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 MedicalStudent 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;
3 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.
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.
10 Physiology of lactation Endocrine control Three main phases of lactation1) Mammogenesis or mammary growth2) Lactogenesis or initiation of milk secretion:Stage I: wks before parturitionStage II: 2-3 days postpartum3) Stage III of Lactogenesis or Galactopoiesis maintenance of milk secretion: das.
11 Three Main Phases of Lactation (hormonal) Phase I - MammogenesisProfound during pregnancy in preparation for lactationPlacental lactogen, estrogen, progesteroneDuctal Sprouting (estrogen), lobular formation (progesterone), Prolactin essential for complete gland growth1111
12 Hormones Involved in Mammary Growth Phase I - MammogenesisHormones Involved in Mammary GrowthEstrogensProgesteroneGHPlacental lactogens (PL)ProlactinGlucocorticoidsGH and PL induce alveolar growthSteroids without GH and PL do not exert any effect
13 Phase I - Mammogenesis INDUCTION OF GROWTH (Normal animals) • Estrogens alone induce alveolar growthLarger than normal alveoli• Estrogen and progesterone induce normal growth
14 Phase II - LACTOGENESIS INITIATION OF LACTATIONAt parturition the mammary gland switches from a growing non secretory tissue to a secreting, non-growing tissueChange is endocrine mediated
15 Three Main Phases of Lactation (hormonal) Phase II - Lactogenesis (initiation of milk):Stage I: starts 12 wks before deliveryGathering of all substrates for milk productionStage II: starts 2-3 days postpartumMilk secretion is copious1515
16 ENDOCRINE REGULATION OF LACTOGENESIS Endocrine Patterns Related to Parturition
17 Endocrine Control of Lactation Milk Production Reflex:Prolactin is a key lactogenic hormone, stimulating initial alveolar milk productionMilk 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 ENDOCRINE REGULATION OF LACTOGENESIS Effect of different hormones in the initiation of milk productionGlucocorticoidsDevelopment of RER (rough endoplasmic reticulum)ProlactinMaturation of GolgiSecretory vesiclesResponsible for milk secretionProgesteronePromotes mammary growth specially alveolar tissueBlocks epithelial secretionAs it decreases, the block for lactogenesis is removed
19 Effect of different hormones in the initiation of milk production MAMMARY GROWTH SLOWS DOWNMost hormones involved in growth have been removedProgesteroneCL has regressed and placenta is removedEstrogensFeto-placental unit no longer availablePlacental lactogensPlacenta was expelledAfter parturition mammary growth slows down because mostgrowth promoting hormones are no longer available
20 Phase III – Galactopoiesis maintenance of Breastmilk Secretion Stage III of Lactogenesis or GalactopoiesisMaintenance of milk secretionFrom daysMature milk is establishedProlactin and Oxytocin essential for effective maintenance of milk supply2020
21 MAINTENANCE OF LACTOGENESIS (Galactopoiesis) Hormones in charge of supporting continuous milk productionResponsibility of prolactin and growth hormoneSupported by thyroid, parathyroid and adrenal glands through adequate metabolic function
22 Autocrine Control of Lactation Influence of of Local Factors Acting on the BreastsIt is not just the level of maternal hormones, but the efficiency of milk removal that governs the volume product in each breastA protein factor called feedback inhibitor of lactation (FIL) is secreted with other milk components into the alveolar lumenFIL, insensitive to prolactin milk production
24 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,andBeing primiparous.Dewey et al, 2001
25 Anatomy & Physiology: Milk production Factors associated with breastfeeding problems at day included:flat or inverted nipples at day 7,stage II labor > 1 hour,birthweight < 3601 gms,Pre-pregnant maternal BMI > 27 kg/m2non breast milk fluids given in the first 48 hours of lifeDewey, 2003
27 Breast-milk Variations of Breastmilk Colostrum (1st 3-5 days of life) Term breastmilk ( mother’s own: – 28 days)Pre-term Milk ( day days)Mature breastmilk ( >30 days)Drip breastmilk ( days postpartum)
