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Nutrition Module Notes Pediatric I – Second Year Rebecca Abiog-Castro, M.D. Rhodora Garcia de Leon, M.D Faculty of Medicine & Surgery, UST.

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Presentation on theme: "Nutrition Module Notes Pediatric I – Second Year Rebecca Abiog-Castro, M.D. Rhodora Garcia de Leon, M.D Faculty of Medicine & Surgery, UST."— Presentation transcript:

1 Nutrition Module Notes Pediatric I – Second Year Rebecca Abiog-Castro, M.D. Rhodora Garcia de Leon, M.D Faculty of Medicine & Surgery, UST

2 Objectives of the Course At the end of the course a Second Year Medical Student should be able: To discuss briefly the anatomy of the breast and physiology of lactation; To discuss briefly the anatomy of the breast and physiology of lactation; To discuss the benefits of breastmilk and the benefits of breastfeeding to both infant and mother; To discuss the benefits of breastmilk and the 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 cows milk; To discuss the difference between breast-milk and cows milk; At the end of the course a Second Year Medical Student should be able: To discuss briefly the anatomy of the breast and physiology of lactation; To discuss briefly the anatomy of the breast and physiology of lactation; To discuss the benefits of breastmilk and the benefits of breastfeeding to both infant and mother; To discuss the benefits of breastmilk and the 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 cows milk; To discuss the difference between breast-milk and cows milk;

3 Objectives of the Course To discuss the steps to encourage Breast-feeding in the hospital: UNICEF / WHO Baby-Friendly; To discuss the steps to encourage Breast-feeding in 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 complementary foods; To discuss the proper method to introduce complementary foods; To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children; To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children; To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for its use; To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for 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 the hospital: UNICEF / WHO Baby-Friendly; To discuss the steps to encourage Breast-feeding in 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 complementary foods; To discuss the proper method to introduce complementary foods; To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children; To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children; To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for its use; To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for its use; To discuss the supplements for breastfed infants. To discuss the supplements for breastfed infants.

4 Mother's milk is the best food a baby can have exclusively in the first 6 months of life; should be continued until two years and beyond.

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6 Anatomy of Breast Internal structures External structures: Cross section of alveolus

7 Breast Structure

8 Anatomy of the Breast

9 Teat Tongue Palate

10 Physiology of lactation Endocrine control Three main phases of lactation 1)Mammogenesis or mammary growth 2)Lactogenesis or initiation of milk secretion: Stage I: 12 wks before parturition Stage II: 2-3 days postpartum 3)Stage III of Lactogenesis or Galactopoiesis maintenance of milk secretion: das. Three main phases of lactation 1)Mammogenesis or mammary growth 2)Lactogenesis or initiation of milk secretion: Stage I: 12 wks before parturition Stage II: 2-3 days postpartum 3)Stage III of Lactogenesis or Galactopoiesis maintenance of milk secretion: das.

11 Three Main Phases of Lactation (hormonal) Phase I - Mammogenesis –Profound during pregnancy in preparation for lactation –Placental lactogen, estrogen, progesterone –Ductal Sprouting (estrogen), lobular formation (progesterone), Prolactin essential for complete gland growth Phase I - Mammogenesis –Profound during pregnancy in preparation for lactation –Placental lactogen, estrogen, progesterone –Ductal Sprouting (estrogen), lobular formation (progesterone), Prolactin essential for complete gland growth

12 Phase I - Mammogenesis Hormones Involved in Mammary Growth Hormones 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

13 INDUCTION OF GROWTH (Normal animals) Estrogens alone induce alveolar growth – –Larger than normal alveoli Estrogen and progesterone induce normal growth Phase I - Mammogenesis

14 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

15 Three Main Phases of Lactation (hormonal) Phase II - Lactogenesis (initiation of milk): –Stage I: starts 12 wks before delivery Gathering of all substrates for milk production Gathering of all substrates for milk production –Stage II: starts 2-3 days postpartum Milk secretion is copious Milk secretion is copious Phase II - Lactogenesis (initiation of milk): –Stage I: starts 12 wks before delivery Gathering of all substrates for milk production Gathering of all substrates for milk production –Stage II: starts 2-3 days postpartum Milk secretion is copious Milk secretion is copious

16 Endocrine Patterns Related to Parturition ENDOCRINE REGULATION OF LACTOGENESIS

17 Endocrine Control of Lactation Milk Production Reflex: Milk Production Reflex: Prolactin is a key lactogenic hormone, stimulating initial alveolar milk production Milk Ejection Reflex: Milk Ejection Reflex: Oxytocin contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts and sinuses where it is removed by the infant Milk Production Reflex: Milk Production Reflex: Prolactin is a key lactogenic hormone, stimulating initial alveolar milk production Milk Ejection Reflex: Milk Ejection Reflex: Oxytocin contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts and sinuses where it is removed by the infant

18 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

19 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

20 Phase III – Galactopoiesis maintenance of Breastmilk Secretion Stage III of Lactogenesis or Galactopoiesis Stage III of Lactogenesis or Galactopoiesis –Maintenance of milk secretion –From days –Mature milk is established –Prolactin and Oxytocin essential for effective maintenance of milk supply Stage III of Lactogenesis or Galactopoiesis Stage III of Lactogenesis or Galactopoiesis –Maintenance of milk secretion –From days –Mature milk is established –Prolactin and Oxytocin essential for effective maintenance of milk supply

21 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)

