Nutrition Module Notes Nutrition Module Notes Pediatric I – Second Year Pediatric I – Second Year Rebecca Abiog-Castro, M.D. Rebecca Abiog-Castro, M.D. Rhodora Garcia de Leon, M.D Rhodora Garcia de Leon, M.D Faculty of Medicine & Surgery, UST Faculty of Medicine & Surgery, UST
Nutrition Module Notes Pediatric I – Second Year Rebecca Abiog -Castro, M.D. Rhodora Garcia de Leon, M.D Faculty of Medicine & Surgery, UST. Objectives of the Course. At the end of the course a Second Year Medical Student should be able: - PowerPoint PPT Presentation
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Nutrition Module NotesNutrition Module Notes Pediatric I – Second YearPediatric I – Second Year
Rhodora Garcia de Leon, M.DRhodora Garcia de Leon, M.D
Faculty of Medicine & Surgery, USTFaculty of Medicine & Surgery, UST
Objectives of the CourseObjectives of the CourseObjectives of the CourseObjectives of the Course
At the end of the course a Second Year Medical At the end of the course a Second Year Medical Student should be able:Student should be able:
To discuss briefly the anatomy of the breast and To discuss briefly the anatomy of the breast and physiology of lactation;physiology of lactation;
To discuss the benefits of breastmilk and the To discuss the benefits of breastmilk and the
benefits of breastfeeding to both infant and mother; benefits of breastfeeding to both infant and mother;
To discuss the barriers on breastfeeding;To discuss the barriers on breastfeeding;
To discuss the composition of mature breast-milk;To discuss the composition of mature breast-milk;
To discuss the difference between breast-milk and To discuss the difference between breast-milk and cow’s milk; cow’s milk;
At the end of the course a Second Year Medical At the end of the course a Second Year Medical Student should be able:Student should be able:
To discuss briefly the anatomy of the breast and To discuss briefly the anatomy of the breast and physiology of lactation;physiology of lactation;
To discuss the benefits of breastmilk and the To discuss the benefits of breastmilk and the
benefits of breastfeeding to both infant and mother; benefits of breastfeeding to both infant and mother;
To discuss the barriers on breastfeeding;To discuss the barriers on breastfeeding;
To discuss the composition of mature breast-milk;To discuss the composition of mature breast-milk;
To discuss the difference between breast-milk and To discuss the difference between breast-milk and cow’s milk; cow’s milk;
Objectives of the CourseObjectives of the CourseObjectives of the CourseObjectives of the Course
To discuss the steps to encourage Breast-feeding in To discuss the steps to encourage Breast-feeding in the hospital: UNICEF / WHO Baby-Friendly;the hospital: UNICEF / WHO Baby-Friendly;
To discuss the features of complementary foods;To discuss the features of complementary foods;
To discuss the proper method to introduce To discuss the proper method to introduce complementary foods;complementary foods;
To utilize the PSPGN Food Guide Pyramid for the To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children;prescription of the proper diet for infant & children;
To classify the different breast-milk substitutes To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for (infant formulas) and determine the indication/s for its use;its use;
To discuss the supplements for breastfed infants.To discuss the supplements for breastfed infants.
To discuss the steps to encourage Breast-feeding in To discuss the steps to encourage Breast-feeding in the hospital: UNICEF / WHO Baby-Friendly;the hospital: UNICEF / WHO Baby-Friendly;
To discuss the features of complementary foods;To discuss the features of complementary foods;
To discuss the proper method to introduce To discuss the proper method to introduce complementary foods;complementary foods;
To utilize the PSPGN Food Guide Pyramid for the To utilize the PSPGN Food Guide Pyramid for the prescription of the proper diet for infant & children;prescription of the proper diet for infant & children;
To classify the different breast-milk substitutes To classify the different breast-milk substitutes (infant formulas) and determine the indication/s for (infant formulas) and determine the indication/s for its use;its use;
To discuss the supplements for breastfed infants.To discuss the supplements for breastfed infants.
Mother's milk is the best Mother's milk is the best
food a baby can have food a baby can have
exclusively in the first 6 exclusively in the first 6
months of life;months of life;
should be continued should be continued
untiluntil
two years and beyond.two years and beyond.
Mother's milk is the best Mother's milk is the best
food a baby can have food a baby can have
exclusively in the first 6 exclusively in the first 6
months of life;months of life;
should be continued should be continued
untiluntil
two years and beyond.two years and beyond.
Anatomy of BreastAnatomy of Breast
Internal structuresExternal structures:External structures: Cross section of alveolus
Breast StructureBreast StructureBreast StructureBreast Structure
Anatomy of the BreastAnatomy of the BreastAnatomy of the BreastAnatomy of the Breast
Teat
Tongue
Palate
Physiology of lactationPhysiology of lactation
Endocrine controlEndocrine control
Physiology of lactationPhysiology of lactation
Endocrine controlEndocrine control
Three main phases of lactationThree main phases of lactation
1)1) MammogenesisMammogenesis or or mammary growthmammary growth
2)2) LactogenesisLactogenesis or or initiation of milk secretion: initiation of milk secretion:
Stage I:Stage I: 12 wks before parturition 12 wks before parturitionStage II:Stage II: 2-3 days postpartum 2-3 days postpartum
3)3) Stage IIIStage III of of LactogenesisLactogenesis or or Galactopoiesis Galactopoiesis maintenance of milk secretionmaintenance of milk secretion: 14-30 das.: 14-30 das.
Three main phases of lactationThree main phases of lactation
1)1) MammogenesisMammogenesis or or mammary growthmammary growth
2)2) LactogenesisLactogenesis or or initiation of milk secretion: initiation of milk secretion:
Stage I:Stage I: 12 wks before parturition 12 wks before parturitionStage II:Stage II: 2-3 days postpartum 2-3 days postpartum
3)3) Stage IIIStage III of of LactogenesisLactogenesis or or Galactopoiesis Galactopoiesis maintenance of milk secretionmaintenance of milk secretion: 14-30 das.: 14-30 das.
