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Formula Feeding of Infants By Nykytyuk S Formula Feeding • - It is a child's diet of infancy, in which she did not receive human milk or its amount is less than 20% of the food and staple food are artificial mixtures. There is an agreement among healthcare professionals, infant food manufacturers and mothers that breastfeeding is the best choice for feeding infants during their first four to six months of life There are several reasons why a mother may not breastfeed her baby: 1. Medical or other health reasons may prevent a mother from breastfeeding. 2. The baby with special requirements may not tolerate breast milk. 3. Some social or psychological reasons can make it more difficult to breastfeed exclusively. The absolute contraindications to breastfeeding 1. Hypergalactosaemia. 2. Phenylketonuria [PKU]. 3. Lactose intolerance. 1. Medical contraindications to breast-feeding connected with mother Decompensated chronic diseases like blood circulation insufficiency, kidney or liver problems, respiratory insufficiency of III grade, HIV-infection, etc. 2. Psychical disorders as epilepsy, schizophrenia, depressive phychosis, postpartum psychosis. 3. Taking certain medications (See tables 1, 2). 4. Substance-abuse (drugs, alcohol, marijuana, cocaine, heroin, ets)(See table 3). Table 1. Drugs that are contraindicated during breast-feeding No. Drug Reported sign or symptom in infant or effect on lactation 1. Bromocriptine Supresses lactation 2. Cocaine Cocaine intoxication Cyclophos3. phamide 4. Cyclosporine Possible immune supression; unknown effect on growth or association with carcinogenesis; neutropenia Possible immune supression; unknown effect on growth or association with carcinogenesis Doxopubicin Possible immune supression; unknown effect on growth or association with carcinogenesis Ergotamine Vomiting, diarrhea, convulsions (doses used in migraine medication) 7. Lithium ⅓ to ½ therapeutic blood concentration in infants 8. Possible immune supression; unknown Methotrexate effect on growth or association with carcinogenesis; neutropenia 9. Phencyclidine (PCP) 5. 6. 10. Phenindione Potent hallucinogen Anticoagulant; increased prothrombin and partial thromboplastin time in infant Table 2. Drugs that have caused significant effects on some nursing infants and should be given to nursing mothers with caution No. Drug Reported sign or symptom in infant or effect on lactation Aspirin 1. (salicylates) Metabolic acidosis (dose related); may affect platelet function; hemorrhagic rash Drowsiness, irritability, refusal to feed, 2. Clemastine high-pitched cry, neck stiffness Sedation; infantile spasms after weaning 3. Phenolbarbitol from milk containing phenolbarbitol, methemoglobinemia 4. Primidone Sedation; feeding problems 5. Sulfasalazine Bloody diarrhea Table 3. Drugs of abuse that are contraindicated during breast-feeding No. Drug Reported sign or symptom in infant or effect on lactation 1. Amphetamine Irritability, poor sleep pattern 2. Cocaine Cocaine intoxication 3. Heroin Irritability, Heroin intoxication Nicotine 4. (smoking) Shock, vomiting, diarrhea, rapid heart rate, restlessness; decreased milk production 5. Phencyclidine Potent hallucinogen Other reasons why a mother may not breastfeed her baby: • • Working outside the home makes it more difficult to breastfeed exclusively, especially if there is no support at her workplace for her to either bring her baby or to express and store her milk. Choosing not to breastfeed for personal reasons, either from the birth of the baby or after breastfeeding for a short while, is a mother's prerogative. Recommendations for Working Women: • The mother who goes back to work can usually continue breast-feeding without problems. The milk supply adjusts itself to the demand. If the mother is working at least 8 hours a day, it is sometimes prudent to pump the breasts once during her work day in order to stay comfortable and maintain a good milk supply. Each woman is different in what is required to maintain a supply. Some women can work for a long time without pumping and without compromising the supply. Others have a supply that is more responsive to decreased feeds. A woman will rarely “dry