Introduction & Infant Feeding YANG FAN (杨凡) Professor of Pediatrics

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What is Pediatrics? Paediatrics is a relatively new medical specialty, developing only in the mid-19th century. Abraham Jacobi (1830–1919) is known as the father of paediatrics. was a pioneer of pediatrics, opening the first children's clinic in the United States.

Contributions to Midwifery and Diseases of Women and Children (with E Contributions to Midwifery and Diseases of Women and Children (with E. Noeggerath; New York, 1859) Dentition and its Derangements (1862) The Raising and Education of Abandoned Children in Europe (1870) Infant Diet (1874) Treatise on Diphtheria (1880)

By Dr Ananya Mandal, MD Pediatrics is the branch of medicine dealing with the health and medical care of infants, children, and adolescents from birth up to the age of 18. The word “paediatrics” means “healer of children”; they are derived from two Greek words: (pais = child) and (iatros = doctor or healer).

Age cut-off point

The young are often among the most vulnerable or disadvantaged in society and thus require special attention.

Facilitate optimal health and well-being for children and their family Focus on the growth and development of children Focus on the prevention of diseases of children Focus on the treatment of diseases of children

Preventive Pediatrics Developmental Pediatrics Clinical Pediatrics

Aims Raise child’s physical endowment Decrease the morbidity and mortality rate Improve the living quality of the children

The infant mortality rate (IMR) is the ratio of the number of deaths among children less than one year old during a given year to the number of live births during the same year.

The death of an infant is often dependent on external factors, especially in developing countries. Poor water quality, an inadequate food supply, substandard health services, and a high level of infectious diseases such as malaria all contribute to a high IMR.

The IMR is therefore considered a good indicator of the level of health in a community The current worldwide average is just under sixty per thousand live births

In the developed and developing world, poor children suffer a disproportionate burden of morbidity and mortality. An estimated 70% of child deaths are preventable. Success has been achieved by identifying cost-effective best practices in child and infant health.  

Characteristics of pediatrics Physiology HR: 1m-1y： 110-130bpm >8y: 70-90bpm BR: neonate: 40-45bpm >8y: 18-20bpm BP (mmHg): SBP: = age ×2+80

Pathology Pneumococcal infection Vitamin D deficiency

clinical medicine disease pattern clinical manifestation

Age Period Infant Period Toddler Age Preschool School Age Adolescence Neonatal Birth 28day 1y 2y 3y 6y 12y 18y

Childhood Age Staging Fetal period first trimester of pregnancy first 12 weeks second semester of pregnancy 13~28weeks third semester of pregnancy 29~40weeks

mother’s medical history (chronic medical conditions, medications taken during pregnancy thalidomide event) smoking, dietary habits occupational exposures to chemicals infections thalidomide event antemetic Without normal limbs

ToRCH infection： T Toxoplasma R Rubella C Cytomegalovirus, CMV H Herpes virus O Others

Neonatal period the first 28 days of life experience great changes from inside uterus to outside the functions are not mature the diseases usually caused by maladjustment high mortality rate

Infancy From birth to 1 year old The most rapid growth period High incidence of malnutrition, dyspepsia, infectious diseases, etc immunization

Toddler’s age from 1 to 3 years old Intelligence development is very fast high incidence of accidental injury

Preschool period from 3 to 6/7 years old School age from 6/7 to preadolescence

Adolescence Biological changes – onset of puberty Cognitive changes – emergence of more advanced cognitive abilities Emotional changes – self image, intimacy, relation with adults and peers group Social changes – transition into new roles in the society

Early adolescence(10 -13yrs): Spurt of growth of development of secondary sex. Middle adolescence(14-16yrs): Separate identity from parents, new relationship to peer groups, with opposite sex and desire for experimentation. Late adolescence(17-19yrs): Distinct identity, well formed opinion and ideas

SMR(Sexual Maturity Rating) Genitalia stage for boys(G1 to G5) Pubic hair stage(PH1 to PH5) Breast development for girls(B1 to B5)

Immunization Denotes the process of inducing or providing immunity artificially by administering an immunologic substances Active Passive

Immunization Routine immunization dramatically decreased morbidity and mortality from a variety of infectious diseases

Vaccination Denotes the physical act of administrating any vaccine or toxoids

Immunobiologic Substances Vaccine - a suspension of live or inactivated microorganism or fractions there of administered to induce immunity and prevent infectious disease or its sequela Toxoid – modified bacterial toxin that has been made nontoxic but retains the ability to stimulate the formation of antitoxins

Antitoxins – a solution of antibodies derived from the serum of animals immunized with specific antigens Passive immunization Diphtheria antitoxin Tetanus antitoxin

VACCINES Hepatitis B Bacille Calmette--Guerin BCG Diphtheria Pertussis Tetanus DPT Poliomyelitis Measels

Immunization schedule age <1d 1 m <2 m 2 m 3 m 4 m 5 m 6 m 8 m vaccine HB 1 HB 2 BCG Polio 1 Polio 2 DPT 1 Polio 3 DPT 2 DPT 3 HB 3 Measles

Infant Feeding Children need food of appropriate quantity and quality for optimal growth and development

The nutritional vulnerability Infants and children are more vulnerable to poor nutrition than are adults Low nutritional stores High nutritional demands for growth Rapid neuronal development Illness

（2000 Chinese Dietary Reference Intakes） Category of nutrients （2000 Chinese Dietary Reference Intakes） Energy： Macronutrients: PRO、FAT、CHO Micronutrients: minerals vitamins (Fat-soluble-vitamins, water-soluble-vitamins) Other diet elements: cellulose, water

CHO FAT PROTEIN Macronutrients Energy produced

Metabolizable Energy Intake Gross Energy Intake Activity Energy Stored “growth” **TEF Metabolizable Energy Intake Growth *BMR Tissue Synthesis Excreta *Basal metabolism rate **Thermic effect of food

Infant feeding

BREAST-FEEDING

WHO definition Exclusive breastfeeding is fed no foods or fluids, even water. Partial breast-feeding is defined as breast milk plus either solid foods or other milks.

Summary of differences between milks Human milk Animal milks Infant formula correct amount, easy too much, difficult to Protein partly corrected to digest digest enough essential fatty lacks essential fatty Fat no lipase acids, lipase to digest acids, no lipase Water enough extra needed may need extra Anti-infective present absent absent properties Adapted from: Breastfeeding counselling: A training course. Geneva, World Health Organization, 1993 (WHO/CDR/93.6). Slide 2.2

To supply with formular Two patterns for partial breast-feeding To supply with formular within 4~6 months For deficient B.M intake To replace B.M with formular after 4~6 months preparation for weaning

"first milk"; immature milk produced in 4-5 days post-partum Components of human milk Colostrum : "first milk"; immature milk produced in 4-5 days post-partum Transitional  Milk: 2weeks The composition is midway between colostrum and mature milk . Mature Milk:

The changes of the components during nursing (g/L) colostrum middle maturity PRO 22.5 15.6 11.5 FAT 28.5 43.7 32.6 CHO 75.9 77.4 75.0 Mineral 3.08 2.41 2.06 Ca 0.33 0.29 0.35 P 0.18 0.18 0.15

Colostrum Property Importance Antibody-rich Many white cells Purgative Growth factors Vitamin-A rich Importance protects against infection and allergy protects against infection clears meconium; helps prevent jaundice helps intestine mature; prevents allergy, intolerance reduces severity of some infection (such as measles and diarrhoea); prevents vitamin A-related eye diseases Slide 2.5

Benefits of breastfeeding Provides superior nutrition for optimum growth. Provides adequate water for hydration. Protects against infection and allergies. Promotes bonding and development. Slide 2.1

Breast feeding The primary benefit of breast milk is nutritional. Human milk contains just the right amount of fatty acids, lactose, water, and amino acids for human digestion, brain development, and growth.

