1. Infant Formula Products

3. The miracle of breastfeeding!

4. Adaptation of milk composition to course of lactation

5. Variation of milk composition during a feed

6. Adaptation of milk composition to climate

7. Breast milk − tailor-made for girls or boys ?

9. Stages of Feeding

10. Infant Formula Products: Introduction Infant physiology and growth Early infancy: -Liquid nutrition only -Frequent feeding: limited stomach capacity: 20-90 ml at birth, 90-150 ml at 1 month -CHO digestion: lactase, sucrase, maltase, isomaltase, glycoamylase are mature. -Lactase activity may be immature in premature infants. -Pancreatic amylase activity and glucose transport are low in both full term and premature infants -Low lipase concentration, bile salt synthesis is low -Protein digestion and absorption are mature

12. Growth -Average birth weight: 3.5 Kg -6-10% weight loss after birth -Weight gain: 20-25gm daily till 4th month, 12gm/day for the coming 8 months -Double wt: 4 months, triple: at 1 year -Changes in body composition occurs as well: at birth, total body water is 70% and decreases to 60% at 1 year. -Adipose tissue increases Normal values are expressed as percentiles: see growth charts

14. Nutritional standards Acceptable growth achieved through adequate intake of energy, protein, carbohydrates, minerals and vitamins. The recommended daily allowances (RDA) are designed to meet the needs of most healthy infants Energy requirements vary with age. Total energy requirement is a combination of basal energy needs (energy needed for food digestion) and activity and growth. The infants' energy requirements are high in relation to body size but declines over time.

15. Components of a healthy infant diet 1.Fluid: -Water intake in the first 6 months is derived from breast milk or formula -From 6 months and above when solid food is introduced, water intake remains high, because most children's food contain 60-70% water. -100ml/kg per day for the first 10 kg + 50ml/kg for each additional kg.

16. 1.CHO: -40-50% of total calories. -Lactose is the primary source. -Adequate fiber intake is favorable to ensure regular stool frequency. -premature infants are relatively lactase deficient and are prone to lactose intolerance -Lactose intolerance: lactase deficiency Congenital lactase deficiency is rare Secondary lactase deficiency: in some cases of gastroenteritis

17. 3.Protein and amino acids: -2.2gm/kg/day (birth-6 months), 1.6gm/kg/day (6-12 months) Composition -Essential a.a.: isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, valine -Conditionally essential a.a.:cystein, taurine, tyrosine, histidine

18. 4. Fat and essential fatty acids -Most dense source of calories in the diet -Supplies 40-50% of the energy intake of infants -Linoliec acid -Linoliec acid deficiency: increased metabolic rate, hair loss, dry flaky skin and impaired wound healing -Manifestations of essential fatty acids deficiency are generally delayed however rapid onset may occur in preterm infants. -Recently, docosahexanoic acid (DHA) and arachidonic acid (ARA) have been added to formulas

19. 5. Micronutrients - Vitamins Infant formulas are supplemented with adequate amounts of vitamins and minerals to meet the needs of most term and premature infants -Biotin, choline and Inositol -Biotin is needed for efficient enzyme systems and considered as an essential vitamin. - Choline and inositol are both components of cell membranes phospholipids and lipoproteins.

20. Minerals Calcium and Phosphorus Iron Zinc, copper manganese

21. Factors controlling drug transfer into breast milk 1.Buffer systems: Milk is buffered by citrate and phosphate, with a limited buffer capacity Milk pH tends to be lower than that in plasma: 7.0-7.25 the pH difference between milk and plasma has a substantial effect on the M/P ratio.

22. 2. Proteins: The total protein concentration in human milk is approximately 0.9 g/dl. 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. Drug binding: mainly, a-lactalbumin, lactoferrin (major), and lactalbumin (major). Drugs can bind these proteins and get trapped in the milk.

23. whey The fluid portion of milk that separates from curd.

