MBBS Letures

1. CF:92

3. CF 85

13. WELCOME ALL
CF61

15. INFANT
FEEDING
Dr Mohammad Nurul Huq
A. Feeding in early 6 months
B. Complementary feeding

16. KEY FACTS
Child has right to good nutrition (Convention on Child Rights)
 Undernutrition is a/with 45% of U-5 mortality
2017: Globally 155 million U-5 are stunted (short), 52mn
wasted (too thin), & 41mn overweight/obese
 <40% are exclusively breastfed (EBF)
 <25% get correct complementary foods (CF)
 1 million U-5 lives could be saved/y, if BF started in 1st h
BM improves IQ, schooling, income as adult; reduces
health costs; & results in economic gains for
families as well as at national level
BM: breastmilk

17. Bangladesh Scenario
 Previously EBF was a norm
 Now, only 55% are EBF (2016)
 80% moms breastfeed their babies
 Family support is often lacking for EBF
 2,000 crore taka could be saved/y by EBF
 Non-breastfeeding is disastrous
 Poor conception about CF is wide spread

18. Principles of Infant Feeding
 Counseling at ANC & after birth
 EBF first 6 mo
 Complementary feeding
 BM for 2y
 No bottle, no machine
 No animal milk in first 2y
 No commercial foods
ANC: antenatal care
EBF: exclusive breastfeeding. BM: breast milk

20. Principles of BF
 Initiate BE within 1h
 EBF for first 6mo
 Demand feeding
 EBM SOS
 BM for 2y
 Correct position & attachment
 Balanced family food for mother
 No pacifier
EBM: expressed breast milk

21. World Breastfeeding Week (1-7 August)
to promote & support BF, improve health of babies
(Innocenti Declaration, Italy: 1990)
– Making workplaces friendly to BF: a long way to go:
much has improved in 23y to make these BF-friendly

22. INNOCENTI DECLARATION (1990)
Protection, Promotion & Support of BF:
 BF is a unique:
– provides ideal nutrition for healthy G&D
– reduces ID (lowers MM)
– reduces risk of breast & ovarian Ca
– increases birth spacing (lactational amenorrhea)
– social & economic benefits to the family & the nation
– provides most women with a sense of satisfaction
G&D: growth and development. MM: morbidity @ mortality

27. First 6 mo: Exclusive
Breast Feeding

29. Exclusive Breast Feeding…
… feeding the newborn with only BM (Mother’s
milk!); not even a drop of water
for 6 calendar mo (180d)
Why no water?
Composition of BM makes extra water unnecessary
even in dry & hot climates! No dehydration!
Better avoid possible contaminated water!

30. Is EBF Enough?
Yes!
 It is proved!
– mother fed her baby in-utero for 9 mo; she can
still do it for another 6 mo
– 2 breasts can support 2 babies!
– no other mammal fails!
Breast takes over the feeding role
of placenta after birth

31. Is BM Enough? …
 Wetness test
If a baby voids urine 6 times/d
& sucks 8-12 times/d
 Weight check
First 6 mo: gains 125g/w
or 500g/mo

32. If mother says: BM not enough: check
– weight gain
– feeding technique
– for illness in baby & mother
– malnutrition in mother
– check for family support
– working place

33. When BM is not enough!
 Baby is not sucking effectively:
Action: position & attachment
 Mother is very busy & suckles less
Action: increase frequency
 Baby does not suck long enough
Action: suckle longer, stroke cheek, any discomfort?
 Formulas are given: advise the mother about EBF
(You can refer the mother to BBF)
BBF: Bangladesh Breastfeeding Foundation

34. FAQ by mother
 BM is not enough, baby cries a lot!
 Shouldn’t I habituate him with a bottle?
 Can I use a bottle to feed Breast Milk?
 Can I give water?
Contd …

35.  He has diarrhea from Breast Milk!
 I am a working mother
 Can I feed him while I am lying?
 He has become very windy on Breast Feeding
 He is passing lot of urine!
FAQ …

36. 101 Benefits of Breast Feeding!
For Mother
 Less obesity, may better lose wt.
 Perfectly easy, cost effective
(save >$1,000/y). Convenient.
You can do it anywhere anytime
 No extra labor/tools
 Bonding. Birth spacing (98%)
Formula bag
 Reduces risks of breast & ovarian Ca, T2DM,
postpartum depression

