Infant Formula Products

1. Infant Formula Products

2. Infant Formula Products: Introduction Infant physiology and growth Early infancy: • Liquid nutrition only • Frequent feeding: limited stomach capacity: 20-90 ml at birth, 90-150 ml at 1 month • CHO digestion: lactase, sucrase, maltase, isomaltase, glycoamylase are mature. • Lactase activity may be immature in premature infants. • Pancreatic amylase activity and glucose transport are low in both full term and premature infants • Low lipase concentration, bile salt synthesis is low • Protein digestion and absorption are mature

3. Components of a healthy infant diet • Fluid: • Water intake in the first 6 months is derived from breast milk or formula • From 6 months and above when solid food is introduced, water intake remains high, because most children's food contain 60-70% water. • 100ml/kg per day for the first 10 kg + 50ml/kg for each additional kg.

4. Contents of various milks

5. Human milk vs. whole cow milk • Both are liquid • Both contain more than 200 ingredient in the fat and water soluble fractions. • Quantity and availability of nutrients is different • Both have similar amount of water, calories, calorie source is different (proteins supply 7% of calories in human milk, 20% in cow milk). Lactose supplies 42% in human milk and 30% in cow milk, % of calories from fat is the same. • CHO: lactose in both cases, cow milk<<human milk

6. Proteins: cow milk 3X minerals and protein, composition is different • Whey: casein ratio: Human milk (60:40), cow milk (20:80) • Whey protein in cow milk is alpha lacalbumin, beta lacatoglobulin, lactoferrin, and serum albumin. Lysozyme and immunoglubulins A, G, M. • Human milk contains all these proteins except betalactoglobulin. • Whey protein is highly soluble, casein is relatively insoluble and forms curd. • The large amount of curd may cause GI distress • a.a. content is inappropriate to the immature enzyme systems

7. Fat: • both have similar total fat content • Human milk contains 3-4.5% fat that consists of triglycerides (98-99% of total milk fat), phospholipids, and cholesterol. • Cholesterol level is different (higher in human milk • The fat composition of human milk changes during lactation,: triglycerides concentration rises and phospholipid and cholesterol concentration decrease during the transition from colostrum to mature milk. • Fat in human milk is different from cow milk in 2 ways: • TG types: cow milk, short and long chain FA, in human milk medium chain • Degree of saturation: human milk:PUFA, cow milk: butter fat • LCPUFA • Lipoprotein lipase

8. Reduced fat cow milk • Reduced fat milks as skimmed milk (0.1% fat) and 2% fat milk have been used to prevent obesity and atherosclerosis. • It is not recommended for children below 12 months of age, not even recommended for young children. • Inadequacy of essential fatty acids is a problem. And there is an imbalance in the source of calories.

9. Whole cow milk • The age at which it is appropriate to introduce whole cow milk into an infant's diet is controversial. • Because the conc. And the bioavailability of iron are low, cow milk has been associated with iron deficiency anemia. That's why it is recommended if an infant does not get human milk, that they get iron fortified formula during the first year of life.

10. Evaporated milk • A sterile convenient source of cow milk that has standardized concentrations of protein, fat and carbohydrates. • When ingested evaporated milk produces smaller and softer curds than boiled whole milk. • Vitamin D is typically added during manufacture, but evaporated milk formula fail to meet recommendations of folic acid, vitamin E and essential fatty acids.

11. Types, uses and selection of commercial infant formulas

12. Types of commercial infant formulas • Milk based formulas: nonfat cow milk, vegetable oils and lactose are added. Supplemented with vitamins and minerals, iron and zinc • Milk based formulas with added whey protein When whey protein is added to nonfat cow milk, the ratio of whey protein to casein can be altered to approximate human milk. • Therapeutic formulas a. Soy protein formula b. Casein hydrolysate based formulas c. Amino acid based formulas d. Whey hydrolysate formula e. Low birhtweight and preterm infants f. Antiregurgitation formulas

13. 2. Proteins: • The total protein concentration in human milk is approximately 0.9 g/dl. • Two fractions: casein and whey. • Casein: precipitated at low pH, constitutes 20–30% of human milk proteins. A heterogeneous group of proteins, molecular weights: 20 000–30 000 • Whey: contains a large number of proteins, which are derived from both milk and plasma.

