Formulas, Breastfeeding, and other juicy stuff

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Formulas, Breastfeeding, and other juicy stuff
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Milk The Principal Source of Nutrition for
Infants

• Consume 120 to 150 cc/kg/day
• Human and Most Standard infant formulas
  67kcal/100cc
• Protein Needs
• Term 2 to 3 g/kg per day
• Preterm 3.5 to 4.0 g/kg per day
• Energy Sources
• 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

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Energy Requirements for the Newborn

• 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 lt2500g

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Breastfeeding

• 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
• 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
• Human milk contains docosahexanoic acid (DHEA),
  an omega-3 fatty acid that may play a role in
  human brain and eye development

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More on Breastfeeding

• 10-15 min each breast
• PROlactin PROduction
• Colostrum low volume, Ab rich
• Poor feeding pattern in the first few days wont
  impact further success so dont switch to bottle

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Those less likely to breastfeed

• 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

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Immune Benefits of Breastfeeding

• maternal antibodies against specific pathogens
  (secretory IgA)
• IgM is noted in significant quantity only in the
  colostrum
• bactericidal compounds
• Lactoferrin iron-binding protein, inhibits
  growth of some bacteria by competing for
  available iron.
• high quantities in human milk, but in very low
  amounts in bovine milk
• Lysozyme-enzyme that has bacteriolytic properties
• 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

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Risks of Breastfeeding

• Can see some deficiencies
• Iron
• Vitamin D
• Vitamin B12
• These are present in adequate amounts in
  commercially available formulas
• Note breastmilk is an incomplete source of
  vitamin E
• Preemies need 10-25 IUs to decrease RBC hemolysis

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Iron and Breastfeeding

• Term newborns have sufficient iron stores to
  sustain them for 3 to 4 months
• even when the mother has anemia
• So they dont 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
• Eg Infant cereals
• If still only breastfeeding Iron 1mg/kg/day

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Vitamin D and Breastfeeding

• human milk may contain lower amounts of vitamin D
  than infant formula
• cases of rickets and hypocalcemia have been
  reported in breastfed infants
• 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.

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Vitamin B-12 and Breastfeeding

• If mom is a strict vegetarian, her milk will have
  low B-12
• At risk for anemia and neurologic sequelae

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Other Differences in Composition

• Protein
• Human Milk Whey-predominant protein
• Lower concentration of protein than formulas-by
  50
• Cow Milk Infant FormulasCasein-predominant
  protein
• Up to 80 versus the 30 in human milk
• Electrolyes
• Formula has higher concentrations of sodium,
  calcium, phosphorus

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Formula Options

• Protein Sources
• cow milk-based
• soy-based
• Casein hydrolysate
• modified amino acid-based
• AVOID LOW IRON FORMULAS!
• 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
• Galactosemia soy formula (no lactose?no
  galactose)
• 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
• phenylketonuria
• hereditary tyrosinemia
• homocystinuria
• maple syrup urine disease
• urea cycle disorders
• organic acidemias

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• Cows Milk-Based Formulas
• Store brands, Enfamil (lipil, AR), Good Start,
  Similac (advance, lactose free)
• Soy Based Formulas
• Store brand, Good Start, Isomil, ProSobee
• Amino Acid Formulas
• EleCare, Neocate
• Casein Hydrolysate Formulas
• Alimentum, Nutramigen, Pregestimil
• Preemie Formulas
• Enfamil Premature, Similac Special Care
• Discharge Formulas
• Enfacare, Neosure

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Soy Formulas

• Cant use for cow milk protein allergya lot of
  cross reactivity
• Dont use it for lt1800gm babies
• Has increased aluminum
• Nutritionally the same as cow milk formulas, same
  fat source
• May be beneficial in post-diarrheal transient
  lactate deficiency

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Formula Feeding

• Should mimick breastfeeding
• 1st week 2-3 oz q 2-3 hrs
• 1st couple months 2-4oz q 2-4 hrs
• Dont go gt5hrs in a neonate
• They should also get Vit D if getting less than
  500ml of formula per day

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Preemie Formulas

• more protein
• less carbs
• same fat
• different electrolyte concentrationmore Ca
• MCTs
• Dont require bile emulsification, helps them
  absorb total dietary lipids
• Dont provide essential fatty acids such as
  linoleic and linolenic acids but the formulas
  (and breast milk) have this

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Food Protein Induced Enterocolitis

• 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
• 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

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Cows Milk Protein Allergy

• Initial Management eliminate the suspected
  protein
• resolves within 6 to 24 months if the offending
  food is avoided
• May recur with re-introduction of cow milk
• 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
• If formula fed
• 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
• 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
• infants and children who have IgE-mediated milk
  food allergies often can switch successfully to a
  soy formula
• If breast fed
• Eliminate milk protein ingestion in mothers or
  removal of milk protein formula results in
• resolution of hematochezia in 2 to 3 days,
  although complete resolution may take several
  weeks

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Solids

• introduction recommended between 4 and 6 months
  of age
• May puree fresh foods and freeze
• Dont use canned sugar and salt
• risks of introducing early
• 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
• if juice introduced too early, carbohydrate load
  may result in diarrhea