28 ColostrumFirst 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.
29 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 PeriodSoluble ProductConcentration in MG /Day at Postpartum<1 week1-2 weeks3-4 weeks>4 weeksIgG502510IgA*50001000IgM703015Lysozyme60100Lactoferrin150020001200
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/DPreTerm MilkWeek of LactationMatureMilkEstimated Needs124Energy (KCAL)120Fluid Vol. (ML)180190150Protein (G)126.96.36.199.43.5Sodium (MMOL)4.02.71.82.03.0Calcium (MG)53464247Phosphorus (MG)2527232680-100
33 HUMAN COW’S Amino-acids Cystine Taurine Enough for growing brain Not enoughFatTotalSaturation of fatty acidsLinoleic acid (essential)Cholesterol4% (average)Enough unsaturatedEnough4%Too much saturatedLipase to digest fatPresentNoneLactose (sugar)7% -- enough3-4% - not enoughSalts (mEq/l)SodiumChloridePotassium6.5 correct amount12 correct amount14 correct amount25 too much29 too much35 too much
34 HUMAN COW’S Minerals (mg/l) Calcium Phosphate 350 correct amount 1,400 too much900 too muchIronSmall amountWell absorbedEnoughPoorly absorbedNot enoughVitaminsWaterNo extra neededExtra needed
35 Nutrients in human and animal milk CowGoatFatProteinLactoseHUMANCOWGOATBUFFALO
40 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.
41 VITAMIN CONTENT Vitamin Human Cow’s A Enough even in 2nd year 2 X in colostrumIn case of deficiency give supplement to motherLess (x 1/2)B GroupPlentyEven moreCEnoughLess (x 1/5)May need supplement if fed artificiallyDLessKUsually enoughMore in ColostrumMoreVitamin 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.
42 Comparison of Human Milk and Cow’s Milk Bacteria contaminationNoneLikelyAnti-infective SubstancesAntibodiesLeucocytesLactoferrinBifidus factorNot activeProtein- Total- Casein- Lactalbumen1%0.5%4% too much3% too much
43 Supplements for Breastfed Infants The following supplementation is generally recommended:Vitamin K supplement in the immediate postpartum period.400 IU of Vitamin DBreastfeeding women should continue taking prenatal vitamins especially vitamin D, calcium and ironComplementary foods should be given once infants reach six months of age
44 Review QuestionsThe 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 ______
45 Benefits of Breastmilk / Breastfeeding to Infants and Mothers
46 Benefits of Breastmilk Enhances Cognitive DevelopmentProtective: Both for baby and motherCheap & Free: Benefits the EconomySafe
47 Benefits of Breastmilk: Infant Enhances Cognitive DevelopmentDocosohexanoic Acid (DHA)Lactose‘Skin to skin’ Contact and ‘face to face’ position
48 Benefits of Breastmilk: Infant DHA (Docosohexanoic Acid):Fatty acid derived from Linolenic AcidOnly found in breastmilk in consistent levelImportant substance for the myelin sheath of nerve fibersVital nutrient for the growth and development of brain tissue and good visionResearches showed that it is this substance that enhances cognitive development
49 Benefits of Breastmilk: Infant LactosePredominant carbohydrate of breastmilkDisaccharide consisting of glucose and galactoseGalactose combines with lipid to form a valuable nutrient, galactose-lipid, for brain tissue development
50 Benefits of Breastmilk: Infant ‘Skin to skin’ contact & ‘Face to Face’ positionEnhances the cognitive and educational development of children as each feeding time is a learning opportunity for mother and child
51 Benefits of Breastmilk: Infant Breastmilk is ProtectiveProtective properties of BM is divided into two:Humoral factors:Consists of the 5 immunoglobulins (antibodies):IgA, s IgA, IgG, Ig E, Ig D, Ig MCellular factors:White Blood cells:NeutrophilsLymphocytesEpithelial cellsMacrophages
53 Benefits of Breastmilk: Infant Breastmilk is ProtectiveWhite Blood CellsBacterial killerHighest concentration of WBC occurs in the 1st few days of lactation > a million/mlColostrum (1-5 days post-natal):Contains 105 – 5 x 106 WBC / ml
54 Benefits of Breastmilk: Infant Breastmilk is ProtectiveBifidus Factor:Enhances the growth of Lactobacillus bifidus preventing growth of pathogenic bacteriaLactoferrin:Binds iron thus preventing the growth of iron-dependent bacteria
55 Host Resistance Factors in BM Non-immunoglobulin components:OligosaccharidesMucinFatty acids
56 Anti-infective Properties Benefits of Breastmilk: InfantAnti-infective PropertiesIgA, IgM, IgG: immunoglobulins that guard the gut against infective bacteriaBifidus factor: stimulates bifido-bacteria, which fight against pathogenic bacteriaLactoferrin: binds iron away from bacteriaMacrophages: phagocytosis of infective bacteriaB12 binding protein: removes B12 from bacteria
