1.

03b
August 8, 2016
BREASTFEEDING (PART 2)
Dr. Nellie Gundao
Department of Pediatrics

TOPIC OUTLINE Protein 1.6%

Fat 1.6%
I. Forms of Cow’s Milk Carbohydrates 11%
II. Milk Not Recommended For Infants (disproportionately
III. Feeding During the First 6 Months of Life high)
a. Feeding Schedule Minerals 0.36%
IV. Feeding During the Second 6 Months of Life 6. DRIED MILK
V. Preparation of the Prospective Mother for  spraying whole or pasteurized milk into a bottle
Breastfeeding chamber by using revolving drums at a very high
VI. Establishing and Maintaining the Milk Supply speed so that the water is volatilized immediately,
VII. Weaning from Breastfeeding or by freeze-drying
VIII. Contraindications to Breastfeeding  Fine curds are produced because the protein is
IX. Choosing the Right Milk for your Baby altered by the process of heating
a. Artificial Feeding, Bottle Feeding or Formula  Vitamin C is not affected by the drying process
Feeding 7. SKIMMED DRIED MILK
b. Infant Formula  fat is removed before the milk is dried so that the
c. Follow-On Formula fat content is only 0.05%
d. Specialty Formula  half skimmed dried milk has a fat content of 1.5%
 useful for patients who have fat intolerance,
FORMS OF COW’S MILK for those recovering from diarrhea, and for some
*This section on the forms of cow’s milk were not discussed in the prematures
lecture. All information below obtained from 2A 2017: 8. FERMENTED MILK
1. CERTIFIED MILK  The acidity of the sour milk is responsible for the
 there is strict supervision of dairies and their changing of the casein curds.
personnel.  Buttermilk
 eliminates the principal source of contamination of  Made from milk that has been allowed to turn sour
milk by nature and its fat removed by churning
2. PASTEURIZED MILK  This process is almost always contaminated
 heating the milk at 63°C for 30 mins or for 15secs  To prevent this, sterile skimmed milk is now
at 72°C followed by rapid cooling to 65°C inoculated with some lactic acid-producing
 destroys all pathogenic bacteria but only 99% of bacteria
saprophytes o Lactobacillus acidophilus
 should be kept at 10°C and should not be used after o Lactobacillus bulgaricus
48hrs o Streptococcus lacticus
3. HOMOGENIZED MILK 9. FERMENTED WHOLE MILK
 processing of milk so that the fat globules are  After, inoculation, the milk is incubated at 27-30oC
broken into a fine emulsion by passing milk for 6-12hrs after which it is refrigerated for several
through a fine aperture at high pressure at days.
pasteurization temperature  Protein milk
 fine emulsion will prevent creaming & renders fat  Introduced by Finkelstein
more easily assimilated  For tx of diarrhea
 is also the method used to incorporate vit D in milk  Lately, it has been proven that the putrefaction
4. EVAPORATED MILK flora it produces is of no value
 evaporated in vacuum at 55-60°C to about 50% of 10. ACID MILK
its volume  Prepared by the addition of dilute material or
 then homogenized, sealed in cans and autoclaved at organic acids to the milk
116°C for some time to destroy spores  Marriott popularized the lactic acid milk
 can cause some damage to the quality of protein 11. FILLED MILK
5. CONDENSED MILK
 carbohydrate content about 60% when diluted  fat content of whole milk is replaced by vegetable
 Caloric value: 67cal/dl oil
 only used for short period of time when a high  Coconut oil
caloric formula is needed o Most widely used in the Philippines
 less fat soluble vitamins &vit. C
o Has low oxidative deterioration & most
 keeping quality & cheap cost

