Transcript Infant Formula - Dr. Riojas

Mónica Riojas, MD
LSU Pediatrics
Principles of Infant Feeding
Energy Requirements: kcal/kg/d
 0-12 mo:
 1-3 yr:
 4-6 yr:
 7-10 yr:
 15+ yr:
100-120
90-100
80-90
70-75
45-50
Principles of Infant Feedings
Formula fed infants feed every 3-4 hrs.
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Feedings/day
0-3 Months:
6-8
4-6 Months:
5-7
6-8 Months:
4-6
9-12 Months:
3-5
Principles of Infant Feeding
Average Volume of Milk per Feeding
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1st wk:
2-4 wks:
1-2 mo:
3-4 mo:
5-6 mo :
1-2 oz
2-3 oz
4-5 oz
5-6 oz
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 Indications
 As 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 Kcals
Breastmilk
Formula
% Protein
6
9
% Fat
52
48
% Carbohydrate
42
42
Question

Which of the following statements about infant
nutrition is true?
Human milk contains more casein than infant
formulas.
B. Infants who receive increased whey protein have been
shown to grow better than those who receive
primarily casein.
C. Iron is absorbed better from cow milk formulas than
from human milk.
D. Lactose-free formulas result in decreased absorption
of calcium.
E. There are no apparent negative effects from the
addition of DHA and ARA to formulas.
A.
Differences Between Types of Milk
Breastmilk
Standard Cow Formula
Cow Milk
Calories
20 kcal/oz
20 kcal/oz
19 kcal/oz
Protein
0.9 g/dL
1.4 g/dL
3.5 g/dL
Minerals (Ca, P, Fe)
Lower
Higher
Iron Absorption
Better
Worse
Vit. ABC
Same
Same
Vit. DEK
Lower
Higher
Renal Solute
Lower
Higher
Whey:Casein
Protein Ratio
70:30
Varies, but not better
than human milk
Terrible
20:80
Benefits of Whey Protein
 Promotes more rapid gastric emptying.
 Consists of soluble proteins that are easily digested.
 Lines the GI tract and plays a role in host defense.
Question
 Is 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 Recommendations
IRON
 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/L
 Cow’s milk has 0.5mg/L of iron.
Dietary Recommendations
VITAMIN D
 400 IU/d
Who 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 Formulas
 Premature Formulas
 Standard Formulas
 Special Formulas
Standard Formulas
COMPOSITION
 Protein
 Whey (β lacto-globulin) & Casein
 Whey predominant (60:40), Casein predominant
(20:80), or 100% whey
 Fat
 Vegetable oils
 Coconut: Saturated, short & MCFA
 Palm oil: Saturated & LCFA
 Safflower, corn & soy: LCFA, DHA & ARA
 Carbohydrate
 Lactose
Standard Infant Formulas
 Provide 20 cal/oz
PRESENTATIONS:
 Powder
 Concentrated Liquid
 Ready to Feed
Preparation of Infant Formula
POWDER
 Add 1 scoop powder to 2 oz of water
CONCENTRATED LIQUID
 Mix 1 oz concentrated liquid and 1 oz water
 13 oz can
READY TO FEED
 Hospital use: 2 and 3 oz bottles
 32 oz container
 Expensive
Preparation of Infant Formula
What 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 Formulas
 Designed to meet the nutritional needs of the
term and near-term infant.
 Enfamil Premium Newborn & Infant
 Similac Advance
 Store Brands
Cow Milk/Standard Formulas
New Infant Formula Features
Prebiotics
 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.
Probiotics
 Live microorganisms that survive digestion and colonize the colon.
Organic
 No pesticides or synthetic fertilizer used.
 No hormones or antibiotics used.
Premature Infant Formulas
 For 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
Composition of Premature Infant Formula
 20, 22, 24 kcal/oz
 Increased protein: whey predominant
 60% whey:40% casein
 Breastmilk - 70% whey:30% casein
 Increased calcium & phosphorus
 Contain AA: cysteine and taurine
 Lactose + glucose polymers
 MCT
 Increased Vitamins & Minerals
Premature Infant Formulas
 Enfamil Premature 20 cal
 Enfamil Premature 24 cal
 Similac Special Care Advance 20 cal
 Similac Special Care Advance 24 cal
 Good Start Premature 24 cal
Premature Infant Formulas
Transitional Formulas
 22 kcal/oz
INDICATIONS
 Infants 34 WGA or 1,800-2,000 g
 How long should infants be on transitional formulas?
 6 to 9 months of age
Transitional Formulas
 Enfamil Enfacare
 Similac Expert Care Neosure
Transition Formula
Question
 What 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 Milk–Based Formula
 If no improvement switch to an extensively hydrolyzed
or AA-based formula
Soy Protein Formulas
 Lactose Free
 Contain higher concentrations of protein, AA,
calcium, phosphorus, zinc and iron.
Primary Carbohydrate
 Glucose polymers from corn syrup solids or
maltodextrin
Soy Protein Formulas
INDICATIONS
 Galactosemia
 Congenital Lactase Deficiency
 Post-diarrhea lactose intolerance
 Strict vegetarian family
Soy Protein Formulas
NOT RECOMMENDED FOR
 Preterm infants with BW ≤ 1800 g.
 Do not meet requirements for calcium and phosphorus.
 Prevention of colic or allergy
 Infants 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 Sensitive
 Store Brand Soy Infant Formula
Soy Protein-Based Formulas
Modified Cow Milk Protein or Soy-Based Formulas
Carbohydrate
• Reduced lactose or lactose-free carbohydrate blends
Protein
• Partially hydrolyzed whey and soy proteins
Other
• Thickeners (rice cereal)
• Soy fiber
• Prebiotics
Modified Cow Milk Protein or Soy-Based Formulas
INDICATIONS
 Infants recovering from diarrhea
 Infants with colic
 Infants with GER
 NOT for infants with galactosemia
 NOT for cow milk formula intolerance
Special Indications
GER
 Enfamil AR
 Similac Sensitive for Spit up
Diarrhea and fussiness
 Similac Expert Care for Diarrhea
 Enfamil Gentlease
 Similac Sensitive Fussiness and Gas
Specialty-metabolic formulas
 Similac PM 60/40
Modified Cow or Soy Milk-Based Formulas
Modified Cow or Soy Milk-Based Formulas
Modified Cow or Soy Milk-Based Formulas
Modified Cow or Soy Milk-Based Formulas
Question
 A 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 Formula
Extensively Hydrolyzed Formulas
 Made for infants who are unable to digest or tolerate
formulas containing intact cow milk protein.
 Lactose free
Protein
 Extensively hydrolyzed casein
 Partially hydrolyzed whey
Carbohydrate
 Glucose polymers and/or sucrose
Fat Content
 Vegetable oils
 LCT/MCT from safflower and soy
Extensively Hydrolyzed Formulas
INDICATIONS
 Cow milk and soy protein allergy
 Malabsorption syndromes
 Cystic fibrosis
 Biliary Atresia
 Short gut syndrome
 Pancreatic insufficiency
 Protein calorie malnutrition
 Autoimmune diseases/immunodeficiency syndromes
Question
 Hydrolysate formulas are MOST often used in
the management of:
A. Celiac disease
B. Cow milk protein allergy
C. Cystic fibrosis
D. GER
E. Lactose intolerance
Extensively Hydrolyzed Formulas
 Nutramigen
 Pregestemil
 Similac Expert Care Alimentum
Extensively Hydrolyzed Formulas
Amino Acid Based Formulas
 Intolerance to intact or hydrolyzed protein.
Protein
 Free Amino Acids
Carbohydrate
 Glucose polymers
Amino Acid Based Formulas
INDICATIONS
 Cow Milk Protein Allergy
 Eosinophilic GI disorders
 Atopic diseases
 Severe food allergy
 Asthma
 Eczema
Amino Acid Based Formulas
 Neocate
 Elecare
 Nutramigen AA
Amino Acid Based Formulas
Other Formulas
Follow-up Formulas
 From 9 months of age - toddlers
 Increased protein, minerals and iron.
 No advantage for infants eating adequate amounts of
formula and solid foods.
Follow-up Formulas
Enfamil
 Enfagrow Premium
 Enfagrow Premium Soy
Similac
 Similac Go and Grow
Good Start
 Good Start 2 Essentials
 Good Start 2 Essentials Soy
Follow-up Formulas
Question
 A 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?
Cow’s Milk
 Introduce 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 Feeding
Number of Meals a Day
 0-3 mo: 6-8 bottles
 4-6 mo: 5 bottles + 1 solid meal
 6-8 mo: 4 bottles + 2 solid meals
 9-12 mo: 3 bottles + 3 solid meals
Infant Nutrition: Solid foods
 Cereal
 Strained Vegetable
 Strained Meats
 Strained fruits
 Table Food
 Juices and desserts
 Vitamins and Minerals
Solid Foods
 Introduce at 4-6 months age
 Has good head control
 No extrusion reflex
 Sits with support
 Has doubled birth weight
 Seems hungry after 32 oz milk
Question

