The Feeding Of Infants And Children


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The Feeding Of Infants And Children in the Philippines

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The Feeding Of Infants And Children

  1. 1. THE FEEDING OF INFANTS AND CHILDREN Sacred Heart Hospital Cebu City, Philippines Crisbert I. Cualteros, M.D.
  3. 3. <ul><li>MOST INFANTS CAN START IMMEDIATELY AFTER BIRTH (1-4 HRS) </li></ul><ul><li>Mothers who wish to initiate BF in the DR should be supported provided no intolerance noted </li></ul>
  4. 4. <ul><li>Time required for an infant’s stomach to empty is 1- 4hrs or more during a single day </li></ul><ul><li>Feeding schedule should be based on self-regulation by the infant </li></ul>
  5. 5. <ul><li>Breastfed infants prefer shorter feeding intervals than formula-fed infants </li></ul><ul><li>By the end of the 1 st week of life: </li></ul><ul><li>6 – 9 feedings/24 hrs </li></ul><ul><li>60 – 90 ml/ feeding </li></ul>
  6. 6. Feeding can be considered to have progressed satisfactorily if: <ul><li>The infant is no longer losing weight by the end of the 1 st week of life </li></ul><ul><li>Gaining weight by the end of 2 nd week </li></ul>
  7. 7. <ul><li>Until 3-6 weeks of age – awaken for middle-of-the-night feeding </li></ul><ul><li>Between 4-8 mos – many infants lose interest in late evening feeding </li></ul><ul><li>By 9-12 mos – most will be satisfied with 3 meals/day with snacks </li></ul>
  8. 8. Breast-FEEDING <ul><li>One of the 1 st decision a new mother must make is whether the infant will be breast-fed or formula-fed. </li></ul><ul><li>Human milk is uniquely adapted to the infant’s needs and the most appropriate milk for the human infant. </li></ul>
  9. 9. <ul><li>Infants cry for other reasons other than hunger and do not need to be fed every time they cry </li></ul><ul><li>Those who awaken and cry consistently at short intervals may not be receiving enough milk or have discomfort from some cause </li></ul><ul><ul><ul><ul><li>Too much clothing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Soiled, wet or uncomfortable diapers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Swallowed air gas </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Uncomfortably hot/cold environment </li></ul></ul></ul></ul>
  10. 10. Advantages of Breastfeeding: <ul><li>The natural food for the full-term infants </li></ul><ul><li>Is the appropriate milk for the 1 st year of life </li></ul><ul><li>Always available at the proper temperature and requires no preparation time </li></ul><ul><li>It is fresh and free of contaminating bacteria ( dec GI disturbances ) </li></ul>
  11. 11. <ul><li>Breast-feeding is asso with fewer feeding difficulties incident to allergy and intolerance to bovine milk </li></ul><ul><li>BF infants appear to have lower freq of certain allergic and chronic diseases in later life </li></ul><ul><li>It contains bacterial and viral antibodies (secretory Ig A) </li></ul>
  12. 12. <ul><li>Macrophages in human milk synthesize complement, lysozyme and lactoferrin </li></ul><ul><li>Lactoferrin – has an inhibitory effect on the growth of E. coli in the intestine </li></ul><ul><li>Contains bile salt stimulated lipase – kills G. lamblia and E. histolytica </li></ul><ul><li>Lower ph of stool of breast-fed infant contribute to the inc bifidobacteria and lactobacilli and fewer E. coli </li></ul>
  13. 13. <ul><li>BM with sufficient and balanced diet supply all the necessary nutrients except flouride and vitamin D </li></ul><ul><li>If water supply is not properly flouridated –atleast 10 ug of flouride daily for the 1 st 6 mos </li></ul><ul><li>Inadequate maternal vit D intake and limited sunlight exposure – 10 ug/24hrs vit D </li></ul>
  14. 14. Human milk: <ul><li>is low in iron – by 4-6mos infant should be supplemented with iron fortified complementary foods / ferrous iron preparation </li></ul><ul><li>is low in Vit K – 1 mg vit K should be given at birth </li></ul>
  15. 15. <ul><li>Transmission of HIV by BF is well documented </li></ul><ul><li>if safe alternatives are available, BF by HIV-infected mothers is not recommended. </li></ul><ul><li>In developing countries , BF is crucial in the infant survival </li></ul>
  16. 16. WHO Recommendation: <ul><li>BF be continued even in areas of high endemic rates of HIV infection, unless safe infant formula is available </li></ul>
