Formulas, Breastfeeding, and other juicy stuff

1. Formulas, Breastfeeding, and other juicy stuff

2. Milk: The Principal Source of Nutrition for Infants • Consume 120 to 150 cc/kg/day • Human and Most Standard infant formulas: 67kcal/100cc • Protein Needs • Term: 2 to 3 g/kg per day • Preterm: 3.5 to 4.0 g/kg per day • Energy Sources • Primary: Fat Calories: (3.8gm) 34 kcal/100 mL • Carbohydrates: lactose: (7 g) 28 kcal/100 mL • Protein (minimal): (1.3 g) 5 kcal/100 mL

3. Energy Requirements for the Newborn • Basic Metabolic Function (basal metabolic rate): 50-60 kcal/kg/day • Temperature regulation: 0-10 kcal/kg/day • Growth of new tissue: 10-15 kcal/kg/day • Storage of Energy (fat): 20-30 kcal/kg/day • Energy Excreted (poo,pee): 10-15 kcal/kg/day • TOTAL: 90-140 kcal/kg/day • Increased for <2500g

4. Breastfeeding • Human Milk: naturally formulated nutrition that is specific for the human neonate • AAP recommends breastfeeding until 1 year of age • rate in the United States has increased • 33% in 1974 to 70% in 2000 • Breastfeeding for 6 months reduces the incidence of food allergies • Studies suggest potential for enhanced maturation of the visual system and improved cognitive development in breastfed infants • Human milk contains docosahexanoic acid (DHEA), an omega-3 fatty acid that may play a role in human brain and eye development

5. More on Breastfeeding • 10-15 min each breast • PROlactin = PROduction • Colostrum: low volume, Ab rich • Poor feeding pattern in the first few days won’t impact further success so don’t switch to bottle

6. Those less likely to breastfeed • Single women • women who have lower educational levels • African-American women • women who work outside the home may abandon breastfeeding if they are in an unsupportive work environment

7. Immune Benefits of Breastfeeding • maternal antibodies against specific pathogens (secretory IgA) • IgM is noted in significant quantity only in the colostrum • bactericidal compounds • Lactoferrin: iron-binding protein, inhibits growth of some bacteria by competing for available iron. • high quantities in human milk, but in very low amounts in bovine milk • Lysozyme-enzyme that has bacteriolytic properties • at much greater quantities than bovine milk • WBCs • Mucin • incidence of both respiratory and GI infections is decreased in the first postnatal year among infants who predominantly or exclusively are breastfed

8. Risks of Breastfeeding • Can see some deficiencies • Iron • Vitamin D • Vitamin B12 • These are present in adequate amounts in commercially available formulas • Note: breastmilk is an incomplete source of vitamin E • Preemies need 10-25 IUs to decrease RBC hemolysis

9. Iron and Breastfeeding • Term newborns have sufficient iron stores to sustain them for 3 to 4 months • even when the mother has anemia • So they don’t need supplements until 4 mos of age • Human milk contains lower quantities of iron but bioavailability is greater • Preterm: miss out on iron stores in the last trimester, may require iron supplementation if they are taking full enteral feedings as early as 2 to 4 weeks of age • Iron supplementation not required at birth except in congenital anemia (rare) • Iron needed for hematopoiesis and brain growth and function • 6 Months: start iron containing foods • Eg Infant cereals • If still only breastfeeding: Iron 1mg/kg/day

10. Vitamin D and Breastfeeding • human milk may contain lower amounts of vitamin D than infant formula • cases of rickets and hypocalcemia have been reported in breastfed infants • especially in African-Americans • exact incidence in breastfed babies is not known, but it is far less than 25% • AAP Committee on Nutrition recommends a supplement of 200 IU/d of vitamin D for breastfed infants.

