Infant Feeding Into the Gaping Maw. What I’ll talk about… Breastfeeding Formula types and uses ▫Reflux ▫Lactose intolerance ▫Milk protein allergy Introducing.

Infant FeedingInto the Gaping Maw

What I’ll talk about…

•Breastfeeding•Formula types and uses

▫Reflux▫Lactose intolerance▫Milk protein allergy

•Introducing foods•…and Star Wars!

Episode IV comes first, it’s just good parenting.

Breast is Best!

•Exclusive breastfeeding is best for baby and recommended up to 4-6 months of age▫No proven benefit to breastfeeding past 6

months of age, but it’s ok to continue up to and past 1 year old with complementary feeding

Benefits of BreastfeedingInfectious Diseases Other Health Outcomes

• Decreased incidence and severity of infectious diseases▫ Bacterial Meningitis▫ Bacteremia▫ Diarrhea▫ Respiratory tract infection▫ NEC▫ Otitis media▫ UTI▫ Sepsis▫ Overall infant mortality

decreased 21%

• Decreased rates of▫ SIDS▫ IDDM and NIDDM▫ Lymphoma▫ Leukemia▫ Overweight and obesity▫ Asthma▫ High cholesterol

Benefits of Breastfeeding

It’s Cheap!

Contraindications to Breastfeeding• Infants with galactosemia• Mothers…

▫With untreated, active TB infection▫Positive for Human T-cell lymphotrophic virus type

I or II▫Receiving diagnostic or therapeutic radioactive

isotopes or with exposure causing radioactive breastmilk

▫Receiving antimetabolites or chemotherapy▫Who are using street drugs of abuse▫Who have active herpes simple lesions on a breast▫Infected with HIV

Problems with Breastfeeding?

•That’s why we have lactation consultants!

But what if…

•Mom tried breastfeeding but it hurt so she quit.

•Mom tried breastfeeding but she was scared she wasn’t making enough milk.

•Mom is on _________ medication and was told not to breastfeed.

•Mom thinks having a baby hang off her breast and feed is gross.

•And many, many others.

Then what…?•Try to convince mom to

start/restart/continue breastfeeding.

•Mom’s not receptive, but really wants to know what formula her baby needs.

“Do or do not, there is no try”

Formula•Mom asks you what formula you

recommend•Healthy, full term infant with a normal

neonatal screening.▫A regular old iron fortified formula is all

that’s needed•But what brand?

Mead Johnson Formulas for Infants•Enfamil Newborn•Enfamil Premium Infant•Enfamil Gentlease for Fussiness and Gas•Enfamil A.R. for Frequent Spit-up•Enfamil Prosobee for Fussiness and Gas •Enfamil Nutramigen for Colic•Enfamil EnfaCare Lipil

"Holding her is dangerous. If word of this gets out, it could generate sympathy for the Rebellion in the Senate."―Commander Daine Jir, to Darth Vader

Abbott Infant Formulas

•Similac Advance•Similac Advance Organic•Similac Sensitive•Similac Soy Isomil•Similac Sensitive for Spit-Up•Similac Expert Care Alimentum•Similac Expert Care Neosure 22 cal/oz•Similac Expert Care for Diarrhea

“Don't try to frighten us with your sorcerous ways, Lord Vader.” Admiral (General?) Conan Antonio Motti

Nestle/Gerber

•Gerber Good Start Gentle Formula•Gerber Good Start Soy•Gerber Good Start Protect

“Until this battle station is fully operational, we are vulnerable.” General Cassio Tagge

Parent’s Choice Formula

•Parent’s Choice Premium Infant•Parent’s Choice NeoCare 22 cal/oz•Parent’s Choice Advantage•Parent’s Choice Gentle•Parent’s Choice Sensitivity•Parent’s Choice Soy•Parent’s Choice Added Rice•Parent’s Choice Organic

"Where are you taking this…thing?"―Lieutenant Shann Childsen

Other Formula Brands

•Walgreen’s•Target•Earth’s Best•Sam’s Club•Kroger’s•Bright Beginnings

"We've analyzed their attack, sir, and there is a danger. Should I have your ship standing by?"―General Moradmin Bast

Formula Types

•“Standard” cow’s milk based formula

•Added rice•Low lactose / lactose free•Soy based•Partially hydrolyzed•Extensively hydrolyzed•Amino Acid•Specialty

Cow’s Milk Formulas

•“Standard”▫Enfamil Premium Newborn▫Enfamil Premium Infant▫Similac Advance▫Similac Advance Organic▫Parent’s Choice Premium▫Parent’s Choice Advantage

Cow’s Milk Formulas

•“Standard”▫20 cal/oz▫Casein is the

predominant protein in breast milk

▫Formulas use either casein or whey as the primary protein

So which formula to recommend?

