nutrition module notes pediatric i – second year rebecca abiog-castro, m.d. rhodora garcia de...
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Nutrition Module NotesNutrition Module Notes Pediatric I – Second YearPediatric I – Second Year
Rebecca Abiog-Castro, M.D.Rebecca Abiog-Castro, M.D.
Rhodora Garcia de Leon, M.DRhodora Garcia de Leon, M.D
Faculty of Medicine & Surgery, USTFaculty of Medicine & Surgery, UST
Objectives of the CourseObjectives of the CourseObjectives of the CourseObjectives of the Course
At the end of the course a Second Year Medical At the end of the course a Second Year Medical Student should be able:Student should be able:
To discuss briefly the anatomy of the breast and To discuss briefly the anatomy of the breast and physiology of lactation;physiology of lactation;
To discuss the benefits of breastmilk and the To discuss the benefits of breastmilk and the
benefits of breastfeeding to both infant and mother; benefits of breastfeeding to both infant and mother;
To discuss the barriers on breastfeeding;To discuss the barriers on breastfeeding;
To discuss the composition of mature breast-milk;To discuss the composition of mature breast-milk;
To discuss the difference between breast-milk and To discuss the difference between breast-milk and cow’s milk; cow’s milk;
At the end of the course a Second Year Medical At the end of the course a Second Year Medical Student should be able:Student should be able:
To discuss briefly the anatomy of the breast and To discuss briefly the anatomy of the breast and physiology of lactation;physiology of lactation;
To discuss the benefits of breastmilk and the To discuss the benefits of breastmilk and the
benefits of breastfeeding to both infant and mother; benefits of breastfeeding to both infant and mother;
To discuss the barriers on breastfeeding;To discuss the barriers on breastfeeding;
To discuss the composition of mature breast-milk;To discuss the composition of mature breast-milk;
To discuss the difference between breast-milk and To discuss the difference between breast-milk and cow’s milk; cow’s milk;
Objectives of the CourseObjectives of the CourseObjectives of the CourseObjectives of the Course
To discuss the steps to encourage Breast-feeding in To discuss the steps to encourage Breast-feeding in the hospital: UNICEF / WHO Baby-Friendly;the hospital: UNICEF / WHO Baby-Friendly;
To discuss the features of complementary foods;To discuss the features of complementary foods;
To discuss the proper method to introduce To discuss the proper method to introduce complementary foods;complementary foods;
To utilize the PSPGN Food Guide Pyramid for the To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children;prescription of the proper diet for infant & children;
To classify the different breast-milk substitutes To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for (infant formulas) and determine the indication/s for its use;its use;
To discuss the supplements for breastfed infants.To discuss the supplements for breastfed infants.
To discuss the steps to encourage Breast-feeding in To discuss the steps to encourage Breast-feeding in the hospital: UNICEF / WHO Baby-Friendly;the hospital: UNICEF / WHO Baby-Friendly;
To discuss the features of complementary foods;To discuss the features of complementary foods;
To discuss the proper method to introduce To discuss the proper method to introduce complementary foods;complementary foods;
To utilize the PSPGN Food Guide Pyramid for the To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children;prescription of the proper diet for infant & children;
To classify the different breast-milk substitutes To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for (infant formulas) and determine the indication/s for its use;its use;
To discuss the supplements for breastfed infants.To discuss the supplements for breastfed infants.
Mother's milk is the best Mother's milk is the best
food a baby can have food a baby can have
exclusively in the first 6 exclusively in the first 6
months of life;months of life;
should be continued should be continued
untiluntil
two years and beyond.two years and beyond.
Mother's milk is the best Mother's milk is the best
food a baby can have food a baby can have
exclusively in the first 6 exclusively in the first 6
months of life;months of life;
should be continued should be continued
untiluntil
two years and beyond.two years and beyond.
Anatomy of BreastAnatomy of Breast
Internal structuresExternal structures:External structures: Cross section of alveolus
Breast StructureBreast StructureBreast StructureBreast Structure
Anatomy of the BreastAnatomy of the BreastAnatomy of the BreastAnatomy of the Breast
Teat
Tongue
Palate
Physiology of lactationPhysiology of lactation
Endocrine controlEndocrine control
Physiology of lactationPhysiology of lactation
Endocrine controlEndocrine control
Three main phases of lactationThree main phases of lactation
1)1) MammogenesisMammogenesis or or mammary growthmammary growth
2)2) LactogenesisLactogenesis or or initiation of milk secretion: initiation of milk secretion:
Stage I:Stage I: 12 wks before parturition 12 wks before parturitionStage II:Stage II: 2-3 days postpartum 2-3 days postpartum
3)3) Stage IIIStage III of of LactogenesisLactogenesis or or Galactopoiesis Galactopoiesis maintenance of milk secretionmaintenance of milk secretion: 14-30 das.: 14-30 das.
Three main phases of lactationThree main phases of lactation
1)1) MammogenesisMammogenesis or or mammary growthmammary growth
2)2) LactogenesisLactogenesis or or initiation of milk secretion: initiation of milk secretion:
Stage I:Stage I: 12 wks before parturition 12 wks before parturitionStage II:Stage II: 2-3 days postpartum 2-3 days postpartum
3)3) Stage IIIStage III of of LactogenesisLactogenesis or or Galactopoiesis Galactopoiesis maintenance of milk secretionmaintenance of milk secretion: 14-30 das.: 14-30 das.
Three Main Phases of Lactation Three Main Phases of Lactation (hormonal)(hormonal)
Three Main Phases of Lactation Three Main Phases of Lactation (hormonal)(hormonal)
Phase I - Phase I - MammogenesisMammogenesis– Profound during pregnancy in preparation for Profound during pregnancy in preparation for
lactationlactation
– Placental lactogen, estrogen, progesteronePlacental lactogen, estrogen, progesterone
– Ductal Sprouting (Ductal Sprouting (estrogenestrogen), lobular formation ), lobular formation ((progesteroneprogesterone), ), ProlactinProlactin essential for complete essential for complete gland growthgland growth
Phase I - Phase I - MammogenesisMammogenesis– Profound during pregnancy in preparation for Profound during pregnancy in preparation for
lactationlactation
– Placental lactogen, estrogen, progesteronePlacental lactogen, estrogen, progesterone
– Ductal Sprouting (Ductal Sprouting (estrogenestrogen), lobular formation ), lobular formation ((progesteroneprogesterone), ), ProlactinProlactin essential for complete essential for complete gland growthgland growth
Phase I - Phase I - MammogenesisMammogenesis
Hormones Involved in Mammary GrowthHormones Involved in Mammary Growth
Estrogens Progesterone GH Placental lactogens (PL)Prolactin Glucocorticoids GH and PL induce alveolar growth Steroids without GH and PL do not exert any effect
INDUCTION OF GROWTH (Normal animals)
• Estrogens alone induce alveolar growth
– Larger than normal alveoli
• Estrogen and progesterone induce normal growth
Phase I - Phase I - MammogenesisMammogenesis
Phase II - LACTOGENESIS
INITIATION OF LACTATION
At parturition the mammary gland switches from a growing non secretory tissue to a secreting, non-growing tissue
Change is endocrine mediated
Three Main Phases of Lactation Three Main Phases of Lactation (hormonal)(hormonal)
Three Main Phases of Lactation Three Main Phases of Lactation (hormonal)(hormonal)
Phase II - Phase II - LactogenesisLactogenesis (initiation of milk):(initiation of milk):
– Stage I:Stage I: starts 12 wks before delivery starts 12 wks before delivery
Gathering of all substrates for milk productionGathering of all substrates for milk production
– Stage II:Stage II: starts 2-3 days postpartum starts 2-3 days postpartum
Milk secretion is copiousMilk secretion is copious
Phase II - Phase II - LactogenesisLactogenesis (initiation of milk):(initiation of milk):
– Stage I:Stage I: starts 12 wks before delivery starts 12 wks before delivery
Gathering of all substrates for milk productionGathering of all substrates for milk production
– Stage II:Stage II: starts 2-3 days postpartum starts 2-3 days postpartum
Milk secretion is copiousMilk secretion is copious
Endocrine Patterns Related to Parturition
ENDOCRINE REGULATION OF LACTOGENESIS
Endocrine Control of LactationEndocrine Control of LactationEndocrine Control of LactationEndocrine Control of Lactation
Milk Production Reflex:Milk Production Reflex:
ProlactinProlactin is a key lactogenic hormone, is a key lactogenic hormone, stimulating initial alveolar milk productionstimulating initial alveolar milk production
Milk Ejection Reflex:Milk Ejection Reflex:
OxytocinOxytocin contracts the myoepithelial; cells, contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts forcing milk from the alveoli into the ducts and sinuses where it is removed by the and sinuses where it is removed by the infantinfant
Milk Production Reflex:Milk Production Reflex:
ProlactinProlactin is a key lactogenic hormone, is a key lactogenic hormone, stimulating initial alveolar milk productionstimulating initial alveolar milk production
Milk Ejection Reflex:Milk Ejection Reflex:
OxytocinOxytocin contracts the myoepithelial; cells, contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts forcing milk from the alveoli into the ducts and sinuses where it is removed by the and sinuses where it is removed by the infantinfant
