The Principles

of
Formula-feeding
and
Mixed-Feeding
of a
Healthy Baby
Bottle-feeding (formula-feeding, artificial feeding)
is feeding of a baby with formulated milk products
during the first year of life.

Classification of milk mixes.

 Highly Adapted mixes
 Partly Adapted mixes
 Nonadapted mixes

Each of them is divided into

insipid and fermented ones.
The aim of the process of adaptation is to bring closer
cow's milk to breast milk.
I. Adaptation of proteins and minerals

Why is it necessary?

 The quantity of proteins in cow’s milk is greater than

in breast milk.
 Correlation between albumin and casein in cow's milk
is 1 to 4, while in breast milk it is 3 to 2.
 The ability of babies to digest food and assimilate
proteins is limitted. It leads to the decrease in
biolassimilation and biological value of cow's milk.
 Disbalance in aminoacid structure in cow’s milk
For example:
In the cow’s milk there is more
tyrosine and phenylalanine,

toxic influence on the brain

Valine, leucine, isoleucine

stimulates insulin production

increasing growth of the baby

I. First step in adaptation is:

- decrease of quantity of proteins from 33–35

g/L in cow’s milk to 15-17 g/L in mixes

- decrease of quantity of minerals from 7.0 g/L

in cow’s milk to 3.5 g/L in mixes.

Achieve it demineralized milk serum which has

undergone special preparation is used.
 With the help of this process the serum proteins
and casein correlation becomes 3:2.

The concentration of active osmotic indicators

decreases.
For example:
- correlation between K and Na gets more than 2 (1:2)
- correlation between Ca and P is not less than 2 (2:1)

The increase of biological value of proteins in mixes

achieves 60-80% and the structure improves
(the decrease of quantity of toxigenic acids).
Taurine is a compulsory element of all highly
adapted mixes, it is added to all of them.

The quantity added is 45-54 mg/L

Taurine is a free aminoacid with S (Sulfur)

in its structure.

In breast milk the quantity of Taurine is

50 mg/L and in cow’s milk it is 1.4 mg/L
The characteristics of Taurin:
 formation of brain and retina
 digestion and assimilation of fats
 membrane stabilization
 antioxigen action
 influences protective qualities of
the organism and haemopoetic
function of marrow

After all these operation take place

in proteins mixes become close to
breast milk.
 II. Adaptation of fat components
The quantity of fat in cow’s and breast milk is approximately
the same and makes up 35-38 g/L.

However they differ in quality composition of fats.

In cow’s milk in contrast to female milk there are
less polyunsaturated fatty acids.
These acids are not synthesized in the baby’s
organism.
That is why to adapt cow’s fat to female one partial
substitution of cow’s fats with oil is carried out.
Vitamin E
Soya lecithin
L-carnitin
PS) Soya lecithin and L-carnitin which are natural
emulgators (emulgent) and help in splitting and
assimilation of milk fat.

L-carnithin has by vitaminlike action, takes

part in choline synthesis that prevents liver
and fat metabolism disfunction.
III. Adaptation of carbohydrate components
The quantity of carbohydrate in breast milk
is greater than in cow’s milk.
Aim of adaptation is carbohydrate quantity increase.

Cow’s milk female milk contain different types of lactose

L-lactose is found β-lactose is found
in cow’s milk in human milk

The qualