Infant feeding, a topic of concern

1. NORMAL INFANT FEEDING
Jonathan Asare

2. Definitions
• Infant
– Period from birth to 1 year of age
• Young child
– Period from 1 year to 5 years

3. Infant Feeding
• First 6mo., feeding may be by;
– Breastfeeding
– Formula feeds
– Other milk feeds
• Basically the intake of milk only by the infant
• Next 6mo.;
– Complementary feeds which may be;
• Soft and pureed foods
• Soft family foods

4. Advantages of Breastfeeding
• For Baby:
– It is specific & therefore allergy to BM is RARE
– Nutritionally balanced and adequate (has all the
right nutrients at the right conc.)
– Protects against illnesses and allergies
• Colostrum contains antibacterial & antiviral agents
– Protects against diarrhoea and respiratory
infections

5. Advantages of Breastfeeding
• For Mother
– Promotes weight loss after pregnancy
• Burns 500 calories/day
– Convenient
• Cheaper and no preparation is needed
– Bonding emotionally
• Known to reduce rates of infant abandonment
– Protection against dx like ovarian and breast
cancer
– Cheaper, easier more convenient and portable.
– Birth spacing (Lactational amenorrhoea)

6. Breastfeeding Policies
• Exclusive breastfeeding for first 6mo
• This entails:
– Feeding on demand, min., 8 feeds/day i.e. 3hrly
– Night feeds
• High prolactin secretion at night
– Complete emptying of breast during feeds…why?

7. Baby friendly Hospitals
10 steps to successful breastfeeding
• Encourage breastfeeding on demand
• Practice rooming in
• No use of artificial teats or pacifiers
• Exclusive breastfeeding unless medically
indicated
• Show mothers how to breastfeed & maintain
lactation even if they should be separated
from their infants
• Inform all pregnant women about the benefits
& management of breastfeeding

8. Baby friendly Hospitals
• Help mothers initiate breastfeeding within
one half hr of birth
• Train all healthcare staff in skills necessary to
implement this policy
• Foster the establishment of breastfeeding
support groups and refer mothers to them n
discharge from hospital or clinic
• Have a written breastfeeding policy that is
routinely communicated to all health care
staff

9. Breast milk
Varies greatly according to:
• Hind milk vs fore milk
– Fore milk is milk produced as soon as the milk flow
begins
– Hind milk is the proportion of milk produced 2-3 min
after the flow begins
• Duration of lactation (reducing protein
concentration)
• Gestational age of baby
• Maternal diet

10. Difference in composition of HBM
• FAT
• F
• EIN
• LACTOSEPL
COLOSTRUM
FOREMILK HINDMILK
MATURE MILK
FAT
PROTEIN
LACTOSE

11. Comparison of human milk & cow’s milk
HBM Cow’s milk
Bacterial contamination None Likely
Anti-infective substances Antibodies, leukocytes,
lactoferrin, bifidus factor
Not active
Not present
Protein:
Total
Casein (curd)
Lactalbumin (whey)
1%
40%
60%
4%
80%
20%
Amino acids:
Cysteine
Taurine
Adequate
Adequate
Inadequate
inadequate
Fat:
Total
Fatty acids
Linoleic acid
Cholesterol
Lipase
CHO: Lactose
4%
Optimum, unsaturated
Adequate
Adequate
Present
7% (enough)
4%
Excessive, saturated
Inadequate
Inadequate
Absent
3-4% not enough

12. Comparison of human milk & cow’s milk
HBM Cow’s milk
Salts (mEq/L):
Na+
Cl-
K+
6.5 Right amount
12 right amount
14 right amount
25 Too much
29 Too much
35 Too much
Minerals:
Calcium
Phosphate
Iron
350 Right amount
150 Right amount
Small amounts
1400 Too much
900 Too much
Small amounts
Vitamins: A, C Adequate Thought to be
inadequate
Water 98% enough Extra needed