14. whey The fluid portion of milk that separates from curd.

15. Soy protein formula (isomil) • Used for infants with milk allergy, lactose intolerance or those of vegetarian parents • Contain soy protein instead of animal protein. Vegetable oils provide fat content and corn syrup and or sucrose supply the carbohydrate • Additional minerals and vitamins are added. Taurine, carnitine (low concentration in food from plant origin) • Soy formula is not suitable for feeding preterm and LBW infants. Additional calcium and phosphorus is needed

16. Casein hydrolysate based formulas (Pregestimil ) • These products use enzymatic hydrolysates of casein as the protein source • They contain non-antigenic proteins with low molecular weight • Casein hydrolysate formulas are fortified with three amino acids: L cysteine, L tyrosine and L tryptophan, because the concentration of thee amino acids are reduced during treatment of the protein.

17. Casein hydrolysate based formulas (Pregestimil ) • These are effective in nutritional management of infants with a variety of severe GI abnormalities in which intolerance to enternal feeding and the malabsorption of standard forms of protein, fat and CHO are common. • Severe diarrhea, severe food allergy, sensitivity to intact protein, disaccharidase deficiency, protein malabsorption and so on.

18. Casein hydrolysate based formulas (Pregestimil ) • The CHO source is usually corn syrup, corn starch, dextrose • Glucose polymers in corn syrup, modified corn starch are useful for children with malabsorption disorders who are frequently intolerant to lactose, sucrose and glucose. • Glucose polymers are a low osmolar form of CHO and contribute little to the osmolar load. • This is an advantage on infants with intestinal disorders • Fat source is usually medium chain triglycerides, 25% soy oil, 10% corn oil, and 10% high oleic safflower or sunflower oil.

19. Amino acid based formulas • These are suitable for infants who are intolerant to casein hydrolysate and require amino acid containing formula. • Fat is supplied from medium chain and long chain fatty acids. • The CHO source are maltodextrin, sucrose and corn syrup solids

20. Whey hydrolysate formula • Enzymatic hydrolysis of whey protein. • GI intolerance to cow milk but not allergic to it. Low birhtweight and preterm infants • Need higher calorie content for growth, whey protein is predominant, mixture of CHO is used, fat mixture as well, iron supplements

21. here 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

22. The absolute contraindications to breast-feeding • Hypergalactosaemia. • Phenylketonuria [PKU]. • Lactose intolerance.

23. Your advice for Working Women: • Working moms can usually continue breast-feeding without problems. • The milk supply adjusts itself to the demand. • Working mothers, however, can easily breast-feed part-time and formula-feed part-time.

24. 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. • 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.

25. Lactating mom should be advised to • To drink approximately 64 oz of fluids per day. • To take an additional 500 calories and 20-30 g of protein a day. • 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.

26. The need for vitamin and mineral supplements Breast fed-full term infants: • Vitamin D might be needed as a supplement if the mothers' diet is not balanced and contains inadequate amounts of vitamin D. • Iron is well absorbed from breast milk, however after 4-6 months the iron stores become depleted and iron deficiency anemia might develop. So an additional iron supplement is needed.

27. The need for vitamin and mineral supplements Formula fed full term infants • Full term infants who consume adequate amounts of an iron fortified formula do not need vitamin and mineral supplement • Vitamins and minerals supplement is not needed after 6 months of age when the infant receive a diet of formula, mixed feedings and increased amount of table food. • A multivitamin with minerals may be needed if the infant is at a nutritional risk.

28. The need for vitamin and mineral supplements Preterm infants • Preterm infants, either breast fed or formula fed, need vitamin and mineral supplementation. • Their nutrient needs are proportionately greater than those of full term infants, because of their rapid growth, inability to ingest an adequate volume of liquid and decreased intestinal absorption (Until they reach 2.5 kg of weight). • A multivitamin supplement should include vitamin E, folic acid, calcium and phosphorus, vitamin D).

