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

2. http://219.221.200.61/2008/xj/ekx/index.html http://www.ekjpkc.com/
1942，Excellent course，Trainee doctors（见习医师），probation（见习）internship（实习医师）， field trip（
实习）

4. 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.

5. 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)

6. 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).

7. Age cut-off point

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

9. 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

10. Preventive Pediatrics
Developmental Pediatrics
Clinical Pediatrics

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

12. 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.

13. 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.

14. 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

15. 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.  

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

18. Pathology Pneumococcal infection Vitamin D deficiency

19. clinical medicine disease pattern clinical manifestation

20. Age Period Infant Period Toddler Age Preschool School Age Adolescence
Neonatal
Birth day y y y y y y

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

22. 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

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

25. 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

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

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

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

29. 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

31. 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

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

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

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

35. Vaccination
Denotes the physical act of administrating any vaccine or toxoids

36. 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

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

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

39. 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 DPT 1
Polio DPT 2
DPT 3
HB 3
Measles

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

41. 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

42. （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

43. CHO FAT PROTEIN
Macronutrients
Energy produced

44. 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

45. Infant feeding

46. BREAST-FEEDING

47. 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.

48. 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

49. 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

50. "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:

51. The changes of the components during nursing (g/L)
colostrum middle maturity
PRO
FAT
CHO
Mineral Ca P

52. 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

53. 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

54. 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.

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

56. 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.

57. 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.

58. 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):
Slide 2.8

59. Relative risks of death from diarrhoeal disease by age and breastfeeding category in Latin America1
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

60. 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

61. Breastfeeding has psychosocial and developmental benefits
Slide 2.20

62. 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

63. 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

64. 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

65. 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

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

67. 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.

68. 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

69. 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

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

71. 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.

72. 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.

73. 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.

74. 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 (%)

75. 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.

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

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

78. 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

79. 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

80. 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.

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

82. Thank You！