Feeding of infants and children up to 3 years of age

Feeding of infants and
children up to 3 years of
age
Department of Pediatrics and Medical Genetics
Medical University
Plovdiv

What is energy used for?
•Base metabolism –60%
•Growth and development –15%
•Physical activity –15% (variable)
•Digestion and resorption of food –5%
•Unused energy –5%
With age the energy used for growth decreases, but
energy used for physical activity increases.

Average requirements (per
kg/day)
Age Kcal/24
hrs
Kcal/kg/da
y
Protein
g/kg/day
Fats
g/kg/day
Carbohydrate
s g/kg/day
0 –3 months 120 -1301.5 4-5 9-10
3 –6 months 110 -1201.5 4-5 9-10
6 –12 months 90 -110 1.5 4-5 9-10
1 –3 yrs 80 -90 1.1 4-5 8-11
3 -6 yrs 70 -80 0.95 4-5 8-11
6 –10 yrs 60 -70 0.95 4-5 8-11
10 –14 yrs, M2400 0.95 4-5 8-11
10 –14 yrs , F2000 0.95 4-5 8-11

Infant feeding
1.Exclusive breastfeeding for the first 4-6 months,
recommended by the WHO
2. Formula feeding –just infant formula
3. Mixed feeding -breastfeeding + formula top-ups

Advantages of breastfeeding
1. For the infant -
•provides the ideal, species-specific nutrition for infants
during the first 4 months to 6 months of life
• is life-saving in developing countries
• reduces the risk of gastrointestinal and respiratory infection,
otitis media, and necrotizing enterocolitis
• enhances the mother–child relationship
• reduces the risk of insulin-dependent diabetes,
hypertension and obesity in later life.

Advantages of breastfeeding
2. For the mother
•promotes close attachment between mother and baby
• increases the time interval between children, which is
important in reducing birth rate in developing countries
• reduces risk of breast and ovarian cancer and type 2
diabetes.

Why „breast is best“
1. Anti-infective properties
Secretory IgA -Comprises 90% of immunoglobulin in human milk.
Provides mucosal protection
Bifidus factor -Promotes growth of Lactobacillus bifidus, which
metabolizes lactose to lactic and acetic acids. The resulting low
pH may inhibit growth of gastrointestinal pathogens
Lysozyme -Bacteriolytic enzyme
Lactoferrin -Iron-binding protein. Inhibits growth of Escherichia coli
Interferon -Antiviral agent
Macrophages -Phagocytic. Synthesize lysozyme, lactoferrin, C3, C4
Lymphocytes -T cells may transfer delayed hypersensitivity
responses to infant. B cells synthesize IgA

Why „breast is best“
2.Nutritional properties
Protein quality -More easily digested curd (whey-to-casein ratio:
60 : 40)
Lipid quality -Rich in oleic acid. Improved digestibility and fat
absorption
Fat metabolism -Enhanced lipolysis, from breast milk lipase
Calcium-to-phosphorus ratio of 2 : 1 Reduces hypocalcaemic tetany
and promotes calcium absorption
Renal solute load -Low
Iron content -Bioavailable (40% to 50% absorption)
Long-chain polyunsaturated fatty acids
Structural lipids; important in retinal development

Phases in breastmilk production
Colostrum–secreted in the first 5-6 days after delivery; high
content of proteins,incl antibodies; fats and fat-soluble
vitamins
Transitional milk–secreted between day 7and day 14, with
gradual decrease in the amount of protein and electrolytes
Mature milk –after 14th day -increased amount of lactose
because of increased energy requirement in the infant.

Phases in breast milk production

Breastfeeding „technique“
1. Duration –15-20 min, in pre-terms and sick infants
up to 20-30 min
2. Interval between breastfeeds: 2 –4 hours
3. Number of breastfeeds:
1st month –7 –12 feeds
2 –5th month –6 –7 feeds
After 6th month –5 feeds
5. Breastfeeding on demand –baby is breastfed
when showing signs of hunger

Hunger signals
Early signals –„I am hungry“
RestlessnessOpening
of the
mouth
Rooting/turning of the head
Late signals–„I am very hungry“
Crying IrritabilityBright red,
inconsolable

„How do I know that my baby is
getting enough breast milk?“
•Soak 6 or more wet diapers a day with clear or pale
yellow urine.
•Pass 1 or more loose, seedy, or curd-like yellow
stools a day (breastfed babies).
•May lose 5-10% of body weight and will then start
gaining weight around 2 weeks of age.
•Babies typically gain 15 to 30 gr/ each day up to 3
months of age.