Effect of different hormones in the initiation of milk production
Glucocorticoids – Development of RER (rough endoplasmic reticulum)
Prolactin – Maturation of Golgi – Secretory vesicles – Responsible for milk secretion
Progesterone – Promotes mammary growth specially alveolar tissue – Blocks epithelial secretion – As it decreases, the block for lactogenesis is removed
ENDOCRINE REGULATION OF LACTOGENESIS
Effect of different hormones in the initiation of milk production
MAMMARY GROWTH SLOWS DOWN
Most hormones involved in growth have been removed – Progesterone
CL has regressed and placenta is removed – Estrogens
Feto-placental unit no longer available – Placental lactogens
Placenta was expelled
After parturition mammary growth slows down because most growth promoting hormones are no longer available
Phase III – Phase III – GalactopoiesisGalactopoiesismaintenance of Breastmilk Secretionmaintenance of Breastmilk Secretion
Phase III – Phase III – GalactopoiesisGalactopoiesismaintenance of Breastmilk Secretionmaintenance of Breastmilk Secretion
Stage III of Stage III of Lactogenesis or GalactopoiesisLactogenesis or Galactopoiesis– Maintenance of milk secretionMaintenance of milk secretion– From 14- 30 daysFrom 14- 30 days– Mature milk is establishedMature milk is established– ProlactinProlactin and and OxytocinOxytocin essential for effective essential for effective
maintenance of milk supplymaintenance of milk supply
Stage III of Stage III of Lactogenesis or GalactopoiesisLactogenesis or Galactopoiesis– Maintenance of milk secretionMaintenance of milk secretion– From 14- 30 daysFrom 14- 30 days– Mature milk is establishedMature milk is established– ProlactinProlactin and and OxytocinOxytocin essential for effective essential for effective
maintenance of milk supplymaintenance of milk supply
Hormones in charge of supporting continuous milk production
Responsibility of prolactin and growth hormone
Supported by thyroid, parathyroid and adrenal glands through adequate metabolic function
MAINTENANCE OF LACTOGENESIS(Galactopoiesis)
Autocrine Control of LactationAutocrine Control of LactationAutocrine Control of LactationAutocrine Control of Lactation
Influence of of Local Factors Acting on the Influence of of Local Factors Acting on the BreastsBreasts
It is not just the level of maternal hormones, but It is not just the level of maternal hormones, but the efficiency of the efficiency of milk removalmilk removal that governs the that governs the volume product in each breastvolume product in each breast
A protein factor called A protein factor called feedback inhibitor of feedback inhibitor of lactation (FIL)lactation (FIL) is secreted with other milk is secreted with other milk components into the alveolar lumencomponents into the alveolar lumen
FILFIL, insensitive to prolactin , insensitive to prolactin milk production milk production
Influence of of Local Factors Acting on the Influence of of Local Factors Acting on the BreastsBreasts
It is not just the level of maternal hormones, but It is not just the level of maternal hormones, but the efficiency of the efficiency of milk removalmilk removal that governs the that governs the volume product in each breastvolume product in each breast
A protein factor called A protein factor called feedback inhibitor of feedback inhibitor of lactation (FIL)lactation (FIL) is secreted with other milk is secreted with other milk components into the alveolar lumencomponents into the alveolar lumen
FILFIL, insensitive to prolactin , insensitive to prolactin milk production milk production
Autocrine Control of LactationAutocrine Control of LactationAutocrine Control of LactationAutocrine Control of Lactation
FILFIL
FILFIL
FILFIL
Anatomy & Physiology: Milk Anatomy & Physiology: Milk production production
Risk factors for delayed onset of lactation Risk factors for delayed onset of lactation were:were:
Stage II labor > 1 hr, Stage II labor > 1 hr,
Pre-pregnant maternal BMI > 27 kg/m2, Pre-pregnant maternal BMI > 27 kg/m2,
Breastfeeding problems at day 3,and Breastfeeding problems at day 3,and
Being primiparous. Being primiparous. Dewey et al, 2001
Factors associated with breastfeeding problems at Factors associated with breastfeeding problems at day 7 day 7 includedincluded: :
flat or inverted nipples at day 7, flat or inverted nipples at day 7,
stage II labor > 1 hour, stage II labor > 1 hour,
birthweight < 3601 gms, birthweight < 3601 gms,
Pre-pregnant maternal BMI > 27 kg/m2Pre-pregnant maternal BMI > 27 kg/m2
non breast milk fluids givennon breast milk fluids given in the first 48 hours of life in the first 48 hours of life
Anatomy & Physiology: Milk Anatomy & Physiology: Milk productionproduction
Dewey, 2003
Breastmilk compositionBreastmilk composition
Breast-milkBreast-milkBreast-milkBreast-milk
Variations of BreastmilkVariations of Breastmilk
– Colostrum (1Colostrum (1stst 3-5 days of life) 3-5 days of life)
– Term breastmilk ( mother’s own: 7 - 10 – 28 Term breastmilk ( mother’s own: 7 - 10 – 28 days)days)
– Pre-term Milk ( day 7- 28 days)Pre-term Milk ( day 7- 28 days)
– Mature breastmilk ( >30 days)Mature breastmilk ( >30 days)
– Drip breastmilk ( 30-90 days postpartum)Drip breastmilk ( 30-90 days postpartum)
Variations of BreastmilkVariations of Breastmilk
– Colostrum (1Colostrum (1stst 3-5 days of life) 3-5 days of life)
– Term breastmilk ( mother’s own: 7 - 10 – 28 Term breastmilk ( mother’s own: 7 - 10 – 28 days)days)
– Pre-term Milk ( day 7- 28 days)Pre-term Milk ( day 7- 28 days)
– Mature breastmilk ( >30 days)Mature breastmilk ( >30 days)
– Drip breastmilk ( 30-90 days postpartum)Drip breastmilk ( 30-90 days postpartum)
ColostrumColostrumColostrumColostrum
First postpartum week’s mammary secretion consisting of First postpartum week’s mammary secretion consisting of
yellowish (beta carotene) thick fluid;yellowish (beta carotene) thick fluid;
Has higher protein, lower fat and lactose; rich in Vitamin A (3x > Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x);BM), carotenoid (10x), vitamin E(3x);
Protein content is rich inProtein content is rich in sIgA and immunologically competent sIgA and immunologically competent mononuclear cells;mononuclear cells;
ContainsContains antioxidants which trap neutrophil-generated oxygen antioxidants which trap neutrophil-generated oxygen radicals.radicals.
First postpartum week’s mammary secretion consisting of First postpartum week’s mammary secretion consisting of
yellowish (beta carotene) thick fluid;yellowish (beta carotene) thick fluid;
Has higher protein, lower fat and lactose; rich in Vitamin A (3x > Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x);BM), carotenoid (10x), vitamin E(3x);
Protein content is rich inProtein content is rich in sIgA and immunologically competent sIgA and immunologically competent mononuclear cells;mononuclear cells;
ContainsContains antioxidants which trap neutrophil-generated oxygen antioxidants which trap neutrophil-generated oxygen radicals.radicals.
Distribution of Immunoglobulins and other Distribution of Immunoglobulins and other Soluble Substances in the Colostrum and Milk Soluble Substances in the Colostrum and Milk Delivered to the Breast-Fed Infant During a Delivered to the Breast-Fed Infant During a
24-Hour Period24-Hour Period
Distribution of Immunoglobulins and other Distribution of Immunoglobulins and other Soluble Substances in the Colostrum and Milk Soluble Substances in the Colostrum and Milk Delivered to the Breast-Fed Infant During a Delivered to the Breast-Fed Infant During a
24-Hour Period24-Hour Period
Soluble Soluble ProductProduct
Concentration in MG /Day at PostpartumConcentration in MG /Day at Postpartum
<1 <1 weekweek
1-2 1-2 weeksweeks
3-4 weeks3-4 weeks >4 >4 weeksweeks
IgGIgG 5050 2525 2525 1010
IgA*IgA* 50005000 10001000 10001000 10001000
IgMIgM 7070 3030 1515 1010
LysozymeLysozyme 5050 6060 6060 100100
LactoferrinLactoferrin 15001500 20002000 20002000 12001200
Type of Volume Energy Protein CHO FAT Type of Volume Energy Protein CHO FAT NANA Milk Milk ml/d ml/d Kcal/100 ml G/100mL G/100 ml G/100 ml Kcal/100 ml G/100mL G/100 ml G/100 ml mmol/100MLmmol/100ML
ColostrumColostrum 100 100 0.67 0.67 2.3 2.3 5.3 2.9 5.3 2.9 1.71.7
(1-5 d) (1-5 d)
TermTerm D7 558 0.73 1.95 6.72 3.52 D7 558 0.73 1.95 6.72 3.52 0.970.97 D 14 591 0.67 1.62 6.97 3.88 D 14 591 0.67 1.62 6.97 3.88
1.271.27
Breastmilk Breastmilk 750 0.69 1.1 7.4 4.2 750 0.69 1.1 7.4 4.2 0.70 0.70
(Mature>30 d)(Mature>30 d)
Type of Volume Energy Protein CHO FAT Type of Volume Energy Protein CHO FAT NANA Milk Milk ml/d ml/d Kcal/100 ml G/100mL G/100 ml G/100 ml Kcal/100 ml G/100mL G/100 ml G/100 ml mmol/100MLmmol/100ML
ColostrumColostrum 100 100 0.67 0.67 2.3 2.3 5.3 2.9 5.3 2.9 1.71.7
(1-5 d) (1-5 d)
TermTerm D7 558 0.73 1.95 6.72 3.52 D7 558 0.73 1.95 6.72 3.52 0.970.97 D 14 591 0.67 1.62 6.97 3.88 D 14 591 0.67 1.62 6.97 3.88
1.271.27
Breastmilk Breastmilk 750 0.69 1.1 7.4 4.2 750 0.69 1.1 7.4 4.2 0.70 0.70
(Mature>30 d)(Mature>30 d)
Type of Volume ENERGY PROTEIN CHO FAT Type of Volume ENERGY PROTEIN CHO FAT NANAMilk Milk (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml mmol/100 mlmmol/100 ml
Preterm Preterm
D7D7 461 461 0.647 0.647 2.59 6.23 4.02 2.59 6.23 4.02 2.452.45
D14D14 413 413 0.68 0.68 2.29 2.29 6.21 4.71 2.2 6.21 4.71 2.2
D28D28 452 0.652 1.91 452 0.652 1.91 6.39 4.33 6.39 4.33 1.51 1.51
DripDripBM BM 0.54 1.35 7.1 0.54 1.35 7.1 2.2 0.52.2 0.5
Cow Cow 0.67 3.4 4.6 3.9 0.67 3.4 4.6 3.9 2.3 2.3
Type of Volume ENERGY PROTEIN CHO FAT Type of Volume ENERGY PROTEIN CHO FAT NANAMilk Milk (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml mmol/100 mlmmol/100 ml
Preterm Preterm
D7D7 461 461 0.647 0.647 2.59 6.23 4.02 2.59 6.23 4.02 2.452.45
D14D14 413 413 0.68 0.68 2.29 2.29 6.21 4.71 2.2 6.21 4.71 2.2