Three Main Phases of Lactation Three Main Phases of Lactation (hormonal)(hormonal)
Three Main Phases of Lactation Three Main Phases of Lactation (hormonal)(hormonal)
Phase I - Phase I - MammogenesisMammogenesis– Profound during pregnancy in preparation for Profound during pregnancy in preparation for
Hormones Involved in Mammary GrowthHormones Involved in Mammary Growth
Estrogens Progesterone GH Placental lactogens (PL)Prolactin Glucocorticoids GH and PL induce alveolar growth Steroids without GH and PL do not exert any effect
INDUCTION OF GROWTH (Normal animals)
• Estrogens alone induce alveolar growth
– Larger than normal alveoli
• Estrogen and progesterone induce normal growth
Phase I - Phase I - MammogenesisMammogenesis
Phase II - LACTOGENESIS
INITIATION OF LACTATION
At parturition the mammary gland switches from a growing non secretory tissue to a secreting, non-growing tissue
Change is endocrine mediated
Three Main Phases of Lactation Three Main Phases of Lactation (hormonal)(hormonal)
Three Main Phases of Lactation Three Main Phases of Lactation (hormonal)(hormonal)
Phase II - Phase II - LactogenesisLactogenesis (initiation of milk):(initiation of milk):
– Stage I:Stage I: starts 12 wks before delivery starts 12 wks before delivery
Gathering of all substrates for milk productionGathering of all substrates for milk production
– Stage II:Stage II: starts 2-3 days postpartum starts 2-3 days postpartum
Milk secretion is copiousMilk secretion is copious
Phase II - Phase II - LactogenesisLactogenesis (initiation of milk):(initiation of milk):
– Stage I:Stage I: starts 12 wks before delivery starts 12 wks before delivery
Gathering of all substrates for milk productionGathering of all substrates for milk production
– Stage II:Stage II: starts 2-3 days postpartum starts 2-3 days postpartum
Milk secretion is copiousMilk secretion is copious
Endocrine Patterns Related to Parturition
ENDOCRINE REGULATION OF LACTOGENESIS
Endocrine Control of LactationEndocrine Control of LactationEndocrine Control of LactationEndocrine Control of Lactation
Milk Production Reflex:Milk Production Reflex:
ProlactinProlactin is a key lactogenic hormone, is a key lactogenic hormone, stimulating initial alveolar milk productionstimulating initial alveolar milk production
Milk Ejection Reflex:Milk Ejection Reflex:
OxytocinOxytocin contracts the myoepithelial; cells, contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts forcing milk from the alveoli into the ducts and sinuses where it is removed by the and sinuses where it is removed by the infantinfant
Milk Production Reflex:Milk Production Reflex:
ProlactinProlactin is a key lactogenic hormone, is a key lactogenic hormone, stimulating initial alveolar milk productionstimulating initial alveolar milk production
Milk Ejection Reflex:Milk Ejection Reflex:
OxytocinOxytocin contracts the myoepithelial; cells, contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts forcing milk from the alveoli into the ducts and sinuses where it is removed by the and sinuses where it is removed by the infantinfant
Effect of different hormones in the initiation of milk production
Glucocorticoids – Development of RER (rough endoplasmic reticulum)
Prolactin – Maturation of Golgi – Secretory vesicles – Responsible for milk secretion
Progesterone – Promotes mammary growth specially alveolar tissue – Blocks epithelial secretion – As it decreases, the block for lactogenesis is removed
ENDOCRINE REGULATION OF LACTOGENESIS
Effect of different hormones in the initiation of milk production
MAMMARY GROWTH SLOWS DOWN
Most hormones involved in growth have been removed – Progesterone
CL has regressed and placenta is removed – Estrogens
Feto-placental unit no longer available – Placental lactogens
Placenta was expelled
After parturition mammary growth slows down because most growth promoting hormones are no longer available
Phase III – Phase III – GalactopoiesisGalactopoiesismaintenance of Breastmilk Secretionmaintenance of Breastmilk Secretion
Phase III – Phase III – GalactopoiesisGalactopoiesismaintenance of Breastmilk Secretionmaintenance of Breastmilk Secretion
Stage III of Stage III of Lactogenesis or GalactopoiesisLactogenesis or Galactopoiesis– Maintenance of milk secretionMaintenance of milk secretion– From 14- 30 daysFrom 14- 30 days– Mature milk is establishedMature milk is established– ProlactinProlactin and and OxytocinOxytocin essential for effective essential for effective
maintenance of milk supplymaintenance of milk supply
Stage III of Stage III of Lactogenesis or GalactopoiesisLactogenesis or Galactopoiesis– Maintenance of milk secretionMaintenance of milk secretion– From 14- 30 daysFrom 14- 30 days– Mature milk is establishedMature milk is established– ProlactinProlactin and and OxytocinOxytocin essential for effective essential for effective
maintenance of milk supplymaintenance of milk supply
Hormones in charge of supporting continuous milk production
Responsibility of prolactin and growth hormone
Supported by thyroid, parathyroid and adrenal glands through adequate metabolic function
MAINTENANCE OF LACTOGENESIS(Galactopoiesis)
Autocrine Control of LactationAutocrine Control of LactationAutocrine Control of LactationAutocrine Control of Lactation
Influence of of Local Factors Acting on the Influence of of Local Factors Acting on the BreastsBreasts
It is not just the level of maternal hormones, but It is not just the level of maternal hormones, but the efficiency of the efficiency of milk removalmilk removal that governs the that governs the volume product in each breastvolume product in each breast
A protein factor called A protein factor called feedback inhibitor of feedback inhibitor of lactation (FIL)lactation (FIL) is secreted with other milk is secreted with other milk components into the alveolar lumencomponents into the alveolar lumen
FILFIL, insensitive to prolactin , insensitive to prolactin milk production milk production
Influence of of Local Factors Acting on the Influence of of Local Factors Acting on the BreastsBreasts
It is not just the level of maternal hormones, but It is not just the level of maternal hormones, but the efficiency of the efficiency of milk removalmilk removal that governs the that governs the volume product in each breastvolume product in each breast
A protein factor called A protein factor called feedback inhibitor of feedback inhibitor of lactation (FIL)lactation (FIL) is secreted with other milk is secreted with other milk components into the alveolar lumencomponents into the alveolar lumen
FILFIL, insensitive to prolactin , insensitive to prolactin milk production milk production
Autocrine Control of LactationAutocrine Control of LactationAutocrine Control of LactationAutocrine Control of Lactation
FILFIL
FILFIL
FILFIL
Anatomy & Physiology: Milk Anatomy & Physiology: Milk production production
Risk factors for delayed onset of lactation Risk factors for delayed onset of lactation were:were:
Has higher protein, lower fat and lactose; rich in Vitamin A (3x > Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x);BM), carotenoid (10x), vitamin E(3x);
Protein content is rich inProtein content is rich in sIgA and immunologically competent sIgA and immunologically competent mononuclear cells;mononuclear cells;
ContainsContains antioxidants which trap neutrophil-generated oxygen antioxidants which trap neutrophil-generated oxygen radicals.radicals.
First postpartum week’s mammary secretion consisting of First postpartum week’s mammary secretion consisting of
Has higher protein, lower fat and lactose; rich in Vitamin A (3x > Has higher protein, lower fat and lactose; rich in Vitamin A (3x > BM), carotenoid (10x), vitamin E(3x);BM), carotenoid (10x), vitamin E(3x);
Protein content is rich inProtein content is rich in sIgA and immunologically competent sIgA and immunologically competent mononuclear cells;mononuclear cells;
ContainsContains antioxidants which trap neutrophil-generated oxygen antioxidants which trap neutrophil-generated oxygen radicals.radicals.
