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

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 the benefits of breastmilk and the benefits of breastfeeding to both infant and mother; To discuss the barriers on breastfeeding; To discuss the composition of mature breast-milk; To discuss the difference between breast-milk and cow’s milk;

Objectives of the Course 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 proper method to introduce complementary foods; 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 discuss the supplements for breastfed infants.

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.

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

Breast Structure

Anatomy of the Breast

Palate Teat Tongue

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: 14-30 das.

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 11 11

Hormones Involved in Mammary Growth Phase I - Mammogenesis 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

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

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

ENDOCRINE REGULATION OF LACTOGENESIS Endocrine Patterns Related to Parturition

Endocrine Control of Lactation Milk Production Reflex: Prolactin is a key lactogenic hormone, stimulating initial alveolar milk production 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

ENDOCRINE REGULATION OF LACTOGENESIS 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

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 – Galactopoiesis maintenance of Breastmilk Secretion Stage III of Lactogenesis or Galactopoiesis Maintenance of milk secretion From 14- 30 days Mature milk is established Prolactin and Oxytocin essential for effective maintenance of milk supply 20 20

MAINTENANCE OF LACTOGENESIS (Galactopoiesis) 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

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 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

Autocrine Control of Lactation FIL FIL FIL

Anatomy & Physiology: Milk production Risk factors for delayed onset of lactation were: Stage II labor > 1 hr, Pre-pregnant maternal BMI > 27 kg/m2, Breastfeeding problems at day 3,and Being primiparous. Dewey et al, 2001

Anatomy & Physiology: Milk production Factors associated with breastfeeding problems at day 7 included: flat or inverted nipples at day 7, stage II labor > 1 hour, birthweight < 3601 gms, Pre-pregnant maternal BMI > 27 kg/m2 non breast milk fluids given in the first 48 hours of life Dewey, 2003

Breastmilk composition

Breast-milk Variations of Breastmilk Colostrum (1st 3-5 days of life) Term breastmilk ( mother’s own: 7 - 10 – 28 days) Pre-term Milk ( day 7- 28 days) Mature breastmilk ( >30 days) Drip breastmilk ( 30-90 days postpartum)

Colostrum First postpartum week’s 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); Protein content is rich in sIgA and immunologically competent mononuclear cells; Contains antioxidants which trap neutrophil-generated oxygen radicals.

Concentration in MG /Day at Postpartum 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 50 25 10 IgA* 5000 1000 IgM 70 30 15 Lysozyme 60 100 Lactoferrin 1500 2000 1200

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 100 0.67 2.3 5.3 2.9 1.7 (1-5 d) Term D7 558 0.73 1.95 6.72 3.52 0.97 D 14 591 0.67 1.62 6.97 3.88 1.27 Breastmilk 750 0.69 1.1 7.4 4.2 0.70 (Mature>30 d)

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 D7 461 0.647 2.59 6.23 4.02 2.45 D14 413 0.68 2.29 6.21 4.71 2.2 D28 452 0.652 1.91 6.39 4.33 1.51 Drip BM 0.54 1.35 7.1 2.2 0.5 Cow 0.67 3.4 4.6 3.9 2.3

Calculated Nutrient Intakes Compared to Estimated Needs for LBW Units/KG/D PreTerm Milk Week of Lactation Mature Milk Estimated Needs 1 2 4 Energy (KCAL) 120 Fluid Vol. (ML) 180 190 150 Protein (G) 3.9 3.4 2.8 2.4 3.5 Sodium (MMOL) 4.0 2.7 1.8 2.0 3.0 Calcium (MG) 53 46 42 47 160-200 Phosphorus (MG) 25 27 23 26 80-100

HUMAN COW’S Amino-acids Cystine Taurine Enough for growing brain Not enough Fat Total Saturation of fatty acids Linoleic acid (essential) Cholesterol 4% (average) Enough unsaturated Enough 4% Too much saturated Lipase to digest fat Present None Lactose (sugar) 7% -- enough 3-4% - not enough Salts (mEq/l) Sodium Chloride Potassium 6.5 correct amount 12 correct amount 14 correct amount 25 too much 29 too much 35 too much

