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. astop breast-feeding immediately and switch to the bottle boffer the breast more frequently to build up the milk supply cencourage the infant to suck longer to empty the breast doffer the breast first then use a bottle if the child is still hungry etry and relax when nursing the baby foffer information on breast-feeding support groups such as Nursing Mothers Assoc

20. Infant Formulas

21. 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. Standard Formulas 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

23. Soy Formulas 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

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. Protein Hydrolysates 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

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