1. The Ideal Formula An infant formula should contain optimal amounts of all nutrients in levels that support normal growth but does not stress the infants still-developing systems. The infant formula should minimize feeding problems.

2. Human milk vs Cow milk -Both are liquid -Quantity and availability of nutrients is different -Both have similar amount of water, calories, calorie source is different (proteins supply 7% of calories in human milk, 20% in cow milk). Lactose supplies 42% in human milk and 30% in cow milk, % of calories from fat is the same. CHO: lactose in both cases, cow milk<<human milk Proteins: cow milk 3X minerals and protein, composition is different Two fractions: casein and whey. Casein: precipitated at low pH, constitutes 20–30% of human milk proteins. A heterogeneous group of proteins, molecular weights: 20 000–30 000 Whey: contains a large number of proteins, which are derived from both milk and plasma. Mainly Whey: casein ratio: Human milk (60:40), cow milk (20:80) The large amount of curd may cause GI distress a.a. content is inappropriate to the immature enzyme systems Infant formulas, why? Contents of various milks

3. Fat: both have similar fat content Linoleic acid (supplies 7% of calories in human milk, 1% cow milk, Formula 10%) Cholesterol level is different (higher in human milk) Fat in human milk is different from cow milk in 2 ways: TG types: cow milk, short and long chain FA, in human milk medium chain Degree of saturation: human milk:PUFA, cow milk: butter fat LCPUFA Lipoprotein lipase Minerals and electrolytes: several times more in cow milk than human milk Calcium and phosphorus: higher level in cow milk (4-7 times more) and the ratio is different Iron, Zinc Na, K and Cl Infant formulas, why? Contents of various milks

5. Reduced fat cow milk Whole cow milk Evaporated milk Types, uses and selection of commercial infant formulas 1.Milk based formulas: nonfat cow milk, vegetable oils (corn oil, sunflower, soy oil) and lactose are added. Supplemented with vitamins and minerals, iron and zinc 2. Milk based formulas with added whey protein

6. Therapeutic Formulas a. Lactose free formula: for lactose intolerance b. Soy protein formula: soy protein instead of animal protein (fortified with methionine). Vegetable oil as fat source, corn syrup or sucrose supply the CHO. Infanct with CMA: respiratory tract, skin, dairrhea Minerals and supplements Lactose free,, no animal protein or fat High PRSL Not suitable for premature or LBW infants. Have to add Ca and P

7. c. Casein hydrolysate fromula: infants with severe GI abnormalities, malabsorption of CHO, protein and fat. Fortified with amino acids CHO source is corn syrup, conr starch, dextrose Fat source: medium chain triglycerides d. Amino acid based formula: infants who are intolerant to casein hydrolysate e. Whey hydrolysate formula Therapeutics formulas

8. LACTOSE INTOLERANCE

9. Medical Need for LF Formulas Lactose intolerance (L I) often a complication of diarrhea. –Secondary lactase deficiency most common cause of LI. –About 23% of well-nourished infants with acute diarrhea develop LI. –Incidence greater in malnourished infants. Lactose intolerance may cause colic in some infants.

10. Symptoms Of Lactose Intolerance: Nausea (?) Abdominal pain and distension Flatulence Watery diarrhea

11. Lactose Free Formulas LF Formulas appropriate for –Infants with secondary lactase deficiency. –Infants with congenital lactase deficiency. –Children and adults with acquired lactase deficiency. Corn syrup solids, or corn syrup solids with sucrose instead of lactose

12. REGURGITATION

13. Mild regurgitation is a common occurrence in infancy. Often considered to be a normal physical phenomenon of early development. Usually no serious health risks. Spontaneously resolves with time. Often considered as a source of parental anxiety.

