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Infant FormulaMnica Riojas, MDLSU Pediatrics

Principles of Infant FeedingEnergy Requirements: kcal/kg/d

0-12 mo: 100-120 1-3 yr: 90-100 4-6 yr: 80-90 7-10 yr: 70-75 15+ yr: 45-50 Principles of Infant FeedingsFormula fed infants feed every 3-4 hrs. Feedings/day 0-3 Months: 6-8 4-6 Months: 5-7 6-8 Months: 4-6 9-12 Months: 3-5

3By 4 mo, the baby is being introduced to solids, these are bottles only. Infants c feeding difficulties eat more freq. or more volume.Principles of Infant FeedingAverage Volume of Milk per Feeding

1st wk: 1-2 oz2-4 wks: 2-3 oz1-2 mo: 4-5 oz3-4 mo: 5-6 oz5-6 mo : 7-8 oz

By 12 mo of age, the average child should be taking an average of 24 oz/d.

INFANT STOMACH CAPACITY

Infant Formula IndicationsAs substitute for human milk in infants for whom BF is medically contraindicated.

As supplement for BF infants who do not gain weight adequately.

As a substitute or supplement for human milk whose mother chooses not to BF or not to do it exclusively.Distribution of KcalsBreastmilkFormula% Protein69% Fat5248% Carbohydrate4242QuestionWhich of the following statements about infant nutrition is true?Human milk contains more casein than infant formulas.Infants who receive increased whey protein have been shown to grow better than those who receive primarily casein.Iron is absorbed better from cow milk formulas than from human milk.Lactose-free formulas result in decreased absorption of calcium.There are no apparent negative effects from the addition of DHA and ARA to formulas.Differences Between Types of MilkBreastmilkStandard Cow FormulaCow MilkCalories20 kcal/oz20 kcal/oz19 kcal/ozProtein0.9 g/dL1.4 g/dL3.5 g/dLMinerals (Ca, P, Fe)LowerHigherIron AbsorptionBetterWorseTerribleVit. ABCSameSameVit. DEKLowerHigherRenal SoluteLowerHigherWhey:Casein Protein Ratio70:30Varies, but not better than human milk20:80Benefits of Whey ProteinPromotes more rapid gastric emptying. Consists of soluble proteins that are easily digested. Lines the GI tract and plays a role in host defense.QuestionIs iron supplementation required at birth? No

When should you start iron supplementation?All babies (including breastfed) should receive supplementation in their food (iron-fortified cereal) by 6 months of age.In FT infants, iron stores become depleted by 4-6 months of age.

Dietary RecommendationsIRON

Pre-term: 2 mg/kg/d at 1-12 mo

Full-term: 1 mg/kg/d at 4-6 mo Iron Fortified Formula: 12 mg/LCows milk has 0.5mg/L of iron.

Dietary RecommendationsVITAMIN D400 IU/dWho should receive Vitamin D?All BF infants, unless they are weaned to at least 1000 ml/d (33 oz) of Vit. D fortified formula.Formula fed infants ingesting 1000 ml/d of Vit. D fortified formula.Children/adolescents who get no sun light, 1 L of Vit. D fortified milk, no MVI.

Infant FormulasPremature Formulas

Standard Formulas

Special Formulas

Standard FormulasCOMPOSITIONProteinWhey ( lacto-globulin) & CaseinWhey predominant (60:40), Casein predominant (20:80), or 100% whey FatVegetable oilsCoconut: Saturated, short & MCFAPalm oil: Saturated & LCFASafflower, corn & soy: LCFA, DHA & ARA Carbohydrate Lactose

Standard Infant FormulasProvide 20 cal/oz

PRESENTATIONS:PowderConcentrated LiquidReady to Feed

Preparation of Infant FormulaPOWDER Add 1 scoop powder to 2 oz of water

CONCENTRATED LIQUIDMix 1 oz concentrated liquid and 1 oz water13 oz can

READY TO FEEDHospital use: 2 and 3 oz bottles32 oz containerExpensive

18Careful reconst. Important forexact concentration. Powder increase volumenPreparation of Infant FormulaWhat type of water should be mixed with the formula? Tap: safe, may boil x 1 min. Distilled water with fluoride. Well: boil 10 min. Give fluoride. Warm, cold or room temperature. Cow Milk/Standard FormulasDesigned to meet the nutritional needs of the term and near-term infant.

