FEEDING OF INFANTS AND

CHILDRENMyrna D.C. San Pedro MD,

FPPS

SPECIFIC OBJECTIVES

• To discuss the physiologic basis for feedings intrauterine, at birth & during the growing years

• To enumerate the guiding principles of infant feeding• To discuss breastfeeding

Identify the anatomical structures of the female breast Explain the physiology of lactation Compare the different types of breast milk Enumerate the factors affecting composition Enumerate the advantages and disadvantages Explain how to determine if breast milk supply adequate Enumerate antenatal techniques and postnatal

procedures to prepare mothers for proper breast-feeding

SPECIFIC OBJECTIVES• To discuss breastfeeding (continuation)

Compare the composition of human breast milk and cow’s milk

Explain wet nursing• To discuss artificial feeding

Compute the fluid and caloric requirement of a cow’s milk formula-feeding infant

Differentiate the various milk formulas Define supplementary and complementary feedings

• To discuss weaning and introduction of solids Define weaning State when to start solid feedings and why Enumerate the recommended solid feedings

• To define and demonstrate a “healthy” diet for children

RELATION OF MATERNAL & FETAL NUTRITION

• Maternal diet ultimate source of fetal nutrients as evidenced by distinctly lower average birth weight among babies in low-income than from high-income groups

• With poor maternal diet, less fat & protein storage in fetus, less vitamin A & iron storage in fetal liver & less Ca+2 deposition in fetal skeleton

• Poor maternal diet also increases incidence of abortions, stillbirths & developmental abnormalities in fetus

• Whatever physical, biochemical, physiologic & behavioral defects due to poor maternal diet intensified during neonatal period

AT BIRTH & NEONATAL PERIOD

• After birth when infant can safely tolerate enteral nutrition judged by normal activity, alertness, suck & cry, feedings started To maintain normal metabolism during transition

from fetal to extrauterine life To promote maternal-infant bonding To decrease risks of hypoglycemia,

hyperkalemia, hyperbilirubinemia & azotemia• Most infants can start breast-feeding immediately

almost always within 1–4 hr• An infant's stomach’s emptying time varies from 1–

4 hr or more during a single day

GENERAL GUIDELINES

• By end of 1st wk, most healthy infants will be taking 60–90 ml/feeding and want 6–9 feedings/24 hr

• By end of 1st month, >90% of infants will have established a suitable & reasonably regular schedule

• Most will wake for a middle-of-the-night feeding until 3–6 wk of age though some will never desire this feeding while others continue it beyond 3–6 wk of age

• Between 4–8 mo of age, many infants will lose interest in the late evening feeding

• By 9–12 mo of age, most will be satisfied with 3 meals/day plus snacks

• Not all infants conform to these general guidelines

REASONS FOR AN INFANT’S CRY OTHER THAN HUNGER

• May not be receiving enough milk• May have discomfort such as

uncomfortable clothing, colic or “gas”, wet diapers or feeling hot or cold

• To gain sufficient or additional attention

• Simply need to be held• Sick infants (uninterested in food and

continue to cry even when held)

BREAST-FEEDING

• Breast milk: the most ideal, safe & complete food

• Breast milk protein of good biological value

• Lactation may continue to 18-24 months (WHO)

BREAST STRUCTURE• Each breast has 15 to 20

lobes of milk-producing glandular tissue

• Each lobe is made up of many smaller lobules

• Special channels called ducts run from these lobes

• Spaces around the lobules and ducts are filled with fatty & connective tissue stroma that determines the size

• Nipple skin contains many nerves, oil & sweat secreting glands

• The actual milk-producing structures nearly the same in all

WHAT HAS CHANGED?