D28D28 452 0.652 1.91 452 0.652 1.91 6.39 4.33 6.39 4.33 1.51 1.51
DripDripBM BM 0.54 1.35 7.1 0.54 1.35 7.1 2.2 0.52.2 0.5
Cow Cow 0.67 3.4 4.6 3.9 0.67 3.4 4.6 3.9 2.3 2.3
Calculated Nutrient Intakes Compared Calculated Nutrient Intakes Compared to Estimated Needs for LBWto Estimated Needs for LBW
Units/KG/DUnits/KG/D PreTerm MilkPreTerm Milk
Week of LactationWeek of LactationMatureMature
MilkMilkEstimateEstimated Needsd Needs
11 22 44
Energy (KCAL)Energy (KCAL) 120120 120120 120120 120120 120120
Fluid Vol. (ML)Fluid Vol. (ML) 180180 180180 180180 190190 150150
Protein (G)Protein (G) 3.93.9 3.43.4 2.82.8 2.42.4 3.53.5
Sodium (MMOL)Sodium (MMOL) 4.04.0 2.72.7 1.81.8 2.02.0 3.03.0
Calcium (MG)Calcium (MG) 5353 4646 4242 4747 160-200160-200
Phosphorus Phosphorus (MG)(MG)
2525 2727 2323 2626 80-10080-100
HUMANHUMAN COW’SCOW’S
Amino-acidsAmino-acids
CystineCystine
TaurineTaurineEnough for growing Enough for growing brainbrain
Not enoughNot enough
FatFat
TotalTotal
Saturation of fatty Saturation of fatty acidsacids
Linoleic acid Linoleic acid (essential)(essential)
CholesterolCholesterol
4% (average)4% (average)
Enough unsaturatedEnough unsaturated
Enough for growing Enough for growing brainbrain
EnoughEnough
4%4%Too much saturatedToo much saturated
Not enoughNot enough
Not enoughNot enough
Lipase to digest fatLipase to digest fat PresentPresent NoneNone
Lactose (sugar)Lactose (sugar) 7% -- enough7% -- enough 3-4% - not 3-4% - not enoughenough
Salts (mEq/l)Salts (mEq/l)
SodiumSodium
ChlorideChloride
PotassiumPotassium
6.5 correct amount6.5 correct amount
12 correct amount12 correct amount
14 correct amount14 correct amount
25 too much25 too much
29 too much29 too much
35 too much35 too much
HUMANHUMAN COW’SCOW’S
Minerals (mg/l)Minerals (mg/l)
CalciumCalcium
PhosphatePhosphate350 correct amount350 correct amount
150 correct amount150 correct amount1,400 too much1,400 too much
900 too much900 too much
IronIron Small amountSmall amount
Well absorbedWell absorbed
EnoughEnough
Small amountSmall amount
Poorly absorbedPoorly absorbed
Not enoughNot enough
VitaminsVitamins EnoughEnough Not enoughNot enough
WaterWater EnoughEnough
No extra neededNo extra neededExtra neededExtra needed
Nutrients in human and animal Nutrients in human and animal milkmilk
FatFat
ProteinProtein
LactoseLactose
Human Cow Goat
7
1
3.8
4.8
3.4
3.4
4.1
2.9
2.9
5.5
3.6
3.6
HUMANHUMAN COWCOW GOATGOAT BUFFALOBUFFALO
VITAMIN CONTENTVITAMIN CONTENT
VitaminVitamin HumanHuman Cow’sCow’sAA Enough even in 2Enough even in 2ndnd
year year
2 X in colostrum2 X in colostrum
In case of deficiency In case of deficiency give supplement to give supplement to mothermother
Less (x 1/2)Less (x 1/2)
B GroupB Group PlentyPlenty Even moreEven more
CC EnoughEnough Less (x 1/5)Less (x 1/5)
May need supplement if May need supplement if fed artificiallyfed artificially
DD EnoughEnough LessLess
KK Usually enoughUsually enough
More in ColostrumMore in ColostrumMoreMore
Comparison of Human Milk and Cow’s MilkComparison of Human Milk and Cow’s Milk
HUMANHUMAN COW’SCOW’S
Bacteria Bacteria contaminationcontamination
NoneNone LikelyLikely
Anti-infective Anti-infective SubstancesSubstances
AntibodiesAntibodies
LeucocytesLeucocytes
LactoferrinLactoferrin
Bifidus factorBifidus factor
Not activeNot active
ProteinProtein
- Total- Total
- Casein- Casein
- Lactalbumen- Lactalbumen
1%1%
0.5%0.5%
0.5%0.5%
4% too much4% too much
3% too much3% too much
0.5%0.5%
Supplements for Breastfed Supplements for Breastfed InfantsInfants
The following supplementation is generally The following supplementation is generally recommended: recommended:
– Vitamin K supplement in the immediate Vitamin K supplement in the immediate postpartum period. postpartum period.
– 400 IU of Vitamin D400 IU of Vitamin D
– Breastfeeding women should continue Breastfeeding women should continue taking prenatal vitamins especially vitamin taking prenatal vitamins especially vitamin D, calcium and iron D, calcium and iron
– Complementary foods should be given once Complementary foods should be given once infants reach six months of ageinfants reach six months of age
Review QuestionsReview Questions
1)1) The part of breast responsible for milk secretion The part of breast responsible for milk secretion _________ under the influence of what hormone? _______________ under the influence of what hormone? ______
2)2) Two important reflexes that are needed for BM Two important reflexes that are needed for BM secretion? ________secretion? ________
3)3) Which part of the breast is milk stored? ________Which part of the breast is milk stored? ________
4)4) Hormone secreted during BF which can reduce Hormone secreted during BF which can reduce BF________BF________
5)5) Major source of protein in BM ______Major source of protein in BM ______
Benefits of Breastmilk / Benefits of Breastmilk /
Breastfeeding to Infants and Breastfeeding to Infants and
MothersMothers
Benefits of Breastmilk
Enhances Cognitive Development Protective: Both for baby and
mother Cheap & Free: Benefits the Economy Safe
Benefits of Breastmilk
Enhances Cognitive Development Protective: Both for baby and
mother Cheap & Free: Benefits the Economy Safe
Enhances Cognitive DevelopmentEnhances Cognitive Development
– Docosohexanoic Acid (DHA)Docosohexanoic Acid (DHA)
– LactoseLactose
– ‘‘Skin to skinSkin to skin’ Contact and ‘’ Contact and ‘face to face’face to face’ positionposition
Enhances Cognitive DevelopmentEnhances Cognitive Development
– Docosohexanoic Acid (DHA)Docosohexanoic Acid (DHA)
– LactoseLactose
– ‘‘Skin to skinSkin to skin’ Contact and ‘’ Contact and ‘face to face’face to face’ positionposition
Benefits of Breastmilk: Infant
Benefits of Breastmilk: Infant
DHA (Docosohexanoic Acid):
Fatty acid derived from Linolenic Acid
Only found in breastmilk in consistent level
Important substance for the myelin sheath of nerve fibers
Vital nutrient for the growth and development of brain tissue and good vision
Researches showed that it is this substance that enhances cognitive development
DHA (Docosohexanoic Acid):
Fatty acid derived from Linolenic Acid
Only found in breastmilk in consistent level
Important substance for the myelin sheath of nerve fibers
Vital nutrient for the growth and development of brain tissue and good vision
Researches showed that it is this substance that enhances cognitive development
Benefits of Breastmilk: InfantBenefits of Breastmilk: Infant
Lactose
Predominant carbohydrate of breastmilk
Disaccharide consisting of glucose and galactose
Galactose combines with lipid to form a valuable nutrient, galactose-lipid, for brain tissue development
Lactose
Predominant carbohydrate of breastmilk
Disaccharide consisting of glucose and galactose
Galactose combines with lipid to form a valuable nutrient, galactose-lipid, for brain tissue development
Benefits of Breastmilk: InfantBenefits of Breastmilk: Infant
‘Skin to skin’ contact & ‘Face to Face’ position
Enhances the cognitive and educational development of children as each feeding time is a learning opportunity for mother and child
‘Skin to skin’ contact & ‘Face to Face’ position
Enhances the cognitive and educational development of children as each feeding time is a learning opportunity for mother and child
Benefits of Breastmilk: InfantBenefits of Breastmilk: Infant
Breastmilk is Protective
Protective properties of BM is divided into two:
– Humoral factors: Consists of the 5 immunoglobulins (antibodies):
– IgA, s IgA, IgG, Ig E, Ig D, Ig M
– Cellular factors: White Blood cells: Neutrophils Lymphocytes Epithelial cells Macrophages
Breastmilk is Protective
Protective properties of BM is divided into two:
– Humoral factors: Consists of the 5 immunoglobulins (antibodies):
– IgA, s IgA, IgG, Ig E, Ig D, Ig M
– Cellular factors: White Blood cells: Neutrophils Lymphocytes Epithelial cells Macrophages
Benefits of Breastmilk: InfantBenefits of Breastmilk: Infant
Breastmilk is Protective
White Blood Cells
Bacterial killer
Highest concentration of WBC occurs in the 1st few days of lactation > a million/ml
Colostrum (1-5 days post-natal):
– Contains 105 – 5 x 106 WBC / ml
Breastmilk is Protective
White Blood Cells
Bacterial killer
Highest concentration of WBC occurs in the 1st few days of lactation > a million/ml
Colostrum (1-5 days post-natal):
– Contains 105 – 5 x 106 WBC / ml
Benefits of Breastmilk: InfantBenefits of Breastmilk: Infant
Breastmilk is Protective
Bifidus Factor:– Enhances the growth of Lactobacillus
bifidus preventing growth of pathogenic bacteria
Lactoferrin:– Binds iron thus preventing the growth of
iron-dependent bacteria
Breastmilk is Protective
Bifidus Factor:– Enhances the growth of Lactobacillus
bifidus preventing growth of pathogenic bacteria
Lactoferrin:– Binds iron thus preventing the growth of
iron-dependent bacteria
Benefits of Breastmilk: InfantBenefits of Breastmilk: Infant
Host Resistance Factors in BMHost Resistance Factors in BMHost Resistance Factors in BMHost Resistance Factors in BM
Non-immunoglobulin components:Non-immunoglobulin components:– OligosaccharidesOligosaccharides– MucinMucin– Fatty acidsFatty acids
Non-immunoglobulin components:Non-immunoglobulin components:– OligosaccharidesOligosaccharides– MucinMucin– Fatty acidsFatty acids
Anti-infective PropertiesAnti-infective PropertiesAnti-infective PropertiesAnti-infective Properties
IgA, IgM, IgGIgA, IgM, IgG:: immunoglobulins that guard the gut immunoglobulins that guard the gut against infective bacteriaagainst infective bacteria
Bifidus factor:Bifidus factor: stimulates bifido-bacteria, which stimulates bifido-bacteria, which fight against pathogenic bacteriafight against pathogenic bacteria
Lactoferrin:Lactoferrin: binds iron away from bacteria binds iron away from bacteria