IMMUNOLOGY Breast milk contains valuable antibodies from the mother that can help the baby resist infections.

About 80 percent of the cells in breast milk are macrophages, cells that kill bacteria, fungi and viruses. Breast-fed babies are protected, in varying degrees, from a number of illnesses, including pneumonia, botulism, bronchitis, staphylococcal infections, influenza, ear infections, and German measles.

Mothers produce antibodies to whatever disease is present in their environment, making their milk custom-designed to fight the diseases their babies are exposed to as well.

Risk of diarrhoea by feeding method for infants aged 0-2 months, Philippines 1.0 3.2 13.3 17.3 5 10 15 20 Breast milk only Breast milk & non-nutritious liquids nutritious supplements No breast milk Adapted from: Popkin BM, Adair L, Akin JS, Black R, et al. Breastfeeding and diarrheal morbidity. Pediatrics, 1990, 86(6): 874-882. Slide 2.8

Relative risks of death from diarrhoeal disease by age and breastfeeding category in Latin America 1 4.1 15.1 2.2 2 4 6 8 10 12 14 16 Diarrhoea 0-3 mo Diarrhoea 4-11 mo exclusive breastfeeding partial no breastfeeding Adapted from: Betran AP, de Onis M, Lauer JA, Villar J. Ecological study of effect of breast feeding on infant mortality in Latin America. BMJ, 2001, 323: 1-5. Slide 2.15

Relative risks of death from acute respiratory infections by age and breastfeeding category in Latin America 1 4 2.1 2.9 0.5 1.5 2 2.5 3 3.5 4.5 ARI 0-3 mo 4-11 mo exclusive breastfeeding partial no breastfeeding Adapted from: Betran AP, de Onis M, Lauer JA, Villar J. Ecological study of effect of breast feeding on infant mortality in Latin America. BMJ, 2001, 323: 1-5. Slide 2.16

Breastfeeding has psychosocial and developmental benefits Slide 2.20

Intelligence quotient by type of feeding BF 12.9 points higher than FF Study in 9.5 year-olds 1996 BF 2 points higher than FF Study in 3-7 year-olds 1982 BF 8.3 points higher than FF Study in 7.5-8 year-olds 1992 BF 2.1 points higher than FF Study in 6 months to 2 year- olds 1988 References: Fergusson DM et al. Soc SciMed 1982 Morrow-Tlucak M et al. SocSciMed 1988 Lucas A et al. Lancet 1992 Riva Eet al. Acta Paediatr 1996 BM 7.5 points higher than no BM Study in 7.5-8 year-olds 1992 BF = breastfed FF = formula fed BM = breast milk Slide 2.21

Benefits of breastfeeding for the mother Protects mother’s health helps reduces risk of uterine bleeding and helps the uterus to return to its previous size reduces risk of breast and ovarian cancer Helps delay a new pregnancy Helps a mother return to pre-pregnancy weight

The disadvantages of breast-feeding Unknown intake Volume of milk intake not known Transmission of infection HIV Breast milk jaundice self-limiting, unconjugated hyperbilirubinaemia Transmission of drugs Antithyroid drugs cathartics, antimetabolites Nutrient inadequacies Prolonged breast-feeding

Vitamin K deficiency insufficient vitamin K in breast milk to prevent haemorrhagic disease of the newborn Potential transmission environmental contaminants nicotine, alcohol, caffeine, etc. Less flexible Other family members cannot help or take part. More difficult in public places Emotional upset if unsuccessful Breast-feeding can be problematic to establish

Main points of breast milk promotion Early nursing Fed on demand Rooming-in Proper technique of feeding Nutrition ,rest, fluid intake of lactating mother