13. Colostrum
Property Importance
Antibody rich (IgA, IgG, and IgM)
IgE binding factors
Protects against infection & allergy
(IgE expression is suppressed)
Abundant WBCs Protect against infection
Vitamin A rich Reduces severity of infection &
prevents eye diseases
Growth factors Helps gut to develop and mature;
Prevents allergy
Purgative Encourages passing of meconium
Clears excess bilirubin and
prevents jaundice

14. Storing Breastmilk
Breastmilk should be stored in clean containers
• Stored at room temperature for 4-8 hrs
• At the back of a refrigerator for 3-8 days
• At the back of a freezer (-150C to -200C) for up
to 3months
• In a deep freezer for up to 6months

15. Indications for formula
feeds/contraindications to breastmilk
• Infants with galactosaemia, lactose intolerance
• Abusing illicit drugs --- cocaine, heroine, alcohol
• Intake of medications contraindicated during
breastfeeding---methotrexate, cyclosporine,
bromocriptine etc
• Mother’s HIV status
• Mothers receiving radiotherapy or chemotherapy
• Breast cancer mothers
• Irresponsible mothers
• Mothers complain about breast sagging

16. Disadvantages of Breastfeeding
“Disavantages of breastfeeding are those factors perceived by the
mother as an inconvenience to her since there are NO known
disadvantages to the normal infant”- Ruth Lawson
For some mothers, the disadvantages include:
• Inability to measure the volume of milk the baby has consumed.
• Breastfeeding can be perceived to be painful, messy and tiring.
• Breastfeeding can be difficult to establish without adequate
support and information.
• Breast-fed babies wake more often during the night to feed.
• It is more difficult for breastfeeding mothers to return to work.
• The mother may need to modify her diet.

17. Problems Encountered in Breastfeeding
• Insufficient milk
• Poor let-down (milk ejection reflex)
• Mastitis
• Cracked nipples
• Cannot feed in public

18. FORMULA FEEDING

19. Formula feeding
• Breast-feeding is the best method of feeding
for all newborn and infants, even for
premature infants and its constitution is
suitable for premature infants, but if it is not
possible, so a formula, which is close in its
composition to breast milk, is indicated.

20. Types of formula feeds
A. Complementary Feeding: Each feed, the breast is
given first until it is emptied then formula is
given to complete the feed.
B. Supplementary Feeding: Formula is given to
substitute one or more feeds, where some feeds
are completely breast milk and others are
completely formula or bottle.
C. Substitutive: - No breast-feeding is given and the
infant is fed on formula only.

21. - This indicated in the following
cases:
1. Death of the mother.
2. Contraindication to breast-feeding, such as
infant’s metabolic disorders (galactosemia)
and mothers who have cancer and under
radiation treatment

22. Types and forms of animal milk used in
formula feeding
• Modified animal milk, which as far as possible, promotes health and
growth of the newborn and infant and as near as possible to breast
milk composition should be used.
1. Fresh milk:
Raw fresh cow, buffalo (gammoussa) and goat milk.
Pasteurized milk (to kill some bacteria and modifies the casein
curds).
Ultra-pasteurized, especially packed milk which can be kept
for several weeks.
• These milks differ in composition from human milk and still
contain microorganisms; therefore, they are not suitable
for infant feeding. They may be safely given to older
children

23. DRIED MILK
• Dried milks are prepared by evaporating water
from fluid milk.
• Each 100 ml of fluid fresh milk is transformed
to 12.5 gm of powder

24. TYPES OF DRIEDMILK
1. DRIED WHOLE MILK
• This is simply dried milk.
• After reconstitution, it is exactly similar in
composition to cow’s milk.
• It cannot be used for feeding young infants
unless modified.
Examples: Nido, Cornation, Francelait, La
Frizan,..

25. 2.Modified Cow’s Milk Formulas:
Modification of cow’s milk to adapt it for newborn and infants
by:
• Reducing casein amount and replacing it with soluble whey
protein.
• Milk fat is replaced by a mixture of milk and vegetable fat to
increase its unsaturated fatty acids content.
• Lactose is increased to 7%.
• Reducing the amount of ash.
• Iron and vitamins are added
However, modified milk can’t be compared to human milk from
the biological point of view.
Examples:
American Milk: Similac, Similac with iron, SMA, Enfamil.
European Milk: Neslac, Nan, Bebelac, No 1 Humanized.