22 Autocrine Control of Lactation Influence of of Local Factors Acting on the Breasts It is not just the level of maternal hormones, but the efficiency of milk removal that governs the volume product in each breast It is not just the level of maternal hormones, but the efficiency of milk removal that governs the volume product in each breast A protein factor called feedback inhibitor of lactation (FIL) is secreted with other milk components into the alveolar lumen A protein factor called feedback inhibitor of lactation (FIL) is secreted with other milk components into the alveolar lumen FIL, insensitive to prolactin milk production FIL, insensitive to prolactin milk production Influence of of Local Factors Acting on the Breasts It is not just the level of maternal hormones, but the efficiency of milk removal that governs the volume product in each breast It is not just the level of maternal hormones, but the efficiency of milk removal that governs the volume product in each breast A protein factor called feedback inhibitor of lactation (FIL) is secreted with other milk components into the alveolar lumen A protein factor called feedback inhibitor of lactation (FIL) is secreted with other milk components into the alveolar lumen FIL, insensitive to prolactin milk production FIL, insensitive to prolactin milk production

23 Autocrine Control of Lactation FIL

24 Anatomy & Physiology: Milk production Risk factors for delayed onset of lactation 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

25 Factors associated with breastfeeding problems at day 7 included : Factors associated with breastfeeding problems at day 7 included : 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/m2 Pre-pregnant maternal BMI > 27 kg/m2 non breast milk fluids given in the first 48 hours of life non breast milk fluids given in the first 48 hours of life Anatomy & Physiology: Milk production Dewey, 2003

26 Breastmilk composition

27 Breast-milkBreast-milk Variations of Breastmilk –Colostrum (1 st 3-5 days of life) –Term breastmilk ( mothers own: – 28 days) –Pre-term Milk ( day days) –Mature breastmilk ( >30 days) –Drip breastmilk ( days postpartum) Variations of Breastmilk –Colostrum (1 st 3-5 days of life) –Term breastmilk ( mothers own: – 28 days) –Pre-term Milk ( day days) –Mature breastmilk ( >30 days) –Drip breastmilk ( days postpartum)

28 ColostrumColostrum First postpartum weeks mammary secretion consisting of yellowish (beta carotene) thick fluid; First postpartum weeks mammary secretion consisting of yellowish (beta carotene) thick fluid; Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x); Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x); Protein content is rich in sIgA and immunologically competent mononuclear cells; Protein content is rich in sIgA and immunologically competent mononuclear cells; Contains antioxidants which trap neutrophil-generated oxygen radicals. Contains antioxidants which trap neutrophil-generated oxygen radicals. First postpartum weeks mammary secretion consisting of yellowish (beta carotene) thick fluid; First postpartum weeks mammary secretion consisting of yellowish (beta carotene) thick fluid; Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x); Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x); Protein content is rich in sIgA and immunologically competent mononuclear cells; Protein content is rich in sIgA and immunologically competent mononuclear cells; Contains antioxidants which trap neutrophil-generated oxygen radicals. Contains antioxidants which trap neutrophil-generated oxygen radicals.

29 Distribution of Immunoglobulins and other Soluble Substances in the Colostrum and Milk Delivered to the Breast-Fed Infant During a 24-Hour Period Soluble Product Concentration in MG /Day at Postpartum <1 week 1-2 weeks 3-4 weeks >4 weeks IgG IgA* IgM Lysozyme Lactoferrin

30 Type of Volume Energy Protein CHO FAT NA Milk ml/d Kcal/100 ml G/100mL G/100 ml G/100 ml mmol/100ML Colostrum (1-5 d) Term D D Breastmilk (Mature>30 d)

31 Type of Volume ENERGY PROTEIN CHO FAT NA Milk (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml mmol/100 ml Preterm D D D Drip BM Cow

32 Calculated Nutrient Intakes Compared to Estimated Needs for LBW Units/KG/D PreTerm Milk Week of Lactation MatureMilk Estimated Needs 124 Energy (KCAL) Fluid Vol. (ML) Protein (G) Sodium (MMOL) Calcium (MG) Phosphorus (MG)

33 HUMANCOWS Amino-acids Cystine Cystine Taurine Taurine Enough for growing brain Not enough Fat Total Total Saturation of fatty acids Saturation of fatty acids Linoleic acid (essential) Linoleic acid (essential) Cholesterol Cholesterol 4% (average) Enough unsaturated Enough for growing brain Enough4% Too much saturated Not enough Lipase to digest fat PresentNone Lactose (sugar) 7% -- enough 3-4% - not enough Salts (mEq/l) Sodium Sodium Chloride Chloride Potassium Potassium 6.5 correct amount 12 correct amount 14 correct amount 25 too much 29 too much 35 too much

34 HUMANCOWS Minerals (mg/l) Calcium Calcium Phosphate Phosphate 350 correct amount 150 correct amount 1,400 too much 900 too much Iron Small amount Well absorbed Enough Small amount Poorly absorbed Not enough VitaminsEnough WaterEnough No extra needed Extra needed

35 Nutrients in human and animal milk Fat Protein Lactose HumanCowGoat HUMANCOWGOATBUFFALO

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38 Composition Iron –Not affected by maternal iron status and dietary iron supplements –Higher absorption: 50% : HM 50% : HM 10% : unfortified cows milk 10% : unfortified cows milk 4% : fortified cows milk 4% : fortified cows milk

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41 VITAMIN CONTENT VitaminHumanCows A Enough even in 2 nd year 2 X in colostrum In case of deficiency give supplement to mother Less (x 1/2) B Group Plenty Even more CEnough Less (x 1/5) May need supplement if fed artificially DEnoughLess K Usually enough More in Colostrum More

42 Comparison of Human Milk and Cows Milk HUMANCOWS Bacteria contamination NoneLikely Anti-infective Substances AntibodiesLeucocytesLactoferrin Bifidus factor Not active Protein - Total - Total - Casein - Casein - Lactalbumen - Lactalbumen1%0.5%0.5% 4% too much 3% too much 0.5%

43 Supplements for Breastfed Infants The following supplementation is generally recommended: –Vitamin K supplement in the immediate postpartum period. –400 IU of Vitamin D –Breastfeeding women should continue taking prenatal vitamins especially vitamin D, calcium and iron –Complementary foods should be given once infants reach six months of age