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available
o Lacks the proper types of fatty acids such as
linoleic acid
o To increase the supply of these FA, corn oil is
added
o However, mixture of coconut oil and corn oil
increases the amount of saturated fatty acids
 Can be used for older infants who can
be given other fat-containing foods
12. RECOMBINED MILK
 When separated nonaqueous ingredients are
mixed together with or without reinclusion of
water, there is a recombination
 For example, in condensed milk recombination, the
butterfat & non-fat milk solids are put together
again.
13. RECONSTITUTED MILK
 The remaking of any milk product to
approximate the composition of fresh cow’s milk
 Hence, if powdered milk made directly from fresh
milk is being used, all that needs to be done is to
add water.
14. INFANT FORMULAS
 Generally used as breast milk substitutes
 Provides 20 cal/oz.
15. FOLLOW-ON FORMULAS
 There is high risk of hypernatremic dehydration
due to high potential renal solute load.
16. SPECIAL FORMULA
 These are formulas where either carbohydrates,
protein, fat or all of these components have been
altered to address the specific needs of certain
metabolic or gastrointestinal problems
 Examples:
o Phenylalanine-free formulas for infants with
PKU
o Protein Hydrolysates for infants with cow’s
milk allergy
o Lactose-free formulas for those with lactose
intolerance
MILK NOT RECOMMENDED FOR INFANTS
1. WHOLE COW’S MILK
• Not recommended for infants less than 1 year of age.
• Its CHON content is much higher than that found in
breastmilk (21% vs 7-16%) thus increasing its renal
solute load.
• Low in iron
• Its use may result in occult blood loss in stools
2. SKIMMED MILK
• Very low fat content
• Deficient in vitamin c and iron
3. GOAT’S MILK
• High protein content
• Deficient in folic acid, iron and its CHO content is only
25% as compared to 35-65% of breastmilk
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Breastfeeding (Part 2)
FEEDING DURING THE 1ST SIX MONTHS OF LIFE
FEEDINGS:
 Should be initiated as soon after birth as possible
 Maintains normal metabolism during the transition
from fetal to extrauterine life
 Promotes maternal-infant bonding (especially breastfeeding)
 Most infants can start breastfeeding shortly after
birth, almost always within4-6 hours
 Condition: if feedings must be withheld for several
hours: parenteral fluids should be administered
Feeding Schedule
 is based on “self-regulation” by the infant
 regular schedule by 1 month of age
 By the end of the 1st week of life, most healthy
infants will want 6-9 feedings/24 hrs.
Generalities
 Breast-fed infants prefer shorter feeding intervals
than formula-fed infants
 80-90 ml feeding: amount taken by most infants by
the end of the 1st week of life
 Satisfactory feeding: if the infant is no longer losing
weight by the end of the 1st week of life and is
gaining weight by the end of the 2nd week
 Most infants will wake up for a middle-of-the-night
feeding until 3-6 weeks of age, some never desire
this feeding and others continue to desire it well
beyond 3-6 weeks of age.
 4-8 mos. of age: many infants will lose interest in the
late evening feeding
 9-12 mos. of age: most will be satisfied with 3
meals/day plus snacks
Number of Feedings Daily
 The number of feedings required per day decreases
throughout the 1st yr. of life
o From 8 or more shortly after birth to only 3 or 4
at 1 yr. of age
 For the 1st 1-2 months, feedings are taken
throughout the 24-hr period
o Thereafter, as the quantity of milk consumed at
each feeding increases and the infant adjusts his
or her demand to the family pattern of daytime
activities, the infant usually sleeps for longer
periods at night.
FEEDING DURING THE 2ND SIX MONTHS OF LIFE
 By 6 months of age, the infant's capacity to digest and absorb
a variety of dietary components as well as to metabolize,
utilize, and excrete the absorbed products of digestion is
near the capacity of the adult.
 With the eruption of teeth, the role of dietary carbohydrate
 Breastfeeding (Part 2)