Macrophages:Macrophages: phagocytosis of infective bacteria phagocytosis of infective bacteria
BB1212 binding protein: binding protein: removes B removes B1212 from bacteria from bacteria
IgA, IgM, IgGIgA, IgM, IgG:: immunoglobulins that guard the gut immunoglobulins that guard the gut against infective bacteriaagainst infective bacteria
Bifidus factor:Bifidus factor: stimulates bifido-bacteria, which stimulates bifido-bacteria, which fight against pathogenic bacteriafight against pathogenic bacteria
Lactoferrin:Lactoferrin: binds iron away from bacteria binds iron away from bacteria
Macrophages:Macrophages: phagocytosis of infective bacteria phagocytosis of infective bacteria
BB1212 binding protein: binding protein: removes B removes B1212 from bacteria from bacteria
Benefits of Breastmilk: Infant
Benefits of Breastmilk: Infant
Antiviral Factors in Human MilkAntiviral Factors in Human MilkFactorFactor Shown, in vitro, to be Shown, in vitro, to be
active against:active against:Effect of HeatEffect of Heat
Secretory Secretory IgAIgA
Poliovirus types 1, 2, 3. Poliovirus types 1, 2, 3. Coxsackie types A9, B3, Coxsackie types A9, B3,
B5, B5,
Echovirus types 6, 9. Echovirus types 6, 9. Semliki Forest VirusSemliki Forest Virus
Ross River VirusRoss River Virus
RotavirusRotavirus
CytomegalovirusCytomegalovirus
Reovirus type 3Reovirus type 3
Rubella virusRubella virus
Herpes simplex virus, Herpes simplex virus, Mumps virusMumps virus
Influenza virus Influenza virus
Respiratory syncytial Respiratory syncytial virusvirus
Stable at 56Stable at 56°C for °C for 30 mins.; 30 mins.;
Some loss (0 – 30%) Some loss (0 – 30%) at 62.5 °C for 30 at 62.5 °C for 30 mins; mins;
destroyed by boilingdestroyed by boiling
Enhanced immune response to Enhanced immune response to immunizationsimmunizations– PolioPolio– TetanusTetanus– DiptheriaDiptheria– Haemophilus influenzaHaemophilus influenza
Enhanced immune response to Enhanced immune response to immunizationsimmunizations– PolioPolio– TetanusTetanus– DiptheriaDiptheria– Haemophilus influenzaHaemophilus influenza
Benefits of Breastmilk: Infant
Benefits of Breastmilk: Infant
Protection Against InfectionProtection Against InfectionProtection Against InfectionProtection Against Infection
Reduces risk and severity of Reduces risk and severity of infectious illness among infectious illness among infantsinfants– diarrheadiarrhea– otitis mediaotitis media– lower respiratory infectionslower respiratory infections– bacteremiabacteremia– bacterial meningitisbacterial meningitis– necrotizing enterocolitisnecrotizing enterocolitis– infant botulisminfant botulism– urinary tract diseaseurinary tract disease– sudden infant death syndrome sudden infant death syndrome
(SIDS)(SIDS)– ColicColic– wheezingwheezing
Reduces risk and severity of Reduces risk and severity of infectious illness among infectious illness among infantsinfants– diarrheadiarrhea– otitis mediaotitis media– lower respiratory infectionslower respiratory infections– bacteremiabacteremia– bacterial meningitisbacterial meningitis– necrotizing enterocolitisnecrotizing enterocolitis– infant botulisminfant botulism– urinary tract diseaseurinary tract disease– sudden infant death syndrome sudden infant death syndrome
(SIDS)(SIDS)– ColicColic– wheezingwheezing
Antibacterial PropertiesAntibacterial Propertiesfound in human milkfound in human milk
FactorFactor Shown, in vitro, to be active Shown, in vitro, to be active against:against:
Effect of HeatEffect of Heat
Secretory IgASecretory IgA E. Coli (also pili and capsular E. Coli (also pili and capsular antigens)antigens)
C. TetaniC. Tetani
C. DiphtheriaeC. Diphtheriae
K. pneumoniaeK. pneumoniae
Salmonella (6 groups)Salmonella (6 groups)
Shigella (2 groups)Shigella (2 groups)
Streptococcus, S. mutans, S. sanguis, Streptococcus, S. mutans, S. sanguis, S. mitis, S. salivarius, S. pneumoniae, S. mitis, S. salivarius, S. pneumoniae,
C. burnetti, C. burnetti,
H. influenzae H. influenzae
E. coli enterotoxin, E. coli enterotoxin,
V. Cholerae enterotoxinV. Cholerae enterotoxin
C. difficile toxinsC. difficile toxins
H. Influenzae capsuleH. Influenzae capsule
Stable at 56Stable at 56°C for °C for 30 min; 30 min;
some loss (0-30%) some loss (0-30%) at 62.5°C for 30 at 62.5°C for 30 min; min;
destroyed by destroyed by boiling boiling
IgM, IgGIgM, IgG V. Cholerae lipopolysaccharide; V. Cholerae lipopolysaccharide; E. coliE. coli
IgM destroyed and IgM destroyed and IgG decreased by a IgG decreased by a third at 62.5third at 62.5°C for °C for 30 min30 min
FactorFactor Shown, in vitro, Shown, in vitro, to be active to be active
against:against:
Effect of HeatEffect of Heat
IgDIgD
Bifidobacterium Bifidobacterium bifidum growthbifidum growth
z factorz factor
E. ColiE. Coli
EnterobacteriaceEnterobacteriacea, enteric a, enteric pathogenspathogens
Stable to boilingStable to boiling
Factor binding Factor binding proteins (zinc, proteins (zinc, vitamin Bvitamin B1212, folate), folate)
Dependent E. coliDependent E. coli Destroyed by Destroyed by boilingboiling
Complement C1-C9 Complement C1-C9 (mainly C3 and C4)(mainly C3 and C4)
Effect not knownEffect not known Destroyed by Destroyed by heating at 56heating at 56°C for °C for 30 min30 min
LactoferrinLactoferrin E. ColiE. Coli Two-thirds Two-thirds destroyed at destroyed at 62.5°C for 30 min; 62.5°C for 30 min; essentially essentially destroyed by destroyed by boiling for 15 minboiling for 15 min
FactorFactor Shown, in vitro, Shown, in vitro, to be active to be active
against:against:
Effect of HeatEffect of Heat
LactoperoxidasLactoperoxidasee
Streptococcus, Streptococcus, Pseudomonas, E. Pseudomonas, E. coli, S. coli, S. typhimuriumtyphimurium
Destroyed by boilingDestroyed by boiling
LysozymeLysozyme E. coli, Salmonella, E. coli, Salmonella, Micrococcus Micrococcus lysodeikticuslysodeikticus
Some loss (0-23%) at Some loss (0-23%) at 62.562.5°C for 30 min; °C for 30 min; essentially destroyed by essentially destroyed by boiling for 15 minboiling for 15 min
Unidentified Unidentified factorsfactors
S. aureus, C. S. aureus, C. difficile toxin Bdifficile toxin B
Stable at autoclaving; Stable at autoclaving; stable at 56°C for 30 minstable at 56°C for 30 min
CarbohydrateCarbohydrate E. coli enterotoxinE. coli enterotoxin Stable at 85°C for 30 minStable at 85°C for 30 min
LipidLipid S. AureusS. Aureus Stable at boilingStable at boiling
Ganglioside Ganglioside (GMI like)(GMI like)
E. Coli enterotoxin, E. Coli enterotoxin, V. cholerae V. cholerae enterotoxinenterotoxin
Stable to boilingStable to boiling
Types of Breast milk
Foremilk
Hindmilk
Protective Factors in BMProtective Factors in BMProtective Factors in BMProtective Factors in BM
Non-immunoglobulin components:Non-immunoglobulin components:
- Non-specific factors:Non-specific factors: Bifidus factorBifidus factor Resistance factor (Anti-staphylococcal Resistance factor (Anti-staphylococcal
factor)factor) Anti-viral factorAnti-viral factor Anti-protozoal factors (bile-salt Anti-protozoal factors (bile-salt
stimulated lipase)stimulated lipase)
– Enzymes: Lysozyme, lipoprotein lipaseEnzymes: Lysozyme, lipoprotein lipase
Non-immunoglobulin components:Non-immunoglobulin components:
- Non-specific factors:Non-specific factors: Bifidus factorBifidus factor Resistance factor (Anti-staphylococcal Resistance factor (Anti-staphylococcal
factor)factor) Anti-viral factorAnti-viral factor Anti-protozoal factors (bile-salt Anti-protozoal factors (bile-salt
stimulated lipase)stimulated lipase)
– Enzymes: Lysozyme, lipoprotein lipaseEnzymes: Lysozyme, lipoprotein lipase
Protective Factors in BMProtective Factors in BMProtective Factors in BMProtective Factors in BM
Anti-inflammatoryAnti-inflammatory properties: properties:
– BM is poor initiators and mediators of BM is poor initiators and mediators of inflammation (complement system, fibrinolytic, inflammation (complement system, fibrinolytic, coagulation system) but rich in anti-coagulation system) but rich in anti-inflammatory agents (sIGA, lysozyme); inflammatory agents (sIGA, lysozyme);
Provides Provides good mucosal barriergood mucosal barrier (growth (growth factors) factors) prevents attachment of bacteria prevents attachment of bacteria & antigen;& antigen;
Anti-inflammatoryAnti-inflammatory properties: properties:
– BM is poor initiators and mediators of BM is poor initiators and mediators of inflammation (complement system, fibrinolytic, inflammation (complement system, fibrinolytic, coagulation system) but rich in anti-coagulation system) but rich in anti-inflammatory agents (sIGA, lysozyme); inflammatory agents (sIGA, lysozyme);
Provides Provides good mucosal barriergood mucosal barrier (growth (growth factors) factors) prevents attachment of bacteria prevents attachment of bacteria & antigen;& antigen;
Maternal HIVMaternal HIV
Maternal-to-Child Viral Transmission (MTCT):Maternal-to-Child Viral Transmission (MTCT):
Breastfeeding vs Formula feeding:Breastfeeding vs Formula feeding:
– Prevalence of MTCT at 24 months:Prevalence of MTCT at 24 months:
Breastfeeding (BF):Breastfeeding (BF): 36.7%36.7% Formula-feeding (FF):Formula-feeding (FF): 20.5%20.5%
– Mortality rate:Mortality rate: BF:BF: 24.4%24.4% FF:FF: 20.0% 20.0%
Nduati R. et al. JAMA 2000Nduati R. et al. JAMA 2000
Maternal HIVMaternal HIV
Maternal-to-Child Viral Transmission (MTCT):Maternal-to-Child Viral Transmission (MTCT):
Breastfeeding vs Formula feeding:Breastfeeding vs Formula feeding:
– Prevalence of MTCT at 24 months:Prevalence of MTCT at 24 months:
Breastfeeding (BF):Breastfeeding (BF): 36.7%36.7% Formula-feeding (FF):Formula-feeding (FF): 20.5%20.5%
– Mortality rate:Mortality rate: BF:BF: 24.4%24.4% FF:FF: 20.0% 20.0%
Nduati R. et al. JAMA 2000Nduati R. et al. JAMA 2000
Benefits of Breastmilk: InfantsBenefits of Breastmilk: Infants
Breastfeeding and premature Breastfeeding and premature infants:infants:
Premature infants fed their mother's milk were Premature infants fed their mother's milk were found to have decreased incidences of sepsis, found to have decreased incidences of sepsis, meningitis, and necrotizing enterocolitismeningitis, and necrotizing enterocolitis
Breastfeeding and premature Breastfeeding and premature infants:infants:
Premature infants fed their mother's milk were Premature infants fed their mother's milk were found to have decreased incidences of sepsis, found to have decreased incidences of sepsis, meningitis, and necrotizing enterocolitismeningitis, and necrotizing enterocolitis
Benefits of Breastmilk: InfantBenefits of Breastmilk: Infant
Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated
– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula
CMAJ 166 2002
– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula
JClin Microbiol 39 2001
Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated
– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula
CMAJ 166 2002
– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula
JClin Microbiol 39 2001
Benefits of Breastmilk: Safe Benefits of Breastmilk: Safe
Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated
– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula
CMAJ 166 2002
– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula
JClin Microbiol 39 2001
Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated
– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula
CMAJ 166 2002
– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula
JClin Microbiol 39 2001
Benefits of Breastmilk: Safe Benefits of Breastmilk: Safe
Joint FAO/WHO Workshop on Enterobacter
Sakazakii and other Microorganisms in
Powdered Infant formula February 2004
Recommendations:
– Guidelines should be developed for the preparation, use and handling of infant formula to decrease the risk of infection
– Make use of Enterobacteriaceae rather than coliform testing as an indicator of hygienic control
Joint FAO/WHO Workshop on Enterobacter
Sakazakii and other Microorganisms in
Powdered Infant formula February 2004
Recommendations:
– Guidelines should be developed for the preparation, use and handling of infant formula to decrease the risk of infection
– Make use of Enterobacteriaceae rather than coliform testing as an indicator of hygienic control
Benefits of Breastmilk: Safe Benefits of Breastmilk: Safe
Benefits of Breastfeeding: MothersBenefits of Breastfeeding: Mothers
Prevents ObesityPrevents Obesity
Early return to pre-pregnancy Early return to pre-pregnancy weightweight
Prevents ObesityPrevents Obesity
Early return to pre-pregnancy Early return to pre-pregnancy weightweight
Breast Cancer
“Meta-Analysis on the Protective Effect of BF on Breast Cancer”. Labbock et al. Ped Clin North Am., 2001 Feb
Eleven studies were evaluated– Results:
RR: 0.54 to 0.85 for 1st 3-6 months of BF
RR: 0.4 to 0.72 for > 2 years
RR: 0.35 for > 6 years Conclusion:
Clear and consistent protective effect of BF on breast cancer have been found in all studies
Breast Cancer
“Meta-Analysis on the Protective Effect of BF on Breast Cancer”. Labbock et al. Ped Clin North Am., 2001 Feb
Eleven studies were evaluated– Results:
RR: 0.54 to 0.85 for 1st 3-6 months of BF
RR: 0.4 to 0.72 for > 2 years
RR: 0.35 for > 6 years Conclusion:
Clear and consistent protective effect of BF on breast cancer have been found in all studies
Benefits of Breastfeeding: Mothers
Benefits of Breastfeeding: Mothers
Ovarian CancerOvarian Cancer
““Breastfeeding and Risk to Ovarian Breastfeeding and Risk to Ovarian Cancer”Cancer”
– Rosenblatt 1993Rosenblatt 1993: : 20-25% 20-25% decrease in riskdecrease in risk for cancer for women who for cancer for women who
breastfed for at least 2 monthsbreastfed for at least 2 months
– Risch et al 1993 & Gwinn 1990:Risch et al 1993 & Gwinn 1990: Showed the Showed the protective effectprotective effect of lactation (RR 0.79 per of lactation (RR 0.79 per
year of lactation; 0.6 respectively)year of lactation; 0.6 respectively)
– Shoham 1994:Shoham 1994: 50% 50% decrease in risk fordecrease in risk for ovarian cancer ovarian cancer
Ovarian CancerOvarian Cancer
““Breastfeeding and Risk to Ovarian Breastfeeding and Risk to Ovarian Cancer”Cancer”
– Rosenblatt 1993Rosenblatt 1993: : 20-25% 20-25% decrease in riskdecrease in risk for cancer for women who for cancer for women who
breastfed for at least 2 monthsbreastfed for at least 2 months
– Risch et al 1993 & Gwinn 1990:Risch et al 1993 & Gwinn 1990: Showed the Showed the protective effectprotective effect of lactation (RR 0.79 per of lactation (RR 0.79 per
year of lactation; 0.6 respectively)year of lactation; 0.6 respectively)
– Shoham 1994:Shoham 1994: 50% 50% decrease in risk fordecrease in risk for ovarian cancer ovarian cancer
Benefits of Breastfeeding: Mothers
Benefits of Breastfeeding: Mothers
Family:– Purchase of formula costs the average poor
family (7,280.00/ month income) about P2,000.00
National Economy (NEDA):– Milk companies import S57.5 M (P3.1 B)
worth of infant formula
– Sell to people 7x cost (WHO) – P21.5 B or S405 B)
Family:– Purchase of formula costs the average poor
family (7,280.00/ month income) about P2,000.00
National Economy (NEDA):– Milk companies import S57.5 M (P3.1 B)
worth of infant formula
– Sell to people 7x cost (WHO) – P21.5 B or S405 B)
Benefits of Breastfeeding: Economy
Benefits of Breastfeeding: Economy
Longer-term Health Outcomes: Longer-term Health Outcomes: Maternal Maternal benefitsbenefitsLonger-term Health Outcomes: Longer-term Health Outcomes: Maternal Maternal benefitsbenefits
Reduces risk of chronic illness in Reduces risk of chronic illness in childhoodchildhood– Some food allergiesSome food allergies– Type-1 insulin dependent diabetesType-1 insulin dependent diabetes– LymphomaLymphoma– AsthmaAsthma– ObesityObesity
Reduces risk of chronic illness in Reduces risk of chronic illness in childhoodchildhood– Some food allergiesSome food allergies– Type-1 insulin dependent diabetesType-1 insulin dependent diabetes– LymphomaLymphoma– AsthmaAsthma– ObesityObesity
Steps to Encourage Breast-Feeding in the Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-FriendlyHospital: UNICEF/WHO Baby-Friendly
HOSPITAL INITIATIVESHOSPITAL INITIATIVES
– Provide all pregnant women with information and Provide all pregnant women with information and counselling.counselling.
– Document the desire to breast-feed in the medical Document the desire to breast-feed in the medical record.record.
– Document the method of feeding in the infant’s record.Document the method of feeding in the infant’s record.– Place the newborn and mother skin- to-skin, and Place the newborn and mother skin- to-skin, and
initiate breast-feeding within 1 hr of birth.initiate breast-feeding within 1 hr of birth.– Continue skin-to-skin contact at other times and Continue skin-to-skin contact at other times and
encourage encourage rooming-in.rooming-in.– Assess breast-feeding and continue encouragement Assess breast-feeding and continue encouragement
and teaching on each shift.and teaching on each shift.
MOTHERS TO LEARNMOTHERS TO LEARN
– Proper position and latch onProper position and latch on– Nutritive sucking and swallowingNutritive sucking and swallowing– Milk production and releaseMilk production and release– Frequency and feeding cuesFrequency and feeding cues– Expression of milk neededExpression of milk needed– Assessment of the infant’s nutritional Assessment of the infant’s nutritional
statusstatus– When to contact the clinicianWhen to contact the clinician
Steps to Encourage Breast-Feeding in the Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-FriendlyHospital: UNICEF/WHO Baby-Friendly
ADDITIONAL INSTRUCTIONSADDITIONAL INSTRUCTIONS
– Refer to lactation consultation if any concerns arise.Refer to lactation consultation if any concerns arise.– Infants should go to the breast at least 8-12 times/24 hr, Infants should go to the breast at least 8-12 times/24 hr,
day and night.day and night.– Avoid time limits on the breasts; offer both breasts at Avoid time limits on the breasts; offer both breasts at
each feeding.each feeding.– Do not give sterile water, glucose, or formula unless Do not give sterile water, glucose, or formula unless
indicated.indicated.– If supplements are given, use cup feeding, a Haberman If supplements are given, use cup feeding, a Haberman
feeder, fingers, or syringe feedings.feeder, fingers, or syringe feedings.– Avoid pacifiers in the newborn nursery except during Avoid pacifiers in the newborn nursery except during
painful procedures.painful procedures.– Avoid anti-lactation drugs.Avoid anti-lactation drugs.
Steps to Encourage Breast-Feeding in the Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-FriendlyHospital: UNICEF/WHO Baby-Friendly
Review QuestionsReview Questions
1.1. What breast structure secretes breastmilk? What breast structure secretes breastmilk? What hormone is responsible for it?What hormone is responsible for it?
2.2. What are the 2 processes are responsible What are the 2 processes are responsible for breastmilk secretion & maintenance?for breastmilk secretion & maintenance?
3.3. Breastmilk is stored in what part of the Breastmilk is stored in what part of the breast?breast?
4.4. 3 phases of lactation?3 phases of lactation?
5.5. Hormone secreted during BF which could Hormone secreted during BF which could cause BM reduction if breast is not emptied cause BM reduction if breast is not emptied completely.completely.
6) What is the protein distribution of BM? What 6) What is the protein distribution of BM? What is the predominant protein component?is the predominant protein component?
7) How much calories is lost per day when bf?7) How much calories is lost per day when bf?
