Mónica Riojas, MD LSU Pediatrics Infant Formula Mónica Riojas, MD LSU Pediatrics

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

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 By 4 mo, the baby is being introduced to solids, these are bottles only. Infants c feeding difficulties eat more freq. or more volume. 3

Principles of Infant Feeding Average Volume of Milk per Feeding 1st 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.

INFANT STOMACH CAPACITY

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.

Distribution of Kcals Breastmilk Formula % Protein 6 9 % Fat 52 48 % Carbohydrate 42

Question Which of the following statements about infant nutrition is true? Human milk contains more casein than infant formulas. Infants who receive increased whey protein have been shown to grow better than those who receive primarily casein. Iron is absorbed better from cow milk formulas than from human milk. Lactose-free formulas result in decreased absorption of calcium. There are no apparent negative effects from the addition of DHA and ARA to formulas.

Differences Between Types of Milk Breastmilk Standard Cow Formula Cow Milk Calories 20 kcal/oz 19 kcal/oz Protein 0.9 g/dL 1.4 g/dL 3.5 g/dL Minerals (Ca, P, Fe) Lower Higher Iron Absorption Better Worse Terrible Vit. ABC Same Vit. DEK Renal Solute Whey:Casein Protein Ratio 70:30 Varies, but not better than human milk 20:80

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.

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.

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 Cow’s milk has 0.5mg/L of iron.

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.

Infant Formulas Premature Formulas Standard Formulas Special Formulas

Standard Formulas COMPOSITION Protein Whey (β 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

Standard Infant Formulas Provide 20 cal/oz PRESENTATIONS: Powder Concentrated Liquid Ready to Feed

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 Careful reconst. Important forexact concentration. Powder increase volumen

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.

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 SMA withdraw from SE area 20

Cow Milk/Standard Formulas Enfamil NB has Vit D 400 IU in 27 oz, SA has lutein good for eye health doesn’t contain palmein oil=improved calcium absorption

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.

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 Show stomach size 23

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 Higher caloric density, more readily absorbed lipids, greater protein content, AA deficient in preemies and important for brain development, 24

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

Premature Infant Formulas

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

Transitional Formulas Enfamil Enfacare Similac Expert Care Neosure

Transition Formula

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 Milk–Based Formula If no improvement switch to an extensively hydrolyzed or AA-based formula Milk protein allergy, IgE mediated reaction

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

Soy Protein Formulas INDICATIONS Galactosemia Congenital Lactase Deficiency Post-diarrhea lactose intolerance Strict vegetarian family

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.

Soy Protein Formulas Enfamil ProSobee Similac Sensitive Store Brand Soy Infant Formula

Soy Protein-Based Formulas

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

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

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

Modified Cow or Soy Milk-Based Formulas Gentleease: milk based powder with iron, partially broken down proteins

Modified Cow or Soy Milk-Based Formulas

Modified Cow or Soy Milk-Based Formulas

Modified Cow or Soy Milk-Based Formulas

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 Child has milk protein intolerance, non-IgE mediated. Usually begins at 2 weeks of age-2 mo.

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

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

Question Hydrolysate formulas are MOST often used in the management of: Celiac disease Cow milk protein allergy Cystic fibrosis GER Lactose intolerance

Extensively Hydrolyzed Formulas Nutramigen Pregestemil Similac Expert Care Alimentum

Extensively Hydrolyzed Formulas

Amino Acid Based Formulas Intolerance to intact or hydrolyzed protein. Protein Free Amino Acids Carbohydrate Glucose polymers

Amino Acid Based Formulas INDICATIONS Cow Milk Protein Allergy Eosinophilic GI disorders Atopic diseases Severe food allergy Asthma Eczema

Amino Acid Based Formulas Neocate Elecare Nutramigen AA

Amino Acid Based Formulas

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.

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

Follow-up Formulas

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?

Cow’s 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)

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

Infant Nutrition: Solid foods Cereal Strained Vegetable Strained Meats Strained fruits Table Food Juices and desserts Vitamins and Minerals

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

Question What is the MOST likely outcome of introducing solid foods at an age of ≤ 3 months? Accelerates the development of oral motor skills Helps the infant sleep through the night Increases the risk of food allergies Increases the risk of GER Increases the risk of GI infections

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.

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

Solid foods Strained Food Stage 1 Foods: 2.5 oz jar, 4-5 mo

Infant Nutrition CEREALS Rice cereal Oatmeal Barley Mixed

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

Rice Cereal

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

Introduction of Solids At 6 months Breakfast: Cereal Lunch: Stage 2 foods Introduction of meats Mixed veggies or dinners Dinner: Stage 2 foods

Introduction of Solids At 9 months Stage 3 and finger foods.

A Typical 6 mo Infant Diet Morning: Cereal Mid-morning: Formula Noon: Vegetable Mid-afternoon: Formula Late afternoon: Dinner Bed-time: Bottle