1. Pediatric Nutrition The first two years Joan Brennan Clinical Dietitian

2. Early Recommendations Breastfeeding and Human Milk exclusive human milk feeding for first 4-6 months of life breastfeeding may continue until two years of age and beyond vitamin D supplementation of 400 IU to all human milk fed infants from birth until diet provides a source of vitamin D

3. Human Milk Feeding either by breast or as expressed human milk using manual expression or pump and given by bottle/tube various pumps available –manual vs. electric –electric most efficient and effective – best one is rental from pharmacy may take 7-10 days to establish breastfeeding frequent feedings will help establish milk supply number of wet diapers in a 24 hour period good indicator of whether baby is getting enough supplemental formula may obstruct establishment breastfeeding

4. Infant Formulas when an informed mother chooses not to breastfeed, commercial infant formulas are the most acceptable alternative to human milk nutrient content of iron-fortified infant formula is designed to meet the nutritional needs of healthy term infants until 12 months of age composition, processing, packaging, labeling are regulated under the Canadian Food and Drug Regulations

5. Infant Formula - Cow’s Milk Based designed for most preterm infants > 2000g and healthy term infants with no family history of allergy designed to resemble human milk in nutrient composition and digestibility available low in iron or as iron-fortified iron-fortified recommended until 9-12 months of age and consuming a variety of foods Eg Enfamil A+, Similac Advance

6. Infant Formula - Follow-up designed for infants in the second six months of life who are eating solid foods more appropriate quantities and forms of nutrients compared to cow’s milk –lower renal solute load –iron-fortified not superior to starter formulas eg Next Step, Follow-up

7. Infant Formula - Lactose-free, cow’s milk based suitable for infants with lactose intolerance –primary lactose intolerance due to congenital lactase deficiency (rare) –secondary due to acute gastroenteritis or chronic conditions glucose polymers from corn syrup are substituted for the lactose eg Enfalac Lactose-free

8. Infant Formula - Soy soy protein and glucose and/or sucrose have been substituted for milk protein and lactose; only available iron-fortified approximately 40 % of infants allergic to milk will also be allergic to soy not suitable for use in children with a family history of allergy suitable for infants with galactosemia or vegan lifestyle

9. Infant Formula - Protein Hydrolysate Two types available in Canada –less extensively hydrolyzed eg Good Start for use in infants at risk for atopy –extensively hydrolyzed (casein-based) eg Nutramigen for infants at high risk for allergy to cow’s milk or soy protein

10. Infant Formula - Specialized designed for infants with disorders of digestion, absorption and/or metabolism of protein, fat or carbohydrate expensive, less palatable, for use under supervision of a health care practitioner eg Pregestimil, Neocate, Alimentum, Portagen

11. Infant Formula - Distribution of Energy

12. Transition to Cow’s Milk pasteurized whole cow’s milk may be introduced between 9-12 months of age and continued throughout the second year of life partly skimmed milk (1% and 2%) is not routinely recommended in the first 2 years of life skim milk is inappropriate in the first 2 years of life

13. Transition to Solid Foods infants between 4 and 6 months of age are physiologically and developmentally ready for new foods, textures and modes of feeding infants intestinal track is relatively permeable and may predispose the infant to absorb foreign proteins resulting in an allergic reaction introduction of single foods makes it easier to identify allergen

14. Transition to Solid Foods single grains such as rice, barley and oat cereals offered first before mixed cereals little nutritional or developmental benefit associated with practice of adding infants cereals or other pureed foods to bottles containing formula introducing solids should support developmental readiness to progress from sucking to spoon feeding

15. Transition to Solid Foods critical learning period where texture should be introduced (6-10 months) or it becomes more difficult with increasing age important to encourage transition from pureed foods to finger foods and table foods by 1 year, a variety of foods should be consumed with less dependency on milk as major source of nutrition

16. Other Highlights iron-containing foods such as iron-fortified cereals are recommended as the first foods fruit juice intake should be limited to avoid interfering with the intake of nutrient containing foods and fluids soy (except soy formula), rice or other vegetarian beverages, whether or not they are fortified, are inappropriate alternatives to human milk, formula or pasteurized whole cow’s milk in the first two years

17. Other Highlights dietary fat restriction during the first 2 years of life is not recommended as it may compromise the intake of energy and EFA and affect growth and development to prevent infant botulism, honey should not be used in infants under 1 year to prevent nursing bottle syndrome, infants should not be fed using a “propped” bottle

18. Gastroenteritis mild to moderate dehydration may be managed with an oral electrolyte solution and early refeeding for infants who are breastfed, continue breastfeeding while supplementing fluid intake with an oral electrolyte solution there is no justification to recommend a lactose free formula for routine feeding after a bout of gastroenteritis

19. Constipation parents should be educated about the wide variation in normal bowel function in infants and toddlers no evidence to support infants on iron-fortified formula are more constipated often seen with transition to whole cow’s milk when done too quickly –transition with half formula/human milk feedings and half whole cow’s milk minimizes complications