Enfamil Premium Newborn & InfantSimilac AdvanceStore Brands 20SMA withdraw from SE areaCow Milk/Standard Formulas

Enfamil NB has Vit D 400 IU in 27 oz, SA has lutein good for eye health doesnt contain palmein oil=improved calcium absorptionNew Infant Formula FeaturesPrebiotics Nondigestible short-chain carbohydrates that stimulate growth and function of specific species of bacteria. Increases concentration of lactobacillus and bifidobacterium.Used to treat chronic diarrhea.Beneficial to atopic children.

ProbioticsLive microorganisms that survive digestion and colonize the colon.

OrganicNo pesticides or synthetic fertilizer used.No hormones or antibiotics used. Premature Infant FormulasFor LBW and Premature Infants

Increased energy requirement: 120 kcal/kg/d

Preterm formulas should always be discontinued before hospital discharge.Increased intake with age excess intake of vitamins/minerals

23Show stomach sizeComposition of Premature Infant Formula20, 22, 24 kcal/oz Increased protein: whey predominant60% whey:40% caseinBreastmilk - 70% whey:30% caseinIncreased calcium & phosphorusContain AA: cysteine and taurineLactose + glucose polymers MCT Increased Vitamins & MineralsHigher caloric density, more readily absorbed lipids, greater protein content, AA deficient in preemies and important for brain development,24Premature Infant FormulasEnfamil Premature 20 calEnfamil Premature 24 calSimilac Special Care Advance 20 calSimilac Special Care Advance 24 calGood Start Premature 24 cal

Premature Infant Formulas

Transitional Formulas 22 kcal/oz

INDICATIONSInfants 34 WGA or 1,800-2,000 g

How long should infants be on transitional formulas?6 to 9 months of age

Transitional FormulasEnfamil EnfacareSimilac Expert Care Neosure

Transition Formula

QuestionWhat type of milk would you recommend a breastfeeding infant that develops rash and hives while eating yogurt and cream cheese, and tolerates foods such as eggs and bread without any problems?

Trial of Soy MilkBased Formula If no improvement switch to an extensively hydrolyzed or AA-based formulaMilk protein allergy, IgE mediated reactionSoy Protein FormulasLactose FreeContain higher concentrations of protein, AA, calcium, phosphorus, zinc and iron.

Primary CarbohydrateGlucose polymers from corn syrup solids or maltodextrinSoy Protein FormulasINDICATIONSGalactosemiaCongenital Lactase DeficiencyPost-diarrhea lactose intolerance Strict vegetarian family

Soy Protein Formulas NOT RECOMMENDED FORPreterm infants with BW 1800 g.Do not meet requirements for calcium and phosphorus.Prevention of colic or allergyInfants with cow milk protein-induced enterocolitis (non-IgE allergic enterocolitis)30% of infants with milk protein allergy also have soy protein allergy.

Soy Protein Formulas Enfamil ProSobee Similac SensitiveStore Brand Soy Infant Formula

Soy Protein-Based Formulas

Modified Cow Milk Protein or Soy-Based FormulasCarbohydrateReduced lactose or lactose-free carbohydrate blendsProteinPartially hydrolyzed whey and soy proteinsOtherThickeners (rice cereal)Soy fiberPrebiotics

Modified Cow Milk Protein or Soy-Based FormulasINDICATIONSInfants recovering from diarrheaInfants with colicInfants with GER

NOT for infants with galactosemiaNOT for cow milk formula intolerance

Special IndicationsGER Enfamil ARSimilac Sensitive for Spit up Diarrhea and fussinessSimilac Expert Care for DiarrheaEnfamil GentleaseSimilac Sensitive Fussiness and Gas Specialty-metabolic formulasSimilac PM 60/40Modified Cow or Soy Milk-Based Formulas

Gentleease: milk based powder with iron, partially broken down proteins39Modified Cow or Soy Milk-Based Formulas

Modified Cow or Soy Milk-Based Formulas

Modified Cow or Soy Milk-Based Formulas

QuestionA mother brings her 1 month old infant to clinic because of a 1 week history of bloody streaks in stool and fussiness. Mom was breastfeeding for the first 3 weeks of life, then switched to a cow milk-based formula 1 week ago. What formula should you recommend?

