Nutrition Module Notes Pediatric I – Second Year Rebecca Abiog-Castro, M.D. Rhodora Garcia de...

Nutrition Module NotesNutrition Module Notes Pediatric I – Second YearPediatric I – Second Year

Rebecca Abiog-Castro, M.D.Rebecca Abiog-Castro, M.D.

Rhodora Garcia de Leon, M.DRhodora Garcia de Leon, M.D

Faculty of Medicine & Surgery, USTFaculty of Medicine & Surgery, UST

Objectives of the CourseObjectives of the CourseObjectives of the CourseObjectives of the Course

At the end of the course a Second Year Medical At the end of the course a Second Year Medical Student should be able:Student should be able:

To discuss briefly the anatomy of the breast and To discuss briefly the anatomy of the breast and physiology of lactation;physiology of lactation;

To discuss the benefits of breastmilk and the To discuss the benefits of breastmilk and the

benefits of breastfeeding to both infant and mother; benefits of breastfeeding to both infant and mother;

To discuss the barriers on breastfeeding;To discuss the barriers on breastfeeding;

To discuss the composition of mature breast-milk;To discuss the composition of mature breast-milk;

To discuss the difference between breast-milk and To discuss the difference between breast-milk and cow’s milk; cow’s milk;

At the end of the course a Second Year Medical At the end of the course a Second Year Medical Student should be able:Student should be able:

To discuss briefly the anatomy of the breast and To discuss briefly the anatomy of the breast and physiology of lactation;physiology of lactation;

To discuss the benefits of breastmilk and the To discuss the benefits of breastmilk and the

benefits of breastfeeding to both infant and mother; benefits of breastfeeding to both infant and mother;

To discuss the barriers on breastfeeding;To discuss the barriers on breastfeeding;

To discuss the composition of mature breast-milk;To discuss the composition of mature breast-milk;

To discuss the difference between breast-milk and To discuss the difference between breast-milk and cow’s milk; cow’s milk;

Objectives of the CourseObjectives of the CourseObjectives of the CourseObjectives of the Course

To discuss the steps to encourage Breast-feeding in To discuss the steps to encourage Breast-feeding in the hospital: UNICEF / WHO Baby-Friendly;the hospital: UNICEF / WHO Baby-Friendly;

To discuss the features of complementary foods;To discuss the features of complementary foods;

To discuss the proper method to introduce To discuss the proper method to introduce complementary foods;complementary foods;

To utilize the PSPGN Food Guide Pyramid for the To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children;prescription of the proper diet for infant & children;

To classify the different breast-milk substitutes To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for (infant formulas) and determine the indication/s for its use;its use;

To discuss the supplements for breastfed infants.To discuss the supplements for breastfed infants.

To discuss the steps to encourage Breast-feeding in To discuss the steps to encourage Breast-feeding in the hospital: UNICEF / WHO Baby-Friendly;the hospital: UNICEF / WHO Baby-Friendly;

To discuss the features of complementary foods;To discuss the features of complementary foods;

To discuss the proper method to introduce To discuss the proper method to introduce complementary foods;complementary foods;

To utilize the PSPGN Food Guide Pyramid for the To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children;prescription of the proper diet for infant & children;

To classify the different breast-milk substitutes To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for (infant formulas) and determine the indication/s for its use;its use;

To discuss the supplements for breastfed infants.To discuss the supplements for breastfed infants.

Mother's milk is the best Mother's milk is the best

food a baby can have food a baby can have

exclusively in the first 6 exclusively in the first 6

months of life;months of life;

should be continued should be continued

untiluntil

two years and beyond.two years and beyond.

Mother's milk is the best Mother's milk is the best

food a baby can have food a baby can have

exclusively in the first 6 exclusively in the first 6

months of life;months of life;

should be continued should be continued

untiluntil

two years and beyond.two years and beyond.

Anatomy of BreastAnatomy of Breast

Internal structuresExternal structures:External structures: Cross section of alveolus

Breast StructureBreast StructureBreast StructureBreast Structure

Anatomy of the BreastAnatomy of the BreastAnatomy of the BreastAnatomy of the Breast

Teat

Tongue

Palate

Physiology of lactationPhysiology of lactation

Endocrine controlEndocrine control

Physiology of lactationPhysiology of lactation

Endocrine controlEndocrine control

Three main phases of lactationThree main phases of lactation

1)1) MammogenesisMammogenesis or or mammary growthmammary growth

2)2) LactogenesisLactogenesis or or initiation of milk secretion: initiation of milk secretion:

Stage I:Stage I: 12 wks before parturition 12 wks before parturitionStage II:Stage II: 2-3 days postpartum 2-3 days postpartum

3)3) Stage IIIStage III of of LactogenesisLactogenesis or or Galactopoiesis Galactopoiesis maintenance of milk secretionmaintenance of milk secretion: 14-30 das.: 14-30 das.

Three main phases of lactationThree main phases of lactation

1)1) MammogenesisMammogenesis or or mammary growthmammary growth

2)2) LactogenesisLactogenesis or or initiation of milk secretion: initiation of milk secretion:

Stage I:Stage I: 12 wks before parturition 12 wks before parturitionStage II:Stage II: 2-3 days postpartum 2-3 days postpartum

3)3) Stage IIIStage III of of LactogenesisLactogenesis or or Galactopoiesis Galactopoiesis maintenance of milk secretionmaintenance of milk secretion: 14-30 das.: 14-30 das.

Three Main Phases of Lactation Three Main Phases of Lactation (hormonal)(hormonal)


Phase I - Phase I - MammogenesisMammogenesis– Profound during pregnancy in preparation for Profound during pregnancy in preparation for

lactationlactation

– Placental lactogen, estrogen, progesteronePlacental lactogen, estrogen, progesterone

– Ductal Sprouting (Ductal Sprouting (estrogenestrogen), lobular formation ), lobular formation ((progesteroneprogesterone), ), ProlactinProlactin essential for complete essential for complete gland growthgland growth

Phase I - Phase I - MammogenesisMammogenesis– Profound during pregnancy in preparation for Profound during pregnancy in preparation for

lactationlactation

– Placental lactogen, estrogen, progesteronePlacental lactogen, estrogen, progesterone

– Ductal Sprouting (Ductal Sprouting (estrogenestrogen), lobular formation ), lobular formation ((progesteroneprogesterone), ), ProlactinProlactin essential for complete essential for complete gland growthgland growth

Phase I - Phase I - MammogenesisMammogenesis

Hormones Involved in Mammary GrowthHormones Involved in Mammary Growth

Estrogens Progesterone GH Placental lactogens (PL)Prolactin Glucocorticoids GH and PL induce alveolar growth Steroids without GH and PL do not exert any effect

INDUCTION OF GROWTH (Normal animals)

• Estrogens alone induce alveolar growth

– Larger than normal alveoli

• Estrogen and progesterone induce normal growth

Phase I - Phase I - MammogenesisMammogenesis

Phase II - LACTOGENESIS

INITIATION OF LACTATION

At parturition the mammary gland switches from a growing non secretory tissue to a secreting, non-growing tissue

Change is endocrine mediated



Phase II - Phase II - LactogenesisLactogenesis (initiation of milk):(initiation of milk):

– Stage I:Stage I: starts 12 wks before delivery starts 12 wks before delivery

Gathering of all substrates for milk productionGathering of all substrates for milk production

– Stage II:Stage II: starts 2-3 days postpartum starts 2-3 days postpartum

Milk secretion is copiousMilk secretion is copious

Phase II - Phase II - LactogenesisLactogenesis (initiation of milk):(initiation of milk):

– Stage I:Stage I: starts 12 wks before delivery starts 12 wks before delivery

Gathering of all substrates for milk productionGathering of all substrates for milk production

– Stage II:Stage II: starts 2-3 days postpartum starts 2-3 days postpartum

Milk secretion is copiousMilk secretion is copious

Endocrine Patterns Related to Parturition

ENDOCRINE REGULATION OF LACTOGENESIS

Endocrine Control of LactationEndocrine Control of LactationEndocrine Control of LactationEndocrine Control of Lactation

Milk Production Reflex:Milk Production Reflex:

ProlactinProlactin is a key lactogenic hormone, is a key lactogenic hormone, stimulating initial alveolar milk productionstimulating initial alveolar milk production

Milk Ejection Reflex:Milk Ejection Reflex:

OxytocinOxytocin contracts the myoepithelial; cells, contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts forcing milk from the alveoli into the ducts and sinuses where it is removed by the and sinuses where it is removed by the infantinfant

Milk Production Reflex:Milk Production Reflex:

ProlactinProlactin is a key lactogenic hormone, is a key lactogenic hormone, stimulating initial alveolar milk productionstimulating initial alveolar milk production

Milk Ejection Reflex:Milk Ejection Reflex:

OxytocinOxytocin contracts the myoepithelial; cells, contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts forcing milk from the alveoli into the ducts and sinuses where it is removed by the and sinuses where it is removed by the infantinfant

Effect of different hormones in the initiation of milk production

Glucocorticoids – Development of RER (rough endoplasmic reticulum)

Prolactin – Maturation of Golgi – Secretory vesicles – Responsible for milk secretion

Progesterone – Promotes mammary growth specially alveolar tissue – Blocks epithelial secretion – As it decreases, the block for lactogenesis is removed

ENDOCRINE REGULATION OF LACTOGENESIS

Effect of different hormones in the initiation of milk production

MAMMARY GROWTH SLOWS DOWN

Most hormones involved in growth have been removed – Progesterone

CL has regressed and placenta is removed – Estrogens

Feto-placental unit no longer available – Placental lactogens

Placenta was expelled

After parturition mammary growth slows down because most growth promoting hormones are no longer available

Phase III – Phase III – GalactopoiesisGalactopoiesismaintenance of Breastmilk Secretionmaintenance of Breastmilk Secretion

Phase III – Phase III – GalactopoiesisGalactopoiesismaintenance of Breastmilk Secretionmaintenance of Breastmilk Secretion

Stage III of Stage III of Lactogenesis or GalactopoiesisLactogenesis or Galactopoiesis– Maintenance of milk secretionMaintenance of milk secretion– From 14- 30 daysFrom 14- 30 days– Mature milk is establishedMature milk is established– ProlactinProlactin and and OxytocinOxytocin essential for effective essential for effective

maintenance of milk supplymaintenance of milk supply

Stage III of Stage III of Lactogenesis or GalactopoiesisLactogenesis or Galactopoiesis– Maintenance of milk secretionMaintenance of milk secretion– From 14- 30 daysFrom 14- 30 days– Mature milk is establishedMature milk is established– ProlactinProlactin and and OxytocinOxytocin essential for effective essential for effective

maintenance of milk supplymaintenance of milk supply

Hormones in charge of supporting continuous milk production

Responsibility of prolactin and growth hormone

Supported by thyroid, parathyroid and adrenal glands through adequate metabolic function

MAINTENANCE OF LACTOGENESIS(Galactopoiesis)

Autocrine Control of LactationAutocrine Control of LactationAutocrine Control of LactationAutocrine Control of Lactation

Influence of of Local Factors Acting on the Influence of of Local Factors Acting on the BreastsBreasts

It is not just the level of maternal hormones, but It is not just the level of maternal hormones, but the efficiency of the efficiency of milk removalmilk removal that governs the that governs the volume product in each breastvolume product in each breast

A protein factor called A protein factor called feedback inhibitor of feedback inhibitor of lactation (FIL)lactation (FIL) is secreted with other milk is secreted with other milk components into the alveolar lumencomponents into the alveolar lumen

FILFIL, insensitive to prolactin , insensitive to prolactin milk production milk production

Influence of of Local Factors Acting on the Influence of of Local Factors Acting on the BreastsBreasts

It is not just the level of maternal hormones, but It is not just the level of maternal hormones, but the efficiency of the efficiency of milk removalmilk removal that governs the that governs the volume product in each breastvolume product in each breast

A protein factor called A protein factor called feedback inhibitor of feedback inhibitor of lactation (FIL)lactation (FIL) is secreted with other milk is secreted with other milk components into the alveolar lumencomponents into the alveolar lumen

FILFIL, insensitive to prolactin , insensitive to prolactin milk production milk production

Autocrine Control of LactationAutocrine Control of LactationAutocrine Control of LactationAutocrine Control of Lactation

FILFIL

FILFIL

FILFIL

Anatomy & Physiology: Milk Anatomy & Physiology: Milk production production

Risk factors for delayed onset of lactation Risk factors for delayed onset of lactation were:were:

Stage II labor > 1 hr, Stage II labor > 1 hr,

Pre-pregnant maternal BMI > 27 kg/m2, Pre-pregnant maternal BMI > 27 kg/m2,

Breastfeeding problems at day 3,and Breastfeeding problems at day 3,and

Being primiparous. Being primiparous. Dewey et al, 2001

Factors associated with breastfeeding problems at Factors associated with breastfeeding problems at day 7 day 7 includedincluded: :

flat or inverted nipples at day 7, flat or inverted nipples at day 7,

stage II labor > 1 hour, stage II labor > 1 hour,

birthweight < 3601 gms, birthweight < 3601 gms,

Pre-pregnant maternal BMI > 27 kg/m2Pre-pregnant maternal BMI > 27 kg/m2

non breast milk fluids givennon breast milk fluids given in the first 48 hours of life in the first 48 hours of life

Anatomy & Physiology: Milk Anatomy & Physiology: Milk productionproduction

Dewey, 2003

Breastmilk compositionBreastmilk composition

Breast-milkBreast-milkBreast-milkBreast-milk

Variations of BreastmilkVariations of Breastmilk

– Colostrum (1Colostrum (1stst 3-5 days of life) 3-5 days of life)

– Term breastmilk ( mother’s own: 7 - 10 – 28 Term breastmilk ( mother’s own: 7 - 10 – 28 days)days)

– Pre-term Milk ( day 7- 28 days)Pre-term Milk ( day 7- 28 days)

– Mature breastmilk ( >30 days)Mature breastmilk ( >30 days)

– Drip breastmilk ( 30-90 days postpartum)Drip breastmilk ( 30-90 days postpartum)

Variations of BreastmilkVariations of Breastmilk

– Colostrum (1Colostrum (1stst 3-5 days of life) 3-5 days of life)

– Term breastmilk ( mother’s own: 7 - 10 – 28 Term breastmilk ( mother’s own: 7 - 10 – 28 days)days)

– Pre-term Milk ( day 7- 28 days)Pre-term Milk ( day 7- 28 days)

– Mature breastmilk ( >30 days)Mature breastmilk ( >30 days)

– Drip breastmilk ( 30-90 days postpartum)Drip breastmilk ( 30-90 days postpartum)

ColostrumColostrumColostrumColostrum

First postpartum week’s mammary secretion consisting of First postpartum week’s mammary secretion consisting of

yellowish (beta carotene) thick fluid;yellowish (beta carotene) thick fluid;

Has higher protein, lower fat and lactose; rich in Vitamin A (3x > Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x);BM), carotenoid (10x), vitamin E(3x);

Protein content is rich inProtein content is rich in sIgA and immunologically competent sIgA and immunologically competent mononuclear cells;mononuclear cells;

ContainsContains antioxidants which trap neutrophil-generated oxygen antioxidants which trap neutrophil-generated oxygen radicals.radicals.

First postpartum week’s mammary secretion consisting of First postpartum week’s mammary secretion consisting of

yellowish (beta carotene) thick fluid;yellowish (beta carotene) thick fluid;

Has higher protein, lower fat and lactose; rich in Vitamin A (3x > Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x);BM), carotenoid (10x), vitamin E(3x);

Protein content is rich inProtein content is rich in sIgA and immunologically competent sIgA and immunologically competent mononuclear cells;mononuclear cells;

ContainsContains antioxidants which trap neutrophil-generated oxygen antioxidants which trap neutrophil-generated oxygen radicals.radicals.

Distribution of Immunoglobulins and other Distribution of Immunoglobulins and other Soluble Substances in the Colostrum and Milk Soluble Substances in the Colostrum and Milk Delivered to the Breast-Fed Infant During a Delivered to the Breast-Fed Infant During a

24-Hour Period24-Hour Period

Distribution of Immunoglobulins and other Distribution of Immunoglobulins and other Soluble Substances in the Colostrum and Milk Soluble Substances in the Colostrum and Milk Delivered to the Breast-Fed Infant During a Delivered to the Breast-Fed Infant During a

24-Hour Period24-Hour Period

Soluble Soluble ProductProduct

Concentration in MG /Day at PostpartumConcentration in MG /Day at Postpartum

<1 <1 weekweek

1-2 1-2 weeksweeks

3-4 weeks3-4 weeks >4 >4 weeksweeks

IgGIgG 5050 2525 2525 1010

IgA*IgA* 50005000 10001000 10001000 10001000

IgMIgM 7070 3030 1515 1010

LysozymeLysozyme 5050 6060 6060 100100

LactoferrinLactoferrin 15001500 20002000 20002000 12001200

Type of Volume Energy Protein CHO FAT Type of Volume Energy Protein CHO FAT NANA Milk Milk ml/d ml/d Kcal/100 ml G/100mL G/100 ml G/100 ml Kcal/100 ml G/100mL G/100 ml G/100 ml mmol/100MLmmol/100ML

ColostrumColostrum 100 100 0.67 0.67 2.3 2.3 5.3 2.9 5.3 2.9 1.71.7

(1-5 d) (1-5 d)

TermTerm D7 558 0.73 1.95 6.72 3.52 D7 558 0.73 1.95 6.72 3.52 0.970.97 D 14 591 0.67 1.62 6.97 3.88 D 14 591 0.67 1.62 6.97 3.88

1.271.27

Breastmilk Breastmilk 750 0.69 1.1 7.4 4.2 750 0.69 1.1 7.4 4.2 0.70 0.70

(Mature>30 d)(Mature>30 d)

Type of Volume Energy Protein CHO FAT Type of Volume Energy Protein CHO FAT NANA Milk Milk ml/d ml/d Kcal/100 ml G/100mL G/100 ml G/100 ml Kcal/100 ml G/100mL G/100 ml G/100 ml mmol/100MLmmol/100ML

ColostrumColostrum 100 100 0.67 0.67 2.3 2.3 5.3 2.9 5.3 2.9 1.71.7

(1-5 d) (1-5 d)

TermTerm D7 558 0.73 1.95 6.72 3.52 D7 558 0.73 1.95 6.72 3.52 0.970.97 D 14 591 0.67 1.62 6.97 3.88 D 14 591 0.67 1.62 6.97 3.88

1.271.27

Breastmilk Breastmilk 750 0.69 1.1 7.4 4.2 750 0.69 1.1 7.4 4.2 0.70 0.70

(Mature>30 d)(Mature>30 d)

Type of Volume ENERGY PROTEIN CHO FAT Type of Volume ENERGY PROTEIN CHO FAT NANAMilk Milk (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml mmol/100 mlmmol/100 ml

Preterm Preterm

D7D7 461 461 0.647 0.647 2.59 6.23 4.02 2.59 6.23 4.02 2.452.45

D14D14 413 413 0.68 0.68 2.29 2.29 6.21 4.71 2.2 6.21 4.71 2.2

D28D28 452 0.652 1.91 452 0.652 1.91 6.39 4.33 6.39 4.33 1.51 1.51

DripDripBM BM 0.54 1.35 7.1 0.54 1.35 7.1 2.2 0.52.2 0.5

Cow Cow 0.67 3.4 4.6 3.9 0.67 3.4 4.6 3.9 2.3 2.3

Type of Volume ENERGY PROTEIN CHO FAT Type of Volume ENERGY PROTEIN CHO FAT NANAMilk Milk (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml mmol/100 mlmmol/100 ml

Preterm Preterm

D7D7 461 461 0.647 0.647 2.59 6.23 4.02 2.59 6.23 4.02 2.452.45

D14D14 413 413 0.68 0.68 2.29 2.29 6.21 4.71 2.2 6.21 4.71 2.2

D28D28 452 0.652 1.91 452 0.652 1.91 6.39 4.33 6.39 4.33 1.51 1.51

DripDripBM BM 0.54 1.35 7.1 0.54 1.35 7.1 2.2 0.52.2 0.5

Cow Cow 0.67 3.4 4.6 3.9 0.67 3.4 4.6 3.9 2.3 2.3

Calculated Nutrient Intakes Compared Calculated Nutrient Intakes Compared to Estimated Needs for LBWto Estimated Needs for LBW

