Introduction BY : Dr . Baha D Moohy Alosy//DCH ,FICMSP12/10/2008

1.The Newborn Service at National Women’s Health promotes breast milk and breastfeeding as the optimum nutrition for infants as it provides many benefits. Benefits apply to both the mother and the infant and include nutritional, immunological, psycho-social and financial components.

2.The cultural, personal and/or physical factors affecting infant feeding are to be respected and staff are to support and assist women in their choice of infant feeding.

Nutritional Needs During Pregnancy

Nearly all nutrients are recommended in increased amounts during pregnancy and lactation

Only small increase in metabolic demands of pregnancy and fetal development2nd trimester - add 350 calories per day3rd trimester - add 450 calories per day

Nutrients deserving special attention during pregnancy:ProteinFolateIronZincCalcium

(© 2002 Wadsworth Group)

Critical Periods of Development

Feeding disorders

can be categorized into three areasSlow to establish feeds Disorganized feeding

Dysfunctional feeding  .Contributing factors to disorganized/dysfunctional feeding patterns and feeding resistance:Delayed introduction of oral feeds .Prematurity .Birth Asphyxia .Neurological problems .Prolonged respiratory distress .Cardiac anomalies .Averse oral stimulation .Multiple caregivers .

Feeding pattern Exclusive breastfeeding rate (< 6 mos. & < 4 mos.)

Timely complementary feeding rate (6-9 mos.) Continued breastfeeding rate (12-15 & 20-23 mos.)

Timely initiation of breastfeeding (within 1 hour of birth) Frequency of complementary feeding (6-11 mos.)

Exclusive Breastfeeding (< 6 months)Percentage of infants exclusively breastfed for the first six (or four) months of lifeAdequately fed infants (0-11 mos.)

WHO/UNICEF Feeding Recommendations

Exclusive breastfeeding for first six months

Continued breastfeeding for two years or more

Safe, appropriate and adequate complementary

foods beginning at 6 months

Frequency of complementary feeding: 2 times

per day for 6-8 month olds; 3 times per day for

9-11 month olds

Background

Exclusive breastfeeding refers to infants who receive only breast milk, or breast milk and

vitamins, mineral supplements or medicine

Complementary feeding refers to children who receive breast milk and solid or semi-solid food

Exclusive BF (MENA)

29

1212121213

162727

29303131

3434

4447

81

0 20 40 60 80 100

Middle East/North Africa

Iraq

Kuwait

Qatar

Yemen

Algeria

SudanJordan

Lebanon

OPT

Egypt

Morocco

Saudi ArabiaBahrain

UAE

Iran

Tunisia

Syria %infantsexclusively

breastfed for the

first 6 months of life

Recommended Breastfeeding Patterns

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Exclusive breastfeeding(0-5 months)

Complementary feeding

(6-9 months)

Continued breastfeeding

(12-15 months)

Continued breastfeeding

(20-23 months)

The WHO recommends human milk asthe exclusive nutrient source forfeeding full-term infants during thefirst 6 months after birth Regardless of when complementaryfoods are introduced, breastfeedingshould be continued through the first

12 months

Recommendations for Infants

Breast Milk Content

Human milk contains protectiveantibodies against enteric infections Caloric density is the same in breast milk and regular infant formulas(20kcal/oz) Fat absorption is more efficient inbreastfed infants when compare to infant formulas

Breast Milk/Formula Content

Human milk has higher concentration ofessential fatty acid Formula has higher protein concentration

(1.5g/dl in formula vs.0.9g/dl in breast milk)whey/casein in human milk- 80:20whey/casein in formula-18:82 Whey protein promotes gastric emptying Whey protein have more lactoferrin andsecretory immunoglobulin A

Breast Milk/Formula Content

Breast Milk/Formula Content Lactose content is equal in breast milkand infant formula Calcium/Phosphorus ratio in humanmilk is higher compared to formula(2:1 vs. 1.5:1) Human milk has lower ironconcentration but iron from humanmilk is more bio-available

Infection and Breast Milk

Human milk may be a source of CMV Human milk is protective againstenter pathogenic E.coli and other GIpathogens. This protection is greatest duringthe infant’s first 3 months of life and declineswith increasing age Human milk is not protective against HSV Breastfeeding is contraindicated in HIVinfection, except in underdevelopedcountries Human milk does not protect againstM.tuberculosis

Infant Benefits of Breastfeeding

Protein in breast milk is more easily digested thatprotein in infant’s formula Human milk protein promotes more rapid gastricemptying Fat absorption from human milk is more efficientwhen compared to formula Many factors in human milk may stimulategastrointestinal growth and motility as well asenhance the maturity of the gastrointestinal track Human milk contains specific protein involved in host defense

Infants who are breastfed for at least 13weeks had significantly less gastrointestinaland respiratory illnesses Breast milk appears to be protective againstsome food allergies during infancy and earlychildhood Maternal-infant bonding is enhanced duringbreastfeeding Improved long-term cognitive and motorabilities in full term infants have been directlycorrelated with duration of breastfeeding

Benefits of Breast Feeding for Mother

Economical and convenientHelps return uterus to normal size fasterHelps return to prepregnancy weight fasterDelays onset of menstruation (not birth control)Improves bone remineralizationReduces risk for ovarian and premenopausal breast cancer

Infant Formulas

Cow milk-based Soy-based Protein hydrolysate Elemental

Characteristics of Cow Milk-BasedFormulas

Caloric density: 20cal/oz Protein: casein/whey (80/20) Carbohydrate: lactose Fat: palm oil, coconut oil,soy-oil, safflower oil Examples:SimilacEnfamilLactofreeNeocareCarnation Follow- up

Characteristics of Soy-BasedFormulas

Caloric density: 20cal/oz Protein: soy protein with addedmethionine Carbohydrate: sucrose, corn syrup solids,glucose polymers Fat: as in cow milk-based formula

Indications for Soy Protein-BasedFormulas

Healthy term infants as the alternative tocow milk-based formula Galactosemia Lactose intolerance IgE-mediated allergy to cow milk Parents seeking a vegetarian-based diet for a term infant

Contraindication for Soy Protein-Based Formulas & Hydrolysate Formulas

Preterm infants with birth weight <1800g Prevention of colic or allergy Cow milk protein induced enterocolitis orenteropathy

Caloric density: 20cal/oz Protein: Casein or whey hydrolysate Carbohydrate: Sucrose, corn syrup solids,cornstarch, tapioca starch Fat: Medium chain triglycerides andvegetable oil*

Indications for Protein HydrolysateFormulas

Intolerance to cow milk and soy proteinformula Fat Malabsorption Short gut syndrome Severe chronic diarrhea Liver disorders (cholestasis, biliary Artesia,cystic fibrosis(Disadvantages of HydrolysateFormulas Poor taste (presence of sulfated aminoacids)

Greater cost High osmolarityProtein Hydrolysate Formulas Examples:

AlimentumNutramigenProgestamil

Characteristics of ElementalFormulas

Caloric density: 20cal/oz Protein: free amino acids Carbohydrate: Glucose polymers, sucrose,modified starch Fat: vegetable oil, medium chaintriglycerides

Indication for Elemental Formula

Severe food allergy Malabsorption Transition from Total Parenteral NutritionElemental Formulas Examples:

Neocate (Infants formula)Elecare (Pediatric formula)Vivonex (Pediatric formula)

Whole Cow Milk

Human milk or formula until 1 year of age Cow milk has Less iron, linoleic acid, vitamin E Excessive sodium, potassium, protein Increased incidence of GI blood loss Low iron content and iron bioavailability Low-fat and non-fat milks areinappropriate in the first two years of life

Complementary Feeding

Can be introduced between ages 4 and 6months Introduce one new food at the time. At least 1 week interval between new foodsintroduction No evidence to support introducing food in aparticular order

Fruit juice should not be introduced toinfants younger than 6 months of age Intake should be limited to 6-8oz/day Intake of more than 250cc of juice per daycan lead to diarrhea (high fructose andsorbitol content of fruit juice(

Complementary Feeding

No need for complementary foods for thefirst 6 months of life in infants fed iron fortifiedformula Iron-fortified formula and complementaryfood in the first year of life will preventdeficiencies of iron, zinc and vitamin D Breastfed and formula-fed infants shouldhave hemoglobin tested at 9 to 12 monthsof age Breast-fed infants need iron supplement starting at 4 to 6 months of life

Complementary Feeding

Iron-fortified infants cereal and meats are goodsource of iron If iron intake not sufficient , elemental ironshould be started at 1mg/kg/d An average of 2 servings (. oz or 15g of drycereal per serving) meet the daily ironrequirements Infants who are exclusively breastfed beyond 6months of life should be supplemented with 200U of vitamin D daily

Complementary Feeding, cont.

Neither breastfed or formula-fed infants requireextra water Whole milk should be avoided in the first year oflife. Complementary foods should not be prepared withadded salt or sugar Hot dogs, nuts, grapes, raisins, raw carrots,popcorn and rounded candies should be avoided inchildren under age of 4 years to prevent the risk ofaspiration

Dietary Supplements

Not recommended for healthy children Supplements needed: Anorexia, inadequate appetite Chronic disease Neglected or abuse children Vegetarian diet without adequate dairy product Failure to thrive Children and adolescent without regular sunexposure, ingestion of less than 500ml/d ofvitamin D

Food Pyramid for Children

Dietary Guidelines in Childhood

Structured 3 meals and 2 snacks Adults should decide when food is offered Eating should occur in a designated areawith the developmentally appropriate chair No grazing between meals For preschoolers offer 1 tablespoon ofeach food for every year of age Snacks should be considered mini-meals