Potential pitfalls in breastfeeding
Unknown intake -Volume of milk intake not known; monitor
weight gain
Transmission of infection -Maternal CMV, hepatitis B and HIV –risk
of transmission to the baby
Transmission of drugs -Antimetabolites and some other drugs
contraindicated. Check formulary
Nutrient inadequacies -Breastfeeding beyond 6 months without
timely introduction of appropriate solids may lead to poor weight
gain and rickets( vitmain D deficiency)
Vitamin K deficiency -Insufficient vitamin K in breast milk to
prevent haemorrhagic disease of the newborn. Supplementation is
required

Potential pitfalls in breastfeeding
Potential transmission of environmental contaminants -Nicotine,
alcohol, caffeine, etc.
Less flexible -Other family members cannot help or take part.
More difficult in public places
Social stigma in some cultures–where are the breasfeeding
facilities in airports?
Emotional upset -If difficulties or lack of success, can be upsetting

Contraindications to
breastfeeding
1. Absolute
a) maternal –active TB, severe psychosis, HIV/AIDS with high viral
load, medications
b) infant –congenital metabolic disorders –phenylketonuria,
galactosemia –specialised formulas
2. Relative –congenital malformations (choanal atresia, cleft lip and
palate) or absent sucking reflex due to neurological conditions.
Can receive breast milk via naso-gastric tube.

How long to continue
breastfeeding for ?
The WHO recommends continuing breastfeeding until 2 years
of age, the American Pediatric Association until 1 year of age.

Infant formula
Based on cow´s milk which has been modified to resemble as
closely as possible breast milk
Reduced protein content, esp. Casein and increased
lactoalbumins (whey) to 40:60 ratio
Part of the fats are removed and replaced with vegetable fats,
like linolic and alfa-linoleic acid
Lactose is added
Reduced amounts of salts
Fortified with vit.D and iron
Addition of biologicaly active substances:
-long chain polyunsaturated acids, nucleotides, taurin, inositol. L-carnitine

Comparison between breast milk, cow´s milk and
infant formula( per 100 ml)

Specialized infant formulas
1. For preterm neonates (higher energy and mineral content)
2. AR formulas, for gastro-oesophageal reflux (rice starch as a
thickener)
3. HA (hypoallergenic) -babies at risk of allergy to cow´s milk
proteins, protein is hydrolised to oligopeptides. Only prevention,
not treatment.
4. Extensively hydrolised formulas –babies with proven allergy to
cow´s milk proteins-the protein is broken down to amino acids

Specialized infant formulas
5. Lactose-free –in lactose intolerance (primary lactase deficiency
or postgastroenteritis intolerance)
6. Soya formulas -should not be used for infants under 6 months of
age as it has a high aluminium content and contains
phytoestrogens (plant substances that mimic the effects of
endogenous oestrogens) PLUS some cross-reactivity with cow´s
milk proteins
7. For infants with congenital metabolic conditions-galactosemia,
phenylketonuria etc.

Formula feeding
1. Amount of each feed:
a) neonatal period –1st day-10 ml/per feed, increase by 10 ml
every day so on day 7 the neonate gets 70 ml/feed. Then increase
gradually to 100 ml/feed by the end of the 1st month.
b)2nd-10th month of life -1Х0 ml/feed
Х –age in months e.g 5-month-old baby-150 ml/feed
At 10 mths of age the individual portion is 200 ml and should be
kept at that till the end of the 1st year.
2. Frequency of feeds –not on demand, every 3 hrs

Mixed feeding –usually in
hypogalactia
•Every effort to increase lactation as true
hypogalactia in only 5% of mothers!
•Baby is breastfed first at each feed and the a top-
up. Do not alternate breastfeeds and formula feeds
as lactation will reduce further.
•Top-up with formula milk, not cow´smilk

Weaning
The process of introducing solid foods into infants’ diet. Varies in
different countries.
After 6 months of age, breast milk becomes increasingly
nutritionally inadequate as a sole feed, as it doesnot provide
sufficient energy, vitamins or iron.
Solid foods are recommended to be introduced from around 6
months of age, not before 17 weeks and no later than 26 weeks
(4-6 months).

Weaning –whystartbetween4
and6 monthsofage
1. Weaning before17 weeksisnotrecommendedbecauseofriskof
electrolytesoverload, infections, allergies, rapidweightgainand
laterobesity.
2. Weaning after26 weeksisalsonotrecommendedasitmaylead
toweightfaltering, nutritionaldeficienciesanddifficultacceptance
ofnewtastesandtexturesotherthanmilk.