37. Benefits for Infant
 It is the nature’s way
 Environmentally friendly
 BM nutrient values are just parallel to actual needs
of the baby
 The baby grows optimally
contd …

38. Benefits for Infant …
Fresh & flows round the clock
Easiest: no tools
Preferred by babies even when sick
Growth factors
Delays allergy
Anemia, scurvy, rickets, etc. are rare

39. Benefits for Infant …
 Solute load of formulas is much
more than that of BM (120 vs
88 mOsm/l)
 Enteral inf. is virtually nil
 ARI, otitis media, UTI rare
 Better IQ

40. Uniques of Breast Milk
 No nutritional deficiencies (mom well-nourished)
 Standard growth
 Unique combination of energy & nutrients
 Numerous anti-infectives:
 Unique bonding
 Uniquely cheap & cost effective (the best cum the
cheapest!)

41. Lack of bonding

42. Anti-infectives in BM
Prevent viruses, bacteria & parasites:
– Specific: antibodies (mainly secretory IgA)
lymphocytes (humoral, CMI)
– Non-specific: lactoferrin
lysozyme
bifidus factors
complements

43. Lactoferrin: iron-binding protein: retards bacterial &
fungal growth
Lysozyme: bacteriolytic enzyme
Complements: with Ab. destroy particulate Ag.
Bifidus factor: prebiotic; stimulates growth of L. bifidus:
lowers pH: suppresses pathogens
Together they make gut unsuitable for pathogens
Ab: Antibody. Ag: Antigen

44. Nutrition in BM
 Energy 70 kcal/100ml
 Lactose 7g/100ml
 Fat 4.2g/100ml
 Protein 1.45g/100ml

45. Micronutrients
 Fe, Zn, Cu, iodine, Ca, Cl, Na, Mn, P, K, etc.
 BM binds Fe, Zn, etc. to ease absorption but
prevent them from use by bacteria
 All vitamins if mother is not deficient

46. EBF Ensures:
a virtually infection free normal
G&D of the infant &
bonding between baby & mother
G&D: growth & development

47. Why Breast is Best
 Breast Feeding is the healthiest for mom & baby
 BF is a wonderful way to bonding
 BM contains all nutrients optimally
 It has antibodies
 It prevents allergies, tummy problems
 Breastfed babies are less obese/have less DM; more IQ
 BF may help prevent SIDS
 BF is the natural, healthy choice for mom & baby
SIDS: sudden infant death syndrome

48. Colostrum
Is made before birth & during first few days, yellowish;
thicker, has more protein, less fat than BM
 Has all conc. nutrients plus antibodies (x100 of BM! kill
bacteria, fungi, parasites, & viruses)
 Gives GI protection from damage & may help heal. More
physical performance, has growth factors
 Laxative action
 Clears jaundice

49. BF Difficulties
Lack of family support; lack of confidence
 Working mother
 Multiple babies
 Some diseases
 Breast engorgement, cracked/retracted nipple
 Breast inf., - abscess
 Breast tumor …

50. Inverted Nipples

51. Breastfeeding Challenges
not always easy for moms & babies:
 Discomfort. Sore nipple is normal in the first weeks
 Time. Baby may take a huge time & effort. More
frequent than formula
 Diet. Baby may be sensitive to certain foods
M o s t mothers find early struggles pass
quickly, & they settle into BF

52. Some Moms Can’t Breastfeed!
A few! But it does not make you a bad mom
 Work. Not all mothers can pump (EBM). Certain jobs may
make it hard to regular pumping
Companies with >50 employees are required by law to
provide the time & place to pump
 Not enough milk
 HIV/AIDS, medicines can make it unsafe to breastfeed
 Addiction problems. Alcohol/drug addict moms
 Galactosemia/PKU. They must be fed soy-based
formula

53. Technique of BF
Mostly natural; just feed on demand
 8-12 feeds/d
 Some techniques ensure success:
correct positioning &
attachment of the baby

54. Positioning the Baby
 Head & body is straight
 Baby held close to body
 Support baby’s whole body
 Baby faces the breast
Good positioning ensures comfort

58. Attachment of the Baby
 Mouth is wide-open
 Lower lip is turned outwards
 Chin is touching breast
 More areola is seen above than below
Correct position-attachment ensure comfort & success of BF

60. Mouth opening

62. MESSAGE
 For 6mo BM is enough
 It protects the baby
 It is ready to feed
easy to do
cost effective
rewarding
environmentally friendly!
 It is unique!