25. 3. Lipids Human milk contains approximately 2.1–3.1% fat. The major components (98%) of human milk lipids are triglycerides 4. Variation in milk composition Milk composition is not constant. Affected by the timing within an individual feeding and the duration of nursing postpartum Within an individual feeding…… Colostrum: secreted from shortly after birth until approximately 5 days postpartum. High in protein content and low in lactose and fat. After 2 weeks:fat levels approximately double, while protein concentrations fall by a factor of four, to reach levels in mature milk. Changes in milk composition can affect drug concentrations in milk.

26. Factors Affecting Excretion in Breast Milk Two other factors are molecular weight& protein binding Eg, heparin (MW~ 12,000) is too large of a molecule to cross a lipid barrier &, hence, is not excreted in milk Warfarin is a weak acid (pKa, 5.05), highly ionized (>99%) & 97% bound to plasma protein. This prevents the passage of warfarin into milk in amounts that could pharmacologically affect the infant

27. Breastfeeding and Drugs

28. Cow’s Milk is NOT SUITABLE To Humans

29. Contents of various milks

30. Human milk vs. whole cow milk Both contain more than 200 ingredients in the fat and water soluble fractions. 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

31. Proteins: cow milk 3X minerals and protein, composition is different Whey: casein ratio: Human milk (60:40), cow milk (20:80) Whey protein in cow milk is alpha lactalbumin, beta lacatoglobulin, lactoferrin, and serum albumin. Lysozyme and immunoglubulins A, G, M. Human milk contains all these proteins except beta-lactoglobulin. Whey protein is highly soluble, casein is relatively insoluble and forms curd. The large amount of curd may cause GI distress a.a. content is inappropriate to the immature enzyme systems

32. Homework

34. Fat: both have similar total fat content Human milk contains 3-4.5% fat that consists of triglycerides (98-99% of total milk fat), phospholipids, and cholesterol. Cholesterol level is different (higher in human milk The fat composition of human milk changes during lactation,: triglycerides concentration rises and phospholipid and cholesterol concentration decrease during the transition from colostrum to mature milk. Fat in human milk is different from cow milk in 2 ways: 1.TG types: cow milk, short and long chain FA, in human milk medium chain 2.Degree of saturation: human milk:PUFA, cow milk: butter fat -LCPUFA (ARA + DHA) -Lipoprotein lipase

35. Medium chain fatty acids: 1.a well–utilized fat in situations where conventional long chain dietary fats are malabsorbed. 2.medium chain triglycerides enhance the absorption of long chain triglycerides. 3.do not require emulsification with bile, 4.are more rapidly and more easily hydrolyzed than longer chain fats, and 5.are directly absorbed into the portal system

36. 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 Calcium to phosphorus ratio human milk is 2:1, cow milk is 1.3:1 in and formula milk is 1.4:1 (phosphorus load) Iron, Zinc Na, K and Cl

37. Types, uses and selection of commercial infant formulas

38. Reduced fat cow milk Reduced fat milks as skimmed milk (0.1% fat) and 2% fat milk have been used to prevent obesity and atherosclerosis. It is not recommended for children below 12 months of age, not even recommended for young children. Inadequacy of essential fatty acids is a problem. And there is an imbalance in the source of calories.

39. Whole cow milk The age at which it is appropriate to introduce whole cow milk into an infant's diet is controversial. Because the bioavailability of iron is low, cow milk has been associated with iron deficiency anemia. That's why it is recommended if an infant does not get human milk, that they get iron fortified formula during the first year of life.

40. Evaporated milk A sterile convenient source of cow milk that has standardized concentrations of protein, fat and carbohydrates. When ingested, evaporated milk produces smaller and softer curds than boiled whole milk. Vitamin D is typically added during manufacture, but evaporated milk formula fail to meet recommendations of folic acid, vitamin E and essential fatty acids.

