Transcript Human Milk and Formulas -- Selection and Composition

Breast Milk
and
Infant Formulas
Lori S. Brizee MS, RD, CSP
Clinical Dietitian
Children’s Hospital and Regional Medical Center
Human Milk and Infant Formulas:

Breast milk

Standard Infant Formulas

Premature Infant Formulas

Specialty Infant Formulas

Modular Additives
Breast Milk Characteristics


First choice feeding for MOST infants
Immunologic factors


Trophic to GI tract


Protective against diarrhea causing
infections and otitis in infants
Well tolerated by infants with short bowel
Fatty acids important to brain/visual
development
Breast Milk vs Standard Milk
Based Formulas


Energy: slightly higher
Protein: Lower, but higher quality (whey
and casein)

Renal Solute load: Lower

Carbohydrate: Mainly lactose

Fats: Long chain; DHA/AA (lipases increase
absorption)
Common Challenges with Breast Feeding
 Baby sided problems
 Illness preventing/interfering
with early feeding
 Anatomic malformations
 Sleepy baby
 Thrush
Common Challenges with Breast Feeding
Sleepy Baby



Sleep cycles
 REM sleep-----deep sleep (15
min +/-) ----wake (quiet alert)
If cannot wake, in deep sleep, try
again in 15+/- minutes
Watch for hunger cues e.g., sucking
on hands
Common Challenges with Breast Feeding
Sleepy Baby

Waking techniques
 Hold
by armpits and dangle
 Put feet on hard surface
 Spin around
 Last resort: stroke palate with finger
until sucking, then take finger out
and put nipple in.
Common Challenges with Breast Feeding

Mom sided problems

Low milk supply
Frequent feeding, pump after feeding
 Medications: Reglan, Domperidone
Fenugreek

Sore Nipples
 Clogged ducts
 Mastitis
 Yeast Infection

Breast Feeding: Is baby getting enough?



Regain birthweight by 1 week
Newborn to 2 months gain > 1
ounce per day
Newborn to 4-6 weeks: 2-10 bowel
movements per day
 Bowel
movements are better clue
than wet diapers.
Standard Infant Formulas, Milk or
Soy Based………..
Formula Brands

Ross
 Similac/Isomil/Alimentum

Mead Johnson
 Enfamil/Prosobee/Enfacare

Nestle
 Good

Start
Wyeth
 Generic

in USA; Gold Brands; SMA
SHS
 NeoCate,
DuoCal
Milk Based Formulas

Standard 0-12 months
 Similac
with/without iron
 Enfamil with
 Good Start Essentials/Good Start Supreme
 Wyeth Generic

Standard 0-12 mos with DHA/ARA
 Similac
Advance with iron
 Enfamil Lipil with/without iron
 Good Start Supreme DHA/ARA
 Wyeth formulas
Milk Based Formulas

Older Infant and toddler formulas
 Similac
2 Advance (9-24 mos)
 Enfamil Next Step Lipil (9-24 mos)
 Good Start 2 Essentials (4 to24 mos)
 Wyeth Generic “follow on formulas”
 Increased Calcium
 Increased protein (Good Start and Enfamil)
 Intended to compliment nutrients in solid milk
Milk Based Formulas
Characteristics

Blend of Whey and Casein Proteins
(8.2-9.6 % total calories)

Carbohydrate: lactose

Fats: long chain

Meet needs of healthy infant
Soy Formulas




Isomil/Isomil DF /Isomil
Advance/Isomil Advance 2
Prosobee/Prosobee Lipil/Next Step
Prosobee
Good Start Essentials Soy/Good
Start 2 Essentials Soy
Wyeth All iron fortified
Soy Formulas
Characteristics compared to Milk Based



Higher protein (lower quality)
Higher sodium, calcium, and
phosphorus
Carbohydrate: Corn syrup solids,
sucrose, and/or maltodextrin; lactose free


Fats: Long chain
Meet needs of healthy infants
Predigested protein based
infant formulas
Protein Hydrolysate Formulas



Alimentum Advance
Pregestimil/Pregestimil Lipil
Nutramigen Lipil



Protein Casein hyrolysate + free AA’s
Fat (Alimentum and Pregestimil) Medium
chain + Long chain triglycerides;
(Nutramigen) Long chain triglycerides
Carbohydrate: Lactose free
Elemental formula for infants
Elemental Infant Formula

NeoCate (SHS)




Protein: Free Amino Acids
Fat: Long chain
Carbohydrate: Lactose Free
Indications for use: Food Allergy or
intolerance to peptides or whole
protein
Premature Infant Breast Milk
Additives and Formulas

