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Breast Milk and Infant Formulas. Lori S. Brizee MS, RD, CSP Clinical Dietitian Children’s Hospital and Regional Medical Center. Human Milk and Infant Formulas:. Breast milk Standard Infant Formulas Premature Infant Formulas Specialty Infant Formulas Modular Additives.

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Breast Milk and Infant Formulas

Lori S. Brizee MS, RD, CSP

Clinical Dietitian

Children’s Hospital and Regional Medical Center

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Human Milk and Infant Formulas:

  • Breast milk

  • Standard Infant Formulas

  • Premature Infant Formulas

  • Specialty Infant Formulas

  • Modular Additives

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Breast Milk Characteristics

  • First choice feeding for MOST infants

  • Immunologic factors

    • Protective against diarrhea causing infections and otitis in infants

  • Trophic to GI tract

    • Well tolerated by infants with short bowel

  • Fatty acids important to brain/visual development

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Breast Milk vs StandardMilk Based Formulas

  • Energy: slightly higher

  • Protein: Lower, but higher quality (whey and casein)

  • Renal Solute load: Lower

  • Carbohydrate: Mainly lactose

  • Fats: Long chain; DHA/AA (lipases increase absorption)

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Common Challenges with Breast Feeding

  • Baby sided problems

    • Illness preventing/interfering with early feeding

    • Anatomic malformations

    • Sleepy baby

    • Thrush

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Common Challenges with Breast Feeding Sleepy Baby

  • Sleep cycles

    • REM sleep-----deep sleep (15 min +/-) ----wake (quiet alert)

  • If cannot wake, in deep sleep, try again in 15+/- minutes

  • Watch for hunger cues e.g., sucking on hands

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Common Challenges with Breast Feeding Sleepy Baby

  • Waking techniques

    • Hold by armpits and dangle

    • Put feet on hard surface

    • Spin around

    • Last resort: stroke palate with finger until sucking, then take finger out and put nipple in.

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Common Challenges with Breast Feeding

  • Mom sided problems

    • Low milk supply

      • Frequent feeding, pump after feeding

      • Medications: Reglan, Domperidone Fenugreek

    • Sore Nipples

    • Clogged ducts

    • Mastitis

    • Yeast Infection

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Breast Feeding: Is baby getting enough?

  • Regain birthweight by 1 week

  • Newborn to 2 months gain > 1 ounce per day

  • Newborn to 4-6 weeks: 2-10 bowel movements per day

    • Bowel movements are better clue than wet diapers.

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Formula Brands

  • Ross

    • Similac/Isomil/Alimentum

  • Mead Johnson

    • Enfamil/Prosobee/Enfacare

  • Nestle

    • Good Start

  • Wyeth

    • Generic in USA; Gold Brands; SMA

  • SHS

    • NeoCate, DuoCal

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Milk Based Formulas

  • Standard 0-12 months

    • Similac with/without iron

    • Enfamil with

    • Good Start Essentials/Good Start Supreme

    • Wyeth Generic

  • Standard 0-12 mos with DHA/ARA

    • Similac Advance with iron

    • Enfamil Lipil with/without iron

    • Good Start Supreme DHA/ARA

    • Wyeth formulas

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Milk Based Formulas

  • Older Infant and toddler formulas

    • Similac 2 Advance (9-24 mos)

    • Enfamil Next Step Lipil (9-24 mos)

    • Good Start 2 Essentials (4 to24 mos)

    • Wyeth Generic “follow on formulas”

      • Increased Calcium

      • Increased protein (Good Start and Enfamil)

      • Intended to compliment nutrients in solid milk

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Milk Based FormulasCharacteristics

  • Blend of Whey and Casein Proteins (8.2-9.6 % total calories)

  • Carbohydrate: lactose

  • Fats: long chain

  • Meet needs of healthy infant

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Soy Formulas

  • Isomil/Isomil DF /Isomil Advance/Isomil Advance 2

  • Prosobee/Prosobee Lipil/Next Step Prosobee

  • Good Start Essentials Soy/Good Start 2 Essentials Soy

  • Wyeth All iron fortified

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Soy FormulasCharacteristics compared to Milk Based

  • Higher protein (lower quality)

  • Higher sodium, calcium, and phosphorus

  • Carbohydrate: Corn syrup solids, sucrose, and/or maltodextrin; lactose free

  • Fats: Long chain

  • Meet needs of healthy infants

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Protein Hydrolysate Formulas

  • Alimentum Advance

  • Pregestimil/Pregestimil Lipil

  • Nutramigen Lipil

    • Protein Casein hyrolysate + free AA’s

    • Fat (Alimentum and Pregestimil) Medium chain + Long chain triglycerides; (Nutramigen) Long chain triglycerides

    • Carbohydrate: Lactose free

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Elemental Infant Formula

  • NeoCate (SHS)