Units/KG/DUnits/KG/D PreTerm MilkPreTerm Milk

Week of LactationWeek of LactationMatureMature

MilkMilkEstimateEstimated Needsd Needs

11 22 44

Energy (KCAL)Energy (KCAL) 120120 120120 120120 120120 120120

Fluid Vol. (ML)Fluid Vol. (ML) 180180 180180 180180 190190 150150

Protein (G)Protein (G) 3.93.9 3.43.4 2.82.8 2.42.4 3.53.5

Sodium (MMOL)Sodium (MMOL) 4.04.0 2.72.7 1.81.8 2.02.0 3.03.0

Calcium (MG)Calcium (MG) 5353 4646 4242 4747 160-200160-200

Phosphorus Phosphorus (MG)(MG)

2525 2727 2323 2626 80-10080-100

HUMANHUMAN COW’SCOW’S

Amino-acidsAmino-acids

CystineCystine

TaurineTaurineEnough for growing Enough for growing brainbrain

Not enoughNot enough

FatFat

TotalTotal

Saturation of fatty Saturation of fatty acidsacids

Linoleic acid Linoleic acid (essential)(essential)

CholesterolCholesterol

4% (average)4% (average)

Enough unsaturatedEnough unsaturated

Enough for growing Enough for growing brainbrain

EnoughEnough

4%4%Too much saturatedToo much saturated



Lipase to digest fatLipase to digest fat PresentPresent NoneNone

Lactose (sugar)Lactose (sugar) 7% -- enough7% -- enough 3-4% - not 3-4% - not enoughenough

Salts (mEq/l)Salts (mEq/l)

SodiumSodium

ChlorideChloride

PotassiumPotassium

6.5 correct amount6.5 correct amount

12 correct amount12 correct amount

14 correct amount14 correct amount

25 too much25 too much




Minerals (mg/l)Minerals (mg/l)

CalciumCalcium

PhosphatePhosphate350 correct amount350 correct amount

150 correct amount150 correct amount1,400 too much1,400 too much


IronIron Small amountSmall amount

Well absorbedWell absorbed

EnoughEnough

Small amountSmall amount

Poorly absorbedPoorly absorbed


VitaminsVitamins EnoughEnough Not enoughNot enough

WaterWater EnoughEnough

No extra neededNo extra neededExtra neededExtra needed

Nutrients in human and animal Nutrients in human and animal milkmilk

FatFat

ProteinProtein

LactoseLactose

Human Cow Goat

7

1

3.8

4.8

3.4

3.4

4.1

2.9

2.9

5.5

3.6

3.6

HUMANHUMAN COWCOW GOATGOAT BUFFALOBUFFALO

VITAMIN CONTENTVITAMIN CONTENT

VitaminVitamin HumanHuman Cow’sCow’sAA Enough even in 2Enough even in 2ndnd

year year

2 X in colostrum2 X in colostrum

In case of deficiency In case of deficiency give supplement to give supplement to mothermother

Less (x 1/2)Less (x 1/2)

B GroupB Group PlentyPlenty Even moreEven more

CC EnoughEnough Less (x 1/5)Less (x 1/5)

May need supplement if May need supplement if fed artificiallyfed artificially

DD EnoughEnough LessLess

KK Usually enoughUsually enough

More in ColostrumMore in ColostrumMoreMore

Comparison of Human Milk and Cow’s MilkComparison of Human Milk and Cow’s Milk


Bacteria Bacteria contaminationcontamination

NoneNone LikelyLikely

Anti-infective Anti-infective SubstancesSubstances

AntibodiesAntibodies

LeucocytesLeucocytes

LactoferrinLactoferrin

Bifidus factorBifidus factor

Not activeNot active

ProteinProtein

- Total- Total

- Casein- Casein

- Lactalbumen- Lactalbumen

1%1%

0.5%0.5%

0.5%0.5%

4% too much4% too much

3% too much3% too much

0.5%0.5%

Supplements for Breastfed Supplements for Breastfed InfantsInfants

The following supplementation is generally The following supplementation is generally recommended: recommended:

– Vitamin K supplement in the immediate Vitamin K supplement in the immediate postpartum period. postpartum period.

– 400 IU of Vitamin D400 IU of Vitamin D

– Breastfeeding women should continue Breastfeeding women should continue taking prenatal vitamins especially vitamin taking prenatal vitamins especially vitamin D, calcium and iron D, calcium and iron

– Complementary foods should be given once Complementary foods should be given once infants reach six months of ageinfants reach six months of age

Review QuestionsReview Questions

1)1) The part of breast responsible for milk secretion The part of breast responsible for milk secretion _________ under the influence of what hormone? _______________ under the influence of what hormone? ______

2)2) Two important reflexes that are needed for BM Two important reflexes that are needed for BM secretion? ________secretion? ________

3)3) Which part of the breast is milk stored? ________Which part of the breast is milk stored? ________

4)4) Hormone secreted during BF which can reduce Hormone secreted during BF which can reduce BF________BF________

5)5) Major source of protein in BM ______Major source of protein in BM ______

Benefits of Breastmilk / Benefits of Breastmilk /

Breastfeeding to Infants and Breastfeeding to Infants and

MothersMothers

Benefits of Breastmilk

Enhances Cognitive Development Protective: Both for baby and

mother Cheap & Free: Benefits the Economy Safe

Benefits of Breastmilk

Enhances Cognitive Development Protective: Both for baby and

mother Cheap & Free: Benefits the Economy Safe

Enhances Cognitive DevelopmentEnhances Cognitive Development

– Docosohexanoic Acid (DHA)Docosohexanoic Acid (DHA)

– LactoseLactose

– ‘‘Skin to skinSkin to skin’ Contact and ‘’ Contact and ‘face to face’face to face’ positionposition

Enhances Cognitive DevelopmentEnhances Cognitive Development

– Docosohexanoic Acid (DHA)Docosohexanoic Acid (DHA)

– LactoseLactose

– ‘‘Skin to skinSkin to skin’ Contact and ‘’ Contact and ‘face to face’face to face’ positionposition

Benefits of Breastmilk: Infant


DHA (Docosohexanoic Acid):

Fatty acid derived from Linolenic Acid

Only found in breastmilk in consistent level

Important substance for the myelin sheath of nerve fibers

Vital nutrient for the growth and development of brain tissue and good vision

Researches showed that it is this substance that enhances cognitive development

DHA (Docosohexanoic Acid):

Fatty acid derived from Linolenic Acid

Only found in breastmilk in consistent level

Important substance for the myelin sheath of nerve fibers

Vital nutrient for the growth and development of brain tissue and good vision

Researches showed that it is this substance that enhances cognitive development

Benefits of Breastmilk: InfantBenefits of Breastmilk: Infant

Lactose

Predominant carbohydrate of breastmilk

Disaccharide consisting of glucose and galactose

Galactose combines with lipid to form a valuable nutrient, galactose-lipid, for brain tissue development

Lactose

Predominant carbohydrate of breastmilk

Disaccharide consisting of glucose and galactose

Galactose combines with lipid to form a valuable nutrient, galactose-lipid, for brain tissue development


‘Skin to skin’ contact & ‘Face to Face’ position

Enhances the cognitive and educational development of children as each feeding time is a learning opportunity for mother and child

‘Skin to skin’ contact & ‘Face to Face’ position

Enhances the cognitive and educational development of children as each feeding time is a learning opportunity for mother and child


Breastmilk is Protective

Protective properties of BM is divided into two:

– Humoral factors: Consists of the 5 immunoglobulins (antibodies):

– IgA, s IgA, IgG, Ig E, Ig D, Ig M

– Cellular factors: White Blood cells: Neutrophils Lymphocytes Epithelial cells Macrophages


Protective properties of BM is divided into two:

– Humoral factors: Consists of the 5 immunoglobulins (antibodies):

– IgA, s IgA, IgG, Ig E, Ig D, Ig M

– Cellular factors: White Blood cells: Neutrophils Lymphocytes Epithelial cells Macrophages



White Blood Cells

Bacterial killer

Highest concentration of WBC occurs in the 1st few days of lactation > a million/ml

Colostrum (1-5 days post-natal):

– Contains 105 – 5 x 106 WBC / ml


White Blood Cells

Bacterial killer

Highest concentration of WBC occurs in the 1st few days of lactation > a million/ml

Colostrum (1-5 days post-natal):

– Contains 105 – 5 x 106 WBC / ml



Bifidus Factor:– Enhances the growth of Lactobacillus

bifidus preventing growth of pathogenic bacteria

Lactoferrin:– Binds iron thus preventing the growth of

iron-dependent bacteria


Bifidus Factor:– Enhances the growth of Lactobacillus

bifidus preventing growth of pathogenic bacteria

Lactoferrin:– Binds iron thus preventing the growth of

iron-dependent bacteria


Host Resistance Factors in BMHost Resistance Factors in BMHost Resistance Factors in BMHost Resistance Factors in BM

Non-immunoglobulin components:Non-immunoglobulin components:– OligosaccharidesOligosaccharides– MucinMucin– Fatty acidsFatty acids

Non-immunoglobulin components:Non-immunoglobulin components:– OligosaccharidesOligosaccharides– MucinMucin– Fatty acidsFatty acids

Anti-infective PropertiesAnti-infective PropertiesAnti-infective PropertiesAnti-infective Properties

IgA, IgM, IgGIgA, IgM, IgG:: immunoglobulins that guard the gut immunoglobulins that guard the gut against infective bacteriaagainst infective bacteria

Bifidus factor:Bifidus factor: stimulates bifido-bacteria, which stimulates bifido-bacteria, which fight against pathogenic bacteriafight against pathogenic bacteria

Lactoferrin:Lactoferrin: binds iron away from bacteria binds iron away from bacteria

Macrophages:Macrophages: phagocytosis of infective bacteria phagocytosis of infective bacteria

BB1212 binding protein: binding protein: removes B removes B1212 from bacteria from bacteria

IgA, IgM, IgGIgA, IgM, IgG:: immunoglobulins that guard the gut immunoglobulins that guard the gut against infective bacteriaagainst infective bacteria