Enfamil Human Milk Fortifier

Similac Human Milk Fortifier


Powdered breast milk additives
Similac Natural Care Advance

Liquid breast milk additive

Similac Special Care Advance

Enfamil Premature +/- Lipil
Premature Formulas
General Characteristics compared to Standard

Increased Protein,Vitamins & Minerals

For infants born at <1.5kg


Feeding of infants > 2500 gm


up to 2000-2500gm
risk of vitamin toxicities
Premature formulas vary in nutrient content
Post Premature Infant
formula
“Post” Premature Formulas


NeoSure Advance
EnfaCare Lipil



Standard Dilution: 22 kcal/oz
Protein: between standard and Premature
Vitamins: Higher than standard,significantly
lower than Premature

Calcium and Phosphorus: between standard
and Premature
Other Specialty Formulas

Portagen



85% fat MCT, 15% fat Corn oil
Used for infants with chylothorax
Similac PM 60/40 (Ross)



(Mead Johnson)
Low in Ca, P, K+ and NA; 2:1 Ca:P ratio
Used for infants with Renal Failure
Formulas for Metabolic Disorders

Several condition specific products by Ross
and Mead Johnson
Modular Products to
Increase Energy/Protein
Modular Products to increase
Energy or Protein
Carbohydrate
Fat
Protein
Polycose
MicroLipid
ProMod
(Ross)
(Mead Johnson)
(Ross)
Moducal
Safflower Oil
Casec
(Mead Johnson)
Super Soluble DuoCal
(SHS)
(Mead Johnson)
Products to Augment Energy and
Protein in Breast Milk

Human Milk Fortifiers


Standard Infant Formula Powder
*

For Premature infants less than 20002500gm only
1 teaspoon to 100mL = 24kcal/oz+/-
Do Not Add CHO or Fat w/o protein:
Final product is TOO LOW in protein
Finding Up to Date Information

www.ross.com Similac products

www.meadjohnson.com Enfamil products

www.verybestbaby.com Nestle products

www.wyethnutritionals.com generic products

www.brightbeginnings.com lower cost formulas made
by Wyeth

www.shsna.com/html/Hypoallergenic.htm
Neocate formulas
When Baby is Not Growing

Normal Weight gain and linear growth



Guo et al J Pediatrics 1991
Assess Feeding

Number feedings/day

Feeding environment

BF: baby “empties” breasts each feeding

Formula: volume per feeding
Vomiting? Diarrhea? Medical issues that increase
needs/decrease intake?
When Baby is Not Growing




Increase number of feedings/day
If baby <6 months d/c solids, increase breast milk or
formula
Monitor weight weekly
If no improvement in 1 week consider increasing
caloric concentration of breast milk or formula to 24
kcal/oz.
When Baby is Not Growing
 In
cases of increased need due to medical
condition or fluid limit, may need to go higher
than 24 kcal/oz
 In

all cases monitor closely watch for
Signs of dehydration (baby may take less volume of
concentrated feed)

Vomiting

Diarrhea
Increasing Caloric Density of Formula

Concentrate formula (decrease water added):
*
Calculate kcals desired (e.g. 30 oz of 24 kcal/oz
formula = 720kcal)
*
Divide kcals by kcal/oz of liquid or scoop of powder
(e.g. 720 kcal divided by 40 kcal/oz liquid conc. = 18
oz liquid conc. Formula).
*
Add water to make final volume (12 oz water + 18 oz
liquid conc. Formula = 30 oz 24kcal/oz formula)
Using Modulars to Increase Calories

Example: Making 30 oz of 30 kcal per oz
formula (30oz X 30kcal/oz = 900 kcal)
*
Start with 24 kcal/oz formula:
24kcal/oz X 30oz = 720 kcal
*
900kcal - 720 kcal = 180 kcal from modulars
*
Use Polycose and Micro lipid to make up
additional kcals (approximately 90 kcal of
each)
Using Modulars to Increase Calories
*
continued
Polycose 23 kcal/TBSP
90 kcal /23kcal/TBSP =3.9TBSP (use 4 TBSP X 23
kcal = 92 kcal; still need 88 kcal)
*
Microlipid 4.5 kcal/mL
88 kcal/4.5 kcal/mL =19.55 mL (use 20 mL X 4.5
kcal = 90 kcal)
Final calculation: 720kcal + 92 kcal + 90 kcal =
902 kcal/30oz =30.07 kcal/oz
Know What You Are Feeding


Caloric density, protein, fat and carbohydrate vitamin and
mineral content.
Osmolality: goal is for <400mOsm/kg H2O; can slowly go
up to 700
 Meds/modulars

increase osmolality
Renal Solute Load: goal is for less than 300mOsm/l (all
infant and pediatric meet this recommendation when
concentrated up to 30 kcal/oz.)
 Addition
of protein will increase Renal Solute Load