8) What are the 3 areas that must be 8) What are the 3 areas that must be addressed in BF based on the addressed in BF based on the recommendation of WHO? recommendation of WHO?
Thank You Thank You and and
God blessGod bless
Thank You Thank You and and
God blessGod bless
Breastmilk SubstitutesBreastmilk Substitutes
Infant Milk FormulasInfant Milk Formulas
Breastmilk SubstitutesBreastmilk Substitutes
Infant Milk FormulasInfant Milk Formulas
TYPES OF INFANT FORMULATYPES OF INFANT FORMULATYPES OF INFANT FORMULATYPES OF INFANT FORMULA
• Pre-term FormulaPre-term Formula• Catch-up Growth FormulaCatch-up Growth Formula• Standard Infant FormulaStandard Infant Formula
Whey Dominant ( 60%)Whey Dominant ( 60%)Casein Dominant ( 60%)Casein Dominant ( 60%)
• Follow-on (up) FormulaFollow-on (up) Formula• Growing-up FormulaGrowing-up Formula• Whole cow’s MilkWhole cow’s Milk• Evaporated MilkEvaporated Milk
• Pre-term FormulaPre-term Formula• Catch-up Growth FormulaCatch-up Growth Formula• Standard Infant FormulaStandard Infant Formula
Whey Dominant ( 60%)Whey Dominant ( 60%)Casein Dominant ( 60%)Casein Dominant ( 60%)
• Follow-on (up) FormulaFollow-on (up) Formula• Growing-up FormulaGrowing-up Formula• Whole cow’s MilkWhole cow’s Milk• Evaporated MilkEvaporated Milk
Types of Infant FormulasTypes of Infant FormulasTypes of Infant FormulasTypes of Infant Formulas
Special Formulas:Special Formulas:
– Hydrolysates:Hydrolysates: Partial HydrolysatesPartial Hydrolysates Complete HydrolysatesComplete Hydrolysates
– Goats milkGoats milk
Special Formulas:Special Formulas:
– Hydrolysates:Hydrolysates: Partial HydrolysatesPartial Hydrolysates Complete HydrolysatesComplete Hydrolysates
– Goats milkGoats milk
Nutrient Sources:Nutrient Sources:FOR INFANTS LESS THAN 2 YEARSFOR INFANTS LESS THAN 2 YEARS
Nutrient Sources:Nutrient Sources:FOR INFANTS LESS THAN 2 YEARSFOR INFANTS LESS THAN 2 YEARS
Three Indications for Use of Infant Three Indications for Use of Infant Formulas:Formulas:
As substitute ( or supplement) for human milk As substitute ( or supplement) for human milk in infants whose mother choose not to in infants whose mother choose not to breastfeed;breastfeed;
As a substitute for human milk in infants for As a substitute for human milk in infants for whom breastfeeding is medically whom breastfeeding is medically contraindicated;contraindicated;
As supplement for infants who do not gain As supplement for infants who do not gain weight appropriately.weight appropriately.
Three Indications for Use of Infant Three Indications for Use of Infant Formulas:Formulas:
As substitute ( or supplement) for human milk As substitute ( or supplement) for human milk in infants whose mother choose not to in infants whose mother choose not to breastfeed;breastfeed;
As a substitute for human milk in infants for As a substitute for human milk in infants for whom breastfeeding is medically whom breastfeeding is medically contraindicated;contraindicated;
As supplement for infants who do not gain As supplement for infants who do not gain weight appropriately.weight appropriately.
Nutrient Sources:Nutrient Sources:< 2 Years of Age< 2 Years of Age
Nutrient Sources:Nutrient Sources:< 2 Years of Age< 2 Years of Age
PRETERM FORMULA:PRETERM FORMULA:
Prescribed for premature until they have Prescribed for premature until they have reached reached 35-36 weeks35-36 weeks of gestation or gained of gestation or gained 2 2 kilograms.kilograms.
When given beyond recommended age may When given beyond recommended age may cause hypercalcemiacause hypercalcemia
Special Features:Special Features:
• Protein: Whey predominant formula at a Protein: Whey predominant formula at a level higher than breast milk & standard level higher than breast milk & standard infant formula infant formula (2.0 2.5g/100ml.)(2.0 2.5g/100ml.)
PRETERM FORMULA:PRETERM FORMULA:
Prescribed for premature until they have Prescribed for premature until they have reached reached 35-36 weeks35-36 weeks of gestation or gained of gestation or gained 2 2 kilograms.kilograms.
When given beyond recommended age may When given beyond recommended age may cause hypercalcemiacause hypercalcemia
Special Features:Special Features:
• Protein: Whey predominant formula at a Protein: Whey predominant formula at a level higher than breast milk & standard level higher than breast milk & standard infant formula infant formula (2.0 2.5g/100ml.)(2.0 2.5g/100ml.)
PRETERM FORMULAPRETERM FORMULAPRETERM FORMULAPRETERM FORMULA
Pre-Aptamil (Milupa): 1:1 dilutionPre-Aptamil (Milupa): 1:1 dilution
Enfalac Premature:Enfalac Premature: 1:1 dilution 1:1 dilution
Pre-Nan:Pre-Nan: 1:1 dilution 1:1 dilution
S-26 LBW:S-26 LBW: 1:2 dilution 1:2 dilution
Pre-Aptamil (Milupa): 1:1 dilutionPre-Aptamil (Milupa): 1:1 dilution
Enfalac Premature:Enfalac Premature: 1:1 dilution 1:1 dilution
Pre-Nan:Pre-Nan: 1:1 dilution 1:1 dilution
S-26 LBW:S-26 LBW: 1:2 dilution 1:2 dilution
STANDARD INFANT FORMULASTANDARD INFANT FORMULASTANDARD INFANT FORMULASTANDARD INFANT FORMULA
Recommended during the firstRecommended during the first 6 –12 months 6 –12 months of life;of life;
Extensively modified from what was originally Extensively modified from what was originally produced by the cow;produced by the cow;
Very little difference between various brandsVery little difference between various brands
Example: S-26, Enfalac, Nan, Similac, Mylac, Example: S-26, Enfalac, Nan, Similac, Mylac, Aptamil, Bonna, NestogenAptamil, Bonna, Nestogen
Recommended during the firstRecommended during the first 6 –12 months 6 –12 months of life;of life;
Extensively modified from what was originally Extensively modified from what was originally produced by the cow;produced by the cow;
Very little difference between various brandsVery little difference between various brands
Example: S-26, Enfalac, Nan, Similac, Mylac, Example: S-26, Enfalac, Nan, Similac, Mylac, Aptamil, Bonna, NestogenAptamil, Bonna, Nestogen
FOLLOW-UP FORMULAFOLLOW-UP FORMULAFOLLOW-UP FORMULAFOLLOW-UP FORMULA
Liquid part of the weaning diet for infants Liquid part of the weaning diet for infants & children& children 12 mos12 mos - - 3 years of age;3 years of age;
Distribution of calories and nutrients is in Distribution of calories and nutrients is in between standard infant formula and whole between standard infant formula and whole cow’s milkcow’s milk
Protein is higher with the ratio of 20% whey Protein is higher with the ratio of 20% whey and 80% caseinand 80% casein
Example: Promil, Nan 2, Gain, MilumilExample: Promil, Nan 2, Gain, Milumil
Liquid part of the weaning diet for infants Liquid part of the weaning diet for infants & children& children 12 mos12 mos - - 3 years of age;3 years of age;
Distribution of calories and nutrients is in Distribution of calories and nutrients is in between standard infant formula and whole between standard infant formula and whole cow’s milkcow’s milk
Protein is higher with the ratio of 20% whey Protein is higher with the ratio of 20% whey and 80% caseinand 80% casein
Example: Promil, Nan 2, Gain, MilumilExample: Promil, Nan 2, Gain, Milumil
COMPOSITION OF VARIOUS NUTRIENT COMPOSITION OF VARIOUS NUTRIENT SOURCESSOURCES
COMPOSITION OF VARIOUS NUTRIENT COMPOSITION OF VARIOUS NUTRIENT SOURCESSOURCES
BM COW A PREM FF-BM COW A PREM FF-UPUP
Energy kcal/100mlEnergy kcal/100ml 6565 6767 6565 8181 6565
Protein G/100 mlProtein G/100 ml 1.11.1 3.53.5 1.51.5 2.42.4 2.82.8WheyWhey 60%60% 60%60% 20%20%CaseinCasein 40%40% 40%40% 80%80%
Fat G/100 mlFat G/100 ml 4.54.5 3.73.7 3.63.6 4.44.4 2.642.64
CHO G/100 mlCHO G/100 ml 6.86.8 4.94.9 7.27.2 8.68.6 8.188.18
CA mg/100 mlCA mg/100 ml 3434 117117 4444 95(75)95(75)P mg/100 mlP mg/100 ml 1414 9292 3333 53(40)53(40)
NA mmol/100 mlNA mmol/100 ml 0.70.7 2.22.2 0.640.64 1.41.4 1.571.57
GROWING –UP FORMULA:GROWING –UP FORMULA:GROWING –UP FORMULA:GROWING –UP FORMULA:
Product used for children above 2 years Product used for children above 2 years to 10 yearsto 10 years
Provides nutrient necessary as they Provides nutrient necessary as they undergo transition from infant to adult undergo transition from infant to adult formulation.formulation.
• Protein is high ( 3 g/100 ml) from SodiumProtein is high ( 3 g/100 ml) from Sodium• Casseinate and soya proteinCasseinate and soya protein
CHO contains a blend of cornstarch and CHO contains a blend of cornstarch and sucrose with very minimal lactosesucrose with very minimal lactose
Product used for children above 2 years Product used for children above 2 years to 10 yearsto 10 years
Provides nutrient necessary as they Provides nutrient necessary as they undergo transition from infant to adult undergo transition from infant to adult formulation.formulation.
