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Mnica Riojas, MD LSU Pediatrics Slide 2 Principles of Infant Feeding Energy Requirements: kcal/kg/d 0-12 mo: 100-120 1-3 yr: 90-100 4-6 yr: 80-90 7-10 yr: 70-75 15+ yr: 45-50 Slide 3 Principles of Infant Feedings Formula fed infants feed every 3-4 hrs. Feedings/day 0-3 Months: 6-8 4-6 Months: 5-7 6-8 Months: 4-6 9-12 Months: 3-5 Slide 4 Principles of Infant Feeding Average Volume of Milk per Feeding 1 st wk: 1-2 oz 2-4 wks: 2-3 oz 1-2 mo: 4-5 oz 3-4 mo: 5-6 oz 5-6 mo : 7-8 oz By 12 mo of age, the average child should be taking an average of 24 oz/d. Slide 5 INFANT STOMACH CAPACITY Slide 6 Infant Formula Indications As substitute for human milk in infants for whom BF is medically contraindicated. As supplement for BF infants who do not gain weight adequately. As a substitute or supplement for human milk whose mother chooses not to BF or not to do it exclusively. Slide 7 Distribution of Kcals BreastmilkFormula % Protein69 % Fat5248 % Carbohydrate42 Slide 8 Question Which of the following statements about infant nutrition is true? A. Human milk contains more casein than infant formulas. B. Infants who receive increased whey protein have been shown to grow better than those who receive primarily casein. C. Iron is absorbed better from cow milk formulas than from human milk. D. Lactose-free formulas result in decreased absorption of calcium. E. There are no apparent negative effects from the addition of DHA and ARA to formulas. Slide 9 Differences Between Types of Milk BreastmilkStandard Cow FormulaCow Milk Calories20 kcal/oz 19 kcal/oz Protein0.9 g/dL1.4 g/dL3.5 g/dL Minerals (Ca, P, Fe)LowerHigher Iron AbsorptionBetterWorseTerrible Vit. ABCSame Vit. DEKLowerHigher Renal SoluteLowerHigher Whey:Casein Protein Ratio 70:30Varies, but not better than human milk 20:80 Slide 10 Benefits of Whey Protein Promotes more rapid gastric emptying. Consists of soluble proteins that are easily digested. Lines the GI tract and plays a role in host defense. Slide 11 Question Is iron supplementation required at birth? No When should you start iron supplementation? All babies (including breastfed) should receive supplementation in their food (iron-fortified cereal) by 6 months of age. In FT infants, iron stores become depleted by 4-6 months of age. Slide 12 Dietary Recommendations IRON Pre-term: 2 mg/kg/d at 1-12 mo Full-term: 1 mg/kg/d at 4-6 mo Iron Fortified Formula: 12 mg/L Cows milk has 0.5mg/L of iron. Slide 13 Dietary Recommendations VITAMIN D 400 IU/d Who should receive Vitamin D? All BF infants, unless they are weaned to at least 1000 ml/d (33 oz) of Vit. D fortified formula. Formula fed infants ingesting 1000 ml/d of Vit. D fortified formula. Children/adolescents who get no sun light, 1 L of Vit. D fortified milk, no MVI. Slide 14 Infant Formulas Premature Formulas Standard Formulas Special Formulas Slide 15 Slide 16 Standard Formulas COMPOSITION Protein Whey ( lacto-globulin) & Casein Whey predominant (60:40), Casein predominant (20:80), or 100% whey Fat Vegetable oils Coconut: Saturated, short & MCFA Palm oil: Saturated & LCFA Safflower, corn & soy: LCFA, DHA & ARA Carbohydrate Lactose Slide 17 Standard Infant Formulas Provide 20 cal/oz PRESENTATIONS: Powder Concentrated Liquid Ready to Feed Slide 18 Preparation of Infant Formula POWDER Add 1 scoop powder to 2 oz of water CONCENTRATED LIQUID Mix 1 oz concentrated liquid and 1 oz water 13 oz can READY TO FEED Hospital use: 2 and 3 oz bottles 32 oz container Expensive Slide 19 Preparation of Infant Formula What type of water should be mixed with the formula? Tap: safe, may boil x 1 min. Distilled water with fluoride. Well: boil 10 min. Give fluoride. Warm, cold or room temperature. Slide 20 Cow Milk/Standard Formulas Designed to meet the nutritional needs of the term and near-term infant. Enfamil Premium Newborn & Infant Similac Advance Store Brands Slide 21 Cow Milk/Standard Formulas Slide 22 New Infant Formula Features Prebiotics Nondigestible short-chain carbohydrates that stimulate growth and function of specific species of bacteria. Increases concentration of lactobacillus and bifidobacterium. Used to treat chronic diarrhea. Beneficial to atopic children. Probiotics Live microorganisms that survive digestion and colonize the colon. Organic No pesticides or synthetic fertilizer used. No hormones or antibiotics used. Slide 23 Premature Infant Formulas For LBW and Premature Infants Increased energy requirement: 120 kcal/kg/d Preterm formulas should always be discontinued before hospital discharge. Increased intake with age excess intake of vitamins/minerals Slide 24 Composition of Premature Infant Formula 20, 22, 24 kcal/oz Increased protein: whey predominant 60% whey:40% casein Breastmilk - 70% whey:30% casein Increased calcium & phosphorus Contain AA: cysteine and taurine Lactose + glucose polymers MCT Increased Vitamins & Minerals Slide 25 Premature Infant Formulas Enfamil Premature 20 cal Enfamil Premature 24 cal Similac Special Care Advance 20 cal Similac Special Care Advance 24 cal Good Start Premature 24 cal Slide 26 Premature Infant Formulas Slide 27 Transitional Formulas 22 kcal/oz INDICATIONS Infants 34 WGA or 1,800-2,000 g How long should infants be on transitional formulas? 6 to 9 months of age Slide 28 Transitional Formulas Enfamil Enfacare Similac Expert Care Neosure Slide 29 Transition Formula Slide 30 Question What type of milk would you recommend a breastfeeding infant that develops rash and hives while eating yogurt and cream cheese, and tolerates foods such as eggs and bread without any problems? Trial of Soy MilkBased Formula If no improvement switch to an extensively hydrolyzed or AA-based formula Slide 31 Soy Protein Formulas Lactose Free Contain higher concentrations of protein, AA, calcium, phosphorus, zinc and iron. Primary Carbohydrate Glucose polymers from corn syrup solids or maltodextrin Slide 32 Soy Protein Formulas INDICATIONS Galactosemia Congenital Lactase Deficiency Post-diarrhea lactose intolerance Strict vegetarian family Slide 33 Soy Protein Formulas NOT RECOMMENDED FOR Preterm infants with BW 1800 g. Do not meet requirements for calcium and phosphorus. Prevention of colic or allergy Infants with cow milk protein-induced enterocolitis (non-IgE allergic enterocolitis) 30% of infants with milk protein allergy also have soy protein allergy. Slide 34 Soy Protein Formulas Enfamil ProSobee Similac Sensitive Store Brand Soy Infant Formula Slide 35 Soy Protein-Based Formulas Slide 36 Modified Cow Milk Protein or Soy-Based Formulas Carbohydrate Reduced lactose or lactose-free carbohydrate blends Protein Partially hydrolyzed whey and soy proteins Other Thickeners (rice cereal) Soy fiber Prebiotics Slide 37 Modified Cow Milk Protein or Soy-Based Formulas INDICATIONS Infants recovering from diarrhea Infants with colic Infants with GER NOT for infants with galactosemia NOT for cow milk formula intolerance Slide 38 Special Indications GER Enfamil AR Similac Sensitive for Spit up Diarrhea and fussiness Similac Expert Care for Diarrhea Enfamil Gentlease Similac Sensitive Fussiness and Gas Specialty-metabolic formulas Similac PM 60/40 Slide 39 Modified Cow or Soy Milk-Based Formulas Slide 40 Slide 41 Slide 42 Slide 43 Question A mother brings her 1 month old infant to clinic because of a 1 week history of bloody streaks in stool and fussiness. Mom was breastfeeding for the first 3 weeks of life, then switched to a cow milk-based formula 1 week ago. What formula should you recommend? Protein Hydrolysate Formula Slide 44 Extensively Hydrolyzed Formulas Made for infants who are unable to digest or tolerate formulas containing intact cow milk protein. Lactose free Protein Extensively hydrolyzed casein Partially hydrolyzed whey Carbohydrate Glucose polymers and/or sucrose Fat Content Vegetable oils LCT/MCT from safflower and soy Slide 45 Extensively Hydrolyzed Formulas INDICATIONS Cow milk and soy protein allergy Malabsorption syndromes Cystic fibrosis Biliary Atresia Short gut syndrome Pancreatic insufficiency Protein calorie malnutrition Autoimmune diseases/immunodeficiency syndromes Slide 46 Question Hydrolysate formulas are MOST often used in the management of: A. Celiac disease B. Cow milk protein allergy C. Cystic fibrosis D. GER E. Lactose intolerance Slide 47 Extensively Hydrolyzed Formulas Nutramigen Pregestemil Similac Expert Care Alimentum Slide 48 Extensively Hydrolyzed Formulas Slide 49 Amino Acid Based Formulas Intolerance to intact or hydrolyzed protein. Protein Free Amino Acids Carbohydrate Glucose polymers Slide 50 Amino Acid Based Formulas INDICATIONS Cow Milk Protein Allergy Eosinophilic GI disorders Atopic diseases Severe food allergy Asthma Eczema Slide 51 Amino Acid Based Formulas Neocate Elecare Nutramigen AA Slide 52 Amino Acid Based Formulas Slide 53 Other Formulas Follow-up Formulas From 9 months of age - toddlers Increased protein, minerals and iron. No advantage for infants eating adequate amounts of formula and solid foods. Slide 54 Follow-up Formulas Enfamil Enfagrow Premium Enfagrow Premium Soy Similac Similac Go and Grow Good Start Good Start 2 Essentials Good Start 2 Essentials Soy Slide 55 Follow-up Formulas Slide 56 Question A 4 month old male is at clinic for his well child check. On questioning of his diet, mom states he drinks whole milk, orange juice, ravioli, and cheetos puffs. How do you counsel on appropriate dietary recommendations for his age? Slide 57 Cows Milk Introduce until 12 months of age!!!! Low iron content. May increase fecal blood loss in some infants. May cause hypocalcemia. High protein and electrolyte content high renal solute. Lower caloric content (19 cal/oz) Slide 58 Principles of Infant Feeding Number of Meals a Day 0-3 mo: 6-8 bottles 4-6 mo: 5 bottles + 1 solid meal 6-8 mo: 4 bottles + 2 solid meals 9-12 mo: 3 bottles + 3 solid meals Slide 59 Infant Nutrition: Solid foods Cereal Strained Vegetable Strained Meats Strained fruits Table Food Juices and desserts Vitamins and Minerals Slide 60 Solid Foods Introduce at 4-6 months age Has good head control No extrusion reflex Sits with support Has doubled birth weight Seems hungry after 32 oz milk Slide 61 Question What is the MOST likely outcome of introducing solid foods at an age of 3 months? A. Accelerates the development of oral motor skills B. Helps the infant sleep through the night C. Increases the risk of food allergies D. Increases the risk of GER E. Increases the risk of GI infections Slide 62 Solid Food Introduce rice cereal first. Advance to single vegetables. Add one food at a time. Feed same for 3-5 days. Combination dinners last. Slide 63 Infant Nutrition 0-4 mo: 100% total calories from milk 6-8 mo: 65% calories from milk 33% calories from solids. 9-12 mo: 50/50 milk and solids Slide 64 Solid foods Strained Food Stage 1 Foods: 2.5 oz jar, 4-5 mo Stage 2 Foods: 3.5 oz jar, 6-8 mo Stage 3 Foods: 6 oz jar, 9 mo Slide 65 Infant Nutrition CEREALS Rice cereal Oatmeal Barley Mixed Slide 66 Infant Nutrition CEREALS First solid introduced at 4-6 months of age Iron Fortified Provides 15 calories per Tbsp Full serving: 4 Tbsp + 4 oz formula or breastmilk DO NOT ADD IN BOTTLE!!!!!!!! Thickened feedings for severe GER Slide 67 Rice Cereal Slide 68 Introduction of Solids Recommendations At 4 months Breakfast: Rice Cereal (4 tbsp cereal/4oz formula) Lunch: Stage 1 veggies/fruits Same vegetable for 3-5 days, then switch to new veggie Slide 69 Slide 70 Introduction of Solids At 6 months Breakfast: Cereal Lunch: Stage 2 foods Introduction of meats Mixed veggies or dinners Dinner: Stage 2 foods Mixed veggies or dinners Slide 71 Introduction of Solids At 9 months Stage 3 and finger foods. Slide 72 A Typical 6 mo Infant Diet Morning: Cereal Mid-morning: Formula Noon: Vegetable Mid-afternoon: Formula Late afternoon: Dinner Bed-time: Bottle Slide 73