up” becayse she has returned to work. • Working mothers, however, can easily breastfeed part-time and formula-feed part-time. Breast pumps and storage of milk • Hand expression is superior if the mother can learn the technique. • Several pumps are available if the mother is unable to express by hand. • It is good if the woman can borrow a pump from a friend before she decides which pump to purchase. Another alternative is to rent an electric pump. • Milk should be stored in clean containers and immediately refrigerated or frozen. – If refrigerated, it will stay good for 48 hours. – If frozen at 0°F, it wiil keep for months. Individual feeding • Breast feeding solves this problem in the best possible way. Every child has it’s individual peculiarities of food corrections’ and adds’ assimilation, that need to be taken into account during the design of child’s ration. • Appropriate physical, mental and psychological development of child is a criteria of food’s adequacy. Female’s milk – is a unique combination of nutrients, complex biological system, which conducts plastic, energetic and immunomodulating functions • Colostrum – is a sticky yellow liquid, which fills up the alveolus during the last trimester of pregnancy and is being produced during the next 3-4 month after the birth of the child Chemical peculiarities of colostrum: • Contains in 4-5 times more proteins than mature milk; • In 2-10 times more vitamine A and carotine; • In 2-3 times more vitamine C; • Contains big amount of secretological Ig A; • Composition of colostrum is close to the composition of tissues of a new-born child: proteins are identical to the proteins of blood; lipids are enriched with olein acid, contain big amount of phospholipids; sugar is represented by lactose; high amounts of mineral salts. Advantages of breast feeding: Child Mother Family Prophylactic of infectious Prevention of postand allergic illnesses pregnancy complications Economic advantages Prophylactic of illnesses of digestive and endocrine systems Healthy child Provision of physiologic development High index of intellectual development Prevention of unwanted pregnancy during the 46 month after the birth of the child Prophylactic of cancer illnesses Healthy society Preservation of reproductive health Psychoemotional unity Recommendations for mother’s diet: • To drink approximately 64 oz of fluids per day. • The nursing mother requires an additional 500 calories and 20-30 g of protein a day. • She has to take her prenatal vitamins with iron. • The mother need not to avoid certain foods unless she observes consistent increased fussiness in the baby in association with the mother ingestion such foods. Foods commonly incriminated: • Garlic • Onions • Cabbage • Chocolate • Great quantities of caffeine. Nursing mother may drink small amounts of alcohol: a glass of sherry or wine may be beneficial in late afternoon if she is having let-down reflex problems. Common problems encountered with brest-feeding • Poor Let-Down (Milk ejection reflex) • Poor Weight Gain • Mastitis • Cracked Nipples • Jaundice From Breast- Feeding Artificial feeding • This is the feeding of infant when he gets cow’s or buffalo’s milk or formula from first days till 4th to 6th month of his life. Classification of artificial feeding • Not adapted: sweet and sour - 2, 3,4. Adapted: high adapted (special), adapted (baseline), following (partially adapted). Treatment: with pre-and probiotics, antireflux to malovahovyh children, for the treatment of anemia, antiallergic. Formula milks • Formula milks are humanized, i.e., they come very close to the composition of breast milk. • However, they are more expensive, so cow’s or buffalo’s milk are quite often used. Размещение баркода Ultrapasterisation T 125 -140 O. ТERMOLISATION Characteristic of milk for artificial feeding • This cow's milk that meets the following requirements: Contains not less than 35 g / l fat, 40-45 g / l of sugar; Has acidity of not more than 20 degrees Turner; Lets not less than 85 g / L solids; Does not contain pathogenic and putrefactive bacteria; The total number of bacteria does not exceed 50 000 in 1 ml; Title coliform 1:10; Used for making baby milk. Composition of cow’s milk versus breast milk. (in 