University of Western Australia’s Human Lactation Research Group, with Medela, investigated the lactating breast using sophisticated ultrasound & research results overturned 160 years of received wisdom concerning the female breast

PHYSIOLOGY OF LACTATION• Nipple stimulation from

baby’s breast sucking• Message sent to spinal

cord, then brain • Increased prolactin

levels released by anterior pituitary for milk production

• Increased oxytocin levels released by posterior pituitary for milk ejection reflex

TYPE TIMINGQUANTIT

YCHARACTERISTICS

COLOSTRUM 1st 2-4 days

10-40 ml/day

• Yellow fluid• More protein (95% globulins & more

IgA)• Less fat & sugar• More vitamins esp. vitamin A• More salt (Na+ & K+)• Sp. gr. 1.040-1.060• Alkaline pH of 7.7

TRANSITIONAL

From 4th-10th day to 1st month

Increases to <600 ml

• Fall in protein, decreasing cells/mm3 & concentration of immunoglobulins but total volume increases

• Gradual increase in fat & lactose• Na+, K+ & Cl- concentrations decrease

but Ca+2 & PO4- constant

MATURE By end of 1st month of lactation

About 600 ml in 1st mo to 800 ml in the 6th mo after which falls to 25-400 ml on the 2nd yr

• About 5% fat, 1.1% protein & 7% lactose that is fairly consistent, fatty acids generally reflect maternal diet, total N2 of 1.2% includes significant portion of non-protein N2

• Sp. gr. 1.026-1.036 average being 1.031

• PH 6.8-7.4 average of 7**In poorly nourished women,

composition constant but total yields lower

FACTORS INFLUENCING COMPOSITION

1. Time of day - Fat content highest early in the day & lowest at night

2. Mother’s diet - Milk usually light blue but the more fat the more yellowish

3. Mother’s emotional state - milk ejection reflex often absent or erratic during periods of pain, fatigue, or emotional distress

4. Whether fore or hind milk - . “Fore” milk, 1st milk expressed is clear, thin & bluish reflecting low fat & high water content but “Hind” milk or end milk is thick & creamy white reflecting higher fat content

5. Drugs - Atropine, opium, lead, iodides, barbiturates, sulfonamides, INH & some antibiotics may be found in milk after prolonged use or in maximum doses

6. Smoking

DETERMINING ADEQUACY

• If infant is satisfied after each nursing period

• Contented and sleeps 2-4 hours between feedings

• Regularly and adequately gaining weight

• The “let-down” or milk ejection reflex in the mother is an important sign

ADVANTAGES OF BREAST-FEEDING

1. Proper quality & quantity of nutrients

2. Rates of growth better in the 1st 3-4 months

3. Anti-infective properties universally accepted

4. Prevents allergy due to high IgA preventing antigen absorption

5. Contraceptive property, high levels of prolactin inhibit synthesis of ovarian steroids causing delay of ovulation & pregnancy

6. Psychological advantagesa. Fosters mother-child relationshipb. Tactile contact makes babies

more secure, emotionally stablec. A sense of fulfillment, satisfaction

& joy for the mother7. Protective against

a. Necrotizing enterocolitisb. Otitis mediac. Dental caries

8. Others:a. Safe, contains no pathogensb. Always at the right temperaturec. Convenient & always available

ANTI-INFECTIVE PROPERTIESa. Breast milk esp.

colostrum contains plenty of antibodies

b. E. coli antibodies present

c. High % of lactose stimulates Lactobacillus bifidus

d. Lactoferrin binds iron & inhibits growth of E. coli, staphylococci & Candida albicans

e. Lysozyme bacteriostatic against enterobacteriaceae & staphylococcus species

f. Anti-staphylococcus factor

g. Lactoperoxidase kills streptococci & enteric bacteria

h. Secretory IgA against intestinal bacteria

i. Macrophages 90% of leucocytes, involved in phagocytosis & synthesis of bacteriostatic proteins: lactoferrin, lysozyme & complements C3, C4

j. Lymphocytes comprise 10%, approximately 34% B-lymphocytes responsible for synthesis of IgA

k. T-lymphocytes 50% against E. coli, rubella, CMV & mumps viruses & transfer delayed hypersensitivity

CONTRAINDICATIONS1. Absolute: chronic diseases like open TB, cardiac

diseases, thyrotoxicosis, advanced nephritis, mental & seizure disorders

2. Relative: when mother is taking anticoagulants, antibiotics, steroids or potentially toxic substances like benzene products