THE CHEAPEST!

Formula Prices

•Enfamil Premium Infant 23.4 oz powder 24.99

•Similac Advance 23.2 oz powder ----------24.10

•Parent’s Choice 23.2 oz powder -----------11.88

•Up and Up (Target) 40 oz powder ---------19.99

•Walgreen’s Premium 23.4 oz powder------13.99

MOMMY GUILT

The FDA and Infant Formula

•Formulas are regulated by the FDA's Center for Food Safety and Applied Nutrition (CFSAN)

”You would prefer another target, a military target? Then name the system!” Grand Moff WilhelmTarkin

Nutrient Minimum 1 Maximum 1Protein (gm) 1.82 4.5.Fat:    gm 3.3 6.0.percent cal 30.0 54.0.Essential fatty acids (linoleate):

percent cal 2.7  mg 300.0  Vitamins:    A (IU) 250.0 (75 µg) 3 750.0 (225 µg) 3D (IU) 40.0 100.0.K (µg) 4.0  

E (IU)0.7 (with 0.7

IU/gm linoleic acid).

C (ascorbic acid) (mg) 8.0  B1 (thiamine) (µg) 40.0  B2 (riboflavin) (µg) 60.0  

B6 (pyridoxine) (µg)35.0 (with 15

µg/gm of protein in formula).

B12 (µg) 0.15  Niacin (µg) 250.0  Folic acid (µg) 4.0  Pantothenic acid (µg) 300.0  Biotin (µg) 1.5 4  Choline (mg) 7.0 4  Inositol (mg) 4.0 4  Minerals:    Calcium (mg) 50.0 5  Phosphorus (mg) 25.0 5  Magnesium (mg) 6.0  Iron (mg) 0.15  Iodine (µg) 5.0  Zinc (mg) 0.5  Copper (µg) 60.0  Manganese (µg) 5.0  Sodium (mg) 20.0 60.0.Potassium (mg) 80.0 200.0.Chloride (mg) 55.0 150.0.

Nutrients required by Sec. 412. [21 USC §350a] Requirements for Infant Formulas

 1 Stated per 100 kilocalories. 2 The source of protein shall be at least nutritionally equivalent to casein. 3 Retinol equivalents. 4 Required to be included in this amount only in formulas which are not milk-based. 5 Calcium to phosphorus ratio must be no less than 1.1 nor more than 2.0.

 ”I think it is time we demonstrated the full power of this station. Set your course for Alderaan.” Grand Moff Wilhelm Tarkin

Compare and Save!

-Lutein to support eye health-DHA/ARA for brain and eye development-Immune supporting nucleotides-Prebiotics for digestive health-Exclusive palm olein-free fat blend to support excellent calcium absorption

Do these really matter?

• -Lutein to support eye health• -DHA/ARA for brain and eye

development• -Immune supporting

nucleotides• -Prebiotics for digestive

health• -Exclusive palm olein-free fat

blend to support excellent calcium absorption

None have been shown to have any long term benefit. But they also don’t hurt anything

Ugnaughts

Ewok

Enfamil NewbornEnfamil Premium Infant

Low Iron Formula

For infants predisposed to or being treated for hypocalcemia with hyperphosphatemia, or those with impaired renal function who would benefit from lowered mineral intake

There are no known medical contraindications toiron-fortified formulas (eg, iron overload syndromes,colic, constipation, cramps, or gastroesophagealreflux).

Added Rice (Anti-Regurgitation?)

•Enfamil A.R.•Similac Sensitive for Spit-Up•Up & Up Rice DHA Milk Based Infant

Formula•Parent’s Choice Added Rice Starch

Formula

Actually Rebel?