44 Review Questions 1) The part of breast responsible for milk secretion _________ under the influence of what hormone? ______ 2) Two important reflexes that are needed for BM secretion? ________ 3) Which part of the breast is milk stored? ________ 4) Hormone secreted during BF which can reduce BF________ 5) Major source of protein in BM ______

45 Benefits of Breastmilk / Breastfeeding to Infants and Mothers

46 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

47 Enhances Cognitive Development Enhances Cognitive Development –Docosohexanoic Acid (DHA) –Lactose –Skin to skin Contact and face to face position Enhances Cognitive Development Enhances Cognitive Development –Docosohexanoic Acid (DHA) –Lactose –Skin to skin Contact and face to face position Benefits of Breastmilk: Infant

48 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: Infant

49 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: Infant

50 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: Infant

51 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: Infant

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53 Breastmilk is Protective White Blood Cells Bacterial killer Highest concentration of WBC occurs in the 1 st few days of lactation > a million/ml Colostrum (1-5 days post-natal): – –Contains 10 5 – 5 x 10 6 WBC / ml Breastmilk is Protective White Blood Cells Bacterial killer Highest concentration of WBC occurs in the 1 st few days of lactation > a million/ml Colostrum (1-5 days post-natal): – –Contains 10 5 – 5 x 10 6 WBC / ml Benefits of Breastmilk: Infant

54 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: Infant

55 Host Resistance Factors in BM Non-immunoglobulin components: Non-immunoglobulin components: –Oligosaccharides –Mucin –Fatty acids Non-immunoglobulin components: Non-immunoglobulin components: –Oligosaccharides –Mucin –Fatty acids

56 Anti-infective Properties IgA, IgM, IgG: immunoglobulins that guard the gut against infective bacteria IgA, IgM, IgG: immunoglobulins that guard the gut against infective bacteria Bifidus factor: stimulates bifido-bacteria, which fight against pathogenic bacteria Bifidus factor: stimulates bifido-bacteria, which fight against pathogenic bacteria Lactoferrin: binds iron away from bacteria Lactoferrin: binds iron away from bacteria Macrophages: phagocytosis of infective bacteria Macrophages: phagocytosis of infective bacteria B 12 binding protein: removes B 12 from bacteria B 12 binding protein: removes B 12 from bacteria IgA, IgM, IgG: immunoglobulins that guard the gut against infective bacteria IgA, IgM, IgG: immunoglobulins that guard the gut against infective bacteria Bifidus factor: stimulates bifido-bacteria, which fight against pathogenic bacteria Bifidus factor: stimulates bifido-bacteria, which fight against pathogenic bacteria Lactoferrin: binds iron away from bacteria Lactoferrin: binds iron away from bacteria Macrophages: phagocytosis of infective bacteria Macrophages: phagocytosis of infective bacteria B 12 binding protein: removes B 12 from bacteria B 12 binding protein: removes B 12 from bacteria Benefits of Breastmilk: Infant

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59 Antiviral Factors in Human Milk Factor Shown, in vitro, to be active against: Effect of Heat Secretory IgA Poliovirus types 1, 2, 3. Coxsackie types A9, B3, B5, B5, Echovirus types 6, 9. Semliki Forest Virus Ross River Virus RotavirusCytomegalovirus Reovirus type 3 Rubella virus Herpes simplex virus, Mumps virus Influenza virus Respiratory syncytial virus Stable at 56°C for 30 mins.; Some loss (0 – 30%) at 62.5 °C for 30 mins; destroyed by boiling

60 Enhanced immune response to immunizations Enhanced immune response to immunizations –Polio –Tetanus –Diptheria –Haemophilus influenza Enhanced immune response to immunizations Enhanced immune response to immunizations –Polio –Tetanus –Diptheria –Haemophilus influenza Benefits of Breastmilk: Infant

61 Protection Against Infection Reduces risk and severity of infectious illness among infants Reduces risk and severity of infectious illness among infants –diarrhea –otitis media –lower respiratory infections –bacteremia –bacterial meningitis –necrotizing enterocolitis –infant botulism –urinary tract disease –sudden infant death syndrome (SIDS) –Colic –wheezing Reduces risk and severity of infectious illness among infants Reduces risk and severity of infectious illness among infants –diarrhea –otitis media –lower respiratory infections –bacteremia –bacterial meningitis –necrotizing enterocolitis –infant botulism –urinary tract disease –sudden infant death syndrome (SIDS) –Colic –wheezing

62 Antibacterial Properties found in human milk

63 Factor Shown, in vitro, to be active against: Effect of Heat Secretory IgA E. Coli (also pili and capsular antigens) C. Tetani C. Diphtheriae K. pneumoniae K. pneumoniae Salmonella (6 groups) Shigella (2 groups) Streptococcus, S. mutans, S. sanguis, S. mitis, S. salivarius, S. pneumoniae, C. burnetti, H. influenzae E. coli enterotoxin, V. Cholerae enterotoxin C. difficile toxins H. Influenzae capsule Stable at 56°C for 30 min; some loss (0-30%) at 62.5°C for 30 min; destroyed by boiling IgM, IgG V. Cholerae lipopolysaccharide; E. coli IgM destroyed and IgG decreased by a third at 62.5°C for 30 min

64 Factor Shown, in vitro, to be active against: Effect of Heat IgD Bifidobacterium bifidum growth z factor z factor E. Coli Enterobacteriacea, enteric pathogens Stable to boiling Factor binding proteins (zinc, vitamin B 12, folate) Dependent E. coli Destroyed by boiling Complement C1-C9 (mainly C3 and C4) Effect not known Destroyed by heating at 56°C for 30 min Lactoferrin E. Coli Two-thirds destroyed at 62.5°C for 30 min; essentially destroyed by boiling for 15 min