3. Mechanical contraindications on the part of the mother: retracted or oversized nipples

4. Mechanical contraindications on the part of the baby: congenital anomalies like harelip & cleft palate but breast milk may be pumped & given

5. Allergy should be proven

REASONS FOR NOT OR STOPPING BREAST-FEEDING

1. Lack of motivation or preparation of mothers2. Anxiety, fear & uncertainty in the mother3. Aesthetic reasons4. Status seeking & effective promotion of infant foods5. Mothers work to increase & augment family income6. Separate maternity & nursery wards7. Milk formula easily sucked from the bottle nipple8. Cultural milieu9. Mothers who can’t despite all desires & attempts10. Presence of contraindications

ANTENATAL TECHNIQUES1. Wear fitted maternity bra from 5th month2. Daily bath enough for cleaning nipples, avoid soap,

alcohol & drying agents3. Rub nipples & areolae with little anhydrous lanolin to

make more supple4. Express colostrum from 7th month by squeezing

areola between index finger & thumb about 3x each side

5. Practice Hoffman’s maneuver (tactile stimulation by thumb & opposing forefinger in the horizontal & vertical planes) for flat or pseudo-inverted nipple

POSTNATAL PROCEDURES

1. Breast-feeding maybe started about 30 min after NSD & 3-4 hrs after C/S

2. The baby should be comfortable, in semi-sitting position with lips engaging considerable areola & breast not obstructing breathing

3. The mother should be seated comfortably & relaxed (recumbent position if preferred) with areola held between her index & middle fingers or between thumb & index finger to control milk flow

4. Baby obtains 95% of milk in the 1st 5 min & frequent feeds as well as short feeds on alternate breasts ideal then burp after

5. Teach mother how to break suction of baby when time to stop by pressing on a portion of the breast near baby’s lips to let air into mouth to prevent painful tagging between mother & child minimizing sore nipples

CONTENT BREAST MILK COW’S MILKpH Both have pH 6.8-7.4 w/ average of 7

Water content & Specific gravity

Both have water content of 87-87.5% w/ sp. gr. 1.026-1.036 average being 1.031

Proteins 1-1.5% 3.3%

a. Whey-to-casein ratio

60:40 20:80

b. Whey proteins -lactalbumin (40%)lactoferrin (25%)lysozyme (0.08%), albumin (0.08%), IgA, IgG, IgM (0.15%)

Mostly -lactoglobulin, some -lactalbumin & traces of lactoferrin

c. Casein Low ratio of methionine to cystine, lower levels phenylalanine & tyrosine

High ratio of methionine to cystine, higher levels phenylalanine & tyrosine

d. Curds Softer, smaller Less digestible

CONTENT BREAST MILKCOW’S MILK

Fats 3.5% but varies w/ maternal diet

a. Neutral fat or triglycerides palmitin, stearin & olein

Twice as much of the more absorbable olein

b. Volatile fatty acids butyric, capric, caproic & caprylic

1.3% 9%

c. Linoleic acid 4-5% of fat calories, hence, better source of this

d. Digestion & absorption

Contains bile-salt stimulated lipase plus specific fatty acids, hence, more efficient

Steatorrhea may occur

Carbohydrates mainly lactose

7% 4.8%

CONTENT BREAST MILK COW’S MILKMineral content

0.15-0.25% 0.7-0.75%

a. And water Ensures free water Need for extra water

b. With diarrhea

Hypotonic dehydration

Hypertonicity & acidosis common

c. Ca+2/P- ratio 2:1 Neonatal hypocalcemia may occur

d. Iron Although low, sufficient because better absorbed

Lower & lesser absorbed

Vitamins

a. Fat-soluble vitamins

Both contains large amounts of vitamin A, minimal vitamin D & should be given vitamin K to prevent hemorrhagic disease of the newborn

b. B complex More niacin More thiamine & riboflavin

c. Ascorbic acid

More vitamin C Lesser

WET NURSING

• Definition: Breast milk fed to an infant obtained from a lactating woman other than the mother

• Purpose: For infants, like LBWs, who don’t seem to do well with any other type of milk