Reflux

•All babies reflux•Most babies are completely asymptomatic

“Happy Spitters” and require no changes to diet or any treatment.

 ”Uh, everything's under control. Situation normal.”

Reflux

•But he’s spitting up everything he eats!▫Show mom the growth curve and explain it▫Discuss how milk is mixed with saliva and

stomach juices, so it looks like a lot coming up but most is staying down

▫Use a water balloon analogy

Reflux

•If reassurance is not working, it’s ok to use an A.R. formula; remembering that it’s basically cosmetic

•A.R. formulas do decrease the frequency and amount of spit up

•They do not decrease the total acid exposure of the esophagus

Reflux

•Babies with pain or poor weight gain have clinically significant symptoms and need treatment, which may include A.R. formulas

•A.R. formulas do decrease the frequency and amount of spit up

•They do not decrease the total acid exposure of the esophagus

Reflux

•How about adding rice cereal to regular formula?▫½ tablespoon rice cereal in 1 oz of formula

increases calories from 20 cal/oz to 27 cal/oz.

▫May require widened nipple▫Most babies are already too fat.

•The A.R. formulas are 20 cal/oz and don’t require a wider nipple

Low Lactose / Lactose Free

•Similac Sensitive•Enfamil Gentlease•Parent’s Choice Sensitivity Formula•Up and Up Lactose Sensitive Formula

Low Lactose / Lactose Free

•A relatively common concern:•“My baby has been spitting up a lot with

this milk based formula. I’m lactose intolerant and I think he is too!”

Low Lactose / Lactose Free

•Primary lactase deficiency▫Missing or low levels of lactase enzyme

needed to breakdown the milk sugar lactose

▫AKA adult-type lactase deficiency, lactase nonpersistence or hereditary lactase deficiency

▫Most common cause of lactose intolerance in adults

Low Lactose / Lactose Free

Lactose Intolerance in Infants, Children and Adolescents Melvin et al. Pediatrics Volume 118, Number 3, September 2006

“Never tell me the odds!”

Low Lactose / Lactose Free

•Primary lactase deficiency▫Develops slowly▫Almost never present before 1 year old

•Congenital lactase deficiency▫Extremely rare; prior to the availability of

lactose free human milk substitute in the 20th century, these babies were not likely to survive.

Low Lactose / Lactose Free

•Lactose intolerance in a healthy infant is extremely rare.

 "Sir, the possibility of successfully navigating an asteroid field is approximately 3721 to 1!"

Low Lactose / Lactose Free

•Secondary lactase deficiency▫Results from small bowel injury - such as

acute gastroenteritis or persistent diarrhea▫More common in infancy

Han. Shot. First.

Low Lactose / Lactose Free

•Secondary lactase deficiency▫Low lactose or lactose free formulas are

usually unnecessary for treatment▫Infants should continue their usual formula

or breastfeeding•Never dilute infant formula or breastmilk.

Always give full strength/mixed according to package instructions

Low Lactose / Lactose Free

•Are necessary only in very rare instances

Soy Formulas

•Enfamil ProSobee•Similac Soy Isomil•Up and Up Soy Infant Formula•Parent’s Choice Soy Formula

Soy Formulas•Not recommended unless medically

necessary;▫for infants with galactosemia or hereditary

lactase deficiency (both rare)▫in situations in which a vegetarian diet is

preferred. •There can be cross reactivity between soy and

milk protein; so not initially recommended for milk allergic infants

•Estrogen like compounds in soy may have long term effects we don’t know about.

Soy Formulas

•Are lactose free!

Partially Hydrolyzed Formulas

•Enfamil Gentlease•Parent’s Choice Gentle•Up and Up Partially Hydrolyzed Infant

Formula•Gerber Good Start Gentle

Partially Hydrolyzed Formulas

•They are not hypoallergenic and are not for use in milk allergic infants

•There is modest evidence of prevention of atopic dermatitis using these formulas, but the extensively hydrolyzed formulas may be more effective

Extensively Hydrolyzed Formula•Enfamil Nutramigen•Similac Alimentum

Extensively Hydrolyzed Formula•Still cow’s milk based, but the majority of

the milk protein has been broken down into it’s constituent amino acids

•Used for infants allergic to cow’s milk•There is moderate evidence that it’s

exclusive use in a non-breastfed infant can help prevent atopic dermatitis in infants at risk

Milk Protein Allergy

•IgE mediated▫Angioedema▫Urticaria▫Wheezing▫Rhinitis▫Vomiting▫Eczema▫Anaphylaxis▫Colic/

irritability(reflux!)