100 ml) Human milk Cow’s milk 67 67 Water 87 % 87 % Carbohydrate 7.4 % 4.4 % β-lactose α-lactose 3.5 % 3.5 % Calories Lactose isomer Fat Protein Lactalbumin:Casein ratio Human milk Cow’s milk 1.5 % 3.5 % 60 : 40 20 : 80 Sodium 15 mg Phosphorus 15 mg Calcium 30 mg Iron 0.5 mg 60 mg (4 times) 90 mg (6 times) 120 mg (4 times) 0.1 mg Other advantages of breast milk versus cow’s milk: • Breast milk is available all the time and is practically free from pathogenic bacteria. • It needs no time for preparation • It is available at the optimum temperature. • It contains antibodies as IgG and IgA and protects against certain infections such as E.Coli, cholera, polio, tetanus, measles etc. IgA antibodies prevent the microorganisms to adhere the intestinal mucosa and provide local GIT immunity. • β-lactose is called Bifidus factor, which promotes the growth of lactobacillus and helps to lower the gut pH, thus inhibiting the growth of E.Coli and yeasts. • Breast milk contains lactoferrin (an ironbinding whey protein), which inhibits bacterial growth by depriving them of iron, which is necessary for growth. • Breast milk contains cystine and tyrosine, which are not synthesized by infants but they are essential for proper growth and development. • Breast milk contains taurine that is synthesized in inadequate amounts in infants. It is important for normal differentiation of CNS. • Breast milk contains nonspecific factors of immune difence: lisozyme, macrofagocytes, neutrofiles, lymphocytes, complement system. • There are 5 times more essential fatty acids (polyunsaturated: arachidonic, docosahexacnoic, linoleic, and α-linolenic) in breasts milk than in cow’s milk. • Breast milk contains ferments (lipase, lactase) and mothers hormones. • Breast milk is ‘species specific’ and therefore allergy to breast milk is rare. Dilution of Cow’s Milk: Child’s Age Cow’s Milk Water First 10 days 1 part 2 parts 10 to 20 days 1 part 1 part Up to 2 mo 2 parts 1 part • If dilution of cow’s milk is required, add 1 TSF of sugar to each ounce of water (5 %) – isocaloric formula) Benefits concoctions in a dilution of milk over water: • Contribute to the creation of colloidal milk because casein clots more easily digested; Some (buckwheat) with a membership of amino acids; With the broth in the child coming polysaccharides, which reduces fermentation; Conjee has protective properties; Slightly increased caloric mixture. Advances in nutritional modifications of infant formulas • Proteins: their amount is adopted to the needs of infant’s organism. Almoust all formulas contain whey:casein ratio as 60:40 and adopted amino acid content. Amino acid Breast Cow’s milk milk “Vitalact” “Similac” Valine 8.2 % 6.6 4.6 % 6.8 % Lysine 10.95 7.8 9.7 % 8.4 % Tryptophan 2.29 1.4 2.4 % 1.4 % • Fats: long-chain polyunsaturated fatty acids are added in amounts similar to those in human milk. Infants fed these formulas or human milk have higher tissue concentrations of long-chain polyunsaturated fatty acids and reportedly have better visual acuity than do infants fed nonsupplemented formulas. Carbohydrates: • Carbohydrates: they are presented by β-lactose, sakcharose, dextrinmaltose, which improve the growth of Bifidum-bacteria. The total quantity of carbohydrates in formulas is 7.5 % • Nucleotides and their related products play key roles in many biological processes. Although nucleotides can be synthesized endogertously, they are considered "conditionally essential." Nucleotide concentrations in human milk are higher than in unsupplemented cow milk-based formulas, and studies in animals and human infants suggest that dietary nucleotides play a role in the development of the gastrointestinal and immune systems Vitamins and minerals Breast milk Fortified Cow’s milk formulas •Vitamin E 0.63 mg% 0.18 0.4-0.6 •Vitamin C 4.2 mg% 1.5 4.5-5.0 •Potassium 55 mg% 140 70-95 2 to 8 µg/L 420 mosm/L 11 to 15 µg/L 320 mosm/L 15 to 20 •Selenium µg/L 260 •Osmolality mosm/L • For infants 0 to 12 months • Whey proteins:casein = 60:40 • Close to breast milk spectrum of amino acids • Contains taurine. • Milk fats – 74 % and plant fats – 26 % • Linoleic : α-linolenic ratio is optimal for absorption 9.9:1 • Osmolality is equal 270 mosm/L • The level