  17. 17. Other viruses demonstrated in breast milk: <ul><li>CMV </li></ul><ul><li>Human t-cell lymphotropic virus type 1 </li></ul><ul><li>Rubella virus </li></ul><ul><li>Hepatitis B virus </li></ul><ul><li>Herpes simplex virus </li></ul>
  18. 18. <ul><li>2/3 of CMV-seronegative BF infants may become infected with CMV </li></ul><ul><li>Vesicles in the mouth - infants fed by mother with Herpes Simplex Virus. </li></ul><ul><li>Strict handwashing and avoid nursing if there are active lesions on or near the nipple. </li></ul>
  19. 19. <ul><li>Hep B virus - delivery is the predominant means of transmission </li></ul><ul><li>>Active immunization of infant w/in the 1 st 24hrs of life </li></ul><ul><li>>(passive) HBIg administration </li></ul><ul><li>> follow up active vaccination </li></ul>
  20. 20. Preparation of the mother for Breastfeeding: <ul><li>The physician should discuss the advantages w/ the mother as early as the mid-trimester of pregnancy or whenever she begins planning for her infant </li></ul>
  21. 21. Factors that are conducive to successful breastfeeding: <ul><li>Good nutritional health </li></ul><ul><li>Proper balance of rest and exercise </li></ul><ul><li>Freedom from worry </li></ul><ul><li>Early and sufficient treatment of any intercurrent disease </li></ul><ul><li>Adequate nutrition </li></ul>
  22. 22. <ul><li>Retracted/ inverted nipple is not a contraindication to BF </li></ul><ul><li>Retracted nipples usually benefit from daily manual breast pump </li></ul><ul><li>Inverted nipples may be helped by the use of milk cups </li></ul>
  23. 23. Establishing and maintaining milk supply: <ul><li>Regular and complete emptying of the breasts – most satisfactory stimulus to the secretion of human milk </li></ul><ul><li>Breastfeeding should begin as soon after delivery </li></ul><ul><li>Infants should room in w/ the mother and not be offered other milks or water supplements </li></ul>
  24. 24. … establishing and maintaining milk supply <ul><li>Infants who can’t feed on demand should be brought to the mother for feeding every 3 hrs during day and night </li></ul><ul><li>Once lactation is well established, most mothers are capable of producing more milk than their infant needs </li></ul>
  25. 25. Appropriate care for tender/ sore nipples: <ul><li>Exposing the nipples to air </li></ul><ul><li>Applying pure lanolin </li></ul><ul><li>Avoiding soap and other agents </li></ul><ul><li>Changing disposable nursing pads frequently </li></ul><ul><li>Nursing more often </li></ul><ul><li>Manually expressing milk </li></ul>
  26. 26. … appropriate care for tender/ sore nipples: <ul><li>Nursing in different positions </li></ul><ul><li>Keeping the breast dry bet feedings </li></ul>
  27. 27. <ul><li>1 st 2 weeks after birth are crucial for establishing BF. </li></ul><ul><li>Daily weight gains of infants should not be overly emphasized during this time </li></ul><ul><li>Supplemental bottle feeding to achieve wt gain should be limited bec these may compromise attempts at BF. </li></ul><ul><li>It is satisfactory to have the mother pump her breasts and feed the infant via a bottle for 1 st 1-2 weeks </li></ul>
  28. 28. <ul><li>When she is relaxed and less anxious, she can attempt BF 1 or 2 times/day until she and infant have achieved a successful routine </li></ul><ul><li>Even after nursing, it may be appropriate for the mother to pump extra milk and store it up to 1 mo in home freezer and up to 24hrs in a refrigerator for use when mother is not available </li></ul>
  29. 29. HYGIENE <ul><li>Prevent irritation and infection of the nipples from : </li></ul><ul><li>prolonged initial nursing </li></ul><ul><li>maceration from wetness of the nipple </li></ul><ul><li>rubbing of clothing </li></ul>
  30. 30. <ul><li>Breast should be washed atleast once a day </li></ul><ul><li>If soap appears to dry the nipple and areolar area – a milder, nondrying soap be used </li></ul><ul><li>- use of soap should be discontinued </li></ul><ul><li>Nipple area should be kept dry as possible </li></ul>
  31. 31. Maternal diet : <ul><li>should contain enough calories and other nutrients to compensate for those secreted in milk </li></ul><ul><li>Diet sufficient to maintain weight and generous in fluid, vitamins and minerals is important </li></ul><ul><li>Wt reducing diet should be avoided while the infant is exclusively BF </li></ul>