65 Factor Shown, in vitro, to be active against: Effect of Heat Lactoperoxidase Streptococcus, Pseudomonas, E. coli, S. typhimurium Destroyed by boiling Lysozyme E. coli, Salmonella, Micrococcus lysodeikticus Some loss (0-23%) at 62.5°C for 30 min; essentially destroyed by boiling for 15 min Unidentified factors S. aureus, C. difficile toxin B Stable at autoclaving; stable at 56°C for 30 min Carbohydrate E. coli enterotoxin Stable at 85°C for 30 min Lipid S. Aureus Stable at boiling Ganglioside (GMI like) E. Coli enterotoxin, V. cholerae enterotoxin Stable to boiling

66 Types of Breast milk Foremilk Hindmilk

67 Protective Factors in BM Non-immunoglobulin components: -Non-specific factors: Bifidus factor Bifidus factor Resistance factor (Anti-staphylococcal factor) Resistance factor (Anti-staphylococcal factor) Anti-viral factor Anti-viral factor Anti-protozoal factors (bile-salt stimulated lipase) Anti-protozoal factors (bile-salt stimulated lipase) –Enzymes: Lysozyme, lipoprotein lipase Non-immunoglobulin components: -Non-specific factors: Bifidus factor Bifidus factor Resistance factor (Anti-staphylococcal factor) Resistance factor (Anti-staphylococcal factor) Anti-viral factor Anti-viral factor Anti-protozoal factors (bile-salt stimulated lipase) Anti-protozoal factors (bile-salt stimulated lipase) –Enzymes: Lysozyme, lipoprotein lipase

68 Protective Factors in BM Anti-inflammatory properties: Anti-inflammatory properties: –BM is poor initiators and mediators of inflammation (complement system, fibrinolytic, coagulation system) but rich in anti-inflammatory agents (sIGA, lysozyme); Provides good mucosal barrier (growth factors) prevents attachment of bacteria & antigen; Provides good mucosal barrier (growth factors) prevents attachment of bacteria & antigen; Anti-inflammatory properties: Anti-inflammatory properties: –BM is poor initiators and mediators of inflammation (complement system, fibrinolytic, coagulation system) but rich in anti-inflammatory agents (sIGA, lysozyme); Provides good mucosal barrier (growth factors) prevents attachment of bacteria & antigen; Provides good mucosal barrier (growth factors) prevents attachment of bacteria & antigen;

69 Maternal 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: Breastfeeding (BF):36.7% Breastfeeding (BF):36.7% Formula-feeding (FF):20.5% Formula-feeding (FF):20.5% –Mortality rate: BF:24.4% BF:24.4% FF:20.0% FF:20.0% Nduati R. et al. JAMA 2000 Nduati R. et al. JAMA 2000 Maternal 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: Breastfeeding (BF):36.7% Breastfeeding (BF):36.7% Formula-feeding (FF):20.5% Formula-feeding (FF):20.5% –Mortality rate: BF:24.4% BF:24.4% FF:20.0% FF:20.0% Nduati R. et al. JAMA 2000 Nduati R. et al. JAMA 2000 Benefits of Breastmilk: Infants

70 Breastfeeding and premature infants: Breastfeeding and premature infants: Premature infants fed their mother's milk were found to have decreased incidences of sepsis, meningitis, and necrotizing enterocolitis Breastfeeding and premature infants: Breastfeeding and premature infants: Premature infants fed their mother's milk were found to have decreased incidences of sepsis, meningitis, and necrotizing enterocolitis Benefits of Breastmilk: Infant

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73 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 – –Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula JClin Microbiol 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 – –Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula JClin Microbiol Benefits of Breastmilk: Safe

74 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 – –Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula JClin Microbiol 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 – –Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula JClin Microbiol Benefits of Breastmilk: Safe

75 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

76 Benefits of Breastfeeding: Mothers Prevents Obesity Early return to pre-pregnancy weight Early return to pre-pregnancy weight Prevents Obesity Early return to pre-pregnancy weight Early return to pre-pregnancy weight

77 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

78 Ovarian Cancer Breastfeeding and Risk to Ovarian Cancer –Rosenblatt 1993: 20-25% decrease in risk for cancer for women who breastfed for at least 2 months 20-25% decrease in risk for cancer for women who breastfed for at least 2 months –Risch et al 1993 & Gwinn 1990: Showed the protective effect of lactation (RR 0.79 per year of lactation; 0.6 respectively) Showed the protective effect of lactation (RR 0.79 per year of lactation; 0.6 respectively) –Shoham 1994: 50% decrease in risk for ovarian cancer 50% decrease in risk for ovarian cancer Ovarian Cancer Breastfeeding and Risk to Ovarian Cancer –Rosenblatt 1993: 20-25% decrease in risk for cancer for women who breastfed for at least 2 months 20-25% decrease in risk for cancer for women who breastfed for at least 2 months –Risch et al 1993 & Gwinn 1990: Showed the protective effect of lactation (RR 0.79 per year of lactation; 0.6 respectively) Showed the protective effect of lactation (RR 0.79 per year of lactation; 0.6 respectively) –Shoham 1994: 50% decrease in risk for ovarian cancer 50% decrease in risk for ovarian cancer Benefits of Breastfeeding: Mothers

79 Family: – –Purchase of formula costs the average poor family (7,280.00/ month income) about P2, 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, 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

80 Longer-term Health Outcomes: Maternal benefits Reduces risk of chronic illness in childhood Reduces risk of chronic illness in childhood –Some food allergies –Type-1 insulin dependent diabetes –Lymphoma –Asthma –Obesity Reduces risk of chronic illness in childhood Reduces risk of chronic illness in childhood –Some food allergies –Type-1 insulin dependent diabetes –Lymphoma –Asthma –Obesity

81 Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly HOSPITAL INITIATIVES HOSPITAL INITIATIVES –Provide all pregnant women with information and counselling. –Document the desire to breast-feed in the medical record. –Document the method of feeding in the infants record. –Place the newborn and mother skin- to-skin, and initiate breast-feeding within 1 hr of birth. –Continue skin-to-skin contact at other times and encourage rooming-in. –Assess breast-feeding and continue encouragement and teaching on each shift.