• A good lactating woman should be able to supply milk for 2-3 babies at same time including own

• A wet nurse should be in good health, have good personal hygiene & enough milk for another infant in addition to her own who is thriving well

ARTIFICIAL FEEDING

• Isocaloric: Infant formulas or breast milk substitutes contain about 20 kcal/oz like breast milk

• Caloric requirements: The average caloric requirement of a FT infant is about 80-120 kcal/kg during the 1st few months of life & 100 kcal/kg by 1 yr

• Fluid requirements: During the 1st 6 months of life, about 130-190 ml/kg/day; as a rule, the infant regulates his or her own fluid requirement provided adequate amounts mostly from orange juice & other foods or water offered

• Number of feedings daily: For the 1st month or 2, feedings throughout 24-hr period, about 8 feedings/day but as quantity increases, number of feedings decrease adjusting to family pattern & by 9-12 months most infants satisfied with 3 meals a day

MILK FORMULAS

• Certified Milk. Milk drawn cooled to <70 C immediately & kept at this temperature till deliverya. Eliminates bovine tuberculosis, typhoid & other

salmonella, dysentery, streptococcus & staphylococcus• Pasteurized Milk. Heating milk at 630 C for 30 min or for

15 sec at 720 C followed by rapid cooling to 650 C.a. Destroys all pathogenic bacteria but only 99% of

saprophytesb. Destroys 20% of vitamin C & 10% of thiaminec. Standards range from 5,000-10,000/ml to 50,000 non-

pathogenic bacteria/mld. Should be kept at 100 C & do not use after 48 hrse. Only fresh milk is pasteurized

MILK FORMULAS

• Homogenized Milk. Processing of milk through a fine aperture at high pressure at pasteurization temperature so that fat globules are broken down into a fine emulsiona. Prevents creaming & renders fat more easily assimilatedb. Method used to incorporate vitamin D in milk

• Evaporated Milk. Cow’s milk vaporized at 55-600 C to about 50% of its volume, homogenized, sealed in cans & autoclaved at 1160 C for some time to destroy sporesa. Process can damage quality of proteinb. If can unopened, can keep for months without

refrigerationc. Lactalbumin less allergenic d. 30 ml or 1 fl oz = 40 kcal

MILK FORMULAS

• Condensed Milk. Cow’s milk to which 45% cane sugar addeda. Carbohydrate content 60% when diluted 1:4b. Percentage composition of proteins 1.6%, fat 1.6%,

carbohydrate 11% & minerals 0.36%c. Used only for short periods of time if high caloric

formula needed since nutritionally “out of balance”d. Less fat-soluble vitamins & vitamin Ce. Main advantages are keeping quality & cheap cost

• Dried Milk. Prepared by spraying whole or pasteurized milk into a hot chamber at a very high speed so that water is volatized immediately or by freeze-dryinga. Fine curds produced because protein alteredb. Vitamin C not affected

MILK FORMULAS• Skimmed Dried Milk. Fat removed before milk is dried so that

fat content only 0.05%a. Half-skimmed dried milk has fat content of 1.5%b. Useful for fat intolerance, diarrhea or some prematures

• Fermented Milk. Acidity of sour milk responsible for changing of the casein curdsa. Buttermilk. Milk allowed to turn sour by nature & its fat

removed by churning; since frequently contaminated, sterile skimmed milk is inoculated with some lactic-acid producing organisms (Lactobacillus acidophilus, L. bulgaricus, or Streptococcus lacticus)

b. Fermented Whole milk. After inoculation, milk incubated at 27-30o C for 6-12 hrs after which refrigerated for several days

c. Protein Milk. Introduced by Finkelstein for treatment of diarrheas

MILK FORMULAS

• Acid Milk. Prepared by addition of dilute mineral or organic acids to the milk, such as lactic acid milk popularized by Marriotta. Overcomes buffer value of cow’s milkb. Bactericidal effect in stomach & duodenumc. May cause acidosis in infants

• Filled Milk. Fat content of whole milk is replaced by vegetable oil, coconut oil & corn oil & this increases the amount of saturated fatty acids