in development of dental caries must be considered. • Proper balance of rest and exercise
 Although it is clear that all nutrient needs during this period • Freedom from worry
can be met with reasonable amounts of currently available • Early and sufficient treatment of any intercurrent disease
infant formulas, addition of other foods after 4–6mos. of age
is recommended.
ESTABLISHING AND MAINTAINING THE MILK SUPPLY
MAJOR STIMULUS: regular and complete emptying of the
 In contrast, the volume of milk produced by many women
breasts.
may not be adequate to meet all nutrient needs of the breast-
RECOMMENDATIONS
fed infant beyond about 6 mos. of age. This is particularly
• Exposing the nipples to air
true for iron. • Applying pure lanolin
 Thus, for breast-fed infants, complementary foods are an • Avoiding Soap, alcohol and tincture of benzoin
important source of nutrients • Changing disposable nursing pads lining the brassiere cups
o Complementary foods (i.e., the additional foods, frequently
including formulas, given to the breast-fed infant) or • Nursing more frequently
replacement foods (i.e.,food other than formula given • Manually expressing milk
to formula-fed infants) should be introduced in a • Nursing in different positions
stepwise fashion to both breast-fed and formula-fed • Keeping the breast dry between feedings
infants, beginning about the time the infant is able to sit If nipple tenderness is sufficient to make the mother
unassisted, usually between 4–6 mos. of age apprehensive,
o Cereals, a good source of iron, should usually be the • The milk-ejection reflex may be delayed
first such foods given. (e.g. Cerelac) • This leads to frustration of the infant and increasingly
o Vegetables and fruits are introduced next, followed vigorous nursing, which further injures the nipple and
shortly by meats and finally, eggs. areolar area
 The order in which these foods are introduced probably is
not crucial, but only one new food should be introduced at a WEANING FROM BREASTFEEDING
time, and additional new foods should be spaced by at least  Most infants gradually reduce the volume and the frequency
3–4 days to allow detection of any adverse reactions to each of breast-feedings between 6 and 12 months of age after
they become accustomed to solid foods and liquids by bottle
newly introduced food.
and/or cup.
NUTRITIONAL FACTS
 As they demand less milk, the mother's supply gradually
diminishes without causing discomfort from engorgement.
Human Infant Cow Follow-  The breast-feedings are eventually replaced with formula,
milk formula up usually over several days, and the infant is weaned
formula completely
Calories 20 20 20  Praise, loving attention, and cuddling are vital to
Protein 1.1 1.8 3.3 2.2 successful weaning
Carbohydrates
CONTRAINDICATIONS TO BREASTFEEDING*
Fat
Mothers with:
Na 7 16 22 20  HIV infection
Ca 300 800 1200 1100  Septicemia
P 150 600 950 800  Active tuberculosis
 Typhoid fever
 Breast cancer
*See Appendix for a summary of infant feeding skills in the two  Malaria
feeding periods (1st and 2nd 6 months of life)  Substance abuse and severe neuroses or psychoses also are
contraindications to breastfeeding
PREPARATION OF THE PROSPECTIVE MOTHER FOR  Allergens to which the infant is sensitized can be conveyed
BREASTFEEDING in the milk, but the presence of such allergens is rarely a
valid reason to stop breastfeeding.
• The physician should discuss the advantages of breast-
*See Appendix: Acceptable Medical Reasons for Use of Breast-
feeding with the mother as early as the midtrimester of
Milk Substitutes (WHO 2009)
pregnancy or whenever the mother begins planning for her
infant.
• Many women must be reassured that breast tone will be CHOOSING THE RIGHT MILK FOR YOUR BABY
preserved (before delivery and during the nursing period)  Most infants gradually reduce the volume and the frequency
of breastfeedings between 6 and 12 months of age after they
become accustomed to solid foods and liquids by bottle
FACTORS FOR SUCCESSFUL BREASTFEEDING: and/or cup.
• Good health and adequate nutrition