82 MOTHERS TO LEARN MOTHERS TO LEARN –Proper position and latch on –Nutritive sucking and swallowing –Milk production and release –Frequency and feeding cues –Expression of milk needed –Assessment of the infants nutritional status –When to contact the clinician Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly

83 ADDITIONAL INSTRUCTIONS ADDITIONAL INSTRUCTIONS –Refer to lactation consultation if any concerns arise. –Infants should go to the breast at least 8-12 times/24 hr, day and night. –Avoid time limits on the breasts; offer both breasts at each feeding. –Do not give sterile water, glucose, or formula unless indicated. –If supplements are given, use cup feeding, a Haberman feeder, fingers, or syringe feedings. –Avoid pacifiers in the newborn nursery except during painful procedures. –Avoid anti-lactation drugs. Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly

84 Review Questions 1. What breast structure secretes breastmilk? What hormone is responsible for it? 2. What are the 2 processes are responsible for breastmilk secretion & maintenance? 3. Breastmilk is stored in what part of the breast? 4. 3 phases of lactation? 5. Hormone secreted during BF which could cause BM reduction if breast is not emptied completely.

85 6) What is the protein distribution of BM? What is the predominant protein component? 7) How much calories is lost per day when bf? 8) What are the 3 areas that must be addressed in BF based on the recommendation of WHO?

86 Thank You and God bless

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88 Breastmilk Substitutes Infant Milk Formulas

89 TYPES 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%) Follow-on (up) FormulaFollow-on (up) Formula Growing-up FormulaGrowing-up Formula Whole cows MilkWhole cows 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%) Follow-on (up) FormulaFollow-on (up) Formula Growing-up FormulaGrowing-up Formula Whole cows MilkWhole cows Milk Evaporated MilkEvaporated Milk

90 Types of Infant Formulas Special Formulas: Special Formulas: –Hydrolysates: Partial Hydrolysates Partial Hydrolysates Complete Hydrolysates Complete Hydrolysates –Goats milk Special Formulas: Special Formulas: –Hydrolysates: Partial Hydrolysates Partial Hydrolysates Complete Hydrolysates Complete Hydrolysates –Goats milk

91 Nutrient Sources: FOR INFANTS LESS THAN 2 YEARS Three Indications for Use of Infant Formulas: As substitute ( or supplement) for human milk in infants whose mother choose not to breastfeed; As substitute ( or supplement) for human milk in infants whose mother choose not to breastfeed; As a substitute for human milk in infants for whom breastfeeding is medically contraindicated; As a substitute for human milk in infants for whom breastfeeding is medically contraindicated; As supplement for infants who do not gain weight appropriately. As supplement for infants who do not gain weight appropriately. Three Indications for Use of Infant Formulas: As substitute ( or supplement) for human milk in infants whose mother choose not to breastfeed; As substitute ( or supplement) for human milk in infants whose mother choose not to breastfeed; As a substitute for human milk in infants for whom breastfeeding is medically contraindicated; As a substitute for human milk in infants for whom breastfeeding is medically contraindicated; As supplement for infants who do not gain weight appropriately. As supplement for infants who do not gain weight appropriately.

92 Nutrient Sources: < 2 Years of Age PRETERM FORMULA: PRETERM FORMULA: Prescribed for premature until they have reached weeks of gestation or gained 2 kilograms. Prescribed for premature until they have reached weeks of gestation or gained 2 kilograms. When given beyond recommended age may cause hypercalcemia When given beyond recommended age may cause hypercalcemia Special Features: Special Features: Protein: Whey predominant formula at a level higher than breast milk & standard infant formula ( g/100ml.)Protein: Whey predominant formula at a level higher than breast milk & standard infant formula ( g/100ml.) PRETERM FORMULA: PRETERM FORMULA: Prescribed for premature until they have reached weeks of gestation or gained 2 kilograms. Prescribed for premature until they have reached weeks of gestation or gained 2 kilograms. When given beyond recommended age may cause hypercalcemia When given beyond recommended age may cause hypercalcemia Special Features: Special Features: Protein: Whey predominant formula at a level higher than breast milk & standard infant formula ( g/100ml.)Protein: Whey predominant formula at a level higher than breast milk & standard infant formula ( g/100ml.)

93 PRETERM FORMULA Pre-Aptamil (Milupa): 1:1 dilution Pre-Aptamil (Milupa): 1:1 dilution Enfalac Premature: 1:1 dilution Enfalac Premature: 1:1 dilution Pre-Nan: 1:1 dilution Pre-Nan: 1:1 dilution S-26 LBW: 1:2 dilution S-26 LBW: 1:2 dilution Pre-Aptamil (Milupa): 1:1 dilution Pre-Aptamil (Milupa): 1:1 dilution Enfalac Premature: 1:1 dilution Enfalac Premature: 1:1 dilution Pre-Nan: 1:1 dilution Pre-Nan: 1:1 dilution S-26 LBW: 1:2 dilution S-26 LBW: 1:2 dilution

94 STANDARD INFANT FORMULA Recommended during the first 6 –12 months of life; Recommended during the first 6 –12 months of life; Extensively modified from what was originally produced by the cow; Extensively modified from what was originally produced by the cow; Very little difference between various brands Very little difference between various brands Example: S-26, Enfalac, Nan, Similac, Mylac, Aptamil, Bonna, Nestogen Example: S-26, Enfalac, Nan, Similac, Mylac, Aptamil, Bonna, Nestogen Recommended during the first 6 –12 months of life; Recommended during the first 6 –12 months of life; Extensively modified from what was originally produced by the cow; Extensively modified from what was originally produced by the cow; Very little difference between various brands Very little difference between various brands Example: S-26, Enfalac, Nan, Similac, Mylac, Aptamil, Bonna, Nestogen Example: S-26, Enfalac, Nan, Similac, Mylac, Aptamil, Bonna, Nestogen