59 Antiviral Factors in Human Milk Shown, in vitro, to be active against:Effect of HeatSecretory IgAPoliovirus types 1, 2, 3. Coxsackie types A9, B3,B5,Echovirus types 6, 9. Semliki Forest VirusRoss River VirusRotavirusCytomegalovirusReovirus type 3Rubella virusHerpes simplex virus, Mumps virusInfluenza virusRespiratory syncytial virusStable at 56°C for 30 mins.;Some loss (0 – 30%) at 62.5 °C for 30 mins;destroyed by boiling59
60 Benefits of Breastmilk: Infant Enhanced immune response to immunizationsPolioTetanusDiptheriaHaemophilus influenza
61 Protection Against Infection Reduces risk and severity of infectious illness among infantsdiarrheaotitis medialower respiratory infectionsbacteremiabacterial meningitisnecrotizing enterocolitisinfant botulismurinary tract diseasesudden infant death syndrome (SIDS)Colicwheezing
62 Antibacterial Properties found in human milk 62
63 Shown, in vitro, to be active against: FactorShown, in vitro, to be active against:Effect of HeatSecretory IgAE. Coli (also pili and capsular antigens)C. TetaniC. DiphtheriaeK. pneumoniaeSalmonella (6 groups)Shigella (2 groups)Streptococcus, S. mutans, S. sanguis, S. mitis, S. salivarius, S. pneumoniae,C. burnetti,H. influenzaeE. coli enterotoxin,V. Cholerae enterotoxinC. difficile toxinsH. Influenzae capsuleStable at 56°C for 30 min;some loss (0-30%) at 62.5°C for 30 min;destroyed by boilingIgM, IgGV. Cholerae lipopolysaccharide; E. coliIgM destroyed and IgG decreased by a third at 62.5°C for 30 min63
64 Shown, in vitro, to be active against: FactorShown, in vitro, to be active against:Effect of HeatIgDBifidobacterium bifidum growthz factorE. ColiEnterobacteriacea, enteric pathogensStable to boilingFactor binding proteins (zinc, vitamin B12, folate)Dependent E. coliDestroyed by boilingComplement C1-C9 (mainly C3 and C4)Effect not knownDestroyed by heating at 56°C for 30 minLactoferrinTwo-thirds destroyed at 62.5°C for 30 min; essentially destroyed by boiling for 15 min64
65 Shown, in vitro, to be active against: FactorShown, in vitro, to be active against:Effect of HeatLactoperoxidaseStreptococcus, Pseudomonas, E. coli, S. typhimuriumDestroyed by boilingLysozymeE. coli, Salmonella, Micrococcus lysodeikticusSome loss (0-23%) at 62.5°C for 30 min; essentially destroyed by boiling for 15 minUnidentified factorsS. aureus, C. difficile toxin BStable at autoclaving; stable at 56°C for 30 minCarbohydrateE. coli enterotoxinStable at 85°C for 30 minLipidS. AureusStable at boilingGanglioside (GMI like)E. Coli enterotoxin, V. cholerae enterotoxinStable to boiling65
68 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;
69 Benefits of Breastmilk: Infants Maternal HIVMaternal-to-Child Viral Transmission (MTCT):Breastfeeding vs Formula feeding:Prevalence of MTCT at 24 months:Breastfeeding (BF): %Formula-feeding (FF): 20.5%Mortality rate:BF: 24.4%FF: 20.0%Nduati R. et al. JAMA 2000
70 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
73 Benefits of Breastmilk: Safe Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminatedWeir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formulaCMAJVan Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formulaJClin Microbiol
74 Benefits of Breastmilk: Safe Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminatedWeir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formulaCMAJVan Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formulaJClin Microbiol
75 Benefits of Breastmilk: Safe Joint FAO/WHO Workshop on Enterobacter Sakazakii and other Microorganisms in Powdered Infant formula February 2004Recommendations:Guidelines should be developed for the preparation, use and handling of infant formula to decrease the risk of infectionMake use of Enterobacteriaceae rather than coliform testing as an indicator of hygienic control
76 Benefits of Breastfeeding: Mothers Prevents ObesityEarly return to pre-pregnancy weight
77 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 FebEleven studies were evaluatedResults:RR: to 0.85 for 1st 3-6 months of BFRR: to 0.72 for > 2 yearsRR: for > 6 yearsConclusion:Clear and consistent protective effect of BF on breast cancer have been found in all studies
78 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 monthsRisch 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
79 Benefits of Breastfeeding: Economy Family:Purchase of formula costs the average poor family (7,280.00/ month income) about P2,000.00National Economy (NEDA):Milk companies import S57.5 M (P3.1 B) worth of infant formulaSell to people 7x cost (WHO) – P21.5 B or S405 B)
80 Longer-term Health Outcomes: Maternal benefits Reduces risk of chronic illness in childhoodSome food allergiesType-1 insulin dependent diabetesLymphomaAsthmaObesity
81 Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly HOSPITAL INITIATIVESProvide 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.