• Protein is high ( 3 g/100 ml) from SodiumProtein is high ( 3 g/100 ml) from Sodium• Casseinate and soya proteinCasseinate and soya protein
CHO contains a blend of cornstarch and CHO contains a blend of cornstarch and sucrose with very minimal lactosesucrose with very minimal lactose
Growing-up FormulasGrowing-up FormulasGrowing-up FormulasGrowing-up Formulas
Enfagrow (MJ):Enfagrow (MJ): 1:1 dilution1:1 dilution
Grow (Abbott):Grow (Abbott): 1:2 dilution1:2 dilution
Lactum (MJ):Lactum (MJ): 1:1 dilution1:1 dilution
Neslac (Nestle):Neslac (Nestle):1:1 dilution1:1 dilution
Progress (Wyeth):Progress (Wyeth): 1:2 dilution1:2 dilution
Enfagrow (MJ):Enfagrow (MJ): 1:1 dilution1:1 dilution
Grow (Abbott):Grow (Abbott): 1:2 dilution1:2 dilution
Lactum (MJ):Lactum (MJ): 1:1 dilution1:1 dilution
Neslac (Nestle):Neslac (Nestle):1:1 dilution1:1 dilution
Progress (Wyeth):Progress (Wyeth): 1:2 dilution1:2 dilution
Whole Cow’s MilkWhole Cow’s MilkWhole Cow’s MilkWhole Cow’s Milk
Maybe given as Maybe given as supplementsupplement to a balanced to a balanced diet from 12 months above;diet from 12 months above;
No modification done to suit the needs of No modification done to suit the needs of infants &childreninfants &children
Example: Alaska, Bear Brand,Example: Alaska, Bear Brand,
Maybe given as Maybe given as supplementsupplement to a balanced to a balanced diet from 12 months above;diet from 12 months above;
No modification done to suit the needs of No modification done to suit the needs of infants &childreninfants &children
Example: Alaska, Bear Brand,Example: Alaska, Bear Brand,
Protein HydrolysatesProtein HydrolysatesProtein HydrolysatesProtein Hydrolysates
Definition:Definition: It refers to the product of an enzymatic It refers to the product of an enzymatic
degradation of protein to proteose, peptone, degradation of protein to proteose, peptone, peptide-AA mix and finally free AA mix.peptide-AA mix and finally free AA mix.
Types:Types:– Partial Hydrolysate:Partial Hydrolysate: Degradation of protein to Degradation of protein to
big, medium size peptides big, medium size peptides less antigenicity; less antigenicity;
– Complete Hydrolysate:Complete Hydrolysate: Degradation of protein Degradation of protein into small peptides and free AAinto small peptides and free AA..
Definition:Definition: It refers to the product of an enzymatic It refers to the product of an enzymatic
degradation of protein to proteose, peptone, degradation of protein to proteose, peptone, peptide-AA mix and finally free AA mix.peptide-AA mix and finally free AA mix.
Types:Types:– Partial Hydrolysate:Partial Hydrolysate: Degradation of protein to Degradation of protein to
big, medium size peptides big, medium size peptides less antigenicity; less antigenicity;
– Complete Hydrolysate:Complete Hydrolysate: Degradation of protein Degradation of protein into small peptides and free AAinto small peptides and free AA..
Protein HydrolysatesProtein Hydrolysates Protein HydrolysatesProtein Hydrolysates
Partially Hydrolyzed Formula:Partially Hydrolyzed Formula:– For For prophylaxisprophylaxis on high risk infants: on high risk infants:
FH of atopy, asthma, food allergyFH of atopy, asthma, food allergy
– Preparation:Preparation: Nan-HANan-HA
Extensively Hydrolyzed Formula:Extensively Hydrolyzed Formula:– For For treatmenttreatment of food allergy during of food allergy during
infancyinfancy– Preparations: Preparations: Pregomin (Milupa)Pregomin (Milupa)
Pregistimil (MJ)Pregistimil (MJ)
Alfare (Nestle)Alfare (Nestle)
Partially Hydrolyzed Formula:Partially Hydrolyzed Formula:– For For prophylaxisprophylaxis on high risk infants: on high risk infants:
FH of atopy, asthma, food allergyFH of atopy, asthma, food allergy
– Preparation:Preparation: Nan-HANan-HA
Extensively Hydrolyzed Formula:Extensively Hydrolyzed Formula:– For For treatmenttreatment of food allergy during of food allergy during
infancyinfancy– Preparations: Preparations: Pregomin (Milupa)Pregomin (Milupa)
Pregistimil (MJ)Pregistimil (MJ)
Alfare (Nestle)Alfare (Nestle)
““Introduction of Complementary Introduction of Complementary Food”Food”
““Introduction of Complementary Introduction of Complementary Food”Food”
Features of Complementary FoodsFeatures of Complementary FoodsFeatures of Complementary FoodsFeatures of Complementary Foods
Timely:Timely: Should be introduced by 6 months Should be introduced by 6 months
AdequateAdequate: Should provide sufficient energy, protein : Should provide sufficient energy, protein
and micronutrientsand micronutrients
SafeSafe:: Hygienically stored and prepared and fed Hygienically stored and prepared and fed
using clean utensils NOT bottles nor teatusing clean utensils NOT bottles nor teat
Properly fed:Properly fed: Meal frequency, feeding methods Meal frequency, feeding methods
should be suitable for age (with fingers, spoon and should be suitable for age (with fingers, spoon and
fork, cups and bowls, guided or self-feeding)fork, cups and bowls, guided or self-feeding)
Complementary Food (CF)Complementary Food (CF) Complementary Food (CF)Complementary Food (CF)
Definition:Definition:
It refers to It refers to supplemental foodssupplemental foods ( (milk & solid milk & solid
foodsfoods) given to infants when breastmilk is ) given to infants when breastmilk is
no longer no longer adequateadequate to sustain normal to sustain normal
growth.growth.
Definition:Definition:
It refers to It refers to supplemental foodssupplemental foods ( (milk & solid milk & solid
foodsfoods) given to infants when breastmilk is ) given to infants when breastmilk is
no longer no longer adequateadequate to sustain normal to sustain normal
growth.growth.
WHY should CF be given?WHY should CF be given? WHY should CF be given?WHY should CF be given?
Three Infant Feeding PeriodsThree Infant Feeding Periods::
Nursing PeriodNursing Period (1 (1stst 6 months of life) 6 months of life)
Transitional PeriodTransitional Period (6-10 months) (6-10 months)
Modified Adult PeriodModified Adult Period ( >10 months) ( >10 months)
Three Infant Feeding PeriodsThree Infant Feeding Periods::
Nursing PeriodNursing Period (1 (1stst 6 months of life) 6 months of life)
Transitional PeriodTransitional Period (6-10 months) (6-10 months)
Modified Adult PeriodModified Adult Period ( >10 months) ( >10 months)
WHY WHY should CF be given? should CF be given?WHY WHY should CF be given? should CF be given?
Three Infant Feeding Periods:Three Infant Feeding Periods:
Nursing Period (1Nursing Period (1stst 6 months of 6 months of life):life):
Breastmilk or standard infant formula is Breastmilk or standard infant formula is sufficientsufficient to provide nutritional to provide nutritional requirements for normal growth;requirements for normal growth;
MILK MILK should be the should be the ONLYONLY source of nutrient. source of nutrient.
Three Infant Feeding Periods:Three Infant Feeding Periods:
Nursing Period (1Nursing Period (1stst 6 months of 6 months of life):life):
Breastmilk or standard infant formula is Breastmilk or standard infant formula is sufficientsufficient to provide nutritional to provide nutritional requirements for normal growth;requirements for normal growth;
MILK MILK should be the should be the ONLYONLY source of nutrient. source of nutrient.
Nursing Period Nursing Period (1(1stst 6 months of life): 6 months of life):
Nursing Period Nursing Period (1(1stst 6 months of life): 6 months of life):
DigestiveDigestive, , mucosal barriermucosal barrier and and renal renal
functionsfunctions are not well developed; are not well developed;
((Zieger EE, J Zieger EE, J Pediatr, 1990)Pediatr, 1990)
Neuro-developmentalNeuro-developmental status: status: not fully not fully developed !developed !
DigestiveDigestive, , mucosal barriermucosal barrier and and renal renal
functionsfunctions are not well developed; are not well developed;
((Zieger EE, J Zieger EE, J Pediatr, 1990)Pediatr, 1990)
Neuro-developmentalNeuro-developmental status: status: not fully not fully developed !developed !
Nursing Period :Nursing Period :(1(1stst 6 months of life) 6 months of life)
Nursing Period :Nursing Period :(1(1stst 6 months of life) 6 months of life)
Addition of Addition of solid foodssolid foods at this time at this time
breastmilk /milk consumption breastmilk /milk consumption proportionally proportionally
growth failuregrowth failure
Stuff et al, JStuff et al, J pediatr,1990pediatr,1990
Addition of Addition of solid foodssolid foods at this time at this time
breastmilk /milk consumption breastmilk /milk consumption proportionally proportionally
growth failuregrowth failure
Stuff et al, JStuff et al, J pediatr,1990pediatr,1990
Transitional Period Transitional Period (6-10 months)(6-10 months)
Transitional Period Transitional Period (6-10 months)(6-10 months)
It is the transition from the It is the transition from the nursing periodnursing period to the to the adult adult modified periodmodified period
Milk (Milk (breastmilk / standard infant formulabreastmilk / standard infant formula) is ) is NONO longer longer adequateadequate to sustain the nutritional needs of to sustain the nutritional needs of growing infantsgrowing infants
It is the transition from the It is the transition from the nursing periodnursing period to the to the adult adult modified periodmodified period
Milk (Milk (breastmilk / standard infant formulabreastmilk / standard infant formula) is ) is NONO longer longer adequateadequate to sustain the nutritional needs of to sustain the nutritional needs of growing infantsgrowing infants
Transitional PeriodTransitional Period(6-10 mos)(6-10 mos)
Transitional PeriodTransitional Period(6-10 mos)(6-10 mos)
Digestive, renal systems and taste are Digestive, renal systems and taste are well developedwell developed;;
Skills needed for feeding are likewise Skills needed for feeding are likewise fully developedfully developed..
Digestive, renal systems and taste are Digestive, renal systems and taste are well developedwell developed;;
Skills needed for feeding are likewise Skills needed for feeding are likewise fully developedfully developed..