95 FOLLOW-UP FORMULA Liquid part of the weaning diet for infants & children 12 mos - 3 years of age; Liquid part of the weaning diet for infants & children 12 mos - 3 years of age; Distribution of calories and nutrients is in between standard infant formula and whole cows milk Distribution of calories and nutrients is in between standard infant formula and whole cows milk Protein is higher with the ratio of 20% whey and 80% casein Protein is higher with the ratio of 20% whey and 80% casein Example: Promil, Nan 2, Gain, Milumil Example: Promil, Nan 2, Gain, Milumil Liquid part of the weaning diet for infants & children 12 mos - 3 years of age; Liquid part of the weaning diet for infants & children 12 mos - 3 years of age; Distribution of calories and nutrients is in between standard infant formula and whole cows milk Distribution of calories and nutrients is in between standard infant formula and whole cows milk Protein is higher with the ratio of 20% whey and 80% casein Protein is higher with the ratio of 20% whey and 80% casein Example: Promil, Nan 2, Gain, Milumil Example: Promil, Nan 2, Gain, Milumil

96 COMPOSITION OF VARIOUS NUTRIENT SOURCES BM COW A PREM FF-UP Energy kcal/100ml Protein G/100 ml Whey60%60%20% Casein40%40%80% Fat G/100 ml CHO G/100 ml CA mg/100 ml (75) P mg/100 ml (40) NA mmol/100 ml

97 GROWING –UP FORMULA: Product used for children above 2 years to 10 years Product used for children above 2 years to 10 years Provides nutrient necessary as they undergo transition from infant to adult formulation. Provides nutrient necessary as they undergo transition from infant to adult 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 sucrose with very minimal lactose CHO contains a blend of cornstarch and sucrose with very minimal lactose Product used for children above 2 years to 10 years Product used for children above 2 years to 10 years Provides nutrient necessary as they undergo transition from infant to adult formulation. Provides nutrient necessary as they undergo transition from infant to adult 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 sucrose with very minimal lactose CHO contains a blend of cornstarch and sucrose with very minimal lactose

98 Growing-up Formulas Enfagrow (MJ):1:1 dilution Enfagrow (MJ):1:1 dilution Grow (Abbott):1:2 dilution Grow (Abbott):1:2 dilution Lactum (MJ):1:1 dilution Lactum (MJ):1:1 dilution Neslac (Nestle):1:1 dilution Neslac (Nestle):1:1 dilution Progress (Wyeth):1:2 dilution Progress (Wyeth):1:2 dilution Enfagrow (MJ):1:1 dilution Enfagrow (MJ):1:1 dilution Grow (Abbott):1:2 dilution Grow (Abbott):1:2 dilution Lactum (MJ):1:1 dilution Lactum (MJ):1:1 dilution Neslac (Nestle):1:1 dilution Neslac (Nestle):1:1 dilution Progress (Wyeth):1:2 dilution Progress (Wyeth):1:2 dilution

99 Whole Cows Milk Maybe given as supplement to a balanced diet from 12 months above; Maybe given as supplement to a balanced diet from 12 months above; No modification done to suit the needs of infants &children No modification done to suit the needs of infants &children Example: Alaska, Bear Brand, Example: Alaska, Bear Brand, Maybe given as supplement to a balanced diet from 12 months above; Maybe given as supplement to a balanced diet from 12 months above; No modification done to suit the needs of infants &children No modification done to suit the needs of infants &children Example: Alaska, Bear Brand, Example: Alaska, Bear Brand,

100 Protein Hydrolysates Definition: Definition: It refers to the product of an enzymatic degradation of protein to proteose, peptone, peptide-AA mix and finally free AA mix. Types: Types: –Partial Hydrolysate: Degradation of protein to big, medium size peptides less antigenicity; –Complete Hydrolysate: Degradation of protein into small peptides and free AA. Definition: Definition: It refers to the product of an enzymatic degradation of protein to proteose, peptone, peptide-AA mix and finally free AA mix. Types: Types: –Partial Hydrolysate: Degradation of protein to big, medium size peptides less antigenicity; –Complete Hydrolysate: Degradation of protein into small peptides and free AA.

101 Protein Hydrolysates Partially Hydrolyzed Formula: Partially Hydrolyzed Formula: – For prophylaxis on high risk infants: FH of atopy, asthma, food allergy FH of atopy, asthma, food allergy –Preparation: Nan-HA Extensively Hydrolyzed Formula: Extensively Hydrolyzed Formula: –For treatment of food allergy during infancy –Preparations: Pregomin (Milupa) Pregistimil (MJ) Pregistimil (MJ) Alfare (Nestle) Alfare (Nestle) Partially Hydrolyzed Formula: Partially Hydrolyzed Formula: – For prophylaxis on high risk infants: FH of atopy, asthma, food allergy FH of atopy, asthma, food allergy –Preparation: Nan-HA Extensively Hydrolyzed Formula: Extensively Hydrolyzed Formula: –For treatment of food allergy during infancy –Preparations: Pregomin (Milupa) Pregistimil (MJ) Pregistimil (MJ) Alfare (Nestle) Alfare (Nestle)

102 Introduction of Complementary Food

103 Features of Complementary Foods Timely: Should be introduced by 6 months Timely: Should be introduced by 6 months Adequate: Should provide sufficient energy, protein and micronutrients Adequate: Should provide sufficient energy, protein and micronutrients Safe: Hygienically stored and prepared and fed using clean utensils NOT bottles nor teat Safe: Hygienically stored and prepared and fed using clean utensils NOT bottles nor teat Properly fed: Meal frequency, feeding methods should be suitable for age (with fingers, spoon and fork, cups and bowls, guided or self-feeding) Properly fed: Meal frequency, feeding methods should be suitable for age (with fingers, spoon and fork, cups and bowls, guided or self-feeding)