42. The need for vitamin and mineral supplements Breast fed-full term infants: 1. Vitamin D might be needed as a supplement if the mothers' diet is not balanced and contains inadequate amounts of vitamin D. 2. Iron is well absorbed from breast milk, however after 4-6 months the iron stores become depleted and iron deficiency anemia might develop. So an additional iron supplement is needed.

43. Formula fed full term infants Full term infants who consume adequate amounts of an iron fortified formula do not need vitamin and mineral supplement Vitamins and minerals supplement is not needed after 6 months of age when the infant receive a diet of formula, mixed feedings and increased amount of table food. A multivitamin with minerals may be needed if the infant is at a nutritional risk. The need for vitamin and mineral supplements

44. Preterm infants Preterm infants, either breast fed or formula fed, need vitamin and mineral supplementation. Their nutrient needs are proportionately greater than those of full term infants (WHY?) A multivitamin supplement should include vitamin E, folic acid, calcium and phosphorus, vitamin D). The need for vitamin and mineral supplements

45. COW’S MILK ALLERGY CMA

46. Infants with CMA have a negative reaction to the proteins in the cow’s milk, which is mediated by the immune system. CMA is estimated to occur in 0.3% - 7.5% of all infants, and tends to run in families. CMA can cause a wide range of symptoms from a mild nasal discharge to life-threatening anaphylactic shock.

47. Cont., Cow’s Milk Allergy (CMA) GI symptoms such as vomiting, diarrhea, and abdominal pain are most common. CMA also may cause skin problems, respiratory symptoms and behavioral disturbances as colic and sleeplessness. In infants who are at risk for CMA, breast feeding helps to prevent allergy. When CMA is suspected, a SOY Formula is usually recommended as a first line management.

48. GALACTOSEMIA It is a metabolic disorder caused by a deficiency in the activity of the enzyme galactose-1-phosphate uridyl transferase. 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.

49. Types of commercial infant formulas 1.Milk based formulas: nonfat cow milk, vegetable oils and lactose are added. Supplemented with vitamins and minerals, iron and zinc 2.Milk based formulas with added whey protein When whey protein is added to nonfat cow milk, the ratio of whey protein to casein can be altered to approximate human milk. 3.Therapeutic formulas a. Soy protein formula b. Casein hydrolysate based formulas c. Amino acid based formulas d. Whey hydrolysate formula e. Low birhtweight and preterm infants f. Antiregurgitation formulas

50. I. Soy protein formula (isomil) Used for infants with milk allergy, lactose intolerance, galactosemia or those of vegetarian parents Contain soy protein instead of animal protein. Vegetable oils provide fat content and corn syrup and or sucrose supply the carbohydrate Additional minerals and vitamins are added. Taurine, carnitine (low concentration in food from plant origin) Soy formula is not suitable for feeding preterm and LBW infants. Additional calcium and phosphorus is needed

52. II. Casein hydrolysate based formulas (Pregestimil ) These are effective in nutritional management of infants with a variety of severe GI abnormalities: Severe diarrhea, severe food allergy, sensitivity to intact protein, disaccharidase deficiency, protein malabsorption and so on.

53. II. Casein hydrolysate based formulas (Pregestimil ) These products use enzymatic hydrolysates of casein as the protein source They contain non-antigenic proteins with low molecular weight Casein hydrolysate formulas are fortified with three amino acids: L cysteine, L tyrosine and L tryptophan, because the concentration of thee amino acids are reduced during treatment of the protein.

54. II. Casein hydrolysate based formulas (Pregestimil ) The CHO source is usually corn syrup, corn starch, dextrose Glucose polymers in corn syrup, modified corn starch are useful for children with malabsorption disorders who are frequently intolerant to lactose, sucrose and glucose. Glucose polymers are a low osmolar form of CHO and contribute little to the osmolar load. This is an advantage on infants with intestinal disorders Fat source is usually medium chain triglycerides, 25% soy oil, 10% corn oil, and 10% high oleic safflower or sunflower oil.