Transitional Period Transitional Period ( 6-10 months)( 6-10 months)
Transitional Period Transitional Period ( 6-10 months)( 6-10 months)
FAILUREFAILURE to offer to offer supplemental foods supplemental foods at this at this
time time difficulty difficulty in accepting them later;in accepting them later;
Underwood BA,Acta Pediatr Scand Underwood BA,Acta Pediatr Scand
Suppl, 1982Suppl, 1982
FAILUREFAILURE to offer to offer supplemental foods supplemental foods at this at this
time time difficulty difficulty in accepting them later;in accepting them later;
Underwood BA,Acta Pediatr Scand Underwood BA,Acta Pediatr Scand
Suppl, 1982Suppl, 1982
““Critical Learning Period”Critical Learning Period”6-15 months6-15 months
““Critical Learning Period”Critical Learning Period”6-15 months6-15 months
6-15 months6-15 months, , “critical learning period”“critical learning period” for for feeding: chewing & swallowing feeding: chewing & swallowing coordination is being developed; coordination is being developed;
FAILUREFAILURE of infants to go through this of infants to go through this process process feeding problems: feeding problems:
– dependence to MILK as source of nutrient dependence to MILK as source of nutrient – picky eaters / neophobicpicky eaters / neophobic– malnutrition (obesity/wasting ,anemia)malnutrition (obesity/wasting ,anemia)
6-15 months6-15 months, , “critical learning period”“critical learning period” for for feeding: chewing & swallowing feeding: chewing & swallowing coordination is being developed; coordination is being developed;
FAILUREFAILURE of infants to go through this of infants to go through this process process feeding problems: feeding problems:
– dependence to MILK as source of nutrient dependence to MILK as source of nutrient – picky eaters / neophobicpicky eaters / neophobic– malnutrition (obesity/wasting ,anemia)malnutrition (obesity/wasting ,anemia)
Modified Adult Period Modified Adult Period (>10 months)(>10 months)
Modified Adult Period Modified Adult Period (>10 months)(>10 months)
Physiologic mechanisms have Physiologic mechanisms have matured to matured to near adult proficiency;near adult proficiency;
Most of the nutrients Most of the nutrients MUSTMUST come from come from table foodstable foods with minimal alteration (cut with minimal alteration (cut into small pieces, bland);into small pieces, bland);
Taste ability & preferences have become Taste ability & preferences have become established.established.
Physiologic mechanisms have Physiologic mechanisms have matured to matured to near adult proficiency;near adult proficiency;
Most of the nutrients Most of the nutrients MUSTMUST come from come from table foodstable foods with minimal alteration (cut with minimal alteration (cut into small pieces, bland);into small pieces, bland);
Taste ability & preferences have become Taste ability & preferences have become established.established.
Scientific Rationale:Scientific Rationale:
– “ “Critical Window”Critical Window” for introducing “lumpy” for introducing “lumpy”
solid foods: if these are delayed beyond solid foods: if these are delayed beyond 10 10
mosmos increased risk of feeding difficulties increased risk of feeding difficulties
later onlater on
Northstone et al, 2001Northstone et al, 2001
– Ingestion of the types of foods depend on Ingestion of the types of foods depend on
the neuromuscular development of infantsthe neuromuscular development of infants
Scientific Rationale:Scientific Rationale:
– “ “Critical Window”Critical Window” for introducing “lumpy” for introducing “lumpy”
solid foods: if these are delayed beyond solid foods: if these are delayed beyond 10 10
mosmos increased risk of feeding difficulties increased risk of feeding difficulties
later onlater on
Northstone et al, 2001Northstone et al, 2001
– Ingestion of the types of foods depend on Ingestion of the types of foods depend on
the neuromuscular development of infantsthe neuromuscular development of infants
What kind of food would you give?What kind of food would you give?
What kind of food would you give?What kind of food would you give?
WHEN should CF be given? WHEN should CF be given? 6 months 6 months
WHEN should CF be given? WHEN should CF be given? 6 months 6 months
Signals that indicate readiness of the Signals that indicate readiness of the infant infant for CF:for CF: Birth weight has doubled;Birth weight has doubled;
Extrusion reflex has completely disappeared;Extrusion reflex has completely disappeared;
Has good head and neck control;Has good head and neck control;
Sits up with support;Sits up with support;
Signals that indicate readiness of the Signals that indicate readiness of the infant infant for CF:for CF: Birth weight has doubled;Birth weight has doubled;
Extrusion reflex has completely disappeared;Extrusion reflex has completely disappeared;
Has good head and neck control;Has good head and neck control;
Sits up with support;Sits up with support;
WHEN should CF be started?WHEN should CF be started? WHEN should CF be started?WHEN should CF be started?
Signals that indicate readiness of infant Signals that indicate readiness of infant for CF:for CF:
Opens mouth if wants food; turns head away Opens mouth if wants food; turns head away when not when not
interested anymore;interested anymore;
Has good chewing & swallowing coordination;Has good chewing & swallowing coordination;
Consumes about Consumes about 32 oz of milk32 oz of milk and wants more; and wants more;
Breastfeeds Breastfeeds > 10x> 10x and wants more and wants more
Signals that indicate readiness of infant Signals that indicate readiness of infant for CF:for CF:
Opens mouth if wants food; turns head away Opens mouth if wants food; turns head away when not when not
interested anymore;interested anymore;
Has good chewing & swallowing coordination;Has good chewing & swallowing coordination;
Consumes about Consumes about 32 oz of milk32 oz of milk and wants more; and wants more;
Breastfeeds Breastfeeds > 10x> 10x and wants more and wants more
Art of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary Food
Introduce Introduce oneone new food new food at timeat time to allow to allow infant to get use to it; continue same food infant to get use to it; continue same food for for 3-4 days3-4 days before giving another food; before giving another food;
Give very small amount of any new food at Give very small amount of any new food at the beginning, the beginning, 1-4 tsp1-4 tsp;;
Introduce Introduce oneone new food new food at timeat time to allow to allow infant to get use to it; continue same food infant to get use to it; continue same food for for 3-4 days3-4 days before giving another food; before giving another food;
Give very small amount of any new food at Give very small amount of any new food at the beginning, the beginning, 1-4 tsp1-4 tsp;;
Art of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary Food
Use thin puree consistency initially --> shift Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food gradually to a more viscous calorie-dense food
Mix foods with ones baby likes, to enhance Mix foods with ones baby likes, to enhance acceptability and nutrient contentacceptability and nutrient content
Cereals +BM: Enhanced acceptance of cereal during Cereals +BM: Enhanced acceptance of cereal during weaning!weaning!
Mennella et al, Pediatr Res, Mennella et al, Pediatr Res, 19971997
Use thin puree consistency initially --> shift Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food gradually to a more viscous calorie-dense food
Mix foods with ones baby likes, to enhance Mix foods with ones baby likes, to enhance acceptability and nutrient contentacceptability and nutrient content
Cereals +BM: Enhanced acceptance of cereal during Cereals +BM: Enhanced acceptance of cereal during weaning!weaning!
Mennella et al, Pediatr Res, Mennella et al, Pediatr Res, 19971997
Art of Introducing Complementary FoodArt of Introducing Complementary Food Art of Introducing Complementary FoodArt of Introducing Complementary Food
Once infant can sit with support at about Once infant can sit with support at about 6 6 mosmos , give fluid (milk or water) using , give fluid (milk or water) using trainer’s cuptrainer’s cup;;
By By 12 months12 months of age milk should be given of age milk should be given by the by the cup or glass;cup or glass;
BOTTLESBOTTLES should be should be OUTOUT by this time! by this time!
Once infant can sit with support at about Once infant can sit with support at about 6 6 mosmos , give fluid (milk or water) using , give fluid (milk or water) using trainer’s cuptrainer’s cup;;
By By 12 months12 months of age milk should be given of age milk should be given by the by the cup or glass;cup or glass;
BOTTLESBOTTLES should be should be OUTOUT by this time! by this time!
Avoid adding salt and sugarAvoid adding salt and sugar
When baby is able to chew at aboutWhen baby is able to chew at about 8-10 8-10 monthsmonths, gradually switch to finely chopped , gradually switch to finely chopped foods foods
DO NOTDO NOT continue soft smooth foods for too continue soft smooth foods for too longlong
Feeding Frequency:Feeding Frequency: 6-8 months: 6-8 months: 22 -3 -3 meals a daymeals a day 9-11 months:9-11 months: 3-4 meals; 1-2 snacks3-4 meals; 1-2 snacks > 12 months:> 12 months: 3-4 meals: 1-2 snacks3-4 meals: 1-2 snacks
Avoid adding salt and sugarAvoid adding salt and sugar
When baby is able to chew at aboutWhen baby is able to chew at about 8-10 8-10 monthsmonths, gradually switch to finely chopped , gradually switch to finely chopped foods foods
DO NOTDO NOT continue soft smooth foods for too continue soft smooth foods for too longlong
Feeding Frequency:Feeding Frequency: 6-8 months: 6-8 months: 22 -3 -3 meals a daymeals a day 9-11 months:9-11 months: 3-4 meals; 1-2 snacks3-4 meals; 1-2 snacks > 12 months:> 12 months: 3-4 meals: 1-2 snacks3-4 meals: 1-2 snacks
Art of Introducing Complementary Art of Introducing Complementary FoodFood
Art of Introducing Complementary Art of Introducing Complementary FoodFood
Art of Introducing Complementary Art of Introducing Complementary foodsfoods
Art of Introducing Complementary Art of Introducing Complementary foodsfoods
By By 12 months12 months,, most of the nutrient should most of the nutrient should come from come from table food table food (modified); infants have (modified); infants have attained attained physiologic maturity of adult physiologic maturity of adult proficiencyproficiency;;
Encourage infant to try new flavors Encourage infant to try new flavors as a variety of foods is important !as a variety of foods is important !
* FNRI-DOST, Nutrition Guidelines for Filipinos, * FNRI-DOST, Nutrition Guidelines for Filipinos, 20002000
* Pediatric Nutrition Handbook, 4* Pediatric Nutrition Handbook, 4thth Edition AAP Edition AAP
By By 12 months12 months,, most of the nutrient should most of the nutrient should come from come from table food table food (modified); infants have (modified); infants have attained attained physiologic maturity of adult physiologic maturity of adult proficiencyproficiency;;
Encourage infant to try new flavors Encourage infant to try new flavors as a variety of foods is important !as a variety of foods is important !
* FNRI-DOST, Nutrition Guidelines for Filipinos, * FNRI-DOST, Nutrition Guidelines for Filipinos, 20002000
* Pediatric Nutrition Handbook, 4* Pediatric Nutrition Handbook, 4thth Edition AAP Edition AAP
Harvard School of Public Health
Harvard School of Public Health
US Department of Agriculture
US Department of Agriculture
New Food Guide PyramidNew Food Guide Pyramid
Thank You Thank You and and
God blessGod bless
Thank You Thank You and and
God blessGod bless
US Dept of Agriculture
US Dept of Agriculture
Endocrine Control of LactationEndocrine Control of LactationEndocrine Control of LactationEndocrine Control of Lactation
Endocrine Control of LactationEndocrine Control of LactationEndocrine Control of LactationEndocrine Control of Lactation