WHO Feeding Recommendations Breastfeed children for at least 2 years No bottle feeding Start breastfeeding immediately after birth Exclusive breastfeeding for first 6 months Introduce solid/mushy foods at 6 months together with breastfeeding Let’s look at WHO’s recommendations: Bihar is doing very well with the points that have been checked (the first two points): breastfeed children for at least 2 years; and no bottle feeding. The last three continue to be challenges: 1.Start breastfeeding immediately after birth. Increased release of a hormone (oxytocin) that caused uterine contractions and helps reduces the risk of hemorrage. Plus, first breast milk, or milk that appears shortly after birth, which is called colostrum, should not be squeezed from the breast before feeding the child, because colostrum provides natural immunity. 2. Exclusive breastfeeding for first 6 months. Because it is often difficult to sterilize the nipple of a bottle properly, the use of bottles with nipples exposes children to an increased risk of getting diarrhea and other diseases. 3. ….And the third challenge, giving solid/mushy food from about six months on, is critical for meeting the protein, energy, and micronutrient needs of the child.

Risks of artificial feeding  Interferes with bonding More allergy and milk intolerance Increased risk of some chronic diseases Overweight Lower scores on intelligence tests  More diarrhoea and respiratory infections  Persistent diarrhoea  Malnutrition Vitamin A deficiency  More likely to die Mother  May become pregnant sooner  Increased risk of anaemia, ovarian and breast cancer Adapted from: Breastfeeding counselling: A training course. Geneva, World Health Organization, 1993 (WHO/CDR/93.6). Slide 2.26

Artificial feeding Choice of breast milk substitute Fresh cow’s milk,other animal’s milk Milk powder,condensed milk Rice powder, bean powder Formula milk

Why ? Although cow's milk contains most of the same components as breast milk, these components are not in the same amounts

Contains too much protein and salt Contains too much protein and salt.It would create too high a solute to their immature kidneys , especially in babies below 6months. And infants are not generally able to concentrate urine well.

Cow’s Milk The infant can develop an allergy to dairy products if given cow's milk too early in life. Cow’s milk can irritate the baby’s intestine, causing the baby to lose small amounts of blood.

Formula Modified cow’s milk to mimic the desirable qualities of breast milk such as a lower protein and sodium content, a higher lactalbumin to casein ratio and emulsified fat are well tolerated by most infants.

Infant formula contains a balance of protein, fat, and carbohydrate that is similar to breast milk. It has been enriched with vitamins and minerals, like breast milk. Modification of cow’s milk Formula Human milk protein carbohydrate fat Contributions of energy (%)

The presence of enzymes and other bioactive components in breast milk that have beneficial effects in digestion and metabolism have not, as yet, been replicated in formula. In addition, breast milk contains enzymes that facilitate digestion.

formula cannot copy breast milk exactly. For example, the antibodies found in breastmilk, however, can never be added to formulas.

Complementary food cereal rice power egg yolk paste of fish,meat ,vegetable, fruit

The changes of food-taking behavior change of food quality : from liquid to solid change of feeding behavior: from sucking to chewing change of feeding utensils : from bottle to spoon change of foster: the feeding person

How to help the child adapt to the change Encourage the child take part in the process of feeding Give the child the opportunity to have many kinds of food Pay attention to the environment of eating ,concentrate child’s attention to eating Try a new food repeatedly until the child accept it To form good eating habit around 1-year old

Current Status of Infant Feeding Practices Initiation of breastfeeding is late Bottle feeding is common About half of infants below 4 months are breastfed exclusively, as recommended Introduction of solid or mushy food is much later than recommended for a majority of children 1. This slide presents a summary of the findings for this sub-section: - Although prolonged breastfeeding is quite common, initiation is late. - Bottle feeding is not common. - A little more than half of infants below 4 months are breastfed exclusively, as recommended - Introduction of solid and semi-solid foods occurs at a much later age than is recommended for a majority of children.

RECOMMENDATIONS Exclusive breast feeding until 6 months of age Introduce complimentary foods with continued breastfeeding Optimum to breastfeed for 2 years or longer

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