26. 3. Follow- on Milk Formulas for Healthy Infants over
6 Months and Children:
– They contain more protein and iron and less fat than the
humanized milk
4.Modified Special Formulas:
– Many milk formulas are modified for those who are
preterm or have medical conditions.
– These formulas may be based on cow’s milk, other
mammal’s milk or on vegetable ingredients,
Examples: Lactose free milk (Isomil A1 110)

27. • 5.Acidified Milk:
– Acidified milks were thought to have an advantage in
facilitating digestion and absorption.
They include:
A. Full-Cream Acidified Milk: It contains 4% lactose,
0.4% lactic acid e.g. Pelargon, Bebelac Z 18
Acidified.
B. Half-Cream Acidified Milk: It contains 1.5% fat,
4% lactose & 0.4 lactic acid e.g. Prodieton,
Bebelac Z9 Acidified

28. The advantages of Dried milk are:
• Dried milk is sterile, highly soluble.
• Constant in its composition.
• Can be modified to meet the needs of
newborns and infants in health and disease.

29. COMPLEMENTARY
FEEDING

30. Definition
• The process beginning where breastmilk is NO
longer sufficient to meet the nutritional demand
of infants. Hence, the need to add other foods &
liquids.
OR
• The introduction of family foods into an infants
diet in addition to breastmilk.
• Target age range is between 6-24mo
• Complementary feeding is a slow process

31. Foods to restrict or avoid in
complementary feeding (weaning)
• Salt
• Sugar & sugary drinks (kalyppo etc.)
• Tea
• Honey
• Nuts: Do not give any type of whole nut to
children under 5 yrs due to risk of choking.
• Recommendation is no more than 240ml of fruit
juice per day

32. Total Energy Req’ts of Healthy
Breast-fed Infants
• 6-8 months
– 615 kcal/day
• 9-11 months
– 686 kcal/day
• 12-23 months
– 894 kcal/day

33. Energy Needs from
Complementary foods
Infants with “average” breast milk intake in
developing countries:
– Approx. 200 kcal/day at 6-8 months
– 300 kcal/day at 9-11 months
– 550 kcal/day at 12-23 months
(WHO/UNICEF, 98)

34. Guidelines For Appropriate
Complementary Feeding
• Continue frequent, on demand breastfeeding until
two years old or beyond;
• Practise responsive feeding (e.g. feed infants directly
and assist older children. Feed slowly and patiently,
encourage them to eat but do not force them, talk to
the child and maintain eye contact);
• Practise good hygiene and proper food handling;
• Start at six months with small amounts of foods and
increase gradually as the child gets older;

35. FOOD CONSISTENCY:
• Gradually increase food consistency and variety with age;
– 6 months, give pureed, mashed & semi-solid foods
– 8 months, give ‘’finger foods’’
– 12 months give family foods e.g. Jollof with tomato stew +
vegetables with tender boneless meat
MEAL FREQUENCY
• Increase the number of times that the child is fed,
– 2-3 meals per day for infants 6-8 months of age,
– 4-5 meals per day for infants 9-23 months of age,
– 6-8 meals per day for infants 12-24 months of age
with 1-2 additional nutritious snacks as required;

36. SNACKS
– Foods eaten between meals and are usually SELF-
FED, CONVENIENT, and EASY TO PREPARE
• E.g. piece of fresh fruit, bread with nut paste,
• Increase fluid intake during illness, including
more breastfeeding, and offer soft, favourite
foods.