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 As they demand less milk, the mother's supply gradually  Most are available in powder, concentrated liquid intended
diminishes without causing discomfort from engorgement. to be diluted 1:1 with water), and ready-to-feed forms.
 The breast-feedings are eventually replaced with formula, Follow-On Formula
usually over several days, and the infant is weaned  also known as toddler formula
completely.  for 6 months of age up to 2 years old
 There are two categories of formula:
Specialty Formula
o “Starter” formulas are designed for babies 0 - 6
Cow’s Milk Protein-Based Formulas
months
 These are heated cow’s milk protein, lactose and minerals
o “Follow-on” formula can be offered to babies older
from cow’s milk, vegetable oils, mineral and vitamins.
than 6 months.
 The amount of each nutrient is set to the standards based on
 There are also a range of specialty formulas available for
levels in breast milk.
babies with problems associated with prematurity, lactose
intolerance, milk allergy, reflux and other more serious
conditions. Soy Formulas
 With the exception of some of the specialty formulas, all  These uses soy as protein source
infant formulas are made up to provide the same amount of  These are used for infant with hereditary lactase deficiency,
energy (calories) per ounce. galactosemia and/or documented secondary lactose
 There is very little difference between the different brands. intolerance.
When choosing a formula for your baby, the most expensive  Examples: Infasoy (Cow & Gate), Enfamil &ProSobee(Mead
is not necessarily the best. Regulations on the manufacture Johnson), Nurture Soya & Isomil (Abbot Nutrition)
of infant formula are very strict in most countries, which
means the different brands of formulas are generally very Protein Hydrolysate Formulas
similar in nutritional content.  These are partially hydrolyzed which contains oligopeptides,
or are extensively hydrolyzed which contains peptides.
Artificial Feeding, Bottle Feeding or Formula Feeding  Extensively hydrolyzed formulas may be more effective in
 Artificial or bottle feeding - the use of bottles for feeding the preventing atopic disease. These are recommended for
infant infants intolerant to cow milk or soy proteins.
 Mixed feeding- the infant receives both breastfeeding and  Examples: Nutramigen (Mead Johnson), Pregestamil
bottle feeding
 Mixed feeding can be done by: Amino Acid Formulas
o Supplemental - when bottle is substituted for a breast
o Complemental- when the bottle is given after the breast  These are peptide-free formulas that contain mixes of
feeding has been completed essential and non-essential amino acids.
 These formulas offer complete nutrition for infants.
Infant Formula  These are for infants who are unable to tolerate extensively-
 Objective nutritional studies of growing infants younger hydrolyzed formulas.
than 4– 6 mos. of age (e.g., rate of growth in weight and  Amino acid-based formulas are also known as “elemental”
length, normality of various constituents in blood, formulas.
performance in metabolic studies, body composition) differ
minimally, if at all, between infants fed human milk and
infants fed modern infant formulas. REFERENCES
 Modern infant formulas are excellent substitutes for human Kliegman, R., & Nelson, W.E. (2016). Nelson textbook of pediatrics.
milk Philadelphia: W.B. Saunders Co.
COMPOSITION OF INFANT FORMULAS
 All must contain minimum amounts of all nutrients known Transes by 2A 2017 and 2A 2018
or thought to be required by infants, and increasing
emphasis is being placed on not exceeding a reasonable
maximum content of each.
 Minimum recommended amount of each nutrient is greater
than the amount of that nutrient in human milk can.
o Perceived lower bioavailability of formula vs. human
milk nutrients.
 Most infant formulas contain a protein source, usually a
mixture of bovine milk proteins but also soy protein or a
variety of hydrolyzed proteins, lactose and/or other sugars,
a mixture of vegetable oils, mineral salts, and vitamins.