HUMAN COW’S Minerals (mg/l) Calcium Phosphate 350 correct amount 1,400 too much 900 too much Iron Small amount Well absorbed Enough Poorly absorbed Not enough Vitamins Water No extra needed Extra needed

Nutrients in human and animal milk Cow Goat Fat Protein Lactose HUMAN COW GOAT BUFFALO

Composition Iron Not affected by maternal iron status and dietary iron supplements Higher absorption: 50% : HM 10% : unfortified cow’s milk 4% : fortified cow’s milk

Minerals in human milk are largely protein bound and balanced which enhanvces bioavailability. Independent of the mother’s iron status, a term NB with adequate iron stores and utilizes little dietary iron before 4-6 months. Iron in breastmilk is readily absorbed, no need to give supplement. Preterm may need supplement because they kack iron stores. Flouride in human milk is not abundant. Addition is nescessary when the fluid level is <0.3ppm – give baby suplement of 0.25mg of flouride is required. The level in water is 0.7 to 1.2 ppm. Excess flouride may damage teeth in the earlt stages of development.

VITAMIN CONTENT Vitamin Human Cow’s A Enough even in 2nd year 2 X in colostrum In case of deficiency give supplement to mother Less (x 1/2) B Group Plenty Even more C Enough Less (x 1/5) May need supplement if fed artificially D Less K Usually enough More in Colostrum More Vitamin K is given one time to newborn as there is only a small amount in breastmilk and it takes time for the intestinal flora to produce adequate amount of Vit K.

Comparison of Human Milk and Cow’s Milk Bacteria contamination None Likely Anti-infective Substances Antibodies Leucocytes Lactoferrin Bifidus factor Not active Protein - Total - Casein - Lactalbumen 1% 0.5% 4% too much 3% too much

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

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

Benefits of Breastmilk / Breastfeeding to Infants and Mothers

Benefits of Breastmilk Enhances Cognitive Development Protective: Both for baby and mother Cheap & Free: Benefits the Economy Safe

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

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

Benefits 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

Benefits 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

Benefits 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

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Benefits 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

Benefits 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

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

Anti-infective Properties Benefits of Breastmilk: Infant Anti-infective Properties IgA, IgM, IgG: immunoglobulins that guard the gut against infective bacteria Bifidus factor: stimulates bifido-bacteria, which fight against pathogenic bacteria Lactoferrin: binds iron away from bacteria Macrophages: phagocytosis of infective bacteria B12 binding protein: removes B12 from bacteria

Antiviral Factors in Human Milk Shown, in vitro, to be active against: Effect of Heat Secretory IgA Poliovirus types 1, 2, 3. Coxsackie types A9, B3, B5, Echovirus types 6, 9. Semliki Forest Virus Ross River Virus Rotavirus Cytomegalovirus 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 59

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

Protection Against Infection 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

Antibacterial Properties found in human milk 62

Shown, in vitro, to be active against: 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 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 63

Shown, in vitro, to be active against: Factor Shown, in vitro, to be active against: Effect of Heat IgD Bifidobacterium bifidum growth z factor E. Coli Enterobacteriacea, enteric pathogens Stable to boiling Factor binding proteins (zinc, vitamin B12, 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 Two-thirds destroyed at 62.5°C for 30 min; essentially destroyed by boiling for 15 min 64

Shown, in vitro, to be active against: 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 65

Types of Breast milk Foremilk Hindmilk

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

Protective Factors in BM 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;

Benefits of Breastmilk: Infants Maternal HIV Maternal-to-Child Viral Transmission (MTCT): Breastfeeding vs Formula feeding: Prevalence of MTCT at 24 months: Breastfeeding (BF): 36.7% Formula-feeding (FF): 20.5% Mortality rate: BF: 24.4% FF: 20.0% Nduati R. et al. JAMA 2000

Benefits of Breastmilk: Infant 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: 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

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

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

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

Benefits of Breastfeeding: Mothers 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 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 Risch et al 1993 & Gwinn 1990: 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

Benefits of Breastfeeding: Economy 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)

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

Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly 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 infant’s 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.

Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly 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 infant’s nutritional status When to contact the clinician

Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly 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.

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

6) What is the protein distribution of BM 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?

Thank You and God bless

Breastmilk Substitutes Infant Milk Formulas

TYPES OF INFANT FORMULA Pre-term Formula Catch-up Growth Formula Standard Infant Formula Whey Dominant ( 60%) Casein Dominant ( 60%) Follow-on (up) Formula Growing-up Formula Whole cow’s Milk Evaporated Milk

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

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 a substitute for human milk in infants for whom breastfeeding is medically contraindicated; As supplement for infants who do not gain weight appropriately.

Nutrient Sources: < 2 Years of Age PRETERM FORMULA: Prescribed for premature until they have reached 35-36 weeks of gestation or gained 2 kilograms. When given beyond recommended age may cause hypercalcemia Special Features: Protein: Whey predominant formula at a level higher than breast milk & standard infant formula (2.0 2.5g/100ml.)

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

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

FOLLOW-UP FORMULA 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 cow’s milk Protein is higher with the ratio of 20% whey and 80% casein Example: Promil, Nan 2, Gain, Milumil

COMPOSITION OF VARIOUS NUTRIENT SOURCES BM COW A PREM FF-UP Energy kcal/100ml 65 67 65 81 65 Protein G/100 ml 1.1 3.5 1.5 2.4 2.8 Whey 60% 60% 20% Casein 40% 40% 80% Fat G/100 ml 4.5 3.7 3.6 4.4 2.64 CHO G/100 ml 6.8 4.9 7.2 8.6 8.18 CA mg/100 ml 34 117 44 95(75) P mg/100 ml 14 92 33 53(40) NA mmol/100 ml 0.7 2.2 0.64 1.4 1.57

GROWING –UP FORMULA: Product used for children above 2 years to 10 years Provides nutrient necessary as they undergo transition from infant to adult formulation. Protein is high ( 3 g/100 ml) from Sodium Casseinate and soya protein CHO contains a blend of cornstarch and sucrose with very minimal lactose

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

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

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

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

“Introduction of Complementary Food”

Features of Complementary Foods Timely: Should be introduced by 6 months Adequate: Should provide sufficient energy, protein and micronutrients 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)

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.

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

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

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

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

Transitional Period (6-10 months)  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  

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

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

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

Modified Adult Period (>10 months) 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); Taste ability & preferences have become established.

What kind of food would you give? 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

WHEN should CF be given? 6 months Signals that indicate readiness of the infant for CF:  Birth weight has doubled;  Extrusion reflex has completely disappeared;  Has good head and neck control;  Sits up with support;

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

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;  Give very small amount of any new food at the beginning, 1-4 tsp;

Art of Introducing Complementary 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 Cereals +BM: Enhanced acceptance of cereal during weaning! Mennella et al, Pediatr Res, 1997

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

Art of Introducing Complementary Food  Avoid adding salt and sugar 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 Feeding Frequency: 6-8 months: 2 -3 meals a day 9-11 months: 3-4 meals; 1-2 snacks > 12 months: 3-4 meals: 1-2 snacks

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;  Encourage infant to try new flavors as a variety of foods is important ! * FNRI-DOST, Nutrition Guidelines for Filipinos, 2000 * Pediatric Nutrition Handbook, 4th Edition AAP

Harvard School of Public Health

New Food Guide Pyramid US Department of Agriculture

Thank You and God bless

US Dept of Agriculture

Endocrine Control of Lactation

Endocrine Control of Lactation