11. Vitamin B-12 and Breastfeeding • If mom is a strict vegetarian, her milk will have low B-12 • At risk for anemia and neurologic sequelae

12. Other Differences in Composition • Protein • Human Milk: Whey-predominant protein • Lower concentration of protein than formulas-by 50% • Cow Milk Infant Formulas:Casein-predominant protein • Up to 80% versus the 30% in human milk • Electrolyes • Formula has higher concentrations of sodium, calcium, phosphorus

13. Formula Options • Protein Sources • cow milk-based • soy-based • Casein hydrolysate • modified amino acid-based • AVOID LOW IRON FORMULAS! • Some people think it makes infants collicky or constipated but this is physiologically inappropriate • if prepared properly, provide adequate amounts of calories, fat, protein, carbohydrate, minerals, and vitamins • Special Conditions • Galactosemia: soy formula (no lactoseno galactose) • Could use a protein hydrosylate or elemental, but they are more expensive and less readily available • Lactose: human milk, cow-milk formulas, most whey hydrosylate formulas • modified amino acid compositions for specific metabolic illnesses: • phenylketonuria • hereditary tyrosinemia • homocystinuria • maple syrup urine disease • urea cycle disorders • organic acidemias

14. Cow’s Milk-Based Formulas • Store brands, Enfamil (lipil, AR), Good Start, Similac (advance, lactose free) • Soy Based Formulas • Store brand, Good Start, Isomil, ProSobee • Amino Acid Formulas • EleCare, Neocate • Casein Hydrolysate Formulas • Alimentum, Nutramigen, Pregestimil • Preemie Formulas • Enfamil Premature, Similac Special Care • Discharge Formulas • Enfacare, Neosure

15. Soy Formulas • Can’t use for cow milk protein allergy—a lot of cross reactivity • Don’t use it for <1800gm babies • Has increased aluminum • Nutritionally the same as cow milk formulas, same fat source • May be beneficial in post-diarrheal transient lactate deficiency

16. Formula Feeding • Should mimick breastfeeding • 1st week: 2-3 oz q 2-3 hrs • 1st couple months: 2-4oz q 2-4 hrs • Don’t go >5hrs in a neonate • They should also get Vit D if getting less than 500ml of formula per day

17. Preemie Formulas • more protein • less carbs • same fat • different electrolyte concentration—more Ca • MCTs • Don’t require bile emulsification, helps them absorb total dietary lipids • Don’t provide essential fatty acids such as linoleic and linolenic acids but the formulas (and breast milk) have this

18. Food Protein Induced Enterocolitis • Si/Sx: recurring painless hematochezia, emesis, and normal abdominal exam • non-IgE-mediated food intolerance that typically affects infants in the first 3 postnatal months • Allergy skin testing identifies IgE-mediated reactions, so it is unhelpful in this case • Most associated with cow milk formula, but if breastfed may be exposed to a sufficient amount of cow milk protein from maternal ingestion to develop the condition • susceptibility of GI barrier to food proteins is the suspected mechanism for immunologic intolerance • milk and soy protein are the most commonly implicated foods in FPIES, eggs, wheat, rice, oats, peanuts, nuts, turkey, and fish also have been reported

19. Cow’s Milk Protein Allergy • Initial Management: eliminate the suspected protein • resolves within 6 to 24 months if the offending food is avoided • May recur with re-introduction of cow milk • Look for hematochezia, emesis, or diarrhea • causes a transient increase in absolute PMNs to at least 3,500 cells/mm³ at 4 to 6 hours • If formula fed: • casein hydrolysated or an amino acid-based formula • Most tolerate a whey or casein extensively hydrolyzed formula • Rarely need a more elemental formula • Avoid partially hydrolyzed formulas • contain 1,000 to 100,000 times higher concentrations of milk protein than extensively hydrolyzed formulas • Changing to a soy formula not recommended because 30% to 50% of affected infants have continued symptoms with soy formulas • infants and children who have IgE-mediated milk food allergies often can switch successfully to a soy formula • If breast fed: • Eliminate milk protein ingestion in mothers or removal of milk protein formula results in • resolution of hematochezia in 2 to 3 days, although complete resolution may take several weeks

20. Solids • introduction recommended between 4 and 6 months of age • May puree fresh foods and freeze • Don’t use canned: sugar and salt • risks of introducing early • potential choking in an infant who has an immature swallow and the • reduction of human milk intake • in some countries in the developing world, solid foods may be contaminated and a source of infection • One benefit of introducing solids such as iron-fortified cereal is a potential reduction in iron deficiency • NO benefit to introducing juices before 6 months • if juice introduced too early, carbohydrate load may result in diarrhea