29. VI. Antiregurgitation formulas = “Prethickenend milk-based formulas”

30. REGURGITATION • Mild regurgitation is a common occurrence in infancy. • Often considered to be a normal physical phenomenon of early development. • Usually no serious health risks. • Spontaneously resolves with time. • Often considered as a source of parental anxiety • 15-30% of infants suffer from GER. • Babycan’t thrive on formula that won’t stay down

31. REGURGITATION • “Young infants are prone to GER due to immaturity of the esophageal sphincter which controls the passage of food into the stomach.” (A problem disappears by the age of 18-months) Bohane TD,Mitchell JD, Gastro-esophageal reflux in infants and children. Mod Med Mid East 12:32-43,1995

32. Common symptoms -Regurgitation -Esophagitis -Excessive crying -Feeding problems -Respiratory problems -Parental anxiety Unusual Symptoms -Failure to thrive -Respiratory problems -Hematemisis SYMPTOMS

33. Prethickened milk-based Formulas • An iron fortified formula that contains: • Carbohydrate blend of lactose (57%), rice starch (30%) and maltodextrin (13%) • High amylopectin rice starch for thickening • Before ingestion: the AR formula has a viscosity (60 cps) 10 times that of ready-to-use standard formula • After ingestion (at low pH)viscosity increases dramatically (532 cps)- equal to formula plus cereal combination

34. Potential Problems with infant formulas Diarrhea Tooth decay

35. Diarrhea • Infants particularly prone to dehydration • Fluid depletion by vomiting or diarrhea may quickly (within 24 hours) produce severe dehydration with fluid and electrolyte imbalances, shock and possible death • Potential cause of diarrhea and vomiting is the improper dilution of a concentrated liquid or powdered formula

36. Diarrhea- Patient Counseling • Frequency of stool • Duration of diarrhea • Preparation method of formula • If the infant is clinically ill (fever, lethargy, anorexia, irritability, dry mucous membranes, decreased urine output, or weight loss) Doctor

37. Diarrhea- Patient Counseling • Mild diarrhea may resolve without medical measures, but the infant should be observed closely for signs of dehydration • Temporarily discontinuing usual dietary intake-unnecessary except 4-6 hr of ORT • ORT may be used cautiously for short term • It should not replace formula or human milk intake

38. Lactose free diet can be considered for severe diarrhea, however, a full strength lactose containing formula can be used in most • Advice parents to seek medical advice if sudden increase in stool output occurs with resumption of feeding

39. Caries is an infectious disease. Several factors need to be combined to develop caries. • teeth need to be present • bacteria need to be present • a substrate (food for the bacteria) needs to be present • caries requires time to develop

40. Tooth decay • In children who are bottle-fed beyond the typical weaning period • Who sleep with their bottles after 1 year of age • Sipping on a bottle frequently during the day • Caries in children younger than 2 y/o

41. Tooth decayPatient Counseling • Wash their mouth twice daily • Avoid bottle while asleep • Substituting plain water for carbohydrate containing formula • Ensuring adequate fluoride intake • Weaning 10-12 months of age • Use special type of nipples (orthodentic) • Never dip soother in honey or other sweetener

43. Silicone vs. rubber nipples?

44. Traditional Orthodentic Flat-topped

45. Latex nipples are softer and more flexible, but they don't last as long. Silicone nipples are firmer and hold their shape longer. • Orthodontic nipples, designed to accommodate the child's palate and gums, have a bulb that's flat on the side that rests on the child's tongue. Flat-topped nipples emulate the shape of a mother's breast.

46. On your pharmacy advice/tell parents • You may have to try a few sizes to find one that works best for your child • Breast milk or formula should drip steadily out of the nipple. If it pours out in a stream, the hole is too big and the nipple should be replaced.

47. Breastfed infants usually take smaller, more frequent feedings than formula-fed infants. • Your baby may need short breaks during the feed and may need to burp sometimes. • Don’t forget to throw away any unused formula or breast milk after the feed.

48. First infant formula is based on the whey of cows' milk --asier to digest • Infant formula based on casein is thought to take longer to digest than whey-based formula. • It's not recommended for young babies, and there is little nutritional difference between this formula and first infant formula. Although it's often described as suitable for "hungrier babies"

49. Infant formula with partially hydrolysed proteins is available in the shops, but this is not suitable for babies with a cows' milk allergy.

50. Follow up milk • These are milks with higher protein and mineral content than ordinary infant formula. They are sold as suitable for babies from six months old. Follow-on milks are advertised as more nutritious than cow's milk because they contain added iron, vitamins and minerals.