Distribution of Immunoglobulins and other Distribution of Immunoglobulins and other Soluble Substances in the Colostrum and Milk Soluble Substances in the Colostrum and Milk Delivered to the Breast-Fed Infant During a Delivered to the Breast-Fed Infant During a
24-Hour Period24-Hour Period
Distribution of Immunoglobulins and other Distribution of Immunoglobulins and other Soluble Substances in the Colostrum and Milk Soluble Substances in the Colostrum and Milk Delivered to the Breast-Fed Infant During a Delivered to the Breast-Fed Infant During a
24-Hour Period24-Hour Period
Soluble Soluble ProductProduct
Concentration in MG /Day at PostpartumConcentration in MG /Day at Postpartum
Type of Volume Energy Protein CHO FAT Type of Volume Energy Protein CHO FAT NANA Milk Milk ml/d ml/d Kcal/100 ml G/100mL G/100 ml G/100 ml Kcal/100 ml G/100mL G/100 ml G/100 ml mmol/100MLmmol/100ML
Type of Volume Energy Protein CHO FAT Type of Volume Energy Protein CHO FAT NANA Milk Milk ml/d ml/d Kcal/100 ml G/100mL G/100 ml G/100 ml Kcal/100 ml G/100mL G/100 ml G/100 ml mmol/100MLmmol/100ML
Type of Volume ENERGY PROTEIN CHO FAT Type of Volume ENERGY PROTEIN CHO FAT NANAMilk Milk (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml mmol/100 mlmmol/100 ml
Type of Volume ENERGY PROTEIN CHO FAT Type of Volume ENERGY PROTEIN CHO FAT NANAMilk Milk (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml mmol/100 mlmmol/100 ml
Supplements for Breastfed Supplements for Breastfed InfantsInfants
The following supplementation is generally The following supplementation is generally recommended: recommended:
– Vitamin K supplement in the immediate Vitamin K supplement in the immediate postpartum period. postpartum period.
– 400 IU of Vitamin D400 IU of Vitamin D
– Breastfeeding women should continue Breastfeeding women should continue taking prenatal vitamins especially vitamin taking prenatal vitamins especially vitamin D, calcium and iron D, calcium and iron
– Complementary foods should be given once Complementary foods should be given once infants reach six months of ageinfants reach six months of age
Review QuestionsReview Questions
1)1) The part of breast responsible for milk secretion The part of breast responsible for milk secretion _________ under the influence of what hormone? _______________ under the influence of what hormone? ______
2)2) Two important reflexes that are needed for BM Two important reflexes that are needed for BM secretion? ________secretion? ________
3)3) Which part of the breast is milk stored? ________Which part of the breast is milk stored? ________
4)4) Hormone secreted during BF which can reduce Hormone secreted during BF which can reduce BF________BF________
5)5) Major source of protein in BM ______Major source of protein in BM ______
Benefits of Breastmilk / Benefits of Breastmilk /
Breastfeeding to Infants and Breastfeeding to Infants and
MothersMothers
Benefits of Breastmilk
Enhances Cognitive Development Protective: Both for baby and
mother Cheap & Free: Benefits the Economy Safe
Benefits of Breastmilk
Enhances Cognitive Development Protective: Both for baby and
mother Cheap & Free: Benefits the Economy Safe
Enhances Cognitive DevelopmentEnhances Cognitive Development
IgA, IgM, IgGIgA, IgM, IgG:: immunoglobulins that guard the gut immunoglobulins that guard the gut against infective bacteriaagainst infective bacteria
Bifidus factor:Bifidus factor: stimulates bifido-bacteria, which stimulates bifido-bacteria, which fight against pathogenic bacteriafight against pathogenic bacteria
Lactoferrin:Lactoferrin: binds iron away from bacteria binds iron away from bacteria
Macrophages:Macrophages: phagocytosis of infective bacteria phagocytosis of infective bacteria
BB1212 binding protein: binding protein: removes B removes B1212 from bacteria from bacteria
IgA, IgM, IgGIgA, IgM, IgG:: immunoglobulins that guard the gut immunoglobulins that guard the gut against infective bacteriaagainst infective bacteria
Bifidus factor:Bifidus factor: stimulates bifido-bacteria, which stimulates bifido-bacteria, which fight against pathogenic bacteriafight against pathogenic bacteria
Lactoferrin:Lactoferrin: binds iron away from bacteria binds iron away from bacteria
Macrophages:Macrophages: phagocytosis of infective bacteria phagocytosis of infective bacteria
BB1212 binding protein: binding protein: removes B removes B1212 from bacteria from bacteria
Benefits of Breastmilk: Infant
Benefits of Breastmilk: Infant
Antiviral Factors in Human MilkAntiviral Factors in Human MilkFactorFactor Shown, in vitro, to be Shown, in vitro, to be
active against:active against:Effect of HeatEffect of Heat
Stable at 56Stable at 56°C for °C for 30 mins.; 30 mins.;
Some loss (0 – 30%) Some loss (0 – 30%) at 62.5 °C for 30 at 62.5 °C for 30 mins; mins;
destroyed by boilingdestroyed by boiling
Enhanced immune response to Enhanced immune response to immunizationsimmunizations– PolioPolio– TetanusTetanus– DiptheriaDiptheria– Haemophilus influenzaHaemophilus influenza
Enhanced immune response to Enhanced immune response to immunizationsimmunizations– PolioPolio– TetanusTetanus– DiptheriaDiptheria– Haemophilus influenzaHaemophilus influenza
Benefits of Breastmilk: Infant
Benefits of Breastmilk: Infant
Protection Against InfectionProtection Against InfectionProtection Against InfectionProtection Against Infection
Reduces risk and severity of Reduces risk and severity of infectious illness among infectious illness among infantsinfants– diarrheadiarrhea– otitis mediaotitis media– lower respiratory infectionslower respiratory infections– bacteremiabacteremia– bacterial meningitisbacterial meningitis– necrotizing enterocolitisnecrotizing enterocolitis– infant botulisminfant botulism– urinary tract diseaseurinary tract disease– sudden infant death syndrome sudden infant death syndrome
(SIDS)(SIDS)– ColicColic– wheezingwheezing
Reduces risk and severity of Reduces risk and severity of infectious illness among infectious illness among infantsinfants– diarrheadiarrhea– otitis mediaotitis media– lower respiratory infectionslower respiratory infections– bacteremiabacteremia– bacterial meningitisbacterial meningitis– necrotizing enterocolitisnecrotizing enterocolitis– infant botulisminfant botulism– urinary tract diseaseurinary tract disease– sudden infant death syndrome sudden infant death syndrome
(SIDS)(SIDS)– ColicColic– wheezingwheezing
Antibacterial PropertiesAntibacterial Propertiesfound in human milkfound in human milk
FactorFactor Shown, in vitro, to be active Shown, in vitro, to be active against:against:
Effect of HeatEffect of Heat
Secretory IgASecretory IgA E. Coli (also pili and capsular E. Coli (also pili and capsular antigens)antigens)
C. TetaniC. Tetani
C. DiphtheriaeC. Diphtheriae
K. pneumoniaeK. pneumoniae
Salmonella (6 groups)Salmonella (6 groups)
Shigella (2 groups)Shigella (2 groups)
Streptococcus, S. mutans, S. sanguis, Streptococcus, S. mutans, S. sanguis, S. mitis, S. salivarius, S. pneumoniae, S. mitis, S. salivarius, S. pneumoniae,
C. burnetti, C. burnetti,
H. influenzae H. influenzae
E. coli enterotoxin, E. coli enterotoxin,
V. Cholerae enterotoxinV. Cholerae enterotoxin
C. difficile toxinsC. difficile toxins
H. Influenzae capsuleH. Influenzae capsule
Stable at 56Stable at 56°C for °C for 30 min; 30 min;
some loss (0-30%) some loss (0-30%) at 62.5°C for 30 at 62.5°C for 30 min; min;
destroyed by destroyed by boiling boiling
IgM, IgGIgM, IgG V. Cholerae lipopolysaccharide; V. Cholerae lipopolysaccharide; E. coliE. coli
IgM destroyed and IgM destroyed and IgG decreased by a IgG decreased by a third at 62.5third at 62.5°C for °C for 30 min30 min
FactorFactor Shown, in vitro, Shown, in vitro, to be active to be active
Dependent E. coliDependent E. coli Destroyed by Destroyed by boilingboiling
Complement C1-C9 Complement C1-C9 (mainly C3 and C4)(mainly C3 and C4)
Effect not knownEffect not known Destroyed by Destroyed by heating at 56heating at 56°C for °C for 30 min30 min
LactoferrinLactoferrin E. ColiE. Coli Two-thirds Two-thirds destroyed at destroyed at 62.5°C for 30 min; 62.5°C for 30 min; essentially essentially destroyed by destroyed by boiling for 15 minboiling for 15 min
FactorFactor Shown, in vitro, Shown, in vitro, to be active to be active
against:against:
Effect of HeatEffect of Heat
LactoperoxidasLactoperoxidasee
Streptococcus, Streptococcus, Pseudomonas, E. Pseudomonas, E. coli, S. coli, S. typhimuriumtyphimurium
Destroyed by boilingDestroyed by boiling
LysozymeLysozyme E. coli, Salmonella, E. coli, Salmonella, Micrococcus Micrococcus lysodeikticuslysodeikticus
Some loss (0-23%) at Some loss (0-23%) at 62.562.5°C for 30 min; °C for 30 min; essentially destroyed by essentially destroyed by boiling for 15 minboiling for 15 min
Unidentified Unidentified factorsfactors
S. aureus, C. S. aureus, C. difficile toxin Bdifficile toxin B
Stable at autoclaving; Stable at autoclaving; stable at 56°C for 30 minstable at 56°C for 30 min
CarbohydrateCarbohydrate E. coli enterotoxinE. coli enterotoxin Stable at 85°C for 30 minStable at 85°C for 30 min
LipidLipid S. AureusS. Aureus Stable at boilingStable at boiling
Ganglioside Ganglioside (GMI like)(GMI like)
E. Coli enterotoxin, E. Coli enterotoxin, V. cholerae V. cholerae enterotoxinenterotoxin
Stable to boilingStable to boiling
Types of Breast milk
Foremilk
Hindmilk
Protective Factors in BMProtective Factors in BMProtective Factors in BMProtective Factors in BM
– BM is poor initiators and mediators of BM is poor initiators and mediators of inflammation (complement system, fibrinolytic, inflammation (complement system, fibrinolytic, coagulation system) but rich in anti-coagulation system) but rich in anti-inflammatory agents (sIGA, lysozyme); inflammatory agents (sIGA, lysozyme);
Provides Provides good mucosal barriergood mucosal barrier (growth (growth factors) factors) prevents attachment of bacteria prevents attachment of bacteria & antigen;& antigen;
– BM is poor initiators and mediators of BM is poor initiators and mediators of inflammation (complement system, fibrinolytic, inflammation (complement system, fibrinolytic, coagulation system) but rich in anti-coagulation system) but rich in anti-inflammatory agents (sIGA, lysozyme); inflammatory agents (sIGA, lysozyme);
Provides Provides good mucosal barriergood mucosal barrier (growth (growth factors) factors) prevents attachment of bacteria prevents attachment of bacteria & antigen;& antigen;
Nduati R. et al. JAMA 2000Nduati R. et al. JAMA 2000
Benefits of Breastmilk: InfantsBenefits of Breastmilk: Infants
Breastfeeding and premature Breastfeeding and premature infants:infants:
Premature infants fed their mother's milk were Premature infants fed their mother's milk were found to have decreased incidences of sepsis, found to have decreased incidences of sepsis, meningitis, and necrotizing enterocolitismeningitis, and necrotizing enterocolitis
Breastfeeding and premature Breastfeeding and premature infants:infants:
Premature infants fed their mother's milk were Premature infants fed their mother's milk were found to have decreased incidences of sepsis, found to have decreased incidences of sepsis, meningitis, and necrotizing enterocolitismeningitis, and necrotizing enterocolitis
Benefits of Breastmilk: InfantBenefits of Breastmilk: Infant
Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated
– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula
CMAJ 166 2002
– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula
JClin Microbiol 39 2001
Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated
– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula
CMAJ 166 2002
– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula
JClin Microbiol 39 2001
Benefits of Breastmilk: Safe Benefits of Breastmilk: Safe
Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated
– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula
CMAJ 166 2002
– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula
JClin Microbiol 39 2001
Breastmilk is sterile free of contamination whereas powdered infant formula maybe contaminated
– Weir reported an outbreak of Enterobacter Sakazakii in US based NICU due to contaminated infant formula
CMAJ 166 2002
– Van Acker et al reported 12 infants developed NEC; 2 died attributed to E. Sakazakii derived from contaminated infant formula
JClin Microbiol 39 2001
Benefits of Breastmilk: Safe Benefits of Breastmilk: Safe
Joint FAO/WHO Workshop on Enterobacter
Sakazakii and other Microorganisms in
Powdered Infant formula February 2004
Recommendations:
– Guidelines should be developed for the preparation, use and handling of infant formula to decrease the risk of infection
– Make use of Enterobacteriaceae rather than coliform testing as an indicator of hygienic control
Joint FAO/WHO Workshop on Enterobacter
Sakazakii and other Microorganisms in
Powdered Infant formula February 2004
Recommendations:
– Guidelines should be developed for the preparation, use and handling of infant formula to decrease the risk of infection
– Make use of Enterobacteriaceae rather than coliform testing as an indicator of hygienic control
