Transcript Formulas, Breastfeeding, and other juicy stuff

Formulas, Breastfeeding, and
other juicy stuff
Milk: The Principal Source of Nutrition
for Infants
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Consume 120 to 150 cc/kg/day
Human and Most Standard infant
formulas: 67kcal/100cc
Protein Needs
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Term: 2 to 3 g/kg per day
Preterm: 3.5 to 4.0 g/kg per day
Energy Sources
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Primary: Fat Calories: (3.8gm) 34 kcal/100 mL
Carbohydrates: lactose: (7 g) 28 kcal/100 mL
Protein (minimal): (1.3 g) 5 kcal/100 mL
Energy Requirements for the Newborn
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Basic Metabolic Function (basal metabolic
rate): 50-60 kcal/kg/day
Temperature regulation: 0-10 kcal/kg/day
Growth of new tissue: 10-15 kcal/kg/day
Storage of Energy (fat): 20-30
kcal/kg/day
Energy Excreted (poo,pee): 10-15
kcal/kg/day
TOTAL: 90-140 kcal/kg/day
Increased for <2500g
Breastfeeding
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Human Milk: naturally formulated nutrition that
is specific for the human neonate
AAP recommends breastfeeding until 1 year of
age
rate in the United States has increased
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33% in 1974 to 70% in 2000
Breastfeeding for 6 months reduces the
incidence of food allergies
Studies suggest potential for enhanced
maturation of the visual system and improved
cognitive development in breastfed infants
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Human milk contains docosahexanoic acid
(DHEA), an omega-3 fatty acid that may play a
role in human brain and eye development
More on Breastfeeding
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10-15 min each breast
PROlactin = PROduction
Colostrum: low volume, Ab rich
Poor feeding pattern in the first few
days won’t impact further success
so don’t switch to bottle
Those less likely to breastfeed
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Single women
women who have lower educational
levels
African-American women
women who work outside the home
may abandon breastfeeding if they
are in an unsupportive work
environment
Immune Benefits of Breastfeeding
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maternal antibodies against specific pathogens
(secretory IgA)
 IgM is noted in significant quantity only in the
colostrum
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bactericidal compounds
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Lactoferrin: iron-binding protein, inhibits growth of
some bacteria by competing for available iron.
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Lysozyme-enzyme that has bacteriolytic properties
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high quantities in human milk, but in very low amounts
in bovine milk
at much greater quantities than bovine milk
WBCs
Mucin
incidence of both respiratory and GI infections is
decreased in the first postnatal year among infants
who predominantly or exclusively are breastfed
Risks of Breastfeeding
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Can see some deficiencies
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Iron
Vitamin D
Vitamin B12
These are present in adequate amounts in
commercially available formulas
Note: breastmilk is an incomplete source
of vitamin E
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Preemies need 10-25 IUs to decrease RBC
hemolysis
Iron and Breastfeeding
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Term newborns have sufficient iron stores to sustain
them for 3 to 4 months
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even when the mother has anemia
So they don’t need supplements until 4 mos of age
Human milk contains lower quantities of iron but
bioavailability is greater
Preterm: miss out on iron stores in the last trimester,
may require iron supplementation if they are taking full
enteral feedings as early as 2 to 4 weeks of age
Iron supplementation not required at birth except in
congenital anemia (rare)
Iron needed for hematopoiesis and brain growth and
function
6 Months: start iron containing foods
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Eg Infant cereals
If still only breastfeeding: Iron 1mg/kg/day
Vitamin D and Breastfeeding
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human milk may contain lower amounts
of vitamin D than infant formula
cases of rickets and hypocalcemia have
been reported in breastfed infants
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especially in African-Americans
exact incidence in breastfed babies is not
known, but it is far less than 25%
AAP Committee on Nutrition recommends
a supplement of 200 IU/d of vitamin D for
breastfed infants.
Vitamin B-12 and Breastfeeding
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If mom is a strict vegetarian, her
milk will have low B-12
At risk for anemia and neurologic
sequelae
Other Differences in Composition
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Protein
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Human Milk: Whey-predominant protein
 Lower concentration of protein than formulasby 50%
Cow Milk Infant Formulas:Casein-predominant
protein
 Up to 80% versus the 30% in human milk
Electrolyes
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Formula has higher concentrations of sodium,
calcium, phosphorus
Formula Options
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Protein Sources
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cow milk-based
soy-based
Casein hydrolysate
modified amino acid-based
AVOID LOW IRON FORMULAS!