82 Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly MOTHERS TO LEARNProper position and latch onNutritive sucking and swallowingMilk production and releaseFrequency and feeding cuesExpression of milk neededAssessment of the infant’s nutritional statusWhen to contact the clinician
83 Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-Friendly ADDITIONAL INSTRUCTIONSRefer 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.
84 Review QuestionsWhat 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.
85 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?
90 Types of Infant Formulas Special Formulas:Hydrolysates:Partial HydrolysatesComplete HydrolysatesGoats 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 a substitute for human milk in infants for whom breastfeeding is medically contraindicated;As supplement for infants who do not gain weight appropriately.
92 Nutrient Sources: < 2 Years of Age PRETERM FORMULA:Prescribed for premature until they have reached weeks of gestation or gained 2 kilograms.When given beyond recommended age may cause hypercalcemiaSpecial Features:Protein: Whey predominant formula at a level higher than breast milk & standard infant formula ( g/100ml.)
94 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 brandsExample: S-26, Enfalac, Nan, Similac, Mylac, Aptamil, Bonna, Nestogen
95 FOLLOW-UP FORMULALiquid part of the weaning diet for infants & children 12 mos years of age;Distribution of calories and nutrients is in between standard infant formula and whole cow’s milkProtein is higher with the ratio of 20% whey and 80% caseinExample: Promil, Nan 2, Gain, Milumil
96 COMPOSITION OF VARIOUS NUTRIENT SOURCES BM COW A PREM FF-UPEnergy kcal/100mlProtein G/100 mlWhey 60% 60% 20%Casein 40% 40% 80%Fat G/100 mlCHO G/100 mlCA 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 yearsProvides nutrient necessary as they undergo transition from infant to adult formulation.Protein is high ( 3 g/100 ml) from SodiumCasseinate and soya proteinCHO contains a blend of cornstarch and sucrose with very minimal lactose
99 Whole Cow’s MilkMaybe given as supplement to a balanced diet from 12 months above;No modification done to suit the needs of infants &childrenExample: Alaska, Bear Brand,
100 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.
101 For prophylaxis on high risk infants: Protein HydrolysatesPartially Hydrolyzed Formula:For prophylaxis on high risk infants:FH of atopy, asthma, food allergyPreparation: Nan-HAExtensively Hydrolyzed Formula:For treatment of food allergy during infancyPreparations: Pregomin (Milupa)Pregistimil (MJ)Alfare (Nestle)
103 Features of Complementary Foods Timely: Should be introduced by 6 monthsAdequate: Should provide sufficient energy, protein and micronutrientsSafe: Hygienically stored and prepared and fed using clean utensils NOT bottles nor teatProperly fed: Meal frequency, feeding methods should be suitable for age (with fingers, spoon and fork, cups and bowls, guided or self-feeding)
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.
107 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)
108 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.
109 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 !
110 Nursing Period : (1st 6 months of life) Addition of solid foods at this time breastmilk /milk consumption proportionally growth failureStuff et al, J pediatr,1990
111 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
112 Transitional Period (6-10 mos) Digestive, renal systems and taste are well 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;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;FAILURE of infants to go through this process feeding problems:dependence to MILK as source of nutrientpicky eaters / neophobicmalnutrition (obesity/wasting ,anemia)
115 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.
116 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, 2001Ingestion of the types of foods depend on the neuromuscular development of infants
117 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;
118 WHEN should CF be started? Signals that indicate readiness of infant for CF: Opens mouth if wants food; turns head away when notinterested anymore; Has good chewing & swallowing coordination; Consumes about 32 oz of milk 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; 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 Mix foods with ones baby likes, to enhance acceptability and nutrient contentCereals +BM: Enhanced acceptance of cereal during weaning!Mennella et al, Pediatr Res, 1997
121 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!
122 Art of Introducing Complementary Food Avoid adding salt and sugarWhen baby is able to chew at about months, gradually switch to finely chopped foodsDO NOT continue soft smooth foods for too longFeeding Frequency:6-8 months: meals a day9-11 months: meals; snacks> 12 months: meals: snacks
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; 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