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APPENDIX

FEEDING SKILLS FROM BIRTH TO 36 MONTHS

Age (months) Feeding/ Oral Sensorimotor
Birth to 4-6 Nipple feeding, breast or bottle
Hand on bottle during feeding (2-4 mos.)
Maintains semi-flexed posture during feeding
Promotion of infant-parent interaction
6-9 (transition Feeding more in upright position
feeding) Spoon feeding thin, pureed foods
Suckle pattern initially suckle, suck
Both hands to hold bottle
Finger feeding introduced
Vertical munching of easily dissolvable solids
Preference for parents to feed
9-12 Cup drinking
Eats lumpy, mashed food
Finger feeding for easily dissolvable solids
Chewing includes rotary jaw action
12-18 Self-feeding, grasps spoon with whole hand
Holds cup with 2 hands
Drinking with 4-5 consecutive swallows
Holding and tipping bottle
>18-24 Swallowing with lip closure
Self-feeding predominates
Chewing broad range food
Up-down tongue movements precise
24-26 Circulatory jaw rotations
Chewing with lips closed
One-handed cup holding and open cup drinking with no spilling
Using fingers to fill spoon
Eating wide range of solid food
Total self-feeding, using fork

Acceptable Medical Reasons for Use of Breast-Milk Substitutes (WHO 2009)

Infant Conditions Indications

Infants who should not receive a. Infants with classic galactosemia: a special galactose-free formula is needed.
breast milk or any other milk b. Infants with maple syrup urine disease: a special formula free of leucine,
except specialized formula.
isoleucine and valine is needed.
c. Infants with phenylketonuria: a special phenylalanine-free formula is needed (some
breastfeeding is possible, under careful monitoring).

Infants for whom breast milk
remains the best feeding option
but who may need other food in
addition to breast milk for a
limited period.
a. Infants born weighing <1500 g (very low birth weight).
b. Infants born at <32 weeks of gestational age (very pre-term).
c. Newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic
adaptation or increased glucose demand (such as those who are preterm, small for
gestational age or who have experienced significant intrapartum hypoxic/ischaemic
stress, those who are ill and those whose mothers are diabetic)if their blood sugar fails
to respond to optimal breastfeeding or breast-milk feeding.

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Maternal Conditions
Maternal conditions that may justify
permanent avoidance of breastfeeding
Maternal conditions that may justify
temporary avoidance of breastfeeding
Maternal conditions during which
breastfeeding can still continue,
although health problems may be of
concern
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Breastfeeding (Part 2)
Indications
HIV infection1: if replacement feeding is acceptable, feasible, affordable, sustainable
and safe (AFASS)
a. Severe illness that prevents a mother from caring for her infant (e.g. sepsis).
b. Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the
mother’s breasts and the infant’s mouth should be avoided until all
active lesions have resolved.
c. Maternal medication:
- sedating psychotherapeutic drugs, anti-epileptic drugs and opioids and their
combinations may cause side effects such as drowsiness and respiratory depression
and are better avoided if a safer alternative is available
- radioactive iodine-131 is better avoided given that safer alternatives are available -
a mother can resume breastfeeding about two months after receiving this
substance;
- excessive use of topical iodine or iodophors (e.g., povidone-iodine), especially on
open wounds or mucous
membranes, can result in thyroid suppression or electrolyte abnormalities in the
breastfed infant and should be avoided;
- cytotoxic chemotherapy requires that a mother stops breastfeeding during
therapy.
a. Breast abscess: breastfeeding should continue on the unaffected breast; feeding
from the affected breast can resume once treatment has started.
b. Hepatitis B: infants should be given hepatitis B vaccine, within the first 48 hours
or as soon as possible thereafter.
c. Hepatitis C.
d. Mastitis: if breastfeeding is very painful, milk must be removed by expression to
prevent progression of the condition.
e. Tuberculosis: mother and baby should be managed according to national
tuberculosis guidelines.
f. Substance use:
- maternal use of nicotine, alcohol, ecstasy, amphetamines, cocaine and related
stimulants has been
demonstrated to have harmful effects on breastfed babies
- alcohol, opioids, benzodiazepines and cannabis can cause sedation in both the
mother and the baby.
* Mothers should be encouraged not to use these substances, and given
opportunities and support to abstain.