INFANT

FEEDING

Dr. Hussein BamashmousConsultant Pediatrician

King Abdulaziz University Hospital

°

WHY?

Provides nutritional requirements

Successful feeding promotes infant’s and mother’s emotional well-being

Successful feeding needs:

Confidence

Comfort

Appropriate guidance and support

Maintains normal metabolism and growth from fetal to extra-uterine life

Decreases risk of:

Hypoglcaemia

Hypokalaemia

Hyperbilirubinaemia

Azotaemia

AFTER BIRTH:

Infants tolerate “Enteral Feeds” judged by:

Normal Activity

Alertness

Good Sucking

Crying

MISTAKES IN FEEDING

Too much Obesity

Too little (In hot weather)

Dehydration fever

Feeding of infant is guided by self-regulation:

By the end of the first month 90% on infants have a suitable and reasonably regular schedule

PHYSIOLOGY OF BREAST FEEDING1. PROLACTIN

A. Breast Development anterior pituitary

B. Milk Secretion estrogen & progesterone neuroendocrine pathway

night time sucking

drugs

emotions

2. OXYTOCIN

Ejection of Milk posterior pituitary

let down reflex

Sensory contact

Emotional responses

Areola contact

3. PROGESTERONE

Development of Lobules and Alveoli

4. ESTROGENS

Proliferation of the Mammary Ducts

(enlargement of lobules and alveoli)

BREAST FEEDING“BREAST IS THE BEST”

ADVANTAGES OF BREAT FEEDING

A. For the MOTHER

• Easy, needs no preparation

• Cheap

• Available

• Involution of the uterus

• Emotional satisfaction

• lower incidence of breast cancer

• Birth spacing

B. For the BABY

• Natural, balance, meets nutritional needs• Self –regulated • Available• Fresh, proper temperature• Easy digestion and absorption• Bonding• Anti infective properties• Incidence of allergy• Incidence of rickets• Incidence of iron deficiency• Lower renal solute for Vit. A & C• Giardia antibodies in breast milk

ANTI INFECTIVE PROPERTIES OF BREAST MILK

HUMORAL FACTORS

1. Antibodies ( antibacterial / antiviral):

– Secretory IgA

– IgG, IgM, IgD

2. Lyzosomes:– Bacteriolytic for enterobacteria & Gram

positive

3. Lactoferrin:– Fe binding protein

– E. coli

4. Interferon: (anti virals)

5. Lactobacillus Bifidus:

6. Stool pH

CELLULAR FACTORS

1. Macrophages ( esp. colostrum)

2. Synthesize : lactoferrin, lysozymes and

complements

3. B and T cell Lymphocytes

4. Epithelial cells

FACTORS INFLUENCING MILK PRODUCTION AND SECRETION

1. ENDOCRINE:

PROLACTIN, OXTOCIN, THYROXIN

2. ANATOMICAL:

SENSORY NERVE SUPPLY OF CHEST

3. MECHANICAL:

GOOD SUCKLING AND COMPLETE EMPTYING

4. PHYCHOLOGICAL:

LET DOWN REFLEX

5. MATERNAL NUTRITION:

6. DRUGS:

CHLORPROMAZINE

METACHLOPRAMIDE

BROMOCRIPTINE

CONTRAINDICATION TO BREAST FEEDING

MATERNAL CAUSES:

1. INFECTIONS:

Septicaemia

Malaria

Typhoid Fever

Active TB

HIV

2. MENTAL & NEUROLOGIC ILLNESS:Severe NeurosisPostpartum psychosisInsanityEpilepsy

3. OTHERS: Allergens in breast milkEclampsiaNephritisProfuse haemorrhageChronic malnutritionDebilitySevere inverted nippleDrugs

INFANT CAUSES:

1. INBORN ERRORS OF METABOLISM:

PKUGalactosaemia

2. SEVERE CONGENITAL ANOMALIES:

Severe cleft palatSevere micrognathia

SOME PROBLEMS WITH LACTATION

1. Mastitis

2. Acute Infection

3. Resumption of Menstrual with breast feeding

4. Pregnancy with breast feeding

5. Breast feeding Give Vit. K

6. Haemolytic disease of newborn and breast feeding

No contraindication

PREPARATION OF THE PROSPECTIVE MOTHER

»Very Successful breast feeding

Sufficient Encouragement

Reassurance

Support

Over persuasion

Advantages of breast feeding (from mid-trimester)

Good health, Rest, Exercise

No Worry

Adequate Nutrition

Treatment of Retracted nipples

ESTABLISHING AND MAINTAINING THE MILK SUPPLY

Psychological Factors

Fatigue

Hygiene of Breast

Diet : No dietingMilk is important for MOM

OR 1 gram calcium / day

Drugs contraindicated with breast feeding: antithyroidsLITHIUMAnticancerINHPhenindione