  32. 32. <ul><li>If mother is allergic/dislikes milk - 1 gm Calcium </li></ul><ul><li>BF mothers should not take any meds contraindicated to BF, unless necessary. </li></ul>
  33. 33. Meds that are harmful to the neonate: <ul><li>antithyroid meds </li></ul><ul><li>lithium </li></ul><ul><li>anticancer agents </li></ul><ul><li>isoniazid </li></ul><ul><li>recreationally abused drugs </li></ul><ul><li>phenindione </li></ul>
  34. 34. Technique in BF: <ul><li>infant should be hungry, dry and thermo-regulated. </li></ul><ul><li>Held in a comfortable semi-sitting position to prevent vomiting </li></ul><ul><li>Mother should also be comfortable and at ease </li></ul><ul><li>Moderately low chair w/ armrest is preferable </li></ul>
  35. 35. <ul><li>Low stool for resting her foot and raising her knee on BF side is advantageous </li></ul><ul><li>Infant should be supported comfortably w/ the face held close to the mother’s breast by one arm and hand, while the other hand supports the breast </li></ul><ul><li>Infant’s lips should engage the areola and nipple </li></ul>
  36. 36. Reflexes present at birth that facilitate BF: <ul><li>Rooting reflex – if the cheek is touched by smooth object infant will turn toward that object and open his mouth </li></ul><ul><li>Sucking reflex – is the process of squeezing the sinuses of the areola rather than sucking the nipple </li></ul><ul><li>Milk in the mouth triggers swallowing reflex </li></ul>
  37. 37. sucking Afferent impulse Mother’s hypothalamus post. pituitary Ant pituitary prolactin Stimulates milk secretion by the cuboidal cells in the acini or alveoli of the breast oxytocin Contraction of the myoepithelial cells surrounding the alveoli deep in the breast MILK LETDOWN OR MILK EJECTION REFLEX: Squeezes milk into larger ducts sucking
  38. 38. <ul><li>Infants who is not hungry will not search for nipple or suck </li></ul><ul><li>Most healthy infants are good nursers at the 4 th to 5 th day of life </li></ul><ul><li>Infants whose mothers sedated during labor suck at lower rates and consume less </li></ul>
  39. 39. <ul><li>Infants can empty a breast in 5 mins, some in 20 mins </li></ul><ul><li>Infants should be allowed to suck until satisfied </li></ul><ul><li>If the infant does not unlatch after a reasonable time, a finger can be inserted into the corner of his mouth to dec suction and facilitate removal </li></ul>
  40. 40. <ul><li>After feeding - be held erect over the mothers shoulder / lap w/ or w/o gently rubbing/patting the back to assist in expelling swallowed air </li></ul><ul><li>Both breasts should be used at each feeding to encourage maximal milk production </li></ul>
  41. 41. <ul><li>After milk supply is established, breast maybe alternated at successive feedings </li></ul><ul><li>Expression of breast milk is useful to: >relieve engorgement of the breast >increase milk production </li></ul><ul><li>>relieve sore nipples </li></ul>
  42. 42. Supplemental feedings <ul><li>Mothers who are returning to work pump enough milk but because of stress and time constraints at work, this often not possible </li></ul><ul><li>it is acceptable to give milk formula in the morning and breast milk in the evening </li></ul><ul><li>Breast milk production will gradually decrease </li></ul>
  43. 43. Weaning from BF: <ul><li>Most infants reduce the volume and freq of BF bet 6-12 mos of age after they become accustomed to solid foods and liquid by bottle or cup </li></ul><ul><li>Can be initiated by substituting formula/bovine milk by bottle or cup for part and subsequently for all of a breastfeeding </li></ul>
  44. 44. <ul><li>BF are eventually replaced by formula, usually over several days until the infant is weaned completely </li></ul><ul><li>When cessation of nursing is necessary at early age, use of tight breast binder and application of icebags help dec milk production </li></ul><ul><li>Restriction of mother’s fluid intake is also helpful </li></ul>
  45. 45. IMPORTANT PRINCIPLES FOR WEANING: <ul><li>Begin at 6 mos of age </li></ul><ul><li>Avoid foods w/ high allergenic potential </li></ul><ul><li>At proper age, encourage cup rather than a bottle </li></ul><ul><li>Introduce 1 food at a time </li></ul><ul><li>Energy density should exceed that of breast milk </li></ul><ul><li>Iron-containing foods are required </li></ul>
