally.
Babies and children don’t need to drink juice. Too much juice, especially apple juice, can cause diarrhea. It can fill up small stomachs and decrease your baby’s appetite for nutritious foods. Too much juice can also cause early childhood tooth decay.
When you do offer juice, be sure it is only 100% fruit juice. Always offer it in a cup, as part of a meal or snack. Offer water to babies and young children between meals and snacks if they are thirsty. Limit juice to 120 to 180 mL (4 to 6 oz.) per day.
Foods not recommended
ü Don’t give babies sugary drinks or foods, such as candies, soda/pop or energy drinks.
ü Don’t give honey to babies under 1 year old, as there is a risk of infant botulism (food poisoning).
ü To reduce the chance of an allergic reaction, avoid giving egg whites until your baby is 1 year old.
ü If you have a family history of allergies, you may want to wait until your baby is 3 years old before introducing peanuts, tree nuts (such as pecans or walnuts) or shellfish.
How to prevent choking
ü Always supervise babies and children while they are eating. They should be sitting down.
ü Don’t feed your baby peanuts, nuts or popcorn.
ü Dice or slice round foods such as wieners or grapes.
ü Grate raw vegetables such as carrots to make them easier to chew.
ü Remove pits from fruits.
ü Cook hard fruits and vegetables to soften them.
ü Spread sticky foods like peanut butter thinly on a cracker or toast rather than bread.
ü Chop or scrape stringy meat and add broth to moisten it.
At around 6 months of age, breast milk may not be sufficient to cover a baby’s energetic and nutritional requirements. Furthermore, the baby is at a stage of development where he/she can start to swallow non-liquid food. At this time, food helps support optimal growth, brain development and the building of natural defenses. Several behavioral changes may indicate the baby’s readiness for solid foods, including new capabilities and changes in eating behavior.
For instance, the baby may:
· sit with support
· play with toes and begin to grasp feet
- support weight on hands with extended arms
- reach for an object with hand
- show anxiety when seeing a stranger and direct smile towards a familiar face
- begin to hold head up
- progressively develop control of muscles and nervous system.
DEVELOPMENTAL MILESTONES RELATED TO FEEDING
|
Age |
Physical milestones |
Social milestones |
|
Birth to 4 months |
· opens mouth wide when |
· recognizes source of milk
|
|
4 to 6 months |
· sucking strength increases |
· socializes during feeding
|
|
6 to 9 months |
· drinks from a cup held by |
· loves to be included at the |
|
9 to 12 months |
· tries to use a spoon |
· is aware of what others |
|
12 to 18 months |
· grasps and releases food |
· wants food that others are |
|
18 to 24 months |
· appetite decreases |
· easily distracted |
Nutritional needs
A recent study by the American Dietetic Association concluded that, on average, babies of 6 to 8 months who are fed with human milk receive less than 50% of the Recommended Daily Allowance (RDA) for iron and zinc, and less than 50% of the Adequate Intake (AI) for manganese, fluoride, vitamin D, vitamin B6, niacin, vitamin E, magnesium, phosphorus, biotin and thiamine. The researchers recommended that infants be given complementary foods to fulfil their nutritional and energy needs, and to encourage exposure to different flavors and textures – and to spoons.
To cover all these energy needs and to ensure adequate intake of minerals, trace elements and vitamins for growth and optimal development of the baby, certain simple solid foods should be introduced as a complement to breast milk.
At Stage 1, the infant’s digestive system is not yet fully developed, and the stomach in particular is still small. So Stage 1 foods must be presented in a nutrient-dense form so as not to overload the digestion process and ensure digestive comfort.
Sugar intake
There is no specific nutritional or metabolic need for the addition of sugars to baby foods, as ingredients containing natural carbohydrates / sugars already provide enough energy for use as weaning food. The immediate effect of high intakes of added sugar is a fast increase of blood glucose level and insulin secretion, while scientific evidence points to dental and weight problems in the long term. It is also worth noting that, contrary to popular opinion, there is no medical reason to favour the use of fructose as a substitution for sucrose.
Salt (sodium) intake
In the body, sodium plays an essential role in regulating fluid volume and blood pressure. However, babies have a limited renal capacity, meaning they caot so easily conserve fluids and excrete solute load. Consequently, their intake of salt (sodium) needs to be moderate. Healthy infants progressively increase their ability to excrete sodium. Studies have shown that a high sodium intake is associated with higher blood pressure, which in turn is a major risk factor for cardiovascular and cerebral diseases. The Scientific Advisory Committee on Nutrition (SACN) recommends target salt levels for children depending on their age.
In brief
ü breast milk or milk formula is still the most important part of baby’s diet
ü the first solid food is the complement that provides required energy and nutrient intake
ü the first solid food is the vehicle for a baby to get accustomed to flavours, textures, and a spoon.
The baby’s daily intake should respect the following recommendations:
ü total energy needs of approximately 550-700 kcal/day
ü total proteieeds of 9-13 g/day
ü fats of 35-55% of total energy (about 31g/day) with balanced n-3:n-6 ratio (4-10)
ü no specific requirement on carbohydrates, only that non-milk-intrinsic sugars (added sugars) should be below 10% of total daily energy intake
ü no gluten / only one ingredient containing gluten
ü low or no added salt
ü low or no added sugars
ü avoid allergenic ingredients
ü only gentle first ingredients.
References
1. Abdulwadud О., Snow М. Interventions in the workplace to support breastfeeding for women in employment // Cochrane Database Syst. Rev. 2007. -V.18, N 3. – CD006177.
- Guise J.M. Resident physician’s knowledges of breastfeeding and infant growth./ J.M. Guise, G.Freed. // Birth. Vol 2000. Vol. 27.—P. 49-53.
- Cernadas J.M., Noceda G., Barrera L., et al. Maternal and perinatal factors influencing the duration of exclusive breastfeeding during the first 6 months of life // Hum. Lact. 2003. – V. 19, N 2. – P. 136-144.
- Krebs N.F., Hambidge K.M. Complementaiy feeding: clinically relevant factors affecting timing and composition // Am. J. Clin. Nutr. 2007. – V.85, N 2.- P. 639-645.
- Mannion C.A., Gray-Donald K., Johnson-Down L., Koski K.G. Lactating women restricting milk are low on select nutrients // J. Am. Coll .Nutr. 2007. -V. 26, N2.-P. 149-55.
- Piper K.M., Berry C.A., Cregan M.D. The bioactive nature of human breast-milk. Breastfeed Rev. – 2007. – V.15, N 3. – P.5-10.
- Santo L.C., De Oliveira L.D., Giugliani E.R. Factors associated with low incidence of exclusive breastfeeding for the first 6 months // Birth. 2007. – V.34, N3.- P. 212-219.
Prepaired by Nykytuyk S., Slyva V
