1
Fifth stage
Pediatric
Lec-2
.د
رواء
1/1/2014
Infant feeding-2
THE objectives
1.To know about technique of breast feeding
2.To know about comparison between human and cow milk
3.Formula milk &types
Technique of breast feeding
At time of feeding the baby should be hungry ,dry, in worm temperature and held in the lap
of the mother in semi sitting position ,the mother should be comfortable and put the nipple
& most of the areola in the mouth of the baby supporting the breast by her hand to prevent
nasal obstruction & for proper latch on ,some infants empty the breast in 5 minutes other
in up to 10-20 minutes & to put the baby on the other breast to ensure efficient milk
production.
Burping procedure (eructation)
At the end of nursing the baby should be held erect over the mother shoulder or on her lap
on his abdomen with gentle rubbing or patting the bag to assist in expelling swallowed air
,it is necessary after each feeding for 5-10 minutes before putting the baby in his bed to
prevent development of gases & colic .
Sufficiency of breast feeding
1.If the infant is satisfied after each feeding he will sleep (2-4 )hours .
2.He will gain weight about 20- 30 gm /day
3.he will have 6-8 soaked napkins(good urine out put )
4.The mother will have the let down reflex (milk ejection reflex) which occur either by
sucking or psychological stimuli to the mother by hearing the crying ,thinking about
her baby she will have ejection of milk from the breast(hormonal stimuli) ) .
The composition of breast milk
Colostrum :
Is the secretion of breast during the latter part of pregnancy &for 2-4 days after
delivery ,it has deep lemon yellow colour as it contain several times the protein of
mature breast milk but less fat & more minerals,it has important immunological
factors(antibodies ) & maturational properties ,its reaction is alkaline and its specific
gravity is (1.040-1.060) ,while mature breast milk sp.gr is 1.030 ,the total amount of
colostrum secreted daily is (10-40) ml
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After the first few days of lactation colostrum is replaced by secretion of transitional
form of milk that assume gradually the characteristics of mature breast milk by the
3rd-4th weeks .
Comparison between breast milk &cow milk
1.Both contain equal amounts of water.
2.The energy contents are equal approximately 20Kcal/kg/oz ,as 1oz=30 ml of milk
3.Protein :cow milk contains higher protein approximately 3 folds,its contents of
casein is about 6folds , while the human milk protein is mainly whey protein
(lactalbumin & lactglobulin ) but 30% casein .
4.Carbohydates :human milk 7% which is lactose while cow milk is 4.5% .
5.Fat :contents are almost equal but there is qualitative differences ,as both
containing triglycerides (olein ,palmitin &stearin ) but human milk contain twice of the
more absorbable olein .
6.Minerals :cow milk contains much more of all the minerals except iron &copper
&although breast milk iron is low but better absorbed (bioavailable) and the infant
will depend on the iron stores in the first 4-6 months .
7.Vitamines :both has large amount of vit.A, cow milk has low vit.C & D ,also human
milk has low vit D and depends largely on the maternal nutrition and sun exposure
.both milk contains adequate amount of vit.B complex so breast fed infants should
receive the daily requirements of vit.D which is 400 I.U / day .
Exclusive breast feeding
Means the complete dependence of the baby on breast milk with out any water or
other fluids or formula .
The stool of the breast fed infant is unformed yellow and seedy and is more frequent
than formula fed infants and last 4-6 weeks ,few weeks later it become less frequent
as every few days will pass a motion .
Infant condition &Breast feeding
Infants conditions in which breast milk is not appropriate and special formula is
required
1.Galactosemia :galactose –free formula(lactose free formula)
2.Maple syrup urine disease :formula free of leucine ,isoleucine &valine
3.Phenylketonurea :phenylalanine –free formula
Infants conditions in which breast milk remains the best feeding option :
1.Very low birth weight (<1,500 g) Formula may be required in addition to breast milk
for a limited period
2.Preterm birth (<32 weeks) Formula may be required in addition to breast milk for a
limited period
3.Risk of hypoglycaemia
Impaired metabolic adaptation or increased glucose demand may occur in infants who
are unwell, preterm, small for gestational age, experience significant intrapartum
hypoxic/ ischaemic stress, or whose mothers have diabetes
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Maternal conditions and breastfeeding
Maternal conditions that may justify permanent avoidance of breastfeeding
1.Human immunodeficiency virus (HIV)
2.Active tuberculosis :
Active pulmonary tuberculosis that has not yet been treated is a contraindication to
breastfeeding. Any close
contact with the infant, including breastfeeding, is not permitted, to prevent
respiratory transmission (regardless
of mode of infant feeding) until the mother has finished 2 weeks of treatment. the
infant is usually prescribed
prophylactic treatment. lactation is initiated and maintained by expressing breast milk
until contact is approved.