37. PRE-TERM INFANTS

38. Definitions
• Preterm Babies
– Infants born before 37 completed weeks of gestation
• Term Babies
– Infants born between 38-42 completed weeks of
gestation
• Low Birth Weight (LBW) Infants
– Infants weighing < 2.5kg due to;
• Shortened gestational period
• Prematurity
• Retarded intrauterine growth rate small for gestational age
The vital organs of preterm & LBW infants are immature &
therefore unable to adapt readily to early extra-uterine
existence

39. Preterm Infants
• Slight 32-36 weeks
– Feeding and temperature problems
– Some have immature lungs
• Moderate 28-31 weeks
– Immature lungs
– Feeding and temperature control problems
– Apneas
• Severe < 28 weeks
– Immature organ system
– ICU

40. Small for Gestational Age (SGA)
• Infant whose birth weight is < 10th centile for
the baby’s gestational age
– 2.5kg is the 10th percentile for a feotus of about 31
weeks gestation
• Intrauterine Growth Retardation (IUGR): Failure
to sustain intrauterine growth at expected rates;
can be caused by
– Placental insufficiency
– Infection with the baby
– Malnutrition
– Smoking, heavy drinking & drugs

41. Common Problems Affecting Nutrition
of Preterm/LBW Babies
Many problems faced by Preterm /LBW infants are
due to
1. Underdeveloped organ system, kidneys, lungs etc.
2. Immature GIT causing poor digestion &
absorption leading to energy & nutrient
deficiencies
3. Poor sucking due to underdeveloped muscular &
neurological system may cause poor intakes
thereby requiring tube feeding
SUCKING matures between 30-34 weeks of gestation

42. 4. Underdeveloped lungs leads to ineffective
breathing causing fatigue & respiratory distress
syndrome (where breathing fast occurs & hence
leading to poor dietary intake & inadequate O2
use
5. Impaired liver function can lead to bilirubin &
other waste products causing jaundice in infant
6. Immature immune system puts them at high risk
of infections which in turn may caloric need &
cause diarrhoea
sanitation is KEY for these infants.
7. Ineffective thermoregulation & inadequate
nutrient stores may caloric need

43. Feeding the LBW Infant
Choice of milk
1. Breastfeeding or mother’s own expressed milk
– There is strong and consistent evidence that feeding
mother’s own milk to pre-term infants of any
gestation is associated with a lower incidence of
infections and necrotising enterocolitis, and
improved neurodevelopmental outcome as
compared with formula feeding

44. Donor human milk.
• The available data indicate that feeding with
donor human milk rather than standard or pre-
term infant formula to LBW infants of <32
weeks gestation reduces the incidence of
necrotising enterocolitis
• Growth is slower in the short term in the
infants fed donor human milk, but there are
insufficient data to assess the effects on long-
term growth outcomes.

45. Pre-term infant formula (e.g preNAN)
• Calorie-enriched and variably protein- and
mineral-enriched to support intra-uterine
nutrient accretion rates
– Approx. 80 kcal/100ml
– at least 2 g/100ml of protein
• Pre-term formula increases growth during the
neonatal period but this is not sustained during
later infancy and childhood. No long-term
benefits (e.g. blood pressure, serum lipid profile
or pro-insulin) have been found.
• Pre-term formula contains more protein, Na, Ca,
Zn, Ph, and vitamins

46. How to feed
Feeding methods
1. Cup feeding compared with bottle feeding.
– cup feeding leads to higher rates of full (exclusive or
predominant) breastfeeding, compared with bottle
feeding at the time of discharge from hospital.
– Risk of aspiration is lowered in cup feeding than in
bottle feeding
– Risk of infection is higher in bottle feeding esp in
developing countries
• Cup feeding is thus recommended by WHO &
UNICEF

47. 2. Nasogastric compared with orogastric feeding
– Ltd clinical outcome on effect of nasogastric
compared with orogastric feeding tubes
– However, evidence show that physiological
parameters may be worse with nasogastric tube
placement in very pre-term infants
• Recommendations:
– No consensus statements or expert committee
reports were located which recommended orogastric
or nasogastric tubes in LBW infants.

48. Feeding schedules
• Need small volumes frequently
• Energy dense foods via addition of fats & oil
• Feeding frequency:
– 4-hourly for infants >2000 g,
– 3-hourly for infants 1500–2000 g,
– 2-hourly for infants 1000–1500 g, and
– hourly in infants <1000 g.
• Feeding intervals are extended on an individual
basis depending on feed tolerance, gastric
aspirates and physiological stability.