Formulas, Breastfeeding, and other juicy stuff

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

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 <2500g

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

More on Breastfeeding

    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

    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

   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

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

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 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   Eg Infant cereals If still only breastfeeding: Iron 1mg/kg/day

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.

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

Other Differences in Composition

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

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

     Cow’s 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

Soy Formulas

     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

     Should mimick breastfeeding 1 st week: 2-3 oz q 2-3 hrs 1 st 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

     more protein less carbs same fat different electrolyte concentration— more Ca MCTs   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

   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

Cow’s 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

Solids

     introduction recommended between 4 and 6 months of age May puree fresh foods and freeze  Don’t use canned: sugar and salt risks of introducing early    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  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 if juice introduced too early, carbohydrate load may result in diarrhea