63. Why Environmentally Friendly
 Renewable source
 No extra energy to make & process
 No plastic pollution
 No extra man power
 No inefficient land use
 No methane from cows!
 No ads.
 No sterilizing
 No luggage of tools

65. Inefficient land use

66. No trees, no crops! Inefficient land use!

70. Mothers! Pl. remember
 Breasts are attached to you
 You can’t forget!
 They serve the perfect food at perfect temp., no
matter where you are!

71. Infant Formulas
Made from cow’s milk & modified as per formula
Varieties: vary in nutrients, calories, taste, digestibility, cost
Standard milk-based formulas:
 Almost all babies do well on these. Fussiness & colic are
common problems. No need to change the formula
 Cow's milk protein has been modified. Vegetable oils,
minerals, vitamins are also added
Lactose-free formulas:
For Galactosemia, alactasia (usually begins after a 12mo)
 In diarrhea: usually no need of lactose-free formula

72. Soy-based formulas:
Soy proteins. No lactose
For parents who do not want animal protein, & for
galactosemia or alactasia
 They do not help milk allergies or colic. Babies may also
be allergic to them
Hypoallergenic IF (protein hydrolysate):
may be helpful for allergies to milk protein, skin rashes or
wheezing c/by allergies. Generally expensive
IF: infant formula

73. Special formulas:used under supervision:
 Reflux formulas: thickened with rice starch. Needed only
for reflux with FTT or who are v. uncomfortable
 Formulas for preemies & LBW have extra calories
and minerals to meet the needs of these infants
 Special formulas for CHD, malabsorption syn, &
problems digesting fat or processing certain amino a
 Toddler formulas are offered as added nutrition for
toddlers who are picky eaters. To date, they have not
been shown to be better than whole milk &
multivitamins. They are also expensive
 Ready-to-use
 Conc. liquid formulas

74. Formulas are
… basically dried cow’s milk
… not designed for our babies
… devoid of the unique properties of BM
… all are same, nothing to choose between
So we do not call these ‘baby foods!’

77. Harms from Formulas
 CMPI
 Solute overload
 Chemicals, additives: flavoured, tastier
 Dislike for breast milk
 No adequate bonding
 Expensive but never fresh!
May cause delay in starting solid foods
Not environmentally friendly
CMPI: cow’s milk protein intolerance

78. FAQ on formulas
 Which brand is the best
 Add sugar?
 Boil?
 What water, mineral water?
 How long can be kept?

79. Feeding Bottle
 The worst invention!
 Very dangerous for babies
 A baby killer sp. in the LICs
 Diarrhea & other ID are x8 :
 Death is x4
So, you do not
advocate it for your baby!
LIC: low income country

80. Bottle-fed babies get diarrhea more
 Difficult to keep bottles clean
 Easily contaminate
 Contaminated water
 VADX from frequent inf.
Bottle-fed babies get ARI more
 Sleep feeding
 VADX from frequent infx.
 Contamination

81. Harms from Bottle
 Easily contaminates
 Mortality & morbidity very high
 Diluted feeds: malnutrition
 Extra sugar/thickened feeds: obesity
 Plastic bottles release BPA
 Baby may refuse solids in time: late in solids:
Mn., behavioral & developmental problems
contd …
Bisphenol A: belongs to diphenyl methane

82.  Feeding during sleep:
– overfeeding
– indigestion, bloating
– throat/respiratory infection
– tooth decay (nursing bottle syn)
 Lactational failure
 Pollutes environment
Harms from Bottle …

83. When giving ORS or EBM
always use a cup &
spoon, never a feeding bottle
EBM: expressed breast
milk

84. BF & Figure
 Mother does not lose her figure
 Helps lose wt
 Breasts regain shape
 Breast changes in pregnancy, so BF or not BF does not
make any difference!

85. Advantages of Bottle Feeding!
 Anyone can feed your baby
 You can get round-the-clock rest
 You can also pump BM & feed by bottle
 You feed less often: babies digest formula slower
Everything you do as a mother, your love, attention,
& care, will give baby the best start in life

86. Conclusion …
 Every mother can BF (<1% cannot)
 Frequent suck keeps up supply of BM
Breasts of all sizes are equally good
 Shape of nipple does not matter, as long as baby
takes the breast well into the mouth

87. MCQ
 EBF for 180 days
 Breast milk contains live cells
 Strict schedule is preferable
 Complementary feeding starts from 4 mo
 BM contains secretory IgA
 Lactoferrin in breast milk helps gut flora
 Vitamin k deficiency is more common in EBF
babies

88.  Extra water is beneficial for EBF babies
 BF in first hr can save 1 million babies
 Formula feeding doesn’t harm bonding
 Formulas are made from milk of millions of cows
 More risk of obesity with bottle feeding
MCQ

89. SAQ
 What are the positioning & attachment for EBF?
 How do you counsel to make BF a success?
 What are the benefits of EBF?
 What are the harms of formula feeding?
 What are the harms of bottle feeding?