Bifidus factor:Bifidus factor: stimulates bifido-bacteria, which stimulates bifido-bacteria, which fight against pathogenic bacteriafight against pathogenic bacteria

Lactoferrin:Lactoferrin: binds iron away from bacteria binds iron away from bacteria

Macrophages:Macrophages: phagocytosis of infective bacteria phagocytosis of infective bacteria

BB1212 binding protein: binding protein: removes B removes B1212 from bacteria from bacteria



Antiviral Factors in Human MilkAntiviral Factors in Human MilkFactorFactor Shown, in vitro, to be Shown, in vitro, to be

active against:active against:Effect of HeatEffect of Heat

Secretory Secretory IgAIgA

Poliovirus types 1, 2, 3. Poliovirus types 1, 2, 3. Coxsackie types A9, B3, Coxsackie types A9, B3,

B5, B5,

Echovirus types 6, 9. Echovirus types 6, 9. Semliki Forest VirusSemliki Forest Virus

Ross River VirusRoss River Virus

RotavirusRotavirus

CytomegalovirusCytomegalovirus

Reovirus type 3Reovirus type 3

Rubella virusRubella virus

Herpes simplex virus, Herpes simplex virus, Mumps virusMumps virus

Influenza virus Influenza virus

Respiratory syncytial Respiratory syncytial virusvirus

Stable at 56Stable at 56°C for °C for 30 mins.; 30 mins.;

Some loss (0 – 30%) Some loss (0 – 30%) at 62.5 °C for 30 at 62.5 °C for 30 mins; mins;

destroyed by boilingdestroyed by boiling

Enhanced immune response to Enhanced immune response to immunizationsimmunizations– PolioPolio– TetanusTetanus– DiptheriaDiptheria– Haemophilus influenzaHaemophilus influenza

Enhanced immune response to Enhanced immune response to immunizationsimmunizations– PolioPolio– TetanusTetanus– DiptheriaDiptheria– Haemophilus influenzaHaemophilus influenza



Protection Against InfectionProtection Against InfectionProtection Against InfectionProtection Against Infection

Reduces risk and severity of Reduces risk and severity of infectious illness among infectious illness among infantsinfants– diarrheadiarrhea– otitis mediaotitis media– lower respiratory infectionslower respiratory infections– bacteremiabacteremia– bacterial meningitisbacterial meningitis– necrotizing enterocolitisnecrotizing enterocolitis– infant botulisminfant botulism– urinary tract diseaseurinary tract disease– sudden infant death syndrome sudden infant death syndrome

(SIDS)(SIDS)– ColicColic– wheezingwheezing

Reduces risk and severity of Reduces risk and severity of infectious illness among infectious illness among infantsinfants– diarrheadiarrhea– otitis mediaotitis media– lower respiratory infectionslower respiratory infections– bacteremiabacteremia– bacterial meningitisbacterial meningitis– necrotizing enterocolitisnecrotizing enterocolitis– infant botulisminfant botulism– urinary tract diseaseurinary tract disease– sudden infant death syndrome sudden infant death syndrome

(SIDS)(SIDS)– ColicColic– wheezingwheezing

Antibacterial PropertiesAntibacterial Propertiesfound in human milkfound in human milk

FactorFactor Shown, in vitro, to be active Shown, in vitro, to be active against:against:

Effect of HeatEffect of Heat

Secretory IgASecretory IgA E. Coli (also pili and capsular E. Coli (also pili and capsular antigens)antigens)

C. TetaniC. Tetani

C. DiphtheriaeC. Diphtheriae

K. pneumoniaeK. pneumoniae

Salmonella (6 groups)Salmonella (6 groups)

Shigella (2 groups)Shigella (2 groups)

Streptococcus, S. mutans, S. sanguis, Streptococcus, S. mutans, S. sanguis, S. mitis, S. salivarius, S. pneumoniae, S. mitis, S. salivarius, S. pneumoniae,

C. burnetti, C. burnetti,

H. influenzae H. influenzae

E. coli enterotoxin, E. coli enterotoxin,

V. Cholerae enterotoxinV. Cholerae enterotoxin

C. difficile toxinsC. difficile toxins

H. Influenzae capsuleH. Influenzae capsule

Stable at 56Stable at 56°C for °C for 30 min; 30 min;

some loss (0-30%) some loss (0-30%) at 62.5°C for 30 at 62.5°C for 30 min; min;

destroyed by destroyed by boiling boiling

IgM, IgGIgM, IgG V. Cholerae lipopolysaccharide; V. Cholerae lipopolysaccharide; E. coliE. coli

IgM destroyed and IgM destroyed and IgG decreased by a IgG decreased by a third at 62.5third at 62.5°C for °C for 30 min30 min

FactorFactor Shown, in vitro, Shown, in vitro, to be active to be active

against:against:


IgDIgD

Bifidobacterium Bifidobacterium bifidum growthbifidum growth

z factorz factor

E. ColiE. Coli

EnterobacteriaceEnterobacteriacea, enteric a, enteric pathogenspathogens

Stable to boilingStable to boiling

Factor binding Factor binding proteins (zinc, proteins (zinc, vitamin Bvitamin B1212, folate), folate)

Dependent E. coliDependent E. coli Destroyed by Destroyed by boilingboiling

Complement C1-C9 Complement C1-C9 (mainly C3 and C4)(mainly C3 and C4)

Effect not knownEffect not known Destroyed by Destroyed by heating at 56heating at 56°C for °C for 30 min30 min

LactoferrinLactoferrin E. ColiE. Coli Two-thirds Two-thirds destroyed at destroyed at 62.5°C for 30 min; 62.5°C for 30 min; essentially essentially destroyed by destroyed by boiling for 15 minboiling for 15 min

FactorFactor Shown, in vitro, Shown, in vitro, to be active to be active

against:against:


LactoperoxidasLactoperoxidasee

Streptococcus, Streptococcus, Pseudomonas, E. Pseudomonas, E. coli, S. coli, S. typhimuriumtyphimurium

Destroyed by boilingDestroyed by boiling

LysozymeLysozyme E. coli, Salmonella, E. coli, Salmonella, Micrococcus Micrococcus lysodeikticuslysodeikticus

Some loss (0-23%) at Some loss (0-23%) at 62.562.5°C for 30 min; °C for 30 min; essentially destroyed by essentially destroyed by boiling for 15 minboiling for 15 min

Unidentified Unidentified factorsfactors

S. aureus, C. S. aureus, C. difficile toxin Bdifficile toxin B

Stable at autoclaving; Stable at autoclaving; stable at 56°C for 30 minstable at 56°C for 30 min

CarbohydrateCarbohydrate E. coli enterotoxinE. coli enterotoxin Stable at 85°C for 30 minStable at 85°C for 30 min

LipidLipid S. AureusS. Aureus Stable at boilingStable at boiling

Ganglioside Ganglioside (GMI like)(GMI like)

E. Coli enterotoxin, E. Coli enterotoxin, V. cholerae V. cholerae enterotoxinenterotoxin

Stable to boilingStable to boiling

Types of Breast milk

Foremilk

Hindmilk

Protective Factors in BMProtective Factors in BMProtective Factors in BMProtective Factors in BM

Non-immunoglobulin components:Non-immunoglobulin components:

- Non-specific factors:Non-specific factors: Bifidus factorBifidus factor Resistance factor (Anti-staphylococcal Resistance factor (Anti-staphylococcal

factor)factor) Anti-viral factorAnti-viral factor Anti-protozoal factors (bile-salt Anti-protozoal factors (bile-salt

stimulated lipase)stimulated lipase)

– Enzymes: Lysozyme, lipoprotein lipaseEnzymes: Lysozyme, lipoprotein lipase

Non-immunoglobulin components:Non-immunoglobulin components:

- Non-specific factors:Non-specific factors: Bifidus factorBifidus factor Resistance factor (Anti-staphylococcal Resistance factor (Anti-staphylococcal

factor)factor) Anti-viral factorAnti-viral factor Anti-protozoal factors (bile-salt Anti-protozoal factors (bile-salt

stimulated lipase)stimulated lipase)

– Enzymes: Lysozyme, lipoprotein lipaseEnzymes: Lysozyme, lipoprotein lipase

Protective Factors in BMProtective Factors in BMProtective Factors in BMProtective Factors in BM

Anti-inflammatoryAnti-inflammatory properties: properties:

– BM is poor initiators and mediators of BM is poor initiators and mediators of inflammation (complement system, fibrinolytic, inflammation (complement system, fibrinolytic, coagulation system) but rich in anti-coagulation system) but rich in anti-inflammatory agents (sIGA, lysozyme); inflammatory agents (sIGA, lysozyme);

Provides Provides good mucosal barriergood mucosal barrier (growth (growth factors) factors) prevents attachment of bacteria prevents attachment of bacteria & antigen;& antigen;

Anti-inflammatoryAnti-inflammatory properties: properties:

– BM is poor initiators and mediators of BM is poor initiators and mediators of inflammation (complement system, fibrinolytic, inflammation (complement system, fibrinolytic, coagulation system) but rich in anti-coagulation system) but rich in anti-inflammatory agents (sIGA, lysozyme); inflammatory agents (sIGA, lysozyme);

Provides Provides good mucosal barriergood mucosal barrier (growth (growth factors) factors) prevents attachment of bacteria prevents attachment of bacteria & antigen;& antigen;

Maternal HIVMaternal HIV

Maternal-to-Child Viral Transmission (MTCT):Maternal-to-Child Viral Transmission (MTCT):

Breastfeeding vs Formula feeding:Breastfeeding vs Formula feeding:

– Prevalence of MTCT at 24 months:Prevalence of MTCT at 24 months:

Breastfeeding (BF):Breastfeeding (BF): 36.7%36.7% Formula-feeding (FF):Formula-feeding (FF): 20.5%20.5%

– Mortality rate:Mortality rate: BF:BF: 24.4%24.4% FF:FF: 20.0% 20.0%

Nduati R. et al. JAMA 2000Nduati R. et al. JAMA 2000

Maternal HIVMaternal HIV

Maternal-to-Child Viral Transmission (MTCT):Maternal-to-Child Viral Transmission (MTCT):