  46. 46. … IMPORTANT PRINCIPLES FOR WEANING: <ul><li>Zinc intake should be encouraged with foods </li></ul><ul><li>Phytate intake should be low to enhance mineral absorption </li></ul><ul><li>Breast milk should continue to 12 mos. Give no more than 24 oz/day of cow’s milk </li></ul><ul><li>Fluids other than breast milk, formula and water should be discouraged. Give no more than 4-6 oz/day of fruit juices. No soda </li></ul>
  47. 47. Contraindications to BF: <ul><li>Septicemia </li></ul><ul><li>Active TB </li></ul><ul><li>Typhoid fever </li></ul><ul><li>Breast cancer </li></ul><ul><li>Malaria </li></ul><ul><li>Substance abuse </li></ul><ul><li>Psychosis </li></ul>
  48. 48. Formula feeding: <ul><li>Similar to BF </li></ul><ul><li>Mother/ caregiver and infant in comfortable position </li></ul><ul><li>Infant should be hungry, fully awake, warm and dry </li></ul><ul><li>Nipple holes should be of size that allows the milk to drop slowly </li></ul><ul><li>Bottle should be held so that milk, not air channels thru the nipple </li></ul>
  49. 49. <ul><li>Bottle propping should be avoided: </li></ul><ul><li>-danger of aspiration </li></ul><ul><ul><li>-otitis media </li></ul></ul><ul><li>Temperature of milk is tested by dropping onto the wrist </li></ul><ul><li>Eructation of air swallowed is important to prevent abdominal discomfort and regurgitation </li></ul>
  50. 50. <ul><li>Number of feedings/day: </li></ul><ul><li>8 or more- shortly after birth </li></ul><ul><li>3 or 4 – at 1 year of age </li></ul><ul><li>interval bet feedings: (3-5hrs) </li></ul><ul><li>1 st 1 -2 mos- feedings are taken throughout the 24hr period </li></ul><ul><li>Thereafter – quantity of milk increases </li></ul><ul><li>- infants adjust to pattern of family daytime activities, sleeps for longer periods at night </li></ul>
  51. 51. FEEDING DURING THE 2 ND 6 MO OF LIFE: <ul><li>By 4-6 mos , infant’s capacity to digest and absorb, metabolize, use and excrete the absorbed products of digestion is near the capacity of adult. </li></ul><ul><li>Complementary/ replacement foods should be introduced in a stepwise fashion beginning at the time the infant is able to sit unassisted. </li></ul>
  52. 52. <ul><li>Cereals are usually introduced 1st, ff by vegetables and fruits , then meats and eggs. </li></ul><ul><li>1 new food should be introduced at a time and additional foods should be spaced atleast 3-4 days to detect adverse reaction to newly introduced food </li></ul>
  53. 53. Feeding problems: 1 st year of life: <ul><li>Underfeeding- restlessness, crying or failure to gain wt adequately </li></ul><ul><li>Overfeeding </li></ul><ul><li>Regurgitation and vomiting - the head should not be lower than the rest of the body( common: 1 st 4-6 mo) </li></ul><ul><li>Loose/ diarrheal stool – stool of BF infant is naturally softer than the formula-fed infant </li></ul>
  54. 54. <ul><li>Constipation </li></ul><ul><li>Colic- symptom complex of paroxysmal abdominal pain </li></ul>
  55. 55. Feeding: 2 nd year of life <ul><li>Most infants adapted to the schedule of 3meals/day plus 2 or 3 snacks </li></ul><ul><li>Reduced food intake- rate of growth decreases toward the end of 1 st year of life and intake also decreases or failed to increase </li></ul><ul><li>Self-selection of diet- children’s strong likes/ dislikes of particular foods become apparent after 1 yo </li></ul>
  56. 56. <ul><li>Self-feeding by infants should be allowed to feed themselves as soon as they are physically able </li></ul><ul><li>infants younger than 4yo, should not be given food that are easily aspirated </li></ul><ul><li>daily selection from each of the food groups provides a balance diet with sufficient macro and micronutrients </li></ul><ul><li>Snacks bet meals – amount of food given should not interfere w/ intake at mealtimes </li></ul>
  57. 57. <ul><li>Vegetarian diet – may have vit B 12 def and trace mineral def </li></ul>
  58. 58. Feeding: later childhood <ul><li>Child’s diet after 2 years of age should not differ from that of the rest of the family </li></ul>