Benefits of Breastmilk: Safe Benefits of Breastmilk: Safe
Benefits of Breastfeeding: MothersBenefits of Breastfeeding: Mothers
Prevents ObesityPrevents Obesity
Early return to pre-pregnancy Early return to pre-pregnancy weightweight
Prevents ObesityPrevents Obesity
Early return to pre-pregnancy Early return to pre-pregnancy weightweight
Breast Cancer
“Meta-Analysis on the Protective Effect of BF on Breast Cancer”. Labbock et al. Ped Clin North Am., 2001 Feb
Eleven studies were evaluated– Results:
RR: 0.54 to 0.85 for 1st 3-6 months of BF
RR: 0.4 to 0.72 for > 2 years
RR: 0.35 for > 6 years Conclusion:
Clear and consistent protective effect of BF on breast cancer have been found in all studies
Breast Cancer
“Meta-Analysis on the Protective Effect of BF on Breast Cancer”. Labbock et al. Ped Clin North Am., 2001 Feb
Eleven studies were evaluated– Results:
RR: 0.54 to 0.85 for 1st 3-6 months of BF
RR: 0.4 to 0.72 for > 2 years
RR: 0.35 for > 6 years Conclusion:
Clear and consistent protective effect of BF on breast cancer have been found in all studies
Benefits of Breastfeeding: Mothers
Benefits of Breastfeeding: Mothers
Ovarian CancerOvarian Cancer
““Breastfeeding and Risk to Ovarian Breastfeeding and Risk to Ovarian Cancer”Cancer”
– Rosenblatt 1993Rosenblatt 1993: : 20-25% 20-25% decrease in riskdecrease in risk for cancer for women who for cancer for women who
breastfed for at least 2 monthsbreastfed for at least 2 months
– Risch et al 1993 & Gwinn 1990:Risch et al 1993 & Gwinn 1990: Showed the Showed the protective effectprotective effect of lactation (RR 0.79 per of lactation (RR 0.79 per
year of lactation; 0.6 respectively)year of lactation; 0.6 respectively)
– Shoham 1994:Shoham 1994: 50% 50% decrease in risk fordecrease in risk for ovarian cancer ovarian cancer
Ovarian CancerOvarian Cancer
““Breastfeeding and Risk to Ovarian Breastfeeding and Risk to Ovarian Cancer”Cancer”
– Rosenblatt 1993Rosenblatt 1993: : 20-25% 20-25% decrease in riskdecrease in risk for cancer for women who for cancer for women who
breastfed for at least 2 monthsbreastfed for at least 2 months
– Risch et al 1993 & Gwinn 1990:Risch et al 1993 & Gwinn 1990: Showed the Showed the protective effectprotective effect of lactation (RR 0.79 per of lactation (RR 0.79 per
year of lactation; 0.6 respectively)year of lactation; 0.6 respectively)
– Shoham 1994:Shoham 1994: 50% 50% decrease in risk fordecrease in risk for ovarian cancer ovarian cancer
Benefits of Breastfeeding: Mothers
Benefits of Breastfeeding: Mothers
Family:– Purchase of formula costs the average poor
family (7,280.00/ month income) about P2,000.00
National Economy (NEDA):– Milk companies import S57.5 M (P3.1 B)
worth of infant formula
– Sell to people 7x cost (WHO) – P21.5 B or S405 B)
Family:– Purchase of formula costs the average poor
family (7,280.00/ month income) about P2,000.00
National Economy (NEDA):– Milk companies import S57.5 M (P3.1 B)
worth of infant formula
– Sell to people 7x cost (WHO) – P21.5 B or S405 B)
Benefits of Breastfeeding: Economy
Benefits of Breastfeeding: Economy
Longer-term Health Outcomes: Longer-term Health Outcomes: Maternal Maternal benefitsbenefitsLonger-term Health Outcomes: Longer-term Health Outcomes: Maternal Maternal benefitsbenefits
Reduces risk of chronic illness in Reduces risk of chronic illness in childhoodchildhood– Some food allergiesSome food allergies– Type-1 insulin dependent diabetesType-1 insulin dependent diabetes– LymphomaLymphoma– AsthmaAsthma– ObesityObesity
Reduces risk of chronic illness in Reduces risk of chronic illness in childhoodchildhood– Some food allergiesSome food allergies– Type-1 insulin dependent diabetesType-1 insulin dependent diabetes– LymphomaLymphoma– AsthmaAsthma– ObesityObesity
Steps to Encourage Breast-Feeding in the Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-FriendlyHospital: UNICEF/WHO Baby-Friendly
HOSPITAL INITIATIVESHOSPITAL INITIATIVES
– Provide all pregnant women with information and Provide all pregnant women with information and counselling.counselling.
– Document the desire to breast-feed in the medical Document the desire to breast-feed in the medical record.record.
– Document the method of feeding in the infant’s record.Document the method of feeding in the infant’s record.– Place the newborn and mother skin- to-skin, and Place the newborn and mother skin- to-skin, and
initiate breast-feeding within 1 hr of birth.initiate breast-feeding within 1 hr of birth.– Continue skin-to-skin contact at other times and Continue skin-to-skin contact at other times and
encourage encourage rooming-in.rooming-in.– Assess breast-feeding and continue encouragement Assess breast-feeding and continue encouragement
and teaching on each shift.and teaching on each shift.
MOTHERS TO LEARNMOTHERS TO LEARN
– Proper position and latch onProper position and latch on– Nutritive sucking and swallowingNutritive sucking and swallowing– Milk production and releaseMilk production and release– Frequency and feeding cuesFrequency and feeding cues– Expression of milk neededExpression of milk needed– Assessment of the infant’s nutritional Assessment of the infant’s nutritional
statusstatus– When to contact the clinicianWhen to contact the clinician
Steps to Encourage Breast-Feeding in the Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-FriendlyHospital: UNICEF/WHO Baby-Friendly
ADDITIONAL INSTRUCTIONSADDITIONAL INSTRUCTIONS
– Refer to lactation consultation if any concerns arise.Refer to lactation consultation if any concerns arise.– Infants should go to the breast at least 8-12 times/24 hr, Infants should go to the breast at least 8-12 times/24 hr,
day and night.day and night.– Avoid time limits on the breasts; offer both breasts at Avoid time limits on the breasts; offer both breasts at
each feeding.each feeding.– Do not give sterile water, glucose, or formula unless Do not give sterile water, glucose, or formula unless
indicated.indicated.– If supplements are given, use cup feeding, a Haberman If supplements are given, use cup feeding, a Haberman
feeder, fingers, or syringe feedings.feeder, fingers, or syringe feedings.– Avoid pacifiers in the newborn nursery except during Avoid pacifiers in the newborn nursery except during
Steps to Encourage Breast-Feeding in the Steps to Encourage Breast-Feeding in the Hospital: UNICEF/WHO Baby-FriendlyHospital: UNICEF/WHO Baby-Friendly
Review QuestionsReview Questions
1.1. What breast structure secretes breastmilk? What breast structure secretes breastmilk? What hormone is responsible for it?What hormone is responsible for it?