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106 Complementary Food (CF) Definition: It refers to supplemental foods (milk & solid foods) given to infants when breastmilk is no longer adequate to sustain normal growth. Definition:

107 WHY should CF be given? Three Infant Feeding Periods: Three Infant Feeding Periods: Nursing Period (1 st 6 months of life) Nursing Period (1 st 6 months of life) Transitional Period (6-10 months) Transitional Period (6-10 months) Modified Adult Period ( >10 months) Modified Adult Period ( >10 months) Three Infant Feeding Periods: Three Infant Feeding Periods: Nursing Period (1 st 6 months of life) Nursing Period (1 st 6 months of life) Transitional Period (6-10 months) Transitional Period (6-10 months) Modified Adult Period ( >10 months) Modified Adult Period ( >10 months)

108 WHY should CF be given? Three Infant Feeding Periods: Nursing Period (1 st 6 months of life): Nursing Period (1 st 6 months of life): Breastmilk or standard infant formula is sufficient to provide nutritional requirements for normal growth; Breastmilk or standard infant formula is sufficient to provide nutritional requirements for normal growth; MILK should be the ONLY source of nutrient. MILK should be the ONLY source of nutrient. Three Infant Feeding Periods: Nursing Period (1 st 6 months of life): Nursing Period (1 st 6 months of life): Breastmilk or standard infant formula is sufficient to provide nutritional requirements for normal growth; Breastmilk or standard infant formula is sufficient to provide nutritional requirements for normal growth; MILK should be the ONLY source of nutrient. MILK should be the ONLY source of nutrient.

109 Nursing Period (1 st 6 months of life): Digestive, mucosal barrier and renal functions are not well developed; Digestive, mucosal barrier and renal functions are not well developed; (Zieger EE, J Pediatr, 1990) (Zieger EE, J Pediatr, 1990) Neuro-developmental status: not fully developed ! Neuro-developmental status: not fully developed ! Digestive, mucosal barrier and renal functions are not well developed; Digestive, mucosal barrier and renal functions are not well developed; (Zieger EE, J Pediatr, 1990) (Zieger EE, J Pediatr, 1990) Neuro-developmental status: not fully developed ! Neuro-developmental status: not fully developed !

110 Nursing Period : (1 st 6 months of life) Addition of solid foods at this time Addition of solid foods at this time breastmilk /milk consumption proportionally breastmilk /milk consumption proportionally growth failure growth failure Stuff et al, J pediatr,1990 Addition of solid foods at this time Addition of solid foods at this time breastmilk /milk consumption proportionally breastmilk /milk consumption proportionally growth failure growth failure Stuff et al, J pediatr,1990

111 Transitional Period (6-10 months) It is the transition from the nursing period to the adult modified period It is the transition from the nursing period to the adult modified period Milk (breastmilk / standard infant formula) is NO longer adequate to sustain the nutritional needs of growing infants Milk (breastmilk / standard infant formula) is NO longer adequate to sustain the nutritional needs of growing infants It is the transition from the nursing period to the adult modified period It is the transition from the nursing period to the adult modified period Milk (breastmilk / standard infant formula) is NO longer adequate to sustain the nutritional needs of growing infants Milk (breastmilk / standard infant formula) is NO longer adequate to sustain the nutritional needs of growing infants

112 Transitional Period (6-10 mos) Digestive, renal systems and taste are well developed; Digestive, renal systems and taste are well developed; Skills needed for feeding are likewise fully developed. Skills needed for feeding are likewise fully developed. Digestive, renal systems and taste are well developed; Digestive, renal systems and taste are well developed; Skills needed for feeding are likewise fully developed. Skills needed for feeding are likewise fully developed.

113 Transitional Period ( 6-10 months) FAILURE to offer supplemental foods at this time difficulty in accepting them later; FAILURE to offer supplemental foods at this time difficulty in accepting them later; Underwood BA,Acta Pediatr Scand Suppl, 1982 Underwood BA,Acta Pediatr Scand Suppl, 1982 FAILURE to offer supplemental foods at this time difficulty in accepting them later; FAILURE to offer supplemental foods at this time difficulty in accepting them later; Underwood BA,Acta Pediatr Scand Suppl, 1982 Underwood BA,Acta Pediatr Scand Suppl, 1982

114 Critical Learning Period 6-15 months 6-15 months, critical learning period for feeding: chewing & swallowing coordination is being developed; 6-15 months, critical learning period for feeding: chewing & swallowing coordination is being developed; FAILURE of infants to go through this process feeding problems: FAILURE of infants to go through this process feeding problems: –dependence to MILK as source of nutrient –picky eaters / neophobic – malnutrition (obesity/wasting,anemia) 6-15 months, critical learning period for feeding: chewing & swallowing coordination is being developed; 6-15 months, critical learning period for feeding: chewing & swallowing coordination is being developed; FAILURE of infants to go through this process feeding problems: FAILURE of infants to go through this process feeding problems: –dependence to MILK as source of nutrient –picky eaters / neophobic – malnutrition (obesity/wasting,anemia)

115 Modified Adult Period (>10 months) Physiologic mechanisms have matured to near adult proficiency; Physiologic mechanisms have matured to near adult proficiency; Most of the nutrients MUST come from table foods with minimal alteration (cut into small pieces, bland); Most of the nutrients MUST come from table foods with minimal alteration (cut into small pieces, bland); Taste ability & preferences have become established. Taste ability & preferences have become established. Physiologic mechanisms have matured to near adult proficiency; Physiologic mechanisms have matured to near adult proficiency; Most of the nutrients MUST come from table foods with minimal alteration (cut into small pieces, bland); Most of the nutrients MUST come from table foods with minimal alteration (cut into small pieces, bland); Taste ability & preferences have become established. Taste ability & preferences have become established.