3.Breast cancer treatment
Maternal conditions that may justify temporary avoidance of breastfeeding
1.Severe illness (e.g. sepsis)
2.Herpes simplex virus type 1 (HSV-1)
3.Recently acquired syphilis
4.Maternal medications :
1-Sedating psychotherapeutic drugs, antiepileptic drugs and opioids and their
combinations may cause side effects
2-Radioactive iodine-131
3-Cytotoxic chemotherapy requires that a mother stops breastfeeding during therapy
Protective effect of human milk
Acute disorders:
o Diarrhea
o Otitis media
o Urinary tract infection
o Necrotizing enterocoliti
o Septicemia
o Infant botulism
Chronic disorders :
o Insulin-dependent diabetes mellitus
o Celiac disease
o Crohn's disease
o Childhood cancer as lymphoma and
o Leukemia
o Recurrent otitis media
o Allergy
o Obesity and overweight
o Hospitalizations
o Infant mortality
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Expressing breast milk
Indications for mothers to express breast milk:
the most common reason for expressing breast milk was to manage
difficulties in breastfeeding, usually due to distended breasts or mastitis
other reasons given by mothers include:
o the infant is sick or preterm
o mother and infant will be temporarily separated
o the mother is returning to her work
o the milk supply needs to be increased
o the mother’s breasts are uncomfortably full.
Guides for storing expressed breast milk at home
1.Wash hands thoroughly with soap and water – hands must be thoroughly dried with
a clean towel, single use towel or hand dryer
2.Refrigerate or freeze milk after expressing Use fresh milk whenever possible
3.Freeze milk that will not be used within 2 days
4. Date the container at the time of collection and use the oldest milk first
Breast milk expression is either done manually ,manual breast pump or electric breast
pump .
Length of time breast milk can be stored
Freshly expressed into sterile container:
-Storage in room temperature 26c for 6-8 hours
-Storage in refrigerator 5c or lower not more than 72 hours
-Storage in freezer :2weeks in freezer(-15c)
3monthes in freezer (-18c )
6-12 months in deep freezer (-20c )
When the stored milk is needed it should be rewarmed and to discard any remained
milk,rewarming is either by special warmer or by warm water.
Formula feeding
Cow milk is the base of most formulas ,milk processing is ranging from simple home boiling
to commercial pasteurization ,homogenization and evaporation ,these processes alter the
casein which is the main protein in cows milk to small readily digestible curds form in the
stomach eliminating the principle cause of indigestibility of cows milk protein .
Formula processing
Commercial milk formulas are modified from cows milk base and their protein and minerals
level are reduced nearer to those of human milk thus decreasing osmolality and renal
excretion load ,the saturated fat of cows milk is replaced with some unsaturated vegetable
fatty acids ,iron and vitamins are added (fortified ),because both human &cow milk are
deficient with these two important elements .
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Digestibility of cow milk
The stomach empties more rapidly after human milk than whole cow milk but no difference
exist between human milk & processed cow milk formula ,because the curd in cow milk is
reduced in size by boiling and made less tough & smaller by the heating required for
evaporation and by the addition of acid &alkali & homogenization .
Types of formula
1.cow’s milk-based formula is suitable for most healthy full-term infants and is
recommended (from birth - 12 months),which are powdered ,evaporated milk .
all modern infant formulas
contain reduced protein and electrolyte levels and have added iron and vitamins
(including A, B group, C, D, E and K and other nutrients
Special infants formula
1-Hydrolysed formula
Hydrolysed formula, which is cow’s milk-based formula that has been processed to
break down most of the proteins
into smaller particles, it may modify the development of allergic disease.
Extensively hydrolyzed formulas are the preferred formulas for infants intolerant to
cow's milk or soy proteins. These formulas are lactose free and can include medium-
chain triglycerides, making them useful in infants with gastrointestinal malabsorption
due to cystic fibrosis, short gut syndrome, and prolonged diarrhea
Soy based formula
Soy protein–based formulas on the market are all free of cow's milk protein and
lactose and provide 67 kcal/dL. They meet the vitamin, mineral, and electrolyte
guidelines from the AAP and the FDA for feeding term infants , indications include :
These indications include galactosemia and hereditary lactase enzyme deficiency,
because soy–based formulas are lactose-free;
Soy protein–based formulas have no advantage over cow's milk protein–based
formulas as a supplement ,however soy protein–based formulas may be indicated
when documented secondary lactose intolerance occurs for the breast-fed infant,
Amino Acid Formulas
Amino acid formulas are peptide-free formulas that contain mixtures of essential and
nonessential amino acids. They are specifically designed for infants with dairy protein
allergy who failed to thrive on extensively hydrolyzed protein formulas
‘Ready to drink’ formulas
‘Ready to drink’ infant formula products are available in aseptically packed glass
bottles for hospital use only or
in aseptically packed tetra packs for domestic use. the liquid formula needs to be
poured into a sterilised bottle
and can be warmed in the bottle if desired, just before feeding.
Goat milk formula
Special milk formula as low electrolyte formula used for congestive heart failure or
low a.a formula as low phenyl alanine formula in patients with phenyl ketonurea