Protein Hydrolysate FormulaChild has milk protein intolerance, non-IgE mediated. Usually begins at 2 weeks of age-2 mo.Extensively Hydrolyzed FormulasMade for infants who are unable to digest or tolerate formulas containing intact cow milk protein.Lactose freeProteinExtensively hydrolyzed caseinPartially hydrolyzed wheyCarbohydrateGlucose polymers and/or sucroseFat ContentVegetable oilsLCT/MCT from safflower and soy

Extensively Hydrolyzed FormulasINDICATIONSCow milk and soy protein allergy Malabsorption syndromesCystic fibrosisBiliary AtresiaShort gut syndromePancreatic insufficiency Protein calorie malnutrition Autoimmune diseases/immunodeficiency syndromes

QuestionHydrolysate formulas are MOST often used in the management of:Celiac diseaseCow milk protein allergyCystic fibrosisGERLactose intolerance

Extensively Hydrolyzed FormulasNutramigenPregestemilSimilac Expert Care AlimentumExtensively Hydrolyzed Formulas

Amino Acid Based FormulasIntolerance to intact or hydrolyzed protein.

ProteinFree Amino Acids

CarbohydrateGlucose polymers

Amino Acid Based FormulasINDICATIONS

Cow Milk Protein AllergyEosinophilic GI disordersAtopic diseasesSevere food allergyAsthmaEczema

Amino Acid Based FormulasNeocateElecareNutramigen AA

Amino Acid Based Formulas

Other FormulasFollow-up Formulas

From 9 months of age - toddlersIncreased protein, minerals and iron.No advantage for infants eating adequate amounts of formula and solid foods.

Follow-up FormulasEnfamilEnfagrow PremiumEnfagrow Premium Soy

SimilacSimilac Go and Grow

Good StartGood Start 2 EssentialsGood Start 2 Essentials Soy

Follow-up Formulas

QuestionA 4 month old male is at clinic for his well child check. On questioning of his diet, mom states he drinks whole milk, orange juice, ravioli, and cheetos puffs. How do you counsel on appropriate dietary recommendations for his age?

Cows MilkIntroduce until 12 months of age!!!!Low iron content.May increase fecal blood loss in some infants.May cause hypocalcemia.High protein and electrolyte content high renal solute.Lower caloric content (19 cal/oz)Principles of Infant FeedingNumber of Meals a Day

0-3 mo: 6-8 bottles4-6 mo: 5 bottles + 1 solid meal6-8 mo: 4 bottles + 2 solid meals9-12 mo: 3 bottles + 3 solid mealsInfant Nutrition: Solid foodsCerealStrained VegetableStrained MeatsStrained fruitsTable FoodJuices and dessertsVitamins and MineralsSolid FoodsIntroduce at 4-6 months ageHas good head controlNo extrusion reflexSits with supportHas doubled birth weightSeems hungry after 32 oz milkQuestionWhat is the MOST likely outcome of introducing solid foods at an age of 3 months?Accelerates the development of oral motor skillsHelps the infant sleep through the nightIncreases the risk of food allergiesIncreases the risk of GERIncreases the risk of GI infectionsSolid Food Introduce rice cereal first.Advance to single vegetables.Add one food at a time.Feed same for 3-5 days.Combination dinners last.

Infant Nutrition0-4 mo: 100% total calories from milk 6-8 mo: 65% calories from milk 33% calories from solids.

9-12 mo: 50/50 milk and solids Solid foodsStrained Food

Stage 1 Foods: 2.5 oz jar, 4-5 moStage 2 Foods: 3.5 oz jar, 6-8 mo Stage 3 Foods: 6 oz jar, 9 mo Infant NutritionCEREALS Rice cereal Oatmeal Barley MixedInfant Nutrition CEREALSFirst solid introduced at 4-6 months of ageIron FortifiedProvides 15 calories per TbspFull serving: 4 Tbsp + 4 oz formula or breastmilk

DO NOT ADD IN BOTTLE!!!!!!!!Thickened feedings for severe GER

Rice CerealIntroduction of SolidsRecommendationsAt 4 monthsBreakfast: Rice Cereal (4 tbsp cereal/4oz formula)Lunch: Stage 1 veggies/fruitsSame vegetable for 3-5 days, then switch to new veggie

Introduction of SolidsAt 6 monthsBreakfast: Cereal

Lunch: Stage 2 foodsIntroduction of meatsMixed veggies or dinners

Dinner: Stage 2 foodsMixed veggies or dinners

Introduction of SolidsAt 9 monthsStage 3 and finger foods.

A Typical 6 mo Infant DietMorning: Cereal Mid-morning: FormulaNoon: VegetableMid-afternoon: FormulaLate afternoon: DinnerBed-time: Bottle