116 Scientific Rationale: – Critical Window for introducing lumpy solid foods: if these are delayed beyond 10 mos increased risk of feeding difficulties later on Northstone et al, 2001 –Ingestion of the types of foods depend on the neuromuscular development of infants Scientific Rationale: – Critical Window for introducing lumpy solid foods: if these are delayed beyond 10 mos increased risk of feeding difficulties later on Northstone et al, 2001 –Ingestion of the types of foods depend on the neuromuscular development of infants What kind of food would you give?

117 WHEN should CF be given? 6 months WHEN should CF be given? 6 months Signals that indicate readiness of the infant 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 infant 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;

118 WHEN should CF be started? Signals that indicate readiness of infant for CF: Signals that indicate readiness of infant for CF: Opens mouth if wants food; turns head away when not Opens mouth if wants food; turns head away when not interested anymore; interested anymore; Has good chewing & swallowing coordination; Has good chewing & swallowing coordination; Consumes about 32 oz of milk and wants more; Consumes about 32 oz of milk and wants more; Breastfeeds > 10x and wants more Breastfeeds > 10x and wants more Signals that indicate readiness of infant for CF: Signals that indicate readiness of infant for CF: Opens mouth if wants food; turns head away when not Opens mouth if wants food; turns head away when not interested anymore; interested anymore; Has good chewing & swallowing coordination; Has good chewing & swallowing coordination; Consumes about 32 oz of milk and wants more; Consumes about 32 oz of milk and wants more; Breastfeeds > 10x and wants more Breastfeeds > 10x and wants more

119 Art of Introducing Complementary Food Introduce one new food at time to allow infant to get use to it; continue same food for 3-4 days before giving another food; Introduce one new food at time to allow infant to get use to it; continue same food for 3-4 days before giving another food; Give very small amount of any new food at the beginning, 1-4 tsp; Give very small amount of any new food at the beginning, 1-4 tsp; Introduce one new food at time to allow infant to get use to it; continue same food for 3-4 days before giving another food; Introduce one new food at time to allow infant to get use to it; continue same food for 3-4 days before giving another food; Give very small amount of any new food at the beginning, 1-4 tsp; Give very small amount of any new food at the beginning, 1-4 tsp;

120 Art of Introducing Complementary Food Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food Mix foods with ones baby likes, to enhance acceptability and nutrient content Mix foods with ones baby likes, to enhance acceptability and nutrient content Cereals +BM: Enhanced acceptance of cereal during weaning! Mennella et al, Pediatr Res, 1997 Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food Mix foods with ones baby likes, to enhance acceptability and nutrient content Mix foods with ones baby likes, to enhance acceptability and nutrient content Cereals +BM: Enhanced acceptance of cereal during weaning! Mennella et al, Pediatr Res, 1997

121 Art of Introducing Complementary Food Art of Introducing Complementary Food Once infant can sit with support at about 6 mos, give fluid (milk or water) using trainers cup; Once infant can sit with support at about 6 mos, give fluid (milk or water) using trainers cup; By 12 months of age milk should be given by the cup or glass; By 12 months of age milk should be given by the cup or glass; BOTTLES should be OUT by this time! BOTTLES should be OUT by this time! Once infant can sit with support at about 6 mos, give fluid (milk or water) using trainers cup; Once infant can sit with support at about 6 mos, give fluid (milk or water) using trainers cup; By 12 months of age milk should be given by the cup or glass; By 12 months of age milk should be given by the cup or glass; BOTTLES should be OUT by this time! BOTTLES should be OUT by this time!

122 Avoid adding salt and sugar Avoid adding salt and sugar When baby is able to chew at about 8-10 months, gradually switch to finely chopped foods When baby is able to chew at about 8-10 months, gradually switch to finely chopped foods DO NOT continue soft smooth foods for too long DO NOT continue soft smooth foods for too long Feeding Frequency: Feeding Frequency: 6-8 months: 2 -3 meals a day 6-8 months: 2 -3 meals a day 9-11 months: 3-4 meals; 1-2 snacks 9-11 months: 3-4 meals; 1-2 snacks > 12 months: 3-4 meals: 1-2 snacks > 12 months: 3-4 meals: 1-2 snacks Avoid adding salt and sugar Avoid adding salt and sugar When baby is able to chew at about 8-10 months, gradually switch to finely chopped foods When baby is able to chew at about 8-10 months, gradually switch to finely chopped foods DO NOT continue soft smooth foods for too long DO NOT continue soft smooth foods for too long Feeding Frequency: Feeding Frequency: 6-8 months: 2 -3 meals a day 6-8 months: 2 -3 meals a day 9-11 months: 3-4 meals; 1-2 snacks 9-11 months: 3-4 meals; 1-2 snacks > 12 months: 3-4 meals: 1-2 snacks > 12 months: 3-4 meals: 1-2 snacks Art of Introducing Complementary Food Art of Introducing Complementary Food

123 Art of Introducing Complementary foods By 12 months, most of the nutrient should come from table food (modified); infants have attained physiologic maturity of adult proficiency; By 12 months, most of the nutrient should come from table food (modified); infants have attained physiologic maturity of adult proficiency; Encourage infant to try new flavors as a variety of foods is important ! Encourage infant to try new flavors as a variety of foods is important ! * FNRI-DOST, Nutrition Guidelines for Filipinos, 2000 * Pediatric Nutrition Handbook, 4 th Edition AAP By 12 months, most of the nutrient should come from table food (modified); infants have attained physiologic maturity of adult proficiency; By 12 months, most of the nutrient should come from table food (modified); infants have attained physiologic maturity of adult proficiency; Encourage infant to try new flavors as a variety of foods is important ! Encourage infant to try new flavors as a variety of foods is important ! * FNRI-DOST, Nutrition Guidelines for Filipinos, 2000 * Pediatric Nutrition Handbook, 4 th Edition AAP

124 Harvard School of Public Health Harvard School of Public Health

125 US Department of Agriculture US Department of Agriculture New Food Guide Pyramid

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127 Thank You and God bless

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131 US Dept of Agriculture US Dept of Agriculture

132 Endocrine Control of Lactation

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