Breastfeeding vs Formula feeding:Breastfeeding vs Formula feeding:

– Prevalence of MTCT at 24 months:Prevalence of MTCT at 24 months:

Breastfeeding (BF):Breastfeeding (BF): 36.7%36.7% Formula-feeding (FF):Formula-feeding (FF): 20.5%20.5%

– Mortality rate:Mortality rate: BF:BF: 24.4%24.4% FF:FF: 20.0% 20.0%

Nduati R. et al. JAMA 2000Nduati R. et al. JAMA 2000

Benefits of Breastmilk: InfantsBenefits of Breastmilk: Infants

Breastfeeding and premature Breastfeeding and premature infants:infants:

Premature infants fed their mother's milk were Premature infants fed their mother's milk were found to have decreased incidences of sepsis, found to have decreased incidences of sepsis, meningitis, and necrotizing enterocolitismeningitis, and necrotizing enterocolitis

Breastfeeding and premature Breastfeeding and premature infants:infants:

Premature infants fed their mother's milk were Premature infants fed their mother's milk were found to have decreased incidences of sepsis, found to have decreased incidences of sepsis, meningitis, and necrotizing enterocolitismeningitis, and necrotizing enterocolitis


Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated

– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula

CMAJ 166 2002

– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula

JClin Microbiol 39 2001

Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated

– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula

CMAJ 166 2002

– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula

JClin Microbiol 39 2001

Benefits of Breastmilk: Safe Benefits of Breastmilk: Safe

Joint FAO/WHO Workshop on Enterobacter

Sakazakii and other Microorganisms in

Powdered Infant formula February 2004

Recommendations:

– Guidelines should be developed for the preparation, use and handling of infant formula to decrease the risk of infection

– Make use of Enterobacteriaceae rather than coliform testing as an indicator of hygienic control

Joint FAO/WHO Workshop on Enterobacter

Sakazakii and other Microorganisms in

Powdered Infant formula February 2004

Recommendations:

– Guidelines should be developed for the preparation, use and handling of infant formula to decrease the risk of infection

– Make use of Enterobacteriaceae rather than coliform testing as an indicator of hygienic control

Benefits of Breastmilk: Safe Benefits of Breastmilk: Safe

Benefits of Breastfeeding: MothersBenefits of Breastfeeding: Mothers

Prevents ObesityPrevents Obesity

Early return to pre-pregnancy Early return to pre-pregnancy weightweight

Prevents ObesityPrevents Obesity

Early return to pre-pregnancy Early return to pre-pregnancy weightweight

Breast Cancer

“Meta-Analysis on the Protective Effect of BF on Breast Cancer”. Labbock et al. Ped Clin North Am., 2001 Feb

Eleven studies were evaluated– Results:

RR: 0.54 to 0.85 for 1st 3-6 months of BF

RR: 0.4 to 0.72 for > 2 years

RR: 0.35 for > 6 years Conclusion:

Clear and consistent protective effect of BF on breast cancer have been found in all studies

Breast Cancer

“Meta-Analysis on the Protective Effect of BF on Breast Cancer”. Labbock et al. Ped Clin North Am., 2001 Feb

Eleven studies were evaluated– Results:

RR: 0.54 to 0.85 for 1st 3-6 months of BF

RR: 0.4 to 0.72 for > 2 years

RR: 0.35 for > 6 years Conclusion:

Clear and consistent protective effect of BF on breast cancer have been found in all studies

Benefits of Breastfeeding: Mothers


Ovarian CancerOvarian Cancer

““Breastfeeding and Risk to Ovarian Breastfeeding and Risk to Ovarian Cancer”Cancer”

– Rosenblatt 1993Rosenblatt 1993: : 20-25% 20-25% decrease in riskdecrease in risk for cancer for women who for cancer for women who

breastfed for at least 2 monthsbreastfed for at least 2 months

– Risch et al 1993 & Gwinn 1990:Risch et al 1993 & Gwinn 1990: Showed the Showed the protective effectprotective effect of lactation (RR 0.79 per of lactation (RR 0.79 per

year of lactation; 0.6 respectively)year of lactation; 0.6 respectively)

– Shoham 1994:Shoham 1994: 50% 50% decrease in risk fordecrease in risk for ovarian cancer ovarian cancer

Ovarian CancerOvarian Cancer

““Breastfeeding and Risk to Ovarian Breastfeeding and Risk to Ovarian Cancer”Cancer”

– Rosenblatt 1993Rosenblatt 1993: : 20-25% 20-25% decrease in riskdecrease in risk for cancer for women who for cancer for women who

breastfed for at least 2 monthsbreastfed for at least 2 months

– Risch et al 1993 & Gwinn 1990:Risch et al 1993 & Gwinn 1990: Showed the Showed the protective effectprotective effect of lactation (RR 0.79 per of lactation (RR 0.79 per

year of lactation; 0.6 respectively)year of lactation; 0.6 respectively)

– Shoham 1994:Shoham 1994: 50% 50% decrease in risk fordecrease in risk for ovarian cancer ovarian cancer



Family:– Purchase of formula costs the average poor

family (7,280.00/ month income) about P2,000.00

National Economy (NEDA):– Milk companies import S57.5 M (P3.1 B)

worth of infant formula

– Sell to people 7x cost (WHO) – P21.5 B or S405 B)

Family:– Purchase of formula costs the average poor

family (7,280.00/ month income) about P2,000.00

National Economy (NEDA):– Milk companies import S57.5 M (P3.1 B)

worth of infant formula

– Sell to people 7x cost (WHO) – P21.5 B or S405 B)

Benefits of Breastfeeding: Economy

Benefits of Breastfeeding: Economy

Longer-term Health Outcomes: Longer-term Health Outcomes: Maternal Maternal benefitsbenefitsLonger-term Health Outcomes: Longer-term Health Outcomes: Maternal Maternal benefitsbenefits

Reduces risk of chronic illness in Reduces risk of chronic illness in childhoodchildhood– Some food allergiesSome food allergies– Type-1 insulin dependent diabetesType-1 insulin dependent diabetes– LymphomaLymphoma– AsthmaAsthma– ObesityObesity

Reduces risk of chronic illness in Reduces risk of chronic illness in childhoodchildhood– Some food allergiesSome food allergies– Type-1 insulin dependent diabetesType-1 insulin dependent diabetes– LymphomaLymphoma– AsthmaAsthma– ObesityObesity

Steps to Encourage Breast-Feeding in the Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-FriendlyHospital: UNICEF/WHO Baby-Friendly

HOSPITAL INITIATIVESHOSPITAL INITIATIVES

– Provide all pregnant women with information and Provide all pregnant women with information and counselling.counselling.

– Document the desire to breast-feed in the medical Document the desire to breast-feed in the medical record.record.

– Document the method of feeding in the infant’s record.Document the method of feeding in the infant’s record.– Place the newborn and mother skin- to-skin, and Place the newborn and mother skin- to-skin, and

initiate breast-feeding within 1 hr of birth.initiate breast-feeding within 1 hr of birth.– Continue skin-to-skin contact at other times and Continue skin-to-skin contact at other times and

encourage encourage rooming-in.rooming-in.– Assess breast-feeding and continue encouragement Assess breast-feeding and continue encouragement

and teaching on each shift.and teaching on each shift.

MOTHERS TO LEARNMOTHERS TO LEARN

– Proper position and latch onProper position and latch on– Nutritive sucking and swallowingNutritive sucking and swallowing– Milk production and releaseMilk production and release– Frequency and feeding cuesFrequency and feeding cues– Expression of milk neededExpression of milk needed– Assessment of the infant’s nutritional Assessment of the infant’s nutritional

statusstatus– When to contact the clinicianWhen to contact the clinician


ADDITIONAL INSTRUCTIONSADDITIONAL INSTRUCTIONS

– Refer to lactation consultation if any concerns arise.Refer to lactation consultation if any concerns arise.– Infants should go to the breast at least 8-12 times/24 hr, Infants should go to the breast at least 8-12 times/24 hr,

day and night.day and night.– Avoid time limits on the breasts; offer both breasts at Avoid time limits on the breasts; offer both breasts at

each feeding.each feeding.– Do not give sterile water, glucose, or formula unless Do not give sterile water, glucose, or formula unless

indicated.indicated.– If supplements are given, use cup feeding, a Haberman If supplements are given, use cup feeding, a Haberman

feeder, fingers, or syringe feedings.feeder, fingers, or syringe feedings.– Avoid pacifiers in the newborn nursery except during Avoid pacifiers in the newborn nursery except during

painful procedures.painful procedures.– Avoid anti-lactation drugs.Avoid anti-lactation drugs.


Review QuestionsReview Questions

1.1. What breast structure secretes breastmilk? What breast structure secretes breastmilk? What hormone is responsible for it?What hormone is responsible for it?

2.2. What are the 2 processes are responsible What are the 2 processes are responsible for breastmilk secretion & maintenance?for breastmilk secretion & maintenance?

3.3. Breastmilk is stored in what part of the Breastmilk is stored in what part of the breast?breast?

4.4. 3 phases of lactation?3 phases of lactation?

5.5. Hormone secreted during BF which could Hormone secreted during BF which could cause BM reduction if breast is not emptied cause BM reduction if breast is not emptied completely.completely.

6) What is the protein distribution of BM? What 6) What is the protein distribution of BM? What is the predominant protein component?is the predominant protein component?

7) How much calories is lost per day when bf?7) How much calories is lost per day when bf?

8) What are the 3 areas that must be 8) What are the 3 areas that must be addressed in BF based on the addressed in BF based on the recommendation of WHO? recommendation of WHO?