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Some people think it makes infants collicky or constipated but this is
physiologically inappropriate
if prepared properly, provide adequate amounts of calories, fat,
protein, carbohydrate, minerals, and vitamins
Special Conditions
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Galactosemia: soy formula (no lactoseno galactose)
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Could use a protein hydrosylate or elemental, but they are more expensive
and less readily available
Lactose: human milk, cow-milk formulas, most whey hydrosylate formulas
modified amino acid compositions for specific metabolic illnesses:
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phenylketonuria
hereditary tyrosinemia
homocystinuria
maple syrup urine disease
urea cycle disorders
organic acidemias
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Cow’s Milk-Based Formulas
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Soy Based Formulas
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EleCare, Neocate
Casein Hydrolysate Formulas
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Store brand, Good Start, Isomil, ProSobee
Amino Acid Formulas
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Store brands, Enfamil (lipil, AR), Good Start,
Similac (advance, lactose free)
Alimentum, Nutramigen, Pregestimil
Preemie Formulas
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Enfamil Premature, Similac Special Care
Discharge Formulas
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Enfacare, Neosure
Soy Formulas
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Can’t use for cow milk protein
allergy—a lot of cross reactivity
Don’t use it for <1800gm babies
Has increased aluminum
Nutritionally the same as cow milk
formulas, same fat source
May be beneficial in post-diarrheal
transient lactate deficiency
Formula Feeding
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Should mimick breastfeeding
1st week: 2-3 oz q 2-3 hrs
1st couple months: 2-4oz q 2-4 hrs
Don’t go >5hrs in a neonate
They should also get Vit D if getting
less than 500ml of formula per day
Preemie Formulas
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more protein
less carbs
same fat
different electrolyte concentration—
more Ca
MCTs
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Don’t require bile emulsification, helps them
absorb total dietary lipids
Don’t provide essential fatty acids such as
linoleic and linolenic acids but the formulas
(and breast milk) have this
Food Protein Induced Enterocolitis
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Si/Sx: recurring painless hematochezia, emesis, and
normal abdominal exam
non-IgE-mediated food intolerance that typically affects
infants in the first 3 postnatal months
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Allergy skin testing identifies IgE-mediated reactions, so it
is unhelpful in this case
Most associated with cow milk formula, but if breastfed
may be exposed to a sufficient amount of cow milk
protein from maternal ingestion to develop the condition
susceptibility of GI barrier to food proteins is the
suspected mechanism for immunologic intolerance
milk and soy protein are the most commonly implicated
foods in FPIES, eggs, wheat, rice, oats, peanuts, nuts,
turkey, and fish also have been reported
Cow’s Milk Protein Allergy
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Initial Management: eliminate the suspected protein
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resolves within 6 to 24 months if the offending food is avoided
May recur with re-introduction of cow milk
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If formula fed:
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casein hydrolysated or an amino acid-based formula
Most tolerate a whey or casein extensively hydrolyzed formula
Rarely need a more elemental formula
Avoid partially hydrolyzed formulas
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contain 1,000 to 100,000 times higher concentrations of milk protein than
extensively hydrolyzed formulas
Changing to a soy formula not recommended because 30% to 50% of
affected infants have continued symptoms with soy formulas
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Look for hematochezia, emesis, or diarrhea
causes a transient increase in absolute PMNs to at least 3,500 cells/mm³ at
4 to 6 hours
infants and children who have IgE-mediated milk food allergies often can
switch successfully to a soy formula
If breast fed:
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Eliminate milk protein ingestion in mothers or removal of milk protein
formula results in
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resolution of hematochezia in 2 to 3 days, although complete resolution may
take several weeks
Solids
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introduction recommended between 4 and 6 months of
age
May puree fresh foods and freeze
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risks of introducing early
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Don’t use canned: sugar and salt
potential choking in an infant who has an immature
swallow and the
reduction of human milk intake
in some countries in the developing world, solid foods
may be contaminated and a source of infection
One benefit of introducing solids such as iron-fortified
cereal is a potential reduction in iron deficiency
NO benefit to introducing juices before 6 months
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if juice introduced too early, carbohydrate load may result
in diarrhea