• Recombined Milk. Separated non-aqueous ingredients mixed together with or without water, e.g. in condensed milk recombination, butterfat & non-fat milk solids are put together again

MILK FORMULAS

• Reconstituted Milk. Remaking of any milk product to approximate the composition of fresh cow’s milk, hence, for powdered milk, all that is needed is water

• Follow-on Milk Formulas. Food intended for use as a liquid part of the weaning diet for the infant from the 6th month onwards & for children between 12-36 months of age

a. Questions raised about the high protein content

b. Risk of hypernatremic dehydration due to high potential renal solute load

c. However, beneficial in places where supplementary foods are low in protein

MILK FORMULAS

• Special Milk Formulas. Where either the carbohydrate, protein, fat or all these components have been altered to address specific needs

a. Phenylalanine-free. Milk formula for phenylketonuria

b. Lactose-free Formulas. For lactose intolerance or galactosemia

c. Soy formulas/Protein Hydrolysates. For infants with cow’s milk allergy

d. Powdered Protein. For prematures or debilitated infants or those with diarrhea

NOT RECOMMENDEDFOR INFANTS

• Whole Cow’s Milka. Protein content much higher than in breast milk 21%

versus 7-16%, thus, increasing solute loadb. Low in ironc. Use may result in occult blood loss in stools

• Skimmed Milk & Low Fat Milka. Very low fat contentb. Deficient in vitamin C & iron

• Goat’s Milka. Just as antigenic as cow’s milkb. High protein content may result in increased renal solute

loadc. Deficient in folic acid & irond. Carbohydrate content 25% versus 35-65% in breast milk

SUPPLEMENTARY AND COMPLEMENTARY FEEDINGS

• Supplementary FeedingsFeedings provided in place of breastfeedingAny food given prior to 6 months, the

recommended duration of exclusive feedingMay include expressed or banked breast milk

• Complementary FeedingsMilk feedings given in addition to

breastfeeding or replacement foods (non-milk feedings)

Foods given in addition to breastfeeding after 6 months needed for adequate nutrition

WEANING• Definition: The process of introducing any non-milk

food into the infant’s diet, irrespective of whether or not breast- or bottle-feeding continues

• Introduction of solids usually done at about 4-6 months of age because:a. Milk supply may no longer meet the nutrient

requirements for growthb. Intestinal tract better able to handle foreign

proteinsc. Kidneys better able to tolerate increased protein

loadsd. The infant exhibits developmental readiness

DEVELOPMENTAL READINESS

FOR WEANING• Able to sit with support or briefly

• Better head control

• Better oral motor coordination (loss of extrusion reflex)

• Better able to communicate degree of satisfaction

WEANING FOODS

• Initial weaning foods are usually cereals, pureed or mashed fruits & vegetables and semi-solids

• Ground fresh beef, liver or strained canned meats may be given initially by 6 months of age

• When infant shows “gumming” or develops chewing motions, usually at 6-8 months of age, chewable biscuits & succulent solids may be introduced

• Egg white, chicken & similar highly antigenic foods should be introduced with caution during the second 6 months to observe for & minimize allergic manifestations

• Lifelong dietary habits may become established at weaning periods, hence, excessive salt & sugar intake should be discouraged

WEANING FOODS

• By 8 months, most infants can also eat "finger foods" (snacks that can be eaten by children alone)

• By 12 months, most children can eat the same types of foods as consumed by the rest of the family

• Avoid foods that may cause choking (i.e., items that have shape and/or consistency that may cause them to become lodged in the trachea like nuts, grapes, raw carrots)

• Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks such as soda

• Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods

WHAT IS A “HEALTHY” DIET?

• The Dietary Guidelines for Americans, 2005, describe a healthy diet as one thatEmphasizes fruits, vegetables, whole grains

and fat-free or low-fat milk and milk products

Includes lean meats, poultry, fish, beans, eggs and nuts

Is low in saturated fats, trans-fats, cholesterol, salt (sodium) and added sugars

WHAT IS A “HEALTHY” DIET?