Thank You Thank You and and

God blessGod bless


God blessGod bless

Breastmilk SubstitutesBreastmilk Substitutes

Infant Milk FormulasInfant Milk Formulas

Breastmilk SubstitutesBreastmilk Substitutes

Infant Milk FormulasInfant Milk Formulas

TYPES OF INFANT FORMULATYPES OF INFANT FORMULATYPES OF INFANT FORMULATYPES OF INFANT FORMULA

• Pre-term FormulaPre-term Formula• Catch-up Growth FormulaCatch-up Growth Formula• Standard Infant FormulaStandard Infant Formula

Whey Dominant ( 60%)Whey Dominant ( 60%)Casein Dominant ( 60%)Casein Dominant ( 60%)

• Follow-on (up) FormulaFollow-on (up) Formula• Growing-up FormulaGrowing-up Formula• Whole cow’s MilkWhole cow’s Milk• Evaporated MilkEvaporated Milk

• Pre-term FormulaPre-term Formula• Catch-up Growth FormulaCatch-up Growth Formula• Standard Infant FormulaStandard Infant Formula

Whey Dominant ( 60%)Whey Dominant ( 60%)Casein Dominant ( 60%)Casein Dominant ( 60%)

• Follow-on (up) FormulaFollow-on (up) Formula• Growing-up FormulaGrowing-up Formula• Whole cow’s MilkWhole cow’s Milk• Evaporated MilkEvaporated Milk

Types of Infant FormulasTypes of Infant FormulasTypes of Infant FormulasTypes of Infant Formulas

Special Formulas:Special Formulas:

– Hydrolysates:Hydrolysates: Partial HydrolysatesPartial Hydrolysates Complete HydrolysatesComplete Hydrolysates

– Goats milkGoats milk

Special Formulas:Special Formulas:

– Hydrolysates:Hydrolysates: Partial HydrolysatesPartial Hydrolysates Complete HydrolysatesComplete Hydrolysates

– Goats milkGoats milk

Nutrient Sources:Nutrient Sources:FOR INFANTS LESS THAN 2 YEARSFOR INFANTS LESS THAN 2 YEARS

Nutrient Sources:Nutrient Sources:FOR INFANTS LESS THAN 2 YEARSFOR INFANTS LESS THAN 2 YEARS

Three Indications for Use of Infant Three Indications for Use of Infant Formulas:Formulas:

As substitute ( or supplement) for human milk As substitute ( or supplement) for human milk in infants whose mother choose not to in infants whose mother choose not to breastfeed;breastfeed;

As a substitute for human milk in infants for As a substitute for human milk in infants for whom breastfeeding is medically whom breastfeeding is medically contraindicated;contraindicated;

As supplement for infants who do not gain As supplement for infants who do not gain weight appropriately.weight appropriately.

Three Indications for Use of Infant Three Indications for Use of Infant Formulas:Formulas:

As substitute ( or supplement) for human milk As substitute ( or supplement) for human milk in infants whose mother choose not to in infants whose mother choose not to breastfeed;breastfeed;

As a substitute for human milk in infants for As a substitute for human milk in infants for whom breastfeeding is medically whom breastfeeding is medically contraindicated;contraindicated;

As supplement for infants who do not gain As supplement for infants who do not gain weight appropriately.weight appropriately.

Nutrient Sources:Nutrient Sources:< 2 Years of Age< 2 Years of Age

Nutrient Sources:Nutrient Sources:< 2 Years of Age< 2 Years of Age

PRETERM FORMULA:PRETERM FORMULA:

Prescribed for premature until they have Prescribed for premature until they have reached reached 35-36 weeks35-36 weeks of gestation or gained of gestation or gained 2 2 kilograms.kilograms.

When given beyond recommended age may When given beyond recommended age may cause hypercalcemiacause hypercalcemia

Special Features:Special Features:

• Protein: Whey predominant formula at a Protein: Whey predominant formula at a level higher than breast milk & standard level higher than breast milk & standard infant formula infant formula (2.0 2.5g/100ml.)(2.0 2.5g/100ml.)

PRETERM FORMULA:PRETERM FORMULA:

Prescribed for premature until they have Prescribed for premature until they have reached reached 35-36 weeks35-36 weeks of gestation or gained of gestation or gained 2 2 kilograms.kilograms.

When given beyond recommended age may When given beyond recommended age may cause hypercalcemiacause hypercalcemia

Special Features:Special Features:

• Protein: Whey predominant formula at a Protein: Whey predominant formula at a level higher than breast milk & standard level higher than breast milk & standard infant formula infant formula (2.0 2.5g/100ml.)(2.0 2.5g/100ml.)

PRETERM FORMULAPRETERM FORMULAPRETERM FORMULAPRETERM FORMULA

Pre-Aptamil (Milupa): 1:1 dilutionPre-Aptamil (Milupa): 1:1 dilution

Enfalac Premature:Enfalac Premature: 1:1 dilution 1:1 dilution

Pre-Nan:Pre-Nan: 1:1 dilution 1:1 dilution

S-26 LBW:S-26 LBW: 1:2 dilution 1:2 dilution

Pre-Aptamil (Milupa): 1:1 dilutionPre-Aptamil (Milupa): 1:1 dilution

Enfalac Premature:Enfalac Premature: 1:1 dilution 1:1 dilution

Pre-Nan:Pre-Nan: 1:1 dilution 1:1 dilution

S-26 LBW:S-26 LBW: 1:2 dilution 1:2 dilution

STANDARD INFANT FORMULASTANDARD INFANT FORMULASTANDARD INFANT FORMULASTANDARD INFANT FORMULA

Recommended during the firstRecommended during the first 6 –12 months 6 –12 months of life;of life;

Extensively modified from what was originally Extensively modified from what was originally produced by the cow;produced by the cow;

Very little difference between various brandsVery little difference between various brands

Example: S-26, Enfalac, Nan, Similac, Mylac, Example: S-26, Enfalac, Nan, Similac, Mylac, Aptamil, Bonna, NestogenAptamil, Bonna, Nestogen

Recommended during the firstRecommended during the first 6 –12 months 6 –12 months of life;of life;

Extensively modified from what was originally Extensively modified from what was originally produced by the cow;produced by the cow;

Very little difference between various brandsVery little difference between various brands

Example: S-26, Enfalac, Nan, Similac, Mylac, Example: S-26, Enfalac, Nan, Similac, Mylac, Aptamil, Bonna, NestogenAptamil, Bonna, Nestogen

FOLLOW-UP FORMULAFOLLOW-UP FORMULAFOLLOW-UP FORMULAFOLLOW-UP FORMULA

Liquid part of the weaning diet for infants Liquid part of the weaning diet for infants & children& children 12 mos12 mos - - 3 years of age;3 years of age;

Distribution of calories and nutrients is in Distribution of calories and nutrients is in between standard infant formula and whole between standard infant formula and whole cow’s milkcow’s milk

Protein is higher with the ratio of 20% whey Protein is higher with the ratio of 20% whey and 80% caseinand 80% casein

Example: Promil, Nan 2, Gain, MilumilExample: Promil, Nan 2, Gain, Milumil

Liquid part of the weaning diet for infants Liquid part of the weaning diet for infants & children& children 12 mos12 mos - - 3 years of age;3 years of age;

Distribution of calories and nutrients is in Distribution of calories and nutrients is in between standard infant formula and whole between standard infant formula and whole cow’s milkcow’s milk

Protein is higher with the ratio of 20% whey Protein is higher with the ratio of 20% whey and 80% caseinand 80% casein

Example: Promil, Nan 2, Gain, MilumilExample: Promil, Nan 2, Gain, Milumil

COMPOSITION OF VARIOUS NUTRIENT COMPOSITION OF VARIOUS NUTRIENT SOURCESSOURCES

COMPOSITION OF VARIOUS NUTRIENT COMPOSITION OF VARIOUS NUTRIENT SOURCESSOURCES

BM COW A PREM FF-BM COW A PREM FF-UPUP

Energy kcal/100mlEnergy kcal/100ml 6565 6767 6565 8181 6565

Protein G/100 mlProtein G/100 ml 1.11.1 3.53.5 1.51.5 2.42.4 2.82.8WheyWhey 60%60% 60%60% 20%20%CaseinCasein 40%40% 40%40% 80%80%

Fat G/100 mlFat G/100 ml 4.54.5 3.73.7 3.63.6 4.44.4 2.642.64

CHO G/100 mlCHO G/100 ml 6.86.8 4.94.9 7.27.2 8.68.6 8.188.18

CA mg/100 mlCA mg/100 ml 3434 117117 4444 95(75)95(75)P mg/100 mlP mg/100 ml 1414 9292 3333 53(40)53(40)

NA mmol/100 mlNA mmol/100 ml 0.70.7 2.22.2 0.640.64 1.41.4 1.571.57

GROWING –UP FORMULA:GROWING –UP FORMULA:GROWING –UP FORMULA:GROWING –UP FORMULA:

Product used for children above 2 years Product used for children above 2 years to 10 yearsto 10 years

Provides nutrient necessary as they Provides nutrient necessary as they undergo transition from infant to adult undergo transition from infant to adult formulation.formulation.

• Protein is high ( 3 g/100 ml) from SodiumProtein is high ( 3 g/100 ml) from Sodium• Casseinate and soya proteinCasseinate and soya protein

CHO contains a blend of cornstarch and CHO contains a blend of cornstarch and sucrose with very minimal lactosesucrose with very minimal lactose

Product used for children above 2 years Product used for children above 2 years to 10 yearsto 10 years

Provides nutrient necessary as they Provides nutrient necessary as they undergo transition from infant to adult undergo transition from infant to adult formulation.formulation.

• Protein is high ( 3 g/100 ml) from SodiumProtein is high ( 3 g/100 ml) from Sodium• Casseinate and soya proteinCasseinate and soya protein

CHO contains a blend of cornstarch and CHO contains a blend of cornstarch and sucrose with very minimal lactosesucrose with very minimal lactose

Growing-up FormulasGrowing-up FormulasGrowing-up FormulasGrowing-up Formulas

Enfagrow (MJ):Enfagrow (MJ): 1:1 dilution1:1 dilution

Grow (Abbott):Grow (Abbott): 1:2 dilution1:2 dilution

Lactum (MJ):Lactum (MJ): 1:1 dilution1:1 dilution

Neslac (Nestle):Neslac (Nestle):1:1 dilution1:1 dilution

Progress (Wyeth):Progress (Wyeth): 1:2 dilution1:2 dilution

Enfagrow (MJ):Enfagrow (MJ): 1:1 dilution1:1 dilution

Grow (Abbott):Grow (Abbott): 1:2 dilution1:2 dilution

Lactum (MJ):Lactum (MJ): 1:1 dilution1:1 dilution

Neslac (Nestle):Neslac (Nestle):1:1 dilution1:1 dilution

Progress (Wyeth):Progress (Wyeth): 1:2 dilution1:2 dilution

Whole Cow’s MilkWhole Cow’s MilkWhole Cow’s MilkWhole Cow’s Milk

Maybe given as Maybe given as supplementsupplement to a balanced to a balanced diet from 12 months above;diet from 12 months above;

No modification done to suit the needs of No modification done to suit the needs of infants &childreninfants &children

Example: Alaska, Bear Brand,Example: Alaska, Bear Brand,

Maybe given as Maybe given as supplementsupplement to a balanced to a balanced diet from 12 months above;diet from 12 months above;

No modification done to suit the needs of No modification done to suit the needs of infants &childreninfants &children

Example: Alaska, Bear Brand,Example: Alaska, Bear Brand,

Protein HydrolysatesProtein HydrolysatesProtein HydrolysatesProtein Hydrolysates

Definition:Definition: It refers to the product of an enzymatic It refers to the product of an enzymatic

degradation of protein to proteose, peptone, degradation of protein to proteose, peptone, peptide-AA mix and finally free AA mix.peptide-AA mix and finally free AA mix.