•Non-IgE mediated▫Pulmonary

hemosiderosis▫Malabsorption▫Eosinophilic

proctocolitis▫Enterocolitis▫Esophagitis

Milk Protein Allergy

•The milk protein in extensively hydrolyzed formulas is tolerated by about 90% of kids with milk protein allergy

Milk Protein Allergy

•Start extensively hydrolyzed formula for at least one month

•If symptoms resolve, may try soy.•If symptoms return, then restart the

extensively hydrolyzed formula

•What if the extensively hydrolyzed formula doesn’t help?

Milk Protein Allergy

•Amino Acid formulas▫Enfamil NutramigenAA▫EleCare▫Neocate

•The milk protein in these formulas is broken down completely into amino acids. Usually reserved for those 10% of milk allergic kids who didn’t tolerate the extensively hydrolyzed formulas

Milk Protein Allergy

•Formula ~ $24 for 23.2 oz---------------$1.03/oz

•Soy Formula ~ $25 for 23.2 oz----------$1.07/oz

•Partially hydrolized ~ $27 for 22.2 oz--$1.21/oz

•Extensively hydrolized ~ $36 for 19 oz-$1.90/oz

•Amino Acid formulas ~ $37 for 14 oz---$2.64/oz

Specialty Formulas

•Formulas for specific metabolic conditions▫Phenyl Free for PKU

•Formulas for premature infants▫Similac Special Care▫Enfamil Premature Lipil

•Infants who have trouble absorbing fat▫Pregestimil (MCT oil)

Iron

•Remember – low iron formulas are never indicated

•Exclusively breastfed infants need iron supplementation starting at 4 months old▫1 mg/kg/day from iron drops or from iron

fortified cereal▫Infants getting more than half feeds from

breast milk also need 1 mg/kg/day•Exclusively formula fed infants don’t need

iron supplementation

Starting Foods

•No complementary foods are required until 6 months old

•Start red meats right at 6 months•Avoid honey until 12 months due to risk of

botulism•Introduce one food at a time so if there is

an allergic reaction the source is easy to find

•Prepackaged baby foods are not required

Starting Foods

•It’s ok for infants to have dairy/cows milk – just don’t substitute the cow’s milk for formula or breastmilk

•The more variety now, the less food fussiness later

•No need to withhold spices•There is no best way!

I have the death sentence on twelve systems! Dr. Cornelius Evazan

Breast is best

References• http://

www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/FDCActChapterIVFood/ucm107864.htm

• http://www.fda.gov/Food/FoodSafety/Product-SpecificInformation/InfantFormula/default.htm• Infant Formulas, Am Fam Physician. 2009;79(7):565-570. • Breastfeeding and the Use of Human Milk; Pediatrics 2005;115:496–506• Clinical Report—Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in

Infants and Young Children (0 –3 Years of Age); Pediatrics 2010;126:1040–1050• Dietary Recommendations for Children and Adolescents: A Guide for Practitioners;

Pediatrics Volume 117, Number 2, February 2006• Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants

and Children; Pediatrics Volume 121, Number 1, January 2008• Pediatric GE Reflux CPG; J Pediatr Gastroenterol Nutr, Vol. 32, Suppl. 2, 2001• Iron Fortification of Infant Formulas; Pediatrics Vol. 104 No. 1 July 1999• Lactose Intolerance in Infants, Children, and Adolescents; Melvin et al. Pediatrics Volume 118,

Number 3, September 2006• Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents; Pediatrics

2008;122:1142–1152• Soy Protein-based Formulas: Recommendations for Use in Infant Feeding; Pediatrics Vol. 101

No. 1 January 1998• The Use and Misuse of Fruit Juice in Pediatrics; Pediatrics Vol. 107 No. 5 May 2001• Pediatric Nutrition Handbook, Fifth Edition; pages 87-113