• The Food Guide Pyramid incorporates current dietary guidelines with strong focus on activity

• “MyPyramid” indicates that nutrient needs vary as a function of age, sex, weight, height and level of activity

• The goal is to support normal rates of weight gain without excessive fat deposition

• The recommendations in the Dietary Guidelines and in MyPyramid are for the general public >2 years of age

Daily Intakes of Each Food GroupNeeded by

a 6-yr-old

Boy

Inactive(<30 min of

vigorous activity/day)

Moderately Active

(30–60 min of vigorous

activity/day)

Very Active

Energy (kcal/day)

1,400 1,600 1,800

Grains (oz/day)

5 5 6

Vegetables (cups/day)

1.5 2 2.5

Fruits (cups/day)

1.5 1.5 1.5

Milk (cups/day)

2 3 3

Meat, beans (oz/day)

4 5 5

WHAT IS A “HEALTHY” DIET?

• The National Cholesterol Education Program and the American Heart Association Step I Diet recommends:Dietary fat to about 30% of total daily energy

intakeSaturated fatty acids <10% of energyCholesterol <100 mg/1,000 kcalPUFA 7–8% of energyMonounsaturated fatty acids 12–13%

• To decrease atherosclerotic heart disease in adulthood and may be effective in preventing obesity

Estimated Amounts of Caloriesa

Gender Age (years) Sedentaryb Moderately Activec Actived

Child 2-3 1,000 1,000-1,400 1,000-1,400

Female

4-89-1314-1819-3031-5051+

1,2001,6001,8002,0001,8001,600

1,400-1,6001,600-2,000

2,0002,000-2,200

2,0001,800

1,400-1,8001,800-2,200

2,4002,4002,200

2,000-2,200

Male

4-89-1314-1819-3031-5051+

1,4001,8002,2002,4002,2002,000

1,400-1,6001,800-2,2002,400-2,8002,600-2,8002,400-2,6002,200-2,400

1,600-2,0002,000-2,6002,800-3,200

3,0002,800-3,0002,400-2,800

a Based on EER from IOM DRIs macronutrients report, 2002, calculated by gender, age and activity level for reference-sized individuals. "Reference size," is based on median height and weight for ages up to 18 yr and median height and weight for that height to give a BMI of 21.5 for adult females and 22.5 for adult males.b Sedentary means a lifestyle that includes only light physical activity associated with typical day-to-day life.c Moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5-3 miles/ day at 3-4 miles/hour, in addition to the light physical activity associated with typical day-to-day lifed Active means a lifestyle that includes physical activity equivalent to walking >3 miles/day at 3-4 miles/hour, in addition to the light physical activity associated with typical day-to-day life.

Daily Protein Requirement2005 Dietary Reference Intakes, U. S. Food and Nutrition Board, National Academy of

Sciences (g/kg BW/day)

1978 FNRI Publications, Daily Requirements of

Filipinos (g/kg BW/day)

0-6 mo (AI) 1.52 0-5 mo 3.57-12 mo (RDA)

1.2 (or 11 g/day of protein) 6-11 mo 3

1-3 yr (RDA) 1.05 (or 13 g/day of protein)

1-2 yr 2.5

4-8 yr (RDA) 0.95 (or 19 g/day of protein)

3-6 yr 2

9-13 yr (RDA) 0.95 (or 34 g/day of protein)

7-15 yr 1.5

Males 16-19 yr 1.214-18 yr (RDA)19-30 yr (RDA)

0.85 (or 52 g/day of protein)0.80 (or 56 g/day of protein)

Females

14-18 yr (RDA)19-30 yr (RDA)

0.85 (or 46 g/day of protein)0.80 (or 46 g/day of protein)

As point of reference: 3 ounces lean beef (the size of a deck of cards) or poultry = 25 g protein; 3 ounces fish or 1 cup soybeans = 20 g protein; 1 cup milk or yogurt = 8 g protein; 1 egg or 1 ounce cheese=6 g protein; 1 cup legumes=15 g protein; cereals, grains, nuts and vegetables = 2 g protein per serving

The positive thinker sees the invisible, feels the intangible, and achieves the impossible.