2.2. What are the 2 processes are responsible What are the 2 processes are responsible for breastmilk secretion & maintenance?for breastmilk secretion & maintenance?
3.3. Breastmilk is stored in what part of the Breastmilk is stored in what part of the breast?breast?
4.4. 3 phases of lactation?3 phases of lactation?
5.5. Hormone secreted during BF which could Hormone secreted during BF which could cause BM reduction if breast is not emptied cause BM reduction if breast is not emptied completely.completely.
6) What is the protein distribution of BM? What 6) What is the protein distribution of BM? What is the predominant protein component?is the predominant protein component?
7) How much calories is lost per day when bf?7) How much calories is lost per day when bf?
8) What are the 3 areas that must be 8) What are the 3 areas that must be addressed in BF based on the addressed in BF based on the recommendation of WHO? recommendation of WHO?
Thank You Thank You and and
God blessGod bless
Thank You Thank You and and
God blessGod bless
Breastmilk SubstitutesBreastmilk Substitutes
Infant Milk FormulasInfant Milk Formulas
Breastmilk SubstitutesBreastmilk Substitutes
Infant Milk FormulasInfant Milk Formulas
TYPES OF INFANT FORMULATYPES OF INFANT FORMULATYPES OF INFANT FORMULATYPES OF INFANT FORMULA
• Pre-term FormulaPre-term Formula• Catch-up Growth FormulaCatch-up Growth Formula• Standard Infant FormulaStandard Infant Formula
Nutrient Sources:Nutrient Sources:FOR INFANTS LESS THAN 2 YEARSFOR INFANTS LESS THAN 2 YEARS
Nutrient Sources:Nutrient Sources:FOR INFANTS LESS THAN 2 YEARSFOR INFANTS LESS THAN 2 YEARS
Three Indications for Use of Infant Three Indications for Use of Infant Formulas:Formulas:
As substitute ( or supplement) for human milk As substitute ( or supplement) for human milk in infants whose mother choose not to in infants whose mother choose not to breastfeed;breastfeed;
As a substitute for human milk in infants for As a substitute for human milk in infants for whom breastfeeding is medically whom breastfeeding is medically contraindicated;contraindicated;
As supplement for infants who do not gain As supplement for infants who do not gain weight appropriately.weight appropriately.
Three Indications for Use of Infant Three Indications for Use of Infant Formulas:Formulas:
As substitute ( or supplement) for human milk As substitute ( or supplement) for human milk in infants whose mother choose not to in infants whose mother choose not to breastfeed;breastfeed;
As a substitute for human milk in infants for As a substitute for human milk in infants for whom breastfeeding is medically whom breastfeeding is medically contraindicated;contraindicated;
As supplement for infants who do not gain As supplement for infants who do not gain weight appropriately.weight appropriately.
Nutrient Sources:Nutrient Sources:< 2 Years of Age< 2 Years of Age
Nutrient Sources:Nutrient Sources:< 2 Years of Age< 2 Years of Age
PRETERM FORMULA:PRETERM FORMULA:
Prescribed for premature until they have Prescribed for premature until they have reached reached 35-36 weeks35-36 weeks of gestation or gained of gestation or gained 2 2 kilograms.kilograms.
When given beyond recommended age may When given beyond recommended age may cause hypercalcemiacause hypercalcemia
Special Features:Special Features:
• Protein: Whey predominant formula at a Protein: Whey predominant formula at a level higher than breast milk & standard level higher than breast milk & standard infant formula infant formula (2.0 2.5g/100ml.)(2.0 2.5g/100ml.)
PRETERM FORMULA:PRETERM FORMULA:
Prescribed for premature until they have Prescribed for premature until they have reached reached 35-36 weeks35-36 weeks of gestation or gained of gestation or gained 2 2 kilograms.kilograms.
When given beyond recommended age may When given beyond recommended age may cause hypercalcemiacause hypercalcemia
Special Features:Special Features:
• Protein: Whey predominant formula at a Protein: Whey predominant formula at a level higher than breast milk & standard level higher than breast milk & standard infant formula infant formula (2.0 2.5g/100ml.)(2.0 2.5g/100ml.)
PRETERM FORMULAPRETERM FORMULAPRETERM FORMULAPRETERM FORMULA
FOLLOW-UP FORMULAFOLLOW-UP FORMULAFOLLOW-UP FORMULAFOLLOW-UP FORMULA
Liquid part of the weaning diet for infants Liquid part of the weaning diet for infants & children& children 12 mos12 mos - - 3 years of age;3 years of age;
Distribution of calories and nutrients is in Distribution of calories and nutrients is in between standard infant formula and whole between standard infant formula and whole cow’s milkcow’s milk
Protein is higher with the ratio of 20% whey Protein is higher with the ratio of 20% whey and 80% caseinand 80% casein
Example: Promil, Nan 2, Gain, MilumilExample: Promil, Nan 2, Gain, Milumil
Liquid part of the weaning diet for infants Liquid part of the weaning diet for infants & children& children 12 mos12 mos - - 3 years of age;3 years of age;
Distribution of calories and nutrients is in Distribution of calories and nutrients is in between standard infant formula and whole between standard infant formula and whole cow’s milkcow’s milk
Protein is higher with the ratio of 20% whey Protein is higher with the ratio of 20% whey and 80% caseinand 80% casein
Example: Promil, Nan 2, Gain, MilumilExample: Promil, Nan 2, Gain, Milumil
COMPOSITION OF VARIOUS NUTRIENT COMPOSITION OF VARIOUS NUTRIENT SOURCESSOURCES
COMPOSITION OF VARIOUS NUTRIENT COMPOSITION OF VARIOUS NUTRIENT SOURCESSOURCES
BM COW A PREM FF-BM COW A PREM FF-UPUP
Energy kcal/100mlEnergy kcal/100ml 6565 6767 6565 8181 6565
Protein G/100 mlProtein G/100 ml 1.11.1 3.53.5 1.51.5 2.42.4 2.82.8WheyWhey 60%60% 60%60% 20%20%CaseinCasein 40%40% 40%40% 80%80%
Fat G/100 mlFat G/100 ml 4.54.5 3.73.7 3.63.6 4.44.4 2.642.64
CHO G/100 mlCHO G/100 ml 6.86.8 4.94.9 7.27.2 8.68.6 8.188.18
CA mg/100 mlCA mg/100 ml 3434 117117 4444 95(75)95(75)P mg/100 mlP mg/100 ml 1414 9292 3333 53(40)53(40)
NA mmol/100 mlNA mmol/100 ml 0.70.7 2.22.2 0.640.64 1.41.4 1.571.57
Product used for children above 2 years Product used for children above 2 years to 10 yearsto 10 years
Provides nutrient necessary as they Provides nutrient necessary as they undergo transition from infant to adult undergo transition from infant to adult formulation.formulation.