14. SYMPTOMS Common symptoms -Regurgitation -Esophagitis -Excessive crying -Feeding problems -Respiratory problems -Parental anxiety Unusual Symptoms -Failure to thrive -Respiratory problems ???-Hematemisis

15. REFLUX & REGURGITATION Reflux: Backward flow of gastric juices out of the stomach up through esophagus. Regurgitation: Backward flow of undigested food ‘spitting-up’

16. Recommendation Step I Parents Reassurance Step II Feed Thickeners Step III Feed Thickener + Medications

17. Rational of AR Formula Regurgitation or spit-up is a common occurrence in infancy 15-30% of infants suffer from GER. Baby can’t thrive on formula that won’t stay down. AR formula reduces parents’ anxiety. Iron fortified formula containing CHO blend of lactose, rice starch and maltodextrin

18. Galactosemia It is a metabolic disorder caused by a deficiency in the activity of the enzyme galactose-1-phosphate uridyl transferase (Type 1). As a result, toxic levels of galactose-1-phosphate accumulate in the body. Without treatment, this disorder is usually fatal. Treatment should eliminate galactose and lactose from the diet. Soya bean formulas may be indicated for these infants.

20. NUTRITIONAL NEEDS OF LBW INFANTS

22. Low-Birth-Weight Infants Infants who are born prior to term, i.e., 38-42 weeks, are classified as premature or preterm by the AAP. Approximately, 12% of infants are born preterm each year. Preterm infants tend to weigh less than term infants (<2,500gm) and are considered LBW.

23. The digestive, metabolic and excretory systems of these infants are less mature than those of term infants, and require special care. Optimal nutrition that meets the special nutritional needs of LBW infants to achieve post-natal growth that approximates intra-uterine growth without placing undue stress on under developed body systems, often creates a dilemma. Cont., Low-Birth-Weight Infants

24. Low-Birth-Weight Formulas LBW formulas must be designed to address the most important problems impeding optimal growth in LBW infants: LBW infants may not have a fully active sucking reflex, making breast feeding impossible. LBW infants have a limited capacity to consume high volumes of formula, and are incapable of complete digestion and absorption.

25. Fat absorption in the intestine is less efficient, as bile salts concentrations are reduced. LBW infant’s inability to properly absorb, digest, and achieve metabolism of food has severe implications. The renal system and liver are not fully developed: –Immature liver: reduced glycogen storage. –Less developed kidneys will not be able to obtain normal absorption mechanisms. Cont., Low-Birth-Weight Formulas

26. Excessive concentrated feedings are not well- tolerated. RSL must be kept within manageable limits. LBW formulas must be fortified with extra calcium, magnesium, phosphorus, and LCPUFAs to meet the special nutritional requirements. Whey is predominant, CHO mixture, additional calcium and phosphorus is needed Cont., Low-Birth-Weight Formulas

27. supplements The need for vitamin and mineral supplements Breast fed full term infants -vitamin D -Iron (after 4-6 months) Formula fed full term infants Preterm infants

29. Potential problems with infant formulas Diarrhea: can lead to failure to thrive or dehydration. Improper dilution or preparation of the formula GI problems: hypersensitivity to cow milk proteins, GI distress Tooth decay: bottle feeding beyond 1 year, caries

30. Infant formula preparation

31. TIPS IN BOTTLE FEEDING Choosing the right bottle: variety of types, selection of the appropriate volume Choosing nipples or teats: Type of teat: rubber latex, or silicon Shape: Orthodontic- type, nubbin-type Nipple hole Sterilizing After a feeding, thoroughly rinse the bottle and nipple under warm water and leave them on a clean towel by the sink, ready for your next sterilizing session. Wash all the equipment in hot soapy water, rinse thoroughly in hot water, and remove the milk scum with a bottle brush. Pad the bottom of a large pan with a towel or dishcloth. Immerse open bottles, nipples, and other equipment in the pan (place bottles on their side to be sure that they are filled with the sterilizing water) and boil for ten minutes with the pan covered. Allow to cool to room temperature while still covered. Remove the bottles and nipples with tongs or a spoon and place the bottles upside down on a clean towel with the nipples and caps alongside. Let the equipment dry.