of proteins is 2.2 % • Whey proteins:casein = 40:60 • Inriched with bifidum-bacteria • Fortified with vitamins • Biologically hydrolyzed casein and whey proteins • Biologically hydrolyzed lactose • Iron fortified (0.8 mg/100 ml) • Contains Bifidobacterium Lactis 2107/1 g • -6 : -3 = 7.9:1 • Osmolality 270 mosm/L Humana Humana-pre 90 мl from 0 till 3 month с Humana-pre 450 мl. from 0 till 3 month Humana pre (300) g. От 0 till 3 month Basic formulas • is adapted for all food ingredients dry milk mixture as close to breast milk for food, biological value and osmolarity. They contain all the necessary food applications (taurine, L-carnitine, lecithin, etc.) that are particularly important for child development. Lactosae-free • Diarea syndrom different etiology пребиот ик For infants with • Hypergalactosaemia • Lactose intolerance • Strong allergy to cow’s milk proteins • Vegetarian babies Next • - A mixture that is recommended for children older than 6 months; This is partly adapted mixture prepared without added protein and whey. Food and energy value of these mixtures is higher than the baseline, except they contain lactose, sucrose and starch. ingredients per 1 kg of body weight when artificial feeding • Adapted mix: 0 - 6 months - 3.0 g protein; Fats - 6,5-6,0 g carbohydrates - 12-14 g; 12.7 months - proteins - 3.5 g fat - 5,5-5,0 g; Carbohydrates - 12-14 g; • Not adapted mixture: 0 - 6 months - protein 3.5 g, fat - 5,5-5,0 g carbohydrates - 12-14 g; 12.7 months - proteins - 4,0 g, fats - 5,5 g, carbohydrates - 13g. Energy needs of the child by artificial feeding • When feeding vysokoadaptovanymy formula - the same as in breast feeding; When fed infant formula - 5% higher than breastfeeding; When feeding not adapted formula 10% higher than in breastfed. • For premature and low-birth-weight (less than 2500 g) babies • Proteins – 2.3 % • Whey : casein ratio = 70:30 • Proteins are particly hydrolyzed (oligopeptids) • Contains lysine, cystine, tryptophan, Lhistidine, and taurine. • Polyunsaturated fatty acids (arachidonic, docosahexacnoic, linoleic, and αlinolenic) are present • For ‘hungry’ babies • For infants with often regurgitation • Contains 77 % of casein • Iron, Iodine, Vit. D, A, E and C enriched. • It doesn’t contain lactose • Only whey proteins are present, 20 % of them are amino acids • Contains nucleotides and selen • Iron and Iodine fortified • Contains taurine, inositol, Lkarnitine. • NAN H.A.1 • NAN H.A.2 • Alfaré • Hypoallergenic elemental diet for • For children with children with strong family allergy malarbsorption • Contains 100 % of syndrome, diarrhea, whey proteins, which for tube feeding are hydrolyzed to oligopeptids (80 %) • Contains hydrolyzed and aminoacids (20 %) whey proteins: 80 % of oligopeptids and 20 % of aminoacids • Hydrolyzed lactose • Short-chain fatty acids Other commercial infant formulas Formula Protein source Carbohydrate s. Fat source For full-term and premature infants with no special nutritional requirements SMA (Wyeth) Nonfat cow's milk, reduced mineral whey: whey/casein ratio: 60:40 Lactose Oleo, coconut, oleic (safflower) and soy oils Enfamil (Mead Johnson) Nonfat cow's milk, demineralized whey: whev/casein ratio: 60:40 Lactose Soy, coconut oils Similac (Ross) Nonfat cow's milk; whey/ casein ratio: 18:82 Lactose Soy and coco oils, mono- a diglycerides Baby formula (Gerber) Nonfat cow's milk; whey/ casein ratio: 18:82 Lactose Soy FOR MILK PROTEIN-SENSITIVE INFANTS (‘MIL ALLERGY’), LACTOSE INTOLERANCE, GALACTOSEM Prosobee (Mead Johnson) Soy protein isolate Corn syrup Soy and coco solids. oils Lactose and sucrose free Isomil (Ross) Soy protein isolate Corn svrup, Soy and coco sucrose oils Lactose free Nursoy (Wyeth) Soy protein isolate Sucrose (liquid Oleo, coconu formula). Corn syrup oleic, and so solids (powdered oils formula) FOR INFANTS WITH MALABSORPTION SYNDROME Soy protein RCF (Ross Carbohydrate isolate Free) (Ross) Soy and coconut oils Portagen (Mead Johnson) Sodium caseinate Corn syrup solids, MCT (coconut sucrose, lactose source) and Pregestimil (Mead Johnson) Casein hydrolysate and L-amino acids Corn syrup solids, modified tapioca starch corn oil Corn oil, MCT For infants with disaccharidase deficiencies, malabsorption