1. BREAST MILK & FORMULA IN THE INFANT DIET Simren Singh, MD University of Chicago (NorthShore) Department of Family Medicine sim0726@gmail.com

2. Objectives By the end of this session the learner will be able to: 1. Access key recommendations from the American Academy of Pediatrics (AAP). 2. Identify indications/contraindications for breast milk vs. formula. 3. Compare/contrast the nutritional, immunological and growth advantages/disadvantages of each type of milk. 4. List 3 formulas available through WIC. 5. Select the appropriate chart to measure infant growth.

3. BREAST MILK

4. B R E A S T I S B E S T !

5. AAP Recommends Human Milk As the sole nutrient for healthy, term infants for approximately the first 6 months of life and supports continued breastfeeding for at least 12 m onths.

6. Epidemiology of Breast Feeding 24% 44% 75% 82% 60% 34%

7. Breast Milk Advantages AOM Gastroenteritis NEC Asthma Severe lower respiratory Tract infections SIDS Obesity Childhood leukemia Type 1 and type 2 diabetes Atopic dermatitis REDUCED RISK OF:

8. Breast milk varies between mothers & changes as it “matures”.

9. Supplementation in Breastfed Infants NutrientWhenDose Vitamin KOnce At Birth1mg Injection Vitamin DBirth until… >1 L/day of vit D fortified formula or whole milk 400 IU/day PO Iron4 months of age until… adequate consumption of iron rich foods 1 mg/kg/day PO

10. Supplementation in Lactating Mother NutrientRecommended Allowance EnergyAdditional 500 kcal/day Omega-3 Fatty Acids200-300 mg/day Vitamin D600 IU/day MineralsSelenium, Iodine, Zinc, Iron Water Soluble VitaminsB12 Limit to 12 ounces (2 servings)/week of lower mercury concentration fish At least 1500kcal/day to maintain milk production

11. B R E A S T I S B E S T !

12. FORMULA

13. Epidemiology of Formula Feeding 25% 56% 76% 24% 44%75%

14. PERCEPTIONREALITY GOODBreast MilkBreast Milk Infant Formula BADBaby PoisonBaby Poison

15. Formula Feeding In the absence of human milk, iron-fortified infant formulas are the most appropriate substitutes for feeding healthy, full-term infants. All currently available formulas meet all of the energy and nutrient requirements for healthy term infants during the first 4-6 months of life.

16. Indications for the Use of Infant Formula As a substitute for human milk in infants: 1. When mothers choose not to breastfeed 2. When mothers choose not to breastfeed exclusively 3. When breastfeeding is medically contraindicated (rare) 4. As a supplement for breastfed infants due to inadequate weight gain

17. Medical Contraindications to Breastfeeding MATERNAL 1. TB: Untreated TB (until two weeks of tx completed) 2. HTLV: Human T-cell lymphotropic virus type I or II 3. HIV: Human immunodeficiency virus 4. HSV: lesions on breast (can feed on other breast) 5. Antimetabolite chemotherapy and ongoing radiation therapy 6. Abuse of street drugs or alcohol INFANT 1. Galactosemia LACTMED DATABASE: TOXNET.NLM.NIH.GOV

18. Historical Perspective on Milk Alternatives for Infants 1838: First published literature Home formula: Unaltered cows milk + corn syrup + water Synthetic Milk Adapted 1919: Match the composition of breast milk Now: Match the growth and development of infants that are fed breast milk The American Academy of Pediatrics has expressed disapproval of direct advertising of infant formula to the general public

19. Deficiencies of Formula 1. Hormones, growth factors, antibodies, immune-modulatory factors, enzymes and live cells 2. The chemical form and composition of the nutrients 3. The time from production to consumption Infant Formula Act of 1980

20. Soy Protein Based Formulas Per the AAP, this is a safe & nutritionally equivalent alternative to cow milk-based formula for term infants who nutritional needs are not met from human milk

21. Soy Formulas Lactose free Vegetarian/vegan, Galactosemia, Lactose intolerance, Acute gastroenteritis Contain phytoestrogens Per a 2008 statement from the AAP: “there is no conclusive evidence from animal, adult human, or infant populations that dietary soy isoflavones may adversely affect human development, reproduction, or endocrine function”.

22. Breast Milk vs. Term Formula vs. Soy Formula ClassCarbohydrate Source Protein Source Powdered Formula (per oz) Ready-to- Feed (per oz) Breast MilkLactoseHuman Milk-- Term Formula LactoseCows Milk$0.14$0.27 Soy FormulaCorn-basedSoy$0.16$0.30 AAFP

23. Amount of Formula Age (mo)OuncesFrequency (hrs) 12-4q3-4 25-6q4-5 66-8q5-6 96-8q5-8 126-8q6-8 On average, 2.5 ounces/day for each pound of body weight Increase by 1 ounce per month until they reach 8 ounces/feed 1 ounce = 30 mL Maximum: 32 ounces/day AAFP

24. INFANT GROWTH

25. Monitoring Growth in Infants CDC vs. WHO growth charts Center for Disease Control (2000): How US children grew In 1970s-1980s breast or bottle fed wide range of social, ethnic and economic conditions World Health Organization (2006): How infants should grow Under ideal conditions of breastfeeding In 2010, the CDC published a report detailing new recommendations for the use of the WHO Growth Charts for Children younger than 24 months (regardless of diet) in place of the 2000 CDC growth charts

26. Key Learning Points 1. Access key recommendations from the American Academy of Pediatrics (AAP) 2. Identify indications/contraindications for breast milk vs. formula 3. Compare/contrast the nutritional, immunological and growth advantages/disadvantages of each type of milk. 4. List 3 formulas available through WIC. 5. Select the appropriate chart for infant growth.

27. Please divide yourselves into three small groups to work on the cases

28. Resources Pediatric Nutrition, 7 th Edition by the American Academy of Pediatrics Up to Date American Academy of Family Practitioners World Health Organization Centers for Disease Control Le Leche League International Google Images (copyright free)

29. END