95. Najat Vallaud-
Belkacem (b. 4
Oct 1977)
Moroccan, is the
first French F.
Minister of Ed,
(age 38)

96. COMPLEMENTARY
FEEDING
After 6mo (180 days):
Family Foods along
with BF for 2y

97. Principles of Complementary Feeding
 Family food, no animal milk
 No bottle, no machine
 Affordable, balanced, locally available
 Demand feeding
 No insistence, not ceremonial !
 Easy preparation
 No sleep feeding
Foods that keep parents healthy, also keep
baby healthy

98. Why CF?
 More calories (rapid growth, more activities )
 Calorie dense foods
 Exploration of foods
 Habituation with family foods
 Integration with the family
 Varieties of foods
 Solid foods after tooth eruption

99.  Less sugars after tooth eruption
 Protective foods (non-nutritional elements)
 Development of behavior & personality
 Iron gap, vitamin A gap
 Fitness
– teeth make the infant functionally mature!
Why CF…

100. W e a n i n g !
 Weaning means taking the child off the breast!
 But avail benefits of BM as long as possible!
 The term is d i s c a r d e d
 Complementary Feeds to complement Breast
Feeding

101. Warning!
 Never give honey to young baby. It may cause botulism
 No cow's milk until 1y; difficult time to digest it
 Never give a bottle at bed: tooth decay
 Use a small spoon to feed. Give water between feeds
 Offer the new foods only when s/he is hungry; give new
foods one at a time. Watch for allergy (DV, rash)
 Avoid foods with added salt or sugar
 Opened containers should be covered & stored in a
fridge for no more than 2 days
DV: diarrhea vomiting

102. CF: is it difficult task?
 No
 It cannot be ..
 It should not be ..
 It is natural!
 Natural is easy!
 We should not make easy thing difficult!

103. Who make it difficult?
Profiteers!
 With fancy food names!
– Follow up-, catch up
– Grow up iron-, -sure, My Boy!
– All Vitamins, A-Z foods, etc.!
 Promotion of bottle & blender
Trade promotion!

104. Time of starting of CF
After 6 calendar mo (180d); starting of 7th mo
Why not earlier?
 Too early may cause diarrhea, malnutrition, IDA
 Risk of obesity, allergy, atherosclerosis
 May deprive the baby of unique BM

105. Why not late?
 Baby adopts family
foods best now (6-8mo)
 Delay may cause
– rejection of solids
– faulty feeding
Prolonged EBF causes
 FTT
 IDA, VADX
 Poor resistance
 Developmental &
behavioral
problems
FTT failure to thrive. VADX: vit A def & xerophthalmia

106. FAQ from our mothers
 When to start Cerelac, Junior Horlicks … ?
 What formula is the BEST?
 Use blender?
 What rice? What oil? ….
 What fruit? What banana?
 Banana & orange cause cold?
 Veggies cause gas!?
FAQ: frequently asked questions

107.  Boil formula?
 Times of feeds?
 If no appetite?
 Add sugar?
 Grapes?
 How much water?
 How to give eggs?
 …
FAQ …

108. Types of food for CF
 Family food is really good; the baby deserves it!
 It is fresh & soft, balanced
varied in texture & flavor
 Consider food value: no poor/rich food
 Not 1 or 2 foods only: monotonous!
 Energy dense; more roughage/fiber
 More vitamins, minerals
 No animal milk!
 Don’t forget water!

109. Why Family Food?
 Always fresh!
 Cheap, affordable
 Foods vary daily
 Integrity with & discovery of family
 Bonding
 Food varies from country to country
No international food!