    • Protein: Free Amino Acids

    • Fat: Long chain

    • Carbohydrate: Lactose Free

    • Indications for use: Food Allergy or intolerance to peptides or whole protein

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Premature Infant Breast Milk Additives and Formulas

  • Enfamil Human Milk Fortifier

  • Similac Human Milk Fortifier

    • Powdered breast milk additives

  • Similac Natural Care Advance

    • Liquid breast milk additive

  • Similac Special Care Advance

  • Enfamil Premature +/- Lipil

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Premature FormulasGeneral Characteristics compared to Standard

  • Increased Protein,Vitamins & Minerals

  • For infants born at <1.5kg

    • up to 2000-2500gm

  • Feeding of infants > 2500 gm

    • risk of vitamin toxicities

  • Premature formulas vary in nutrient content

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“Post” Premature Formulas

  • NeoSure Advance

  • EnfaCare Lipil

    • Standard Dilution: 22 kcal/oz

    • Protein: between standard and Premature

    • Vitamins: Higher than standard,significantly lower than Premature

    • Calcium and Phosphorus: between standard and Premature

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Other Specialty Formulas

  • Portagen (Mead Johnson)

    • 85% fat MCT, 15% fat Corn oil

    • Used for infants with chylothorax

  • Similac PM 60/40(Ross)

    • Low in Ca, P, K+ and NA; 2:1 Ca:P ratio

    • Used for infants with Renal Failure

  • Formulas for Metabolic Disorders

    • Several condition specific products by Ross and Mead Johnson

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Products to Augment Energy and Protein in Breast Milk

  • Human Milk Fortifiers

    • For Premature infants less than 2000-2500gm only

  • Standard Infant Formula Powder

    • 1 teaspoon to 100mL = 24kcal/oz+/-

  • Do Not Add CHO or Fat w/o protein: Final product is TOO LOW in protein

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Finding Up to Date Information

  • Similac products

  • Enfamil products

  • Nestle products

  • generic products

    • lower cost formulas made by Wyeth


    Neocate formulas

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When Baby is Not Growing

  • Normal Weight gain and linear growth

    • Guo et al J Pediatrics 1991

  • Assess Feeding

    • Number feedings/day

    • Feeding environment

    • BF: baby “empties” breasts each feeding

    • Formula: volume per feeding

  • Vomiting? Diarrhea? Medical issues that increase needs/decrease intake?

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When Baby is Not Growing

  • Increase number of feedings/day

  • If baby <6 months d/c solids, increase breast milk or formula

  • Monitor weight weekly

  • If no improvement in 1 week consider increasing caloric concentration of breast milk or formula to 24 kcal/oz.

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When Baby is Not Growing

  • In cases of increased need due to medical condition or fluid limit, may need to go higher than 24 kcal/oz

  • In all cases monitor closely watch for

    • Signs of dehydration (baby may take less volume of concentrated feed)

    • Vomiting

    • Diarrhea

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Increasing Caloric Density of Formula

  • Concentrate formula (decrease water added):

    • Calculate kcals desired (e.g. 30 oz of 24 kcal/oz formula = 720kcal)

    • Divide kcals by kcal/oz of liquid or scoop of powder (e.g. 720 kcal divided by 40 kcal/oz liquid conc. = 18 oz liquid conc. Formula).

    • Add water to make final volume (12 oz water + 18 oz liquid conc. Formula = 30 oz 24kcal/oz formula)

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Using Modulars to Increase Calories

  • Example: Making 30 oz of 30 kcal per oz formula (30oz X 30kcal/oz = 900 kcal)

    • Start with 24 kcal/oz formula:

      • 24kcal/oz X 30oz = 720 kcal

    • 900kcal - 720 kcal = 180 kcal from modulars

    • Use Polycose and Micro lipid to make up additional kcals (approximately 90 kcal of each)

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Using Modulars to Increase Calories continued

  • Polycose 23 kcal/TBSP

  • 90 kcal /23kcal/TBSP =3.9TBSP (use 4 TBSP X 23 kcal = 92 kcal; still need 88 kcal)

  • Microlipid 4.5 kcal/mL

  • 88 kcal/4.5 kcal/mL =19.55 mL (use 20 mL X 4.5 kcal = 90 kcal)

  • Final calculation:720kcal + 92 kcal + 90 kcal = 902 kcal/30oz =30.07 kcal/oz

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Know What You Are Feeding

  • Caloric density, protein, fat and carbohydrate vitamin and mineral content.

  • Osmolality: goal is for <400mOsm/kg H2O; can slowly go up to 700

    • Meds/modulars increase osmolality

  • Renal Solute Load: goal is for less than 300mOsm/l (all infant and pediatric meet this recommendation when concentrated up to 30 kcal/oz.)

    • Addition of protein will increase Renal Solute Load