Types:Types:– Partial Hydrolysate:Partial Hydrolysate: Degradation of protein to Degradation of protein to

big, medium size peptides big, medium size peptides less antigenicity; less antigenicity;

– Complete Hydrolysate:Complete Hydrolysate: Degradation of protein Degradation of protein into small peptides and free AAinto small peptides and free AA..

Definition:Definition: It refers to the product of an enzymatic It refers to the product of an enzymatic

degradation of protein to proteose, peptone, degradation of protein to proteose, peptone, peptide-AA mix and finally free AA mix.peptide-AA mix and finally free AA mix.

Types:Types:– Partial Hydrolysate:Partial Hydrolysate: Degradation of protein to Degradation of protein to

big, medium size peptides big, medium size peptides less antigenicity; less antigenicity;

– Complete Hydrolysate:Complete Hydrolysate: Degradation of protein Degradation of protein into small peptides and free AAinto small peptides and free AA..

Protein HydrolysatesProtein Hydrolysates Protein HydrolysatesProtein Hydrolysates

Partially Hydrolyzed Formula:Partially Hydrolyzed Formula:– For For prophylaxisprophylaxis on high risk infants: on high risk infants:

FH of atopy, asthma, food allergyFH of atopy, asthma, food allergy

– Preparation:Preparation: Nan-HANan-HA

Extensively Hydrolyzed Formula:Extensively Hydrolyzed Formula:– For For treatmenttreatment of food allergy during of food allergy during

infancyinfancy– Preparations: Preparations: Pregomin (Milupa)Pregomin (Milupa)

Pregistimil (MJ)Pregistimil (MJ)

Alfare (Nestle)Alfare (Nestle)

Partially Hydrolyzed Formula:Partially Hydrolyzed Formula:– For For prophylaxisprophylaxis on high risk infants: on high risk infants:

FH of atopy, asthma, food allergyFH of atopy, asthma, food allergy

– Preparation:Preparation: Nan-HANan-HA

Extensively Hydrolyzed Formula:Extensively Hydrolyzed Formula:– For For treatmenttreatment of food allergy during of food allergy during

infancyinfancy– Preparations: Preparations: Pregomin (Milupa)Pregomin (Milupa)

Pregistimil (MJ)Pregistimil (MJ)

Alfare (Nestle)Alfare (Nestle)

““Introduction of Complementary Introduction of Complementary Food”Food”

““Introduction of Complementary Introduction of Complementary Food”Food”

Features of Complementary FoodsFeatures of Complementary FoodsFeatures of Complementary FoodsFeatures of Complementary Foods

Timely:Timely: Should be introduced by 6 months Should be introduced by 6 months

AdequateAdequate: Should provide sufficient energy, protein : Should provide sufficient energy, protein

and micronutrientsand micronutrients

SafeSafe:: Hygienically stored and prepared and fed Hygienically stored and prepared and fed

using clean utensils NOT bottles nor teatusing clean utensils NOT bottles nor teat

Properly fed:Properly fed: Meal frequency, feeding methods Meal frequency, feeding methods

should be suitable for age (with fingers, spoon and should be suitable for age (with fingers, spoon and

fork, cups and bowls, guided or self-feeding)fork, cups and bowls, guided or self-feeding)

Complementary Food (CF)Complementary Food (CF) Complementary Food (CF)Complementary Food (CF)

Definition:Definition:

It refers to It refers to supplemental foodssupplemental foods ( (milk & solid milk & solid

foodsfoods) given to infants when breastmilk is ) given to infants when breastmilk is

no longer no longer adequateadequate to sustain normal to sustain normal

growth.growth.

Definition:Definition:

It refers to It refers to supplemental foodssupplemental foods ( (milk & solid milk & solid

foodsfoods) given to infants when breastmilk is ) given to infants when breastmilk is

no longer no longer adequateadequate to sustain normal to sustain normal

growth.growth.

WHY should CF be given?WHY should CF be given? WHY should CF be given?WHY should CF be given?

Three Infant Feeding PeriodsThree Infant Feeding Periods::

Nursing PeriodNursing Period (1 (1stst 6 months of life) 6 months of life)

Transitional PeriodTransitional Period (6-10 months) (6-10 months)

Modified Adult PeriodModified Adult Period ( >10 months) ( >10 months)

Three Infant Feeding PeriodsThree Infant Feeding Periods::

Nursing PeriodNursing Period (1 (1stst 6 months of life) 6 months of life)

Transitional PeriodTransitional Period (6-10 months) (6-10 months)

Modified Adult PeriodModified Adult Period ( >10 months) ( >10 months)

WHY WHY should CF be given? should CF be given?WHY WHY should CF be given? should CF be given?

Three Infant Feeding Periods:Three Infant Feeding Periods:

Nursing Period (1Nursing Period (1stst 6 months of 6 months of life):life):

Breastmilk or standard infant formula is Breastmilk or standard infant formula is sufficientsufficient to provide nutritional to provide nutritional requirements for normal growth;requirements for normal growth;

MILK MILK should be the should be the ONLYONLY source of nutrient. source of nutrient.

Three Infant Feeding Periods:Three Infant Feeding Periods:

Nursing Period (1Nursing Period (1stst 6 months of 6 months of life):life):

Breastmilk or standard infant formula is Breastmilk or standard infant formula is sufficientsufficient to provide nutritional to provide nutritional requirements for normal growth;requirements for normal growth;

MILK MILK should be the should be the ONLYONLY source of nutrient. source of nutrient.

Nursing Period Nursing Period (1(1stst 6 months of life): 6 months of life):

Nursing Period Nursing Period (1(1stst 6 months of life): 6 months of life):

DigestiveDigestive, , mucosal barriermucosal barrier and and renal renal

functionsfunctions are not well developed; are not well developed;

((Zieger EE, J Zieger EE, J Pediatr, 1990)Pediatr, 1990)

Neuro-developmentalNeuro-developmental status: status: not fully not fully developed !developed !

DigestiveDigestive, , mucosal barriermucosal barrier and and renal renal

functionsfunctions are not well developed; are not well developed;

((Zieger EE, J Zieger EE, J Pediatr, 1990)Pediatr, 1990)

Neuro-developmentalNeuro-developmental status: status: not fully not fully developed !developed !

Nursing Period :Nursing Period :(1(1stst 6 months of life) 6 months of life)

Nursing Period :Nursing Period :(1(1stst 6 months of life) 6 months of life)

Addition of Addition of solid foodssolid foods at this time at this time

breastmilk /milk consumption breastmilk /milk consumption proportionally proportionally

growth failuregrowth failure

Stuff et al, JStuff et al, J pediatr,1990pediatr,1990

Addition of Addition of solid foodssolid foods at this time at this time

breastmilk /milk consumption breastmilk /milk consumption proportionally proportionally

growth failuregrowth failure

Stuff et al, JStuff et al, J pediatr,1990pediatr,1990

Transitional Period Transitional Period (6-10 months)(6-10 months)

Transitional Period Transitional Period (6-10 months)(6-10 months)

It is the transition from the It is the transition from the nursing periodnursing period to the to the adult adult modified periodmodified period

Milk (Milk (breastmilk / standard infant formulabreastmilk / standard infant formula) is ) is NONO longer longer adequateadequate to sustain the nutritional needs of to sustain the nutritional needs of growing infantsgrowing infants

It is the transition from the It is the transition from the nursing periodnursing period to the to the adult adult modified periodmodified period

Milk (Milk (breastmilk / standard infant formulabreastmilk / standard infant formula) is ) is NONO longer longer adequateadequate to sustain the nutritional needs of to sustain the nutritional needs of growing infantsgrowing infants

Transitional PeriodTransitional Period(6-10 mos)(6-10 mos)

Transitional PeriodTransitional Period(6-10 mos)(6-10 mos)

Digestive, renal systems and taste are Digestive, renal systems and taste are well developedwell developed;;

Skills needed for feeding are likewise Skills needed for feeding are likewise fully developedfully developed..

Digestive, renal systems and taste are Digestive, renal systems and taste are well developedwell developed;;

Skills needed for feeding are likewise Skills needed for feeding are likewise fully developedfully developed..