Temporary cessation of B.F. with:Radiographic agents

ChloramphenicolMetronidazole

Sulfonamide

NO SMOKING- Sudden Infant Death Syndrome

NO ALCOHOL – FETAL Alcohol Syndrome

SOME CHEMICALS SECRETED WITH BREAST MILK:

Aresenicals Iodides Salicylates

Barbiturates Lead Opium

Bromides Mercury Atropine

Most Antibiotics

ONE OR BOTH BREAST PER FEEDING:

• Early weeks both breast

• Late one will do, Unless milk secretion is

too great

ADEQUACY OF BREAST FEEDING

• Infant calm and satisfied

• Sleeps well

• Normal Stools (frequent, yellow, soft, acidic)

• Normal amount of urine

• Normal weight gain

• Positive “LET DOWN” of milk ejection reflex

CRITERIA OF UNDERFEEDING IN BREAST FED INFANT:

• Irritable baby

• Stays on breast for longer period

• Very short sleeps

• Oliguria

• Hunger diarrhea

• Slow gain Static weight loss

TREAT: SUPPLEMENTARY OR COMPLEMENT FEEDS

FORMULA FEEDING

BY FORMULA FEEDING WE MEAN:

WHOLE COW’S MILK

MODIFIED COW’S MILK

MILK SUBSTITUTES

STERILIZATION & REFREGIRATION OF FORMULA

MORBIDITY & MORTALITY FROM GASTROINTESTINAL INFECTONS

MILK PROCESSING :

( Alters CASEIN Small digested curds)

SIMPLE HOME BOILING

PASTEURIZATION

HOMOGENIZATION

EVAPORATION

NOTE:

CHANGING CULTURAL & SOCIAL PATTERNFORMULA FEEDING

OBJECTIVE NUTRITIONAL STUDIES OF INFANTS SHOW LITTLE DIFFERENCE BETWEEN BREAST ED AND COW’S MILK FED INFANT

CONVENTIONAL FORMULAS OF WHOLE AND EVAPORATED COW’S MILK

3-4 gram PROTEIN/K/DAY

HUMAN AND HUMANIZED MILK

3-4 gram /K/ DAY

COMMERCIAL FORMULAS ARE MODIFIED

FROM COW’S MILK BASE: THEIR PROTEIN

AND ASH CONTENT IS TO HUMAN MILK

LEVELS

1. OSMOLALITY

2. RENAL EXCRETORY LOAD

SATURATED FAT OF COW’S MILK IS

REPLACED WITH SOME UNSATURATED

VEGETABLE FATTY ACIDS

VITAMINS ARE ADDED

SOME FORMULAS:

LACTOPROTEIN (WHEY) CYSTEIN

CASEIN AS IN BREAST MILK

COMPARISON OF HUMAN MILK AND COW’S MILK

CONSTITUENT HUMAN COLOSTRUM COW

WATER 88 87 88

PROTEIN(G%) 1 2.7 3.3

CASEIN 0.4 1.5 2.7

WHEY:

Lactoalb

Lactoglob

0.4

0.2

-

1.2

0.4

0.2

FAT (G%)

% P.U.F.A

3.8

8%

2.9

7%

3.8

7%

CONSTITUENT HUMAN COLOSTRUM COW

LACTOSE (G%) 7 5.3 4.8

CALORIES 67 - 67

CALCIUM (mg%)

34 30 117

PHOSPHATE 15 15 92

IRON (mg/L) 0.5 0.1 0.5

ZINC (mg/L) 4 6 4

VITAMIN A (IU) 1900 - 1025

VITAMIN C (mg) 43 - 11

VITAMIN D (IU) 22 - 14

VITAMIN E (mg) 2 - 0.4

COLUSTRUM

FIRST 2-4 DAYS

LEMON YELLOW IN COLOUR

ALKALINE

S.G. 1.040 – 1.060 ( Mature Breast Milk=1.030)

DAILY PRODUCTION: 10-40 ml

COLUSTRUM CONTAINS:

PROTEIN

MINERALS

CHO

FAT

SECRETORY IgA

MACROPHAGES

LACTOERRIN

LYSOZYMES

COLUSTRUM TRANSITIONAL MILK

BY THIRD OR FOURTH DAY MATURE MILK

BACTERIAL CONTENT:

• MASTITIS - Pathogenic organism in breast milk

Infected Mothers Infected Milk with:

Tuberculosis

Thypoid Bacilli

Herpes Simplex

Hepatitis B Virus

Rubella Virus

Mumps Virus

HIV

CMV

MILK-BORNE INFECTIONS:

STREPTOCOCCAL DISEASES

DIPHTERIA

TYPHOID FEVER

SALMONELLOSIS

T.B. & BRUCELLOSIS

DIGESTABILITY

HUMAN MILK RAPID STOMACH

EMPTYING

GASTROINTESTINAL PASSAGE TIME

EQUAL IN BREAST MILK AND COWS MILK

IN THE FIRST 45 DAYS.