• Protein is high ( 3 g/100 ml) from SodiumProtein is high ( 3 g/100 ml) from Sodium• Casseinate and soya proteinCasseinate and soya protein
CHO contains a blend of cornstarch and CHO contains a blend of cornstarch and sucrose with very minimal lactosesucrose with very minimal lactose
Product used for children above 2 years Product used for children above 2 years to 10 yearsto 10 years
Provides nutrient necessary as they Provides nutrient necessary as they undergo transition from infant to adult undergo transition from infant to adult formulation.formulation.
• Protein is high ( 3 g/100 ml) from SodiumProtein is high ( 3 g/100 ml) from Sodium• Casseinate and soya proteinCasseinate and soya protein
CHO contains a blend of cornstarch and CHO contains a blend of cornstarch and sucrose with very minimal lactosesucrose with very minimal lactose
Protein HydrolysatesProtein HydrolysatesProtein HydrolysatesProtein Hydrolysates
Definition:Definition: It refers to the product of an enzymatic It refers to the product of an enzymatic
degradation of protein to proteose, peptone, degradation of protein to proteose, peptone, peptide-AA mix and finally free AA mix.peptide-AA mix and finally free AA mix.
Types:Types:– Partial Hydrolysate:Partial Hydrolysate: Degradation of protein to Degradation of protein to
big, medium size peptides big, medium size peptides less antigenicity; less antigenicity;
– Complete Hydrolysate:Complete Hydrolysate: Degradation of protein Degradation of protein into small peptides and free AAinto small peptides and free AA..
Definition:Definition: It refers to the product of an enzymatic It refers to the product of an enzymatic
degradation of protein to proteose, peptone, degradation of protein to proteose, peptone, peptide-AA mix and finally free AA mix.peptide-AA mix and finally free AA mix.
Types:Types:– Partial Hydrolysate:Partial Hydrolysate: Degradation of protein to Degradation of protein to
big, medium size peptides big, medium size peptides less antigenicity; less antigenicity;
– Complete Hydrolysate:Complete Hydrolysate: Degradation of protein Degradation of protein into small peptides and free AAinto small peptides and free AA..
Protein HydrolysatesProtein Hydrolysates Protein HydrolysatesProtein Hydrolysates
Partially Hydrolyzed Formula:Partially Hydrolyzed Formula:– For For prophylaxisprophylaxis on high risk infants: on high risk infants:
FH of atopy, asthma, food allergyFH of atopy, asthma, food allergy
– Preparation:Preparation: Nan-HANan-HA
Extensively Hydrolyzed Formula:Extensively Hydrolyzed Formula:– For For treatmenttreatment of food allergy during of food allergy during
WHY WHY should CF be given? should CF be given?WHY WHY should CF be given? should CF be given?
Three Infant Feeding Periods:Three Infant Feeding Periods:
Nursing Period (1Nursing Period (1stst 6 months of 6 months of life):life):
Breastmilk or standard infant formula is Breastmilk or standard infant formula is sufficientsufficient to provide nutritional to provide nutritional requirements for normal growth;requirements for normal growth;
MILK MILK should be the should be the ONLYONLY source of nutrient. source of nutrient.
Three Infant Feeding Periods:Three Infant Feeding Periods:
Nursing Period (1Nursing Period (1stst 6 months of 6 months of life):life):
Breastmilk or standard infant formula is Breastmilk or standard infant formula is sufficientsufficient to provide nutritional to provide nutritional requirements for normal growth;requirements for normal growth;
MILK MILK should be the should be the ONLYONLY source of nutrient. source of nutrient.
Nursing Period Nursing Period (1(1stst 6 months of life): 6 months of life):
Nursing Period Nursing Period (1(1stst 6 months of life): 6 months of life):
DigestiveDigestive, , mucosal barriermucosal barrier and and renal renal
functionsfunctions are not well developed; are not well developed;
Stuff et al, JStuff et al, J pediatr,1990pediatr,1990
Transitional Period Transitional Period (6-10 months)(6-10 months)
Transitional Period Transitional Period (6-10 months)(6-10 months)
It is the transition from the It is the transition from the nursing periodnursing period to the to the adult adult modified periodmodified period
Milk (Milk (breastmilk / standard infant formulabreastmilk / standard infant formula) is ) is NONO longer longer adequateadequate to sustain the nutritional needs of to sustain the nutritional needs of growing infantsgrowing infants
It is the transition from the It is the transition from the nursing periodnursing period to the to the adult adult modified periodmodified period
Milk (Milk (breastmilk / standard infant formulabreastmilk / standard infant formula) is ) is NONO longer longer adequateadequate to sustain the nutritional needs of to sustain the nutritional needs of growing infantsgrowing infants
6-15 months6-15 months, , “critical learning period”“critical learning period” for for feeding: chewing & swallowing feeding: chewing & swallowing coordination is being developed; coordination is being developed;
FAILUREFAILURE of infants to go through this of infants to go through this process process feeding problems: feeding problems:
– dependence to MILK as source of nutrient dependence to MILK as source of nutrient – picky eaters / neophobicpicky eaters / neophobic– malnutrition (obesity/wasting ,anemia)malnutrition (obesity/wasting ,anemia)
6-15 months6-15 months, , “critical learning period”“critical learning period” for for feeding: chewing & swallowing feeding: chewing & swallowing coordination is being developed; coordination is being developed;
FAILUREFAILURE of infants to go through this of infants to go through this process process feeding problems: feeding problems:
– dependence to MILK as source of nutrient dependence to MILK as source of nutrient – picky eaters / neophobicpicky eaters / neophobic– malnutrition (obesity/wasting ,anemia)malnutrition (obesity/wasting ,anemia)
Modified Adult Period Modified Adult Period (>10 months)(>10 months)
Modified Adult Period Modified Adult Period (>10 months)(>10 months)
Physiologic mechanisms have Physiologic mechanisms have matured to matured to near adult proficiency;near adult proficiency;
Most of the nutrients Most of the nutrients MUSTMUST come from come from table foodstable foods with minimal alteration (cut with minimal alteration (cut into small pieces, bland);into small pieces, bland);
Taste ability & preferences have become Taste ability & preferences have become established.established.
Physiologic mechanisms have Physiologic mechanisms have matured to matured to near adult proficiency;near adult proficiency;
Most of the nutrients Most of the nutrients MUSTMUST come from come from table foodstable foods with minimal alteration (cut with minimal alteration (cut into small pieces, bland);into small pieces, bland);
Taste ability & preferences have become Taste ability & preferences have become established.established.