Transitional Period Transitional Period ( 6-10 months)( 6-10 months)

Transitional Period Transitional Period ( 6-10 months)( 6-10 months)

FAILUREFAILURE to offer to offer supplemental foods supplemental foods at this at this

time time difficulty difficulty in accepting them later;in accepting them later;

Underwood BA,Acta Pediatr Scand Underwood BA,Acta Pediatr Scand

Suppl, 1982Suppl, 1982

FAILUREFAILURE to offer to offer supplemental foods supplemental foods at this at this

time time difficulty difficulty in accepting them later;in accepting them later;

Underwood BA,Acta Pediatr Scand Underwood BA,Acta Pediatr Scand

Suppl, 1982Suppl, 1982

““Critical Learning Period”Critical Learning Period”6-15 months6-15 months

““Critical Learning Period”Critical Learning Period”6-15 months6-15 months

6-15 months6-15 months, , “critical learning period”“critical learning period” for for feeding: chewing & swallowing feeding: chewing & swallowing coordination is being developed; coordination is being developed;

FAILUREFAILURE of infants to go through this of infants to go through this process process feeding problems: feeding problems:

– dependence to MILK as source of nutrient dependence to MILK as source of nutrient – picky eaters / neophobicpicky eaters / neophobic– malnutrition (obesity/wasting ,anemia)malnutrition (obesity/wasting ,anemia)

6-15 months6-15 months, , “critical learning period”“critical learning period” for for feeding: chewing & swallowing feeding: chewing & swallowing coordination is being developed; coordination is being developed;

FAILUREFAILURE of infants to go through this of infants to go through this process process feeding problems: feeding problems:

– dependence to MILK as source of nutrient dependence to MILK as source of nutrient – picky eaters / neophobicpicky eaters / neophobic– malnutrition (obesity/wasting ,anemia)malnutrition (obesity/wasting ,anemia)

Modified Adult Period Modified Adult Period (>10 months)(>10 months)

Modified Adult Period Modified Adult Period (>10 months)(>10 months)

Physiologic mechanisms have Physiologic mechanisms have matured to matured to near adult proficiency;near adult proficiency;

Most of the nutrients Most of the nutrients MUSTMUST come from come from table foodstable foods with minimal alteration (cut with minimal alteration (cut into small pieces, bland);into small pieces, bland);

Taste ability & preferences have become Taste ability & preferences have become established.established.

Physiologic mechanisms have Physiologic mechanisms have matured to matured to near adult proficiency;near adult proficiency;

Most of the nutrients Most of the nutrients MUSTMUST come from come from table foodstable foods with minimal alteration (cut with minimal alteration (cut into small pieces, bland);into small pieces, bland);

Taste ability & preferences have become Taste ability & preferences have become established.established.

Scientific Rationale:Scientific Rationale:

– “ “Critical Window”Critical Window” for introducing “lumpy” for introducing “lumpy”

solid foods: if these are delayed beyond solid foods: if these are delayed beyond 10 10

mosmos increased risk of feeding difficulties increased risk of feeding difficulties

later onlater on

Northstone et al, 2001Northstone et al, 2001

– Ingestion of the types of foods depend on Ingestion of the types of foods depend on

the neuromuscular development of infantsthe neuromuscular development of infants

Scientific Rationale:Scientific Rationale:

– “ “Critical Window”Critical Window” for introducing “lumpy” for introducing “lumpy”

solid foods: if these are delayed beyond solid foods: if these are delayed beyond 10 10

mosmos increased risk of feeding difficulties increased risk of feeding difficulties

later onlater on

Northstone et al, 2001Northstone et al, 2001

– Ingestion of the types of foods depend on Ingestion of the types of foods depend on

the neuromuscular development of infantsthe neuromuscular development of infants

What kind of food would you give?What kind of food would you give?

What kind of food would you give?What kind of food would you give?

WHEN should CF be given? WHEN should CF be given? 6 months 6 months

WHEN should CF be given? WHEN should CF be given? 6 months 6 months

Signals that indicate readiness of the Signals that indicate readiness of the infant infant for CF:for CF: Birth weight has doubled;Birth weight has doubled;

Extrusion reflex has completely disappeared;Extrusion reflex has completely disappeared;

Has good head and neck control;Has good head and neck control;

Sits up with support;Sits up with support;

Signals that indicate readiness of the Signals that indicate readiness of the infant infant for CF:for CF: Birth weight has doubled;Birth weight has doubled;

Extrusion reflex has completely disappeared;Extrusion reflex has completely disappeared;

Has good head and neck control;Has good head and neck control;

Sits up with support;Sits up with support;

WHEN should CF be started?WHEN should CF be started? WHEN should CF be started?WHEN should CF be started?

Signals that indicate readiness of infant Signals that indicate readiness of infant for CF:for CF:

Opens mouth if wants food; turns head away Opens mouth if wants food; turns head away when not when not

interested anymore;interested anymore;

Has good chewing & swallowing coordination;Has good chewing & swallowing coordination;

Consumes about Consumes about 32 oz of milk32 oz of milk and wants more; and wants more;

Breastfeeds Breastfeeds > 10x> 10x and wants more and wants more

Signals that indicate readiness of infant Signals that indicate readiness of infant for CF:for CF:

Opens mouth if wants food; turns head away Opens mouth if wants food; turns head away when not when not

interested anymore;interested anymore;

Has good chewing & swallowing coordination;Has good chewing & swallowing coordination;

Consumes about Consumes about 32 oz of milk32 oz of milk and wants more; and wants more;

Breastfeeds Breastfeeds > 10x> 10x and wants more and wants more

Art of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary Food

Introduce Introduce oneone new food new food at timeat time to allow to allow infant to get use to it; continue same food infant to get use to it; continue same food for for 3-4 days3-4 days before giving another food; before giving another food;

Give very small amount of any new food at Give very small amount of any new food at the beginning, the beginning, 1-4 tsp1-4 tsp;;

Introduce Introduce oneone new food new food at timeat time to allow to allow infant to get use to it; continue same food infant to get use to it; continue same food for for 3-4 days3-4 days before giving another food; before giving another food;

Give very small amount of any new food at Give very small amount of any new food at the beginning, the beginning, 1-4 tsp1-4 tsp;;

Art of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary Food

Use thin puree consistency initially --> shift Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food gradually to a more viscous calorie-dense food

Mix foods with ones baby likes, to enhance Mix foods with ones baby likes, to enhance acceptability and nutrient contentacceptability and nutrient content

Cereals +BM: Enhanced acceptance of cereal during Cereals +BM: Enhanced acceptance of cereal during weaning!weaning!

Mennella et al, Pediatr Res, Mennella et al, Pediatr Res, 19971997

Use thin puree consistency initially --> shift Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food gradually to a more viscous calorie-dense food

Mix foods with ones baby likes, to enhance Mix foods with ones baby likes, to enhance acceptability and nutrient contentacceptability and nutrient content

Cereals +BM: Enhanced acceptance of cereal during Cereals +BM: Enhanced acceptance of cereal during weaning!weaning!

Mennella et al, Pediatr Res, Mennella et al, Pediatr Res, 19971997

Art of Introducing Complementary FoodArt of Introducing Complementary Food Art of Introducing Complementary FoodArt of Introducing Complementary Food

Once infant can sit with support at about Once infant can sit with support at about 6 6 mosmos , give fluid (milk or water) using , give fluid (milk or water) using trainer’s cuptrainer’s cup;;

By By 12 months12 months of age milk should be given of age milk should be given by the by the cup or glass;cup or glass;

BOTTLESBOTTLES should be should be OUTOUT by this time! by this time!

Once infant can sit with support at about Once infant can sit with support at about 6 6 mosmos , give fluid (milk or water) using , give fluid (milk or water) using trainer’s cuptrainer’s cup;;

By By 12 months12 months of age milk should be given of age milk should be given by the by the cup or glass;cup or glass;

BOTTLESBOTTLES should be should be OUTOUT by this time! by this time!

Avoid adding salt and sugarAvoid adding salt and sugar

When baby is able to chew at aboutWhen baby is able to chew at about 8-10 8-10 monthsmonths, gradually switch to finely chopped , gradually switch to finely chopped foods foods

DO NOTDO NOT continue soft smooth foods for too continue soft smooth foods for too longlong

Feeding Frequency:Feeding Frequency: 6-8 months: 6-8 months: 22 -3 -3 meals a daymeals a day 9-11 months:9-11 months: 3-4 meals; 1-2 snacks3-4 meals; 1-2 snacks > 12 months:> 12 months: 3-4 meals: 1-2 snacks3-4 meals: 1-2 snacks

Avoid adding salt and sugarAvoid adding salt and sugar

When baby is able to chew at aboutWhen baby is able to chew at about 8-10 8-10 monthsmonths, gradually switch to finely chopped , gradually switch to finely chopped foods foods

DO NOTDO NOT continue soft smooth foods for too continue soft smooth foods for too longlong

Feeding Frequency:Feeding Frequency: 6-8 months: 6-8 months: 22 -3 -3 meals a daymeals a day 9-11 months:9-11 months: 3-4 meals; 1-2 snacks3-4 meals; 1-2 snacks > 12 months:> 12 months: 3-4 meals: 1-2 snacks3-4 meals: 1-2 snacks

Art of Introducing Complementary Art of Introducing Complementary FoodFood

Art of Introducing Complementary Art of Introducing Complementary FoodFood

Art of Introducing Complementary Art of Introducing Complementary foodsfoods

Art of Introducing Complementary Art of Introducing Complementary foodsfoods

By By 12 months12 months,, most of the nutrient should most of the nutrient should come from come from table food table food (modified); infants have (modified); infants have attained attained physiologic maturity of adult physiologic maturity of adult proficiencyproficiency;;

Encourage infant to try new flavors Encourage infant to try new flavors as a variety of foods is important !as a variety of foods is important !

* FNRI-DOST, Nutrition Guidelines for Filipinos, * FNRI-DOST, Nutrition Guidelines for Filipinos, 20002000

* Pediatric Nutrition Handbook, 4* Pediatric Nutrition Handbook, 4thth Edition AAP Edition AAP

By By 12 months12 months,, most of the nutrient should most of the nutrient should come from come from table food table food (modified); infants have (modified); infants have attained attained physiologic maturity of adult physiologic maturity of adult proficiencyproficiency;;

Encourage infant to try new flavors Encourage infant to try new flavors as a variety of foods is important !as a variety of foods is important !

* FNRI-DOST, Nutrition Guidelines for Filipinos, * FNRI-DOST, Nutrition Guidelines for Filipinos, 20002000

* Pediatric Nutrition Handbook, 4* Pediatric Nutrition Handbook, 4thth Edition AAP Edition AAP

Harvard School of Public Health

Harvard School of Public Health

US Department of Agriculture

US Department of Agriculture

New Food Guide PyramidNew Food Guide Pyramid


God blessGod bless


God blessGod bless

US Dept of Agriculture

US Dept of Agriculture

Endocrine Control of LactationEndocrine Control of LactationEndocrine Control of LactationEndocrine Control of Lactation

Nutrition Module Notes Pediatric I – Second Year Rebecca Abiog-Castro, M.D. Rhodora Garcia de...

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