What is the MOST likely outcome of introducing
solid foods at an age of ≤ 3 months?
A. Accelerates the development of oral motor skills
B. Helps the infant sleep through the night
C. Increases the risk of food allergies
D. Increases the risk of GER
E. Increases the risk of GI infections
Solid 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 Nutrition
 0-4 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 foods
Strained Food
 Stage 1 Foods:
 Stage 2 Foods:
 Stage 3 Foods:
2.5 oz jar, 4-5 mo
3.5 oz jar, 6-8 mo
6 oz jar, 9 mo
Infant Nutrition
CEREALS
 Rice cereal
 Oatmeal
 Barley
 Mixed
Infant Nutrition
CEREALS
 First solid introduced at 4-6 months of age
 Iron Fortified
 Provides 15 calories per Tbsp
 Full serving: 4 Tbsp + 4 oz formula or
breastmilk

DO NOT ADD IN BOTTLE!!!!!!!!
 Thickened feedings for severe GER
Rice Cereal
Introduction of Solids
Recommendations
 At 4 months
 Breakfast: Rice Cereal (4 tbsp cereal/4oz formula)
 Lunch: Stage 1 veggies/fruits

Same vegetable for 3-5 days, then switch to new veggie
Introduction of Solids
At 6 months
 Breakfast: Cereal
 Lunch: Stage 2 foods
 Introduction of meats
 Mixed veggies or dinners
 Dinner: Stage 2 foods
 Mixed veggies or dinners
Introduction of Solids
At 9 months
 Stage 3 and finger foods.
A Typical 6 mo Infant Diet
Morning:
Mid-morning:
Noon:
Mid-afternoon:
Late afternoon:
Bed-time:
Cereal
Formula
Vegetable
Formula
Dinner
Bottle