  59. 59. MALNUTRITION <ul><li>Marasmus (infantile atrophy): </li></ul><ul><ul><li>Clinical picture: inadequate caloric intake due to: </li></ul></ul><ul><ul><li>>Insufficient diet </li></ul></ul><ul><ul><li>>Improper feeding habits – disturbed parent-child relations, metabolic abnormalities or congenital malformations </li></ul></ul>
  60. 60. Clinical manifestations: <ul><ul><li>>failure to gain wt </li></ul></ul><ul><ul><li>>loss of wt until emaciation results </li></ul></ul><ul><ul><li>>loss of skin turgor </li></ul></ul><ul><ul><li>>abdomen: distended/ flat </li></ul></ul><ul><ul><li>>atrophy of the muscles occur: hypotonia </li></ul></ul><ul><ul><li>>temp usually subnormal </li></ul></ul>
  61. 61. …clinical manifestations: <ul><ul><li>>pulse may be slow </li></ul></ul><ul><ul><li>>BMR is reduced </li></ul></ul><ul><ul><li>>appetite diminishes </li></ul></ul><ul><ul><li>>usually constipated </li></ul></ul><ul><ul><li>>starvation type of diarrhea may appear: freq small stools cont. mucus </li></ul></ul>
  62. 62. Protein malnutrition (kwashiorkor): <ul><li>Principal symptoms: </li></ul><ul><li>>insufficient intake of protein </li></ul><ul><li>>impaired absorption of protein (chronic diarrheal states </li></ul><ul><li>>abnormal losses of protein in proteinuria, infection, hemorrhage, burns </li></ul><ul><li>>failure of protein synthesis </li></ul>
  63. 63. Kwashiorkor results from: <ul><li>Severe def of protein </li></ul><ul><li>Inadequate caloric intake </li></ul><ul><li>Secondary vitamin and mineral def </li></ul><ul><li>Clinical manifestations: </li></ul><ul><li>>early: vague: lethargy, apathy or irritability </li></ul>
  64. 64. <ul><li>> well advanced: >inadeq growth </li></ul><ul><li> >lack of stamina </li></ul><ul><li> >loss of muscular tissue </li></ul><ul><li> >increase susceptibility to infections </li></ul><ul><li>>edema </li></ul>
  65. 65. <ul><li>Immunodeficiency - one of the most serious and constant manifestation </li></ul><ul><li>Anorexia </li></ul><ul><li>Flabbiness of subcutaneous tissue </li></ul><ul><li>Loss of muscle tone </li></ul><ul><li>Failure to gain wt may be masked by edema </li></ul>
  66. 66. <ul><li>Laboratory data: </li></ul><ul><ul><li>Decrease of serum albumin concentration </li></ul></ul><ul><ul><li>K and Mg def are frequent </li></ul></ul><ul><ul><li>Mngt: </li></ul></ul><ul><ul><li>IVF are necessary for the treatment of severe dehydration </li></ul></ul><ul><ul><li>If DHN is corrected, oral/ nasogastric feeding starts with small freq feedings of dilute milk </li></ul></ul>
  67. 67. OBESITY <ul><li>significant increase in the prevalence of overwt and obesity despite awareness programs. </li></ul><ul><li>The consequences are the occurrence of adult diseases in young (DM, HPN,hyperlipidemia) </li></ul><ul><li>Obesity – individuals whose BMI exceeds the age-gender-specific 95 percentile </li></ul>
  68. 68. <ul><li>Overweight – those whose BMI is bet 85 th to 95 th percentile </li></ul><ul><li>Etiology: </li></ul><ul><li>>multifactorial </li></ul><ul><li>>except in single gene disorders(Prader-Willi, Bardet-Biedl, Ahlstrom, Cohen Syndrome) </li></ul>
  69. 69. <ul><li>>excessive intake of high energy foods </li></ul><ul><li>>inadeq exercise in rel to age and activity </li></ul><ul><li>>low metabolic rate relative to body composition and mass </li></ul><ul><li>>increase respiratory quotient in the resting state </li></ul><ul><li>>increased insulin sensitivity </li></ul>
  70. 70. Obesity due to: <ul><li>Excessively high caloric intake -heavier and taller than others in their cohort and bone age is advanced </li></ul><ul><li>Adiposity in the mammary region in boys </li></ul><ul><li>Abdomen: pendulous with white/purple striae </li></ul><ul><li>Ext. Genitalia: (boys) disproportionately small </li></ul>
  71. 71. <ul><li>DX: BMI (kg/m2) </li></ul><ul><li>Complications: </li></ul><ul><li>>elevated serum levels of LDL and TG </li></ul><ul><li>>low HDL </li></ul><ul><li>>sleep apnea </li></ul><ul><li>>Ortho: Blount Dse – overgrowth of proximal medial tibial metaphysis </li></ul><ul><li>>Pickwickian Syndome- severe cardiorespi distress w/ alveolar hypoventilation </li></ul>
  72. 72. <ul><li>Prevention/ treatment: </li></ul><ul><li>> program of energetic exercise </li></ul><ul><li>>modification of diet and caloric content </li></ul><ul><li>> behavior modification for the child </li></ul><ul><li>Prognosis: </li></ul><ul><li>>diet/ exercise modification – short time success </li></ul>