Feed That Baby!

1. Feed That Baby! Kathryn Camp, MS, RD, CSP Assistant Professor of Pediatrics USUHS Pediatric Nutritionist, WRAMC

2. Infant Nutrition • The interplay of meeting nutritional demands and developmental milestones • 100kcal/kg/day; 2.2 g pro/kg/day • Breastmilk or Iron fortified formulas

4. Breastmilk • Four stages of composition • Colostrum: fat and calories; protein/vit/min • Transitional milk • Mature milk • Extended lactation • Hindmilk vs foremilk • Needs of lactating women • additional 500 calories, 12-15grams of protein

5. Breastmilk Composition • Energy- 20cal/oz, variable within a feeding • 50% fat, 40% carbohydrate, 10% protein • Fat • Palmitic, linoleic, oleic • EFA--linolenic and linoleic • Docosahexaenoic and arachidonic acids • Carbohydrate • Lactose (glucose + galactose) • Protein • 70% whey and 30% casein

7. Composition cont: • Immunological factors • anti-inflammatory • -protect against atopy • anitmicrobial • Secretory IgA • immunomodulating • cytokines

8. AAP Recommendations Breastfeeding • Exclusive breast feeding during the first 4-6 months • Continuation of breast feeding for the 2nd 6 months as optimum source of nutrition

9. What Are the Advantages of Breastfeeding?

10. Advantages of Breastfeeding INFANT: • Superior nutritional composition • Immunologic properties • Decreased immune mediated dz • Improved cognitive ability • Protective against childhood obesity

11. Advantages Cont: MOTHER/SOCIETY: • Enhanced maternal-infant bonding • Reduced risk of ovarian and breast cancer and osteoporosis • Safest in disaster and poverty settings • Lower cost (including paraphernalia) • Increased convenience

12. Barriers to Breastfeeding • Sore nipples and engorgement • Concern for hyperbilirubinemia • Maternal fatigue • Return to work • Concern for milk supply vs infant needs • Unnecessary formula supplementation

14. Signs of Adequate Breastmilk • Feeding 8-10 times per day • Rhythmic suck and audible swallows • Number of wet diapers • Number of bowel movements • Infant behavior • Weight and physical exam

15. Expressed Milk • Clean hands and equipment • Safe for 8-10 hrs at room temp • Up to 8 days in coldest part of refrigerator • 4-6 months in self-defrosting freezer • Up to 1 year in deep freezer • Defrost in refrigerator overnight • Never microwave or refreeze

16. Under What Circumstances Would You Recommend Using Formula?

17. Indications for Use of Infant Formulas • Maternal conditions • do not wish to or cannot provide BM • infection with organisms transmitted in BM • chemotherapy, certain medications or drugs • Infant conditions • inborn errors of metabolism • failure to gain weight despite breastfeeding intervention

18. Question:A 2 month old infant is brought to you with failure to thrive. The mother reports she is breast-feeding the child every 6 hours but the child only sucks for 5 minutes before falling asleep. The mother also reports that she is very anxious. What will be your advice to her?Answers follow

19. stop breast-feeding immediately and switch to the bottle • offer the breast more frequently to build up the milk supply • encourage the infant to suck longer to empty the breast • offer the breast first then use a bottle if the child is still hungry • try and relax when nursing the baby • offer information on breast-feeding support groups such as Nursing Mothers Assoc

20. Infant Formulas

21. Infant Formulas • Four main categories of formulas: • Standard formula (cow’s milk) • Enfamil, Similac • Soy • Isomil, Prosobee • Protein hydrolysates • Pregestimil, Alimentum, Nutramigen • Purified amino acid based • Neocate

22. Breastmilk 20cal/oz Human milk fat Lactose whey:casein 70:30 Iron 0.3mg/L Vitamin D 21 IU/L Renal solute load 91 Enfamil/Similac 20cal/oz Soy, coconut, sunflower, palm Lactose 60:40, 18:82 Iron 12mg/L Vitamin D 405 IU/L Renal solute load 130s Standard Formulas

23. Breastmilk 20cal/oz Human milk fat Lactose whey:casein 70:30 Iron 0.3mg/L Vitamin D 21IU/L Renal solute load 91 Isomil/Prosobee 20cal/oz palm olein, soy,coconut,sunflower Corn syrup/sucrose Protein=soy isolate and L-methionine Iron 12mg/L Vitamin D 405 IU/L Renal solute load 150s Soy Formulas

24. Soy Formulas • Not appropriate for preterm infants/CF • Aluminum content, risk of osteopenia, growth concerns • Indications for use • Milk protein intolerance • Lactose intolerance (rare) • Galactosemia • Vegetarian diet

25. Milk Protein Allergy • Not lactose intolerance!! • Onset first 4 months of life • Sxs: diarrhea, heme +, vomiting, rashes, respiratory sxs, systemic rxn • Tx- elimination of milk protein until 1-2yrs of age at which time it is reintroduced • 50-60% infants will also have allergy to soy

26. Lactose Intolerance • Two types of lactose intolerance • Primary congenital lactase deficiency (RARE) • Secondary lactase deficiency s/p acute gastritis • Soy and Lactose free formulas (Lactofree) can be used short term but there is little justification

27. Breastmilk 20cal/oz Human milk fat Lactose 70%whey 30%casein Iron 0.3mg/L Vit D 21 IU/L Renal solute load 91 Pregestimil 20cal/oz MCT, safflower, soy Sucrose, corn starch *Casein Hydrolysate-nonantigenic peptides Iron 12mg/L Vitamin D 405 IU/L Renal solute load 170s Protein Hydrolysates

28. QUESTION • Which formula should these infants have? • Infant with galactosemia • Infant with multiple food allergies • Healthy term infant • Infant with decreased pancreatic lipase and bile salts

29. Vitamin and Mineral Needs • Vitamin K IM x1 for all newborns • Prevents hemorrhagic disease of the newborn • Low stores at birth and sterile gut • Vitamin D supplementation • Exclusively BF infants at risk • Fat malabsorption, dark skinned, low exposure to sunlight • Adequate sunlight • Dose 400IU/day

30. Vitamins & Minerals (cont) • Iron supplementation • Recommended for BF infants by 4-6mo • Infant cereal/iron drops • Fluoride supplementation • Recommended for those infants >6months who live in areas where water supply contains <0.3ppm of fluoride • Bottled, well water, or RTF formulas

31. Introduction of solids • Readiness- physical and social factors • extrusion reflex disappears • can hold head up, sit independently, and maintain balance while using hands to reach/grasp • Can show desire for food as well as disinterest in food or satiety • Doubles BW and weighs at least 13lbs • Seems hungry after 8-10 BF/day or drinks more than 32oz of formula/day • Typical age 4-6months

32. Progression of Solids • Need for solids • Feedings • 4-6 months-infant rice cereal • 7 months- strained vegetables/fruits • 8-10 months- juices and meats • >9-10 months- finger foods

33. Whole Milk • NOT BEFORE 12 MONTHS • Risks of early introduction • Increased risk of milk protein allergy and GI bleed secondary to GI immaturity • Development of iron deficiency • Low stores by 4-6mo • Low bioavailability of iron in cow’s milk • GI blood loss • Poor source of vitamins C & E as well as essential FA

35. QUESTION • A 5mo infant weighing 6kg consumes 4oz of Similac q 3 hours during the day to total 6 bottles and sleeps through the night. No solids. Is this adequate? • What is the total calorie intake? • 480 calories/day • How many kcal/kg? • 80 kcal/kg • How many calories does the infant need? • Around 600