55. III. Amino acid based formulas These are suitable for infants who are intolerant to casein hydrolysate and require amino acid containing formula. Fat is supplied from medium chain and long chain fatty acids. The CHO source are maltodextrin, sucrose and corn syrup solids

56. IV. Whey hydrolysate formula Enzymatic hydrolysis of whey protein. GI intolerance to cow milk but not allergic to it. V. Low birhtweight and preterm infants human milk is insufficient in proteins, phosphorus and calcium. The goal is to achieve postnatal growth that approximated the inutero condition

57. LBW Infants 1.Do not have a fully active sucking reflex, 2.limited capacity to consume high volumes of formula, 3.Fat absorption in the intestine is less efficient, as bile salts concentrations are reduced. 4.LBW infant’s inability to properly absorb, digest, and achieve metabolism of food has severe implications. 5.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.

58. 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.

59. V. Low birth-weight and preterm infants 1.whey protein is predominant 2.Mixture of CHO source is present, lactose, corn syrup solids, and glucose polymers, 3.fat mixture (long, medium and short TG) 4.These infants are specially susceptible to iron deficiency aneamia (WHY?) Therefore iron supplement is needed 5.Fortified with extra Ca, Mg, P, and LCPUFA

60. VI. Antiregurgitation formulas = “Prethickenend milk-based formulas”

61. REGURGITATION 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 15-30% of infants suffer from GER. Baby can’t thrive on formula that won’t stay down

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

63. REFLUX & REGURGITATION “Young infants are prone to GER due to immaturity of the esophageal sphincter which controls the passage of food into the stomach.” (A problem disappears by the age of 18-months ) Bohane TD,Mitchell JD, Gastro-esophageal reflux in infants and children. Mod Med Mid East 12:32-43,1995

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

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

66. TREATMENT  ESPGAN consider the use of thickened feeds as “ A safe approach with good clinical results, since in most infants the observed symptoms of regurgitation and emesis decreases”

67. Prethickened milk-based Formulas An iron fortified formula that contains: 1.Carbohydrate blend of lactose (57%), rice starch (30%) and maltodextrin (13%) 2.High amylopectin rice starch for thickening Before ingestion: the AR formula has a viscosity (60 cps) 10 times that of ready-to-use standard formula After ingestion (at low pH)  viscosity increases dramatically (532 cps)- equal to formula plus cereal combination

68. Potential Problems with infant formulas Diarrhea Tooth decay

69. Diarrhea Infants particularly prone to dehydration Fluid depletion by vomiting or diarrhea may quickly (within 24 hours) produce severe dehydration with fluid and electrolyte imbalances, shock and possible death Potential cause of diarrhea and vomiting is the improper dilution of a concentrated liquid or powdered formula

70. Diarrhea- Patient Counseling Frequency of stool Duration of diarrhea Preparation method of formula If the infant is clinically ill (fever, lethargy, anorexia, irritability, dry mucous membranes, decreased urine output, or weight loss)  Doctor

71. Diarrhea- Patient Counseling Mild diarrhea may resolve without medical measures, but the infant should be observed closely for signs of dehydration Temporarily discontinuing usual dietary intake- unnecessary except 4-6 hr of ORT ORT may be used cautiously for short term It should not replace formula or human milk intake

72. Lactose free diet can be considered for severe diarrhea, however, a full strength lactose containing formula can be used in most Advice parents to seek medical advice if sudden increase in stool output occurs with resumption of feeding

73. Tooth decay 1.In children who are bottle-fed beyond the typical weaning period 2.Who sleep with their bottles after 1 year of age 3.Sipping on a bottle frequently during the day Caries in children younger than 2 y/o May involve: maxillary incisors, molars and canines

75. Preventing tooth-decay: 1.Wash their mouth 2.Avoid bottle while asleep 3.Substituting plain water for carbohydrate containing formula 4.Ensuring adequate fluoride intake 5.Weaning 10-12 months of age 6.Use special type of teats