COW’S MILK CURD IS BY: BOILING

(Milk-Processing) ACID

ALKALI

HOMOGENIZATION

COW’S MILK FAT IS LESS READILY

DIGESTED

MILK USED IN FORMULA

RAW MILK:

NOT ADVISED IN INFANTS

LARGE CURDS

SLOWLY DIGESTED

EASILY CONTAMINATED

PASTURIZED MILK

DESTROS PATHOGENIC BACTERIA

MODIFIES CASEIN

PASTURIZATION:

HEATED MILK AT 63° C X 30 SEC.

HEATED MILK AT 72° C X 15 SEC.

THEN COOLING RAPIDLY TO 65° C OR 60 ° C

ALLOWED BACTERIAL CONTENT (NON-PATHOGENIC) UP TO 50,000/ml.

AVERAGE COUNT : 5,000 – 10,000/ml.

HOMOGENIZED MILK

FAT GLOBULES BROKEN TO MINUTE PARTICLES & REMAIN DISPERSED

SMALLER LESS TOUGH CURD PRODUCED IN THE STOMACH

EVAPORATED MILK UNIVERSALLY AVAILABLE

MONTHS WITHOUT REFRIGERATION

CASEIN CURD: SOFT & SMALL

LACTOALBUMIN LESS ALLERGENIC

VITAMIN D IS ADDED

PREPARED MILK:

ADDITION OF WATER IN 1:1 PROPORTION

MOST DERIVED FROM COW’S MILK

EITHER POWDER OR LIQUID

MAJORITY SIMULATES HUMAN MILK

ALL FORTIFIED WITH VIT. D

SOME HAVE ADDED IRON

MANY CONTAIN OTHER VITAMINS

FORMULA WITH VERY LOW ELECTROLYTES

CONGENITAL HEART DISEASE

NEPHROGENIC D.I.

MARGINAL R.F.

SODIUM FORMULA = 1mmol/quart

(for C.H.D.)

MILK PREPARED FROM HYDROLYZED WHEY OR CASEIN

FOR: MALABSORPTION

MILK ALLERGY

SPECIAL FORMULA WITH ELIMINATION OF SPECIFIC AMINO ACID

INBORN ERROR OF METABOLISM

LACTOSE FREE FORMULA

FOR: LACTOSE INTOLERANCE

GALACTOSAEMIA

CONDENSED MILK

USED ONLY WHEN CALORIES ARE

NEEDED

ADDITION OF 45% CANE SUGAR

IN EVAPORATED FORM: 60% CHO

PROTEIN & FAT

DRIED WHOLE MILK :

THE FAT CONTENT OF FLUID MILK ADJUSTED TO 3.5%.

DRIED SKIM MILK:

NON-FAT SKIM MILK ( FAT 0.5%)

HALF-SKIM MILK (FAT 1.5 %)

FOR: FAT INTOLERANCE

NOT FOR FIRST YEAR

PROTEIN & MINERALS

RENAL SOLUTE LOAD DEHYDRATION

ACID AND FERMENTED MILK:

ACID BY : ADDING ACID

FERMENTED : LACTIC ACID PRODUCING ORGANISM

THESE MILKS REQUIRE:

1. HCL ACID IN STOMACH

2. CASEIN SMALL LESS TOUGH CURDS

ACIDS MILKS ACIDOSIS RARELY USED NOW

GOAT’S MILK

BRUCELLOSIS

WIDELY USED

USED FOR COW’S MILK ALLERGY

GOAT’S MILK: Na

K

CL

LINOELIC &

ARACHIDONIC ACID

FAT DIGESTABLELOWER CURD TENSION THAN COW’S MILK

VIT. D & IRON

FOLIC ACID MEGALOBLASTIC ANAEMIA

MILK PROTEINTO PROTEIN CONTENT OF SOME FORMULA

FED TO:

PRETERMS

DEBILITATED INFANTS

INFANTS WITH DIARRHEA SHOULD BE USED CAREFULLY , FOR SHORT DURATION

MILK SUBSTITUED & HYPOALLERGENIC FORMULA:

SOYA BASED FORMULA

FOR: 1. VEGETARIANS

2. COW’S MILK PROTEIN

INTOLERANCE

LACTOSE FREE FORMULA

FOR: 1. GALACTOSAEMIA

2. LACTOSE INTOLERANCE

PROTEIN HYDROLYSATE FORMULA

FOR: 1. COW’S MILK PROTEIN

INTOLERANCE

2. LACTOSE INTOLERANCE

PHENYLALANINE FREE FORMULA

FOR: PKU

VALINE , LUCINE, ISOLUCINE FREE

FORMULA

FOR: MSUD

MILK FORMULAS

CALORIC REQUIREMENTS:

FIRST FEW MONTHS:100-120 kcal/kg/day

BY ONE YEAR: 100 kcal/kg/day

FLUID REQUIREMENTS:

FIRST 6 MONTHS: 130-190 ml/kg/day

NUMBER OF FEEDINGS:

BIRTH - 1 WEEK 6-10 feeds/day

BY 8 – 12 MONTHS 3 feeds/day

INTERVAL BETWEEN FEEDS:

• EARLY FEEDING THROUGHOUT 24 H

• GRADUALLY

• FULL TERM: EVERY 3-5 H 4 hourly

• SMALL / WEAK INFANTS: 2-3 hourly

INFANT ADJUSTS DEMAND TO THE FAMILY PATTERN OF DAYTIME ACTIVITY

QUANTITY FORMULA / each feed

IT DIFFERS WITH:

DIFFERENT INFANTS OF THE SAME AGE

SAME INFANT AT DIFFERENT FEEDS

AVERAGE AMOUNTS AT VARIOUS AGES / each feed

1ST and 2nd WEEK 60-90 ml/feed

3W - 2/12 120-150 ml/feed

2/12 - 3/12 150-180 ml/feed

4/12 - 5/12 180-210 ml/feed

6/12 - 1 YEAR 210-240 ml/feed

AFTER 6/12 OF AGE :

MILK INTAKE IS

MILK IS SUBSTITUTED WITH OTHER FOODS

OTHER FOODS

VITAMINS

ORANGE & CITRUS NATURAL SOURCES

OF VIT. C

YOUNG INFANTS CAN NOT TOLERATE

LARGE AMOUNTS GIVE 50 milligrams/day

VIT. D IS SUPPLIED IF FORMULA IS DEVOID

OF IT START IT IN NEONATAL PERIOD AS

10 microgram/day

IRON

START IT AT 6/52 OF AGE

IRON FORTIFIED FORMULA

OR 2 milligram/Kg ( UP TO 15 milligram/day)

CEREAL + IRON INSUFFICIENT

ABSORPTION

SOLID FOODS

NOT BEFORE 4-6 MONTHS OF AGE

HIGH CALORIES FOOD AS:

EGG YOLK, CEREALS, MEAT, PUDDING

→OBESITY

SOLID FOOD WHEN:

MILK ALONE NO SATISFACTION(HUNGER)

WHEN THEY FIT INTO THE DAILY

SCHEDULE

INFANT’S APPETITE BEST INDEX FOR

PROPER AMOUNT

RESPECT INFANTS WISHES

CEREALS

MOST CONTAIN IRON + FACTORS OF VIT. B

COMPLEX

FRUITS

MILD LAXATIVE EFFECT

INFANTS LIKE IT

RAW RIPE READILY DIGESTED

VEGETABLES:

GOOD SOURCE OF VIT. C + IRON

SHOULD BE FRESHLY COOKED

STRAINED

ADDED BY 7 MONTHS OF AGE

MEAT, EGGS, STARCHY FOOD:STARCHY FOOD IN THE SECOND 6/12 OF

LIFE

EGG YOLK COULD BE GIVEN EARLIER

EGG WHITE ALLERGIC MANIFESTATIONS

TOAST, CRACKERS 6- 8/12 ( GUMMING)

INFANTS LEARN TO CHEW + FEED

THEMSELVES

MEAT PROTEIN

IRON + VITAMINS

START BT 6/12 OF AGE

DESSERTS

GOOD FOR OLDER INFANTS

BRIBE OR REWARD POOR EATING HABITS

SALT INTAKE

SHOULD BE DISCOURAGED

INTAKE FUTURE BP

FOOD ADDITIVES

ARTIFICIAL FLAVOURS (3000) + COLOURS

ALLERGIC DISORDERS

URTICARIA & ANGIODEMA

LESIONS OF TOUNGE & BUCCAL MUCOSA

DIGESTIVE DISTURBANCES

ARTHRALGIA

HYDROARTHROSIS

HEADACHE

HYPERKINESIS

FIRST YEAR FEEDING PROBLEMS

UNDERFEEDING

OVERFEEDING

REGURGITATION, VOMITING &

RUMINATIONS

LOOSE DIARRHEAL STOOLS

CONSTIPATION

COLIC

THAN Q