Scientific Rationale:Scientific Rationale:
– “ “Critical Window”Critical Window” for introducing “lumpy” for introducing “lumpy”
solid foods: if these are delayed beyond solid foods: if these are delayed beyond 10 10
mosmos increased risk of feeding difficulties increased risk of feeding difficulties
later onlater on
Northstone et al, 2001Northstone et al, 2001
– Ingestion of the types of foods depend on Ingestion of the types of foods depend on
the neuromuscular development of infantsthe neuromuscular development of infants
Scientific Rationale:Scientific Rationale:
– “ “Critical Window”Critical Window” for introducing “lumpy” for introducing “lumpy”
solid foods: if these are delayed beyond solid foods: if these are delayed beyond 10 10
mosmos increased risk of feeding difficulties increased risk of feeding difficulties
later onlater on
Northstone et al, 2001Northstone et al, 2001
– Ingestion of the types of foods depend on Ingestion of the types of foods depend on
the neuromuscular development of infantsthe neuromuscular development of infants
What kind of food would you give?What kind of food would you give?
What kind of food would you give?What kind of food would you give?
WHEN should CF be given? WHEN should CF be given? 6 months 6 months
WHEN should CF be given? WHEN should CF be given? 6 months 6 months
Signals that indicate readiness of the Signals that indicate readiness of the infant infant for CF:for CF: Birth weight has doubled;Birth weight has doubled;
Extrusion reflex has completely disappeared;Extrusion reflex has completely disappeared;
Has good head and neck control;Has good head and neck control;
Sits up with support;Sits up with support;
Signals that indicate readiness of the Signals that indicate readiness of the infant infant for CF:for CF: Birth weight has doubled;Birth weight has doubled;
Extrusion reflex has completely disappeared;Extrusion reflex has completely disappeared;
Has good head and neck control;Has good head and neck control;
Sits up with support;Sits up with support;
WHEN should CF be started?WHEN should CF be started? WHEN should CF be started?WHEN should CF be started?
Signals that indicate readiness of infant Signals that indicate readiness of infant for CF:for CF:
Opens mouth if wants food; turns head away Opens mouth if wants food; turns head away when not when not
interested anymore;interested anymore;
Has good chewing & swallowing coordination;Has good chewing & swallowing coordination;
Consumes about Consumes about 32 oz of milk32 oz of milk and wants more; and wants more;
Breastfeeds Breastfeeds > 10x> 10x and wants more and wants more
Signals that indicate readiness of infant Signals that indicate readiness of infant for CF:for CF:
Opens mouth if wants food; turns head away Opens mouth if wants food; turns head away when not when not
interested anymore;interested anymore;
Has good chewing & swallowing coordination;Has good chewing & swallowing coordination;
Consumes about Consumes about 32 oz of milk32 oz of milk and wants more; and wants more;
Breastfeeds Breastfeeds > 10x> 10x and wants more and wants more
Art of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary Food
Introduce Introduce oneone new food new food at timeat time to allow to allow infant to get use to it; continue same food infant to get use to it; continue same food for for 3-4 days3-4 days before giving another food; before giving another food;
Give very small amount of any new food at Give very small amount of any new food at the beginning, the beginning, 1-4 tsp1-4 tsp;;
Introduce Introduce oneone new food new food at timeat time to allow to allow infant to get use to it; continue same food infant to get use to it; continue same food for for 3-4 days3-4 days before giving another food; before giving another food;
Give very small amount of any new food at Give very small amount of any new food at the beginning, the beginning, 1-4 tsp1-4 tsp;;
Art of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary FoodArt of Introducing Complementary Food
Use thin puree consistency initially --> shift Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food gradually to a more viscous calorie-dense food
Mix foods with ones baby likes, to enhance Mix foods with ones baby likes, to enhance acceptability and nutrient contentacceptability and nutrient content
Cereals +BM: Enhanced acceptance of cereal during Cereals +BM: Enhanced acceptance of cereal during weaning!weaning!
Mennella et al, Pediatr Res, Mennella et al, Pediatr Res, 19971997
Use thin puree consistency initially --> shift Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food gradually to a more viscous calorie-dense food
Mix foods with ones baby likes, to enhance Mix foods with ones baby likes, to enhance acceptability and nutrient contentacceptability and nutrient content
Cereals +BM: Enhanced acceptance of cereal during Cereals +BM: Enhanced acceptance of cereal during weaning!weaning!
Mennella et al, Pediatr Res, Mennella et al, Pediatr Res, 19971997
Art of Introducing Complementary FoodArt of Introducing Complementary Food Art of Introducing Complementary FoodArt of Introducing Complementary Food
Once infant can sit with support at about Once infant can sit with support at about 6 6 mosmos , give fluid (milk or water) using , give fluid (milk or water) using trainer’s cuptrainer’s cup;;
By By 12 months12 months of age milk should be given of age milk should be given by the by the cup or glass;cup or glass;
BOTTLESBOTTLES should be should be OUTOUT by this time! by this time!
Once infant can sit with support at about Once infant can sit with support at about 6 6 mosmos , give fluid (milk or water) using , give fluid (milk or water) using trainer’s cuptrainer’s cup;;
By By 12 months12 months of age milk should be given of age milk should be given by the by the cup or glass;cup or glass;
BOTTLESBOTTLES should be should be OUTOUT by this time! by this time!
Avoid adding salt and sugarAvoid adding salt and sugar
When baby is able to chew at aboutWhen baby is able to chew at about 8-10 8-10 monthsmonths, gradually switch to finely chopped , gradually switch to finely chopped foods foods
DO NOTDO NOT continue soft smooth foods for too continue soft smooth foods for too longlong
Avoid adding salt and sugarAvoid adding salt and sugar
When baby is able to chew at aboutWhen baby is able to chew at about 8-10 8-10 monthsmonths, gradually switch to finely chopped , gradually switch to finely chopped foods foods
DO NOTDO NOT continue soft smooth foods for too continue soft smooth foods for too longlong
Art of Introducing Complementary Art of Introducing Complementary FoodFood
Art of Introducing Complementary Art of Introducing Complementary FoodFood
Art of Introducing Complementary Art of Introducing Complementary foodsfoods
Art of Introducing Complementary Art of Introducing Complementary foodsfoods
By By 12 months12 months,, most of the nutrient should most of the nutrient should come from come from table food table food (modified); infants have (modified); infants have attained attained physiologic maturity of adult physiologic maturity of adult proficiencyproficiency;;
Encourage infant to try new flavors Encourage infant to try new flavors as a variety of foods is important !as a variety of foods is important !
* FNRI-DOST, Nutrition Guidelines for Filipinos, * FNRI-DOST, Nutrition Guidelines for Filipinos, 20002000
By By 12 months12 months,, most of the nutrient should most of the nutrient should come from come from table food table food (modified); infants have (modified); infants have attained attained physiologic maturity of adult physiologic maturity of adult proficiencyproficiency;;
Encourage infant to try new flavors Encourage infant to try new flavors as a variety of foods is important !as a variety of foods is important !
* FNRI-DOST, Nutrition Guidelines for Filipinos, * FNRI-DOST, Nutrition Guidelines for Filipinos, 20002000