110. International food?
No!
 Local foods
 Family foods
 Mother’s foods for mother’s baby!
Be careful! They like to rob away your kitchen

111. Why not commercial foods?
 Costly! Not natural; not fresh!
 Monotonous!
 Many chemicals!
– preservatives, additives, tasting salt, flavors, etc.
 It may be old, contaminated
 Risk of obesity
 … using bottle
 … constipation
 … late starting of solids
 … addiction

112. How to start CF?
 Offer when the child is hungry!
 Start foods of plant origin; first a CHO preferably
rice (suji); add sugar, oil, spice
 At 1-2w intervals add others (khichury, soup, etc)
 Start egg in little amounts & increase gradually
 Give fruits, vegetables, water

113. Schedule of CF
 3 times a day for 6-9 months
 4 times a day for 9-12 ,,
 5 times a day for 12-24 ,,
Up to 12mo: BF first, then CF
1-2 years: CF first

114. Foods for 6-9 months
 Suji, rice
 Khir or payesh
 Khichury, fruits, vegetables
 Egg, meat, fish
 Water
Make the child habituated with family food within
6-8 months; may be a modified suitable way

115. Foods for 9-12 months
 Khichury, rice, dal, soup
 Fruits, vegetables
 Eggs, meat, fish
 Home made sweets
Foods for 12-24 mo
 More solids, more varied
 Regular foods taken with parents

116. Favour for fruits
 Seasonal fresh fruits
 Vitamins, minerals, fiber
 Protectants
 Fresh vs processed?
 How much juice a day?
 Fruits in diarrhea: up to 100ml/d

118. A banana a day
keeps the Dr away
Energy, protection, stimulant, relaxant (tryptophan)
Number 1 fruit for athletes
Better academic performance
Contains all vitamins
Good calories (2 bananas = 90min work)
Prebiotic more

119. A banana a day …
 All 3 sugars (fructose, sucrose, glucose)
 Fiber, iron, laxative
 Extremely high in K+, low in salt:
regulates BP. Low risk of stroke
 Anti-irritant for skin
Well protected, tasty!
Available year round

120. Grapes are sour for our baby!!
 Partly rotten!
 Difficult to clean
 Chance of contamination
 Not protected
 Mainly sugar
 Expensive!

121. Vibrant Rainbow Vegetables
 Non-nutritious parts: fiber
 Protectants
 Rich in vitamins & minerals
 Prebiotic
 Some can be taken fresh
60% drugs are derived from plants

123. The egg story
• After 6mo
• First class protein
• Must be: well cooked/hard boiled/fried
• Never poached or half boiled
• Cooking destroys 70% allergenicity
Semicooked eggs contains bugs from poultry unless pasteurized!

124. The ‘khichury’
The basic food !
 Really tasty. You can add anything to it!
 Plant origin
 Unique! All essential amino acids
 Different taste from different ingredients
 It is new daily!
 Not monotonous

125. The chips/fizzy drinks story
 No outdoor foods (chips, biscuits, candies!)
 Chance of contamination
 Are mainly sweets, not balanced
 Salt overload
 May not be of good quality
 Additives
These are Empty calories!

126. Non-nutritious: empty
calories!

127. How to offer?
 Breast feed first
 Make the session enjoyable
 No bottle/blender: use cup & spoon
 Temporary withdrawal of rejected food
 Postpone foods causing V&D

129. The blender story
 Risk of contamination
 Solids may be rejected
 Risk of habituation
 Expensive!

131. How frequently?
 On demand!
 Don’t force/insist!
 Don’t expect eating the whole amount
 Don’t feed in sleep (only possible with bottle)

132. Adopt the baby to family foods
 After suji give khichury, soup, etc.
 Don’t hurry! Give a slice of orange/lemon or a
piece of carrot! S/he explores it!
 Keep the baby with you at the dinning table
– offer something on dish. S/he will spill some!
– don’t be upset!

133. Working mother
 Not a problem
 Problem not with working status
 The attendant should be convinced, trained
 Cup & spoon feeding
 Adequate maternity leave

134. Conclusion
Family foods are:
 scientific, hygienic
 cheap, affordable
 natural
 simple, easy
 really good!
 enjoyable
 every day new!
 no problem with
working mother!
We do not make feeding a difficult job!

135. Mom must be
beside me!

136. MCQ
 CF started after 6mo
 Blending makes food more digestible
 Vegetables have non-nutritional protectants
 Before 1y CF should be given first
 Best age to adapt family foods is 6-8mo

137. MCQ
 Rich foods are the best foods
 Feeding bottle is a baby killer
 Vegetables cause gas
 Oranges cause cold
 Family foods are away for integrity with
the family

138. Next lecture
E. P. I. TARGET
DISEASES