svndromes, cystic fibrosis. Specialty formulas Formula (manufacturer) Indication for use Comments Lonalac (Mead Johnson) Powder For long-term For children with congestive cardiac management, additional sodium must be given. failure, who require Supplement with reduced sodium vitamins C and D and intake. iron. Na = 1 mEq/L Similac PM 60/ 40 (Ross) Powder For newborns predisposed to hypocalcemia and infants with impaired renal, digestive, and cardiovascular functions. Low calcium, potassium, and phosphorus. Relatively low solute load. Na — 7 mEq/L ofenalac (Mead ohnson) For infants and children with phenylketonuria. henyl-free (Mead ohnson) For children over 1 Phenylalanine free. year of age with Permits increased phenylketonuria. supplementation with normal foods. KU 1 (Milupa) For infants with phenylketonuria (Available as PKU 2 for children over 1 year of age.) For infants with homocystinuria w Methionine Diet wder (Product 3200K) MeadJohnson) 111 mg phenylalanine per quart of formula Phenylalanine- and fat-free. Contains vitamins,minerals, and trace elements Nutritionally complete, but requires monitoring of amino acid levels 65 Developmental milestones associated with feeding Age (months) Development • Birth – Has sucking, rooting, and swallowing reflexes; – Feels hunger and indicates desire for food by crying; – Expresses satiety by falling asleep • 1 - Has strong extrusion reflex • 3-4 – Extrusion reflex is fading; – Begins to develop hand-eye coordination • 4-5- Can approximate lips to the rim of a cup • 5-6- Can use fingers to feed self a cracker • 6-7 – Chews and bites; – May hold own bottle, but may not drink from it (prefers for it to be held) • 7-9 – Refuses food by keeping lips closed; has taste preferences; – Holds a spoon and plays with it during feeding; – May drink from a straw; – Drinks from a cup with assistance • 9-12 – Picks up small morsels of food (finger foods) and feeds self – Holds own bottle and drinks from it – Drinks from a household cup without assistance but spills some – Uses a spoon with much spilling • 12-18 – Drools less – Drinks well from a household cup, but may drop it when finished – Holds cup with both hands • 24 – – – – • 36 Can use a straw Chews food with mouth closed and shifts food in mouth Distinguishes between finger and spoon foods Holds small glass in one hand; replaces glass without dropping – Spills small amount from spoon – Begins to use fork; holds it in fist – Uses adult pattern of chewing, which involves rotary action of jaw • 48 – Rarely spills when using spoon – Serves self finger foods – Eats with fork held with fingers • 54 Uses fork in preference to spoon • 72 Spreads with knife Principles of artificial feeding: • Careful and precise execution of technique preparation of mixtures; Move baby to bottle-feeding should not be too fast; Diet remains free (in children before the introduction of complementary foods 6-7 times a day, after the introduction of complementary foods - 5 times a day); foods should be given with a spoon; Introduction of complementary foods for children who are bottle-fed vysokoadaptovanymy mixtures do not differ from those in children with breastfeeding volume of food in children during the first 10 days of life: • 70 or 80 x n, where n-day life of the newborn (formula Finkelstein); 2% of body weight at birth x n, where n-day life of the child (formula Zaitseva); Caloric methods On the first six mounth-120 - 115 ccal/kg daily, On the next six mounth - 115 - 110 ccal|kg daily . Daily volume of milk (volume method) Age of child Part from the weight of body 2 weak- 2 mounth 1/5 2 mounth-4 mounth 1/6 4 mounth– 6 mounth 1/7 6 mounth and more 1l Criteria for evaluating the effectiveness of artificial feeding: • The general condition of the child: characterization health, emotional state; Development of static and locomotor functions; Condition of the skin and mucous membranes; Development of subcutaneous fat basis; Turgor pressure; Condition muscular and skeletal systems; Functional status of the digestive system and other internal organs; The growth; Dynamics of body weight; Incidence; Laboratory parameters: hemoglobin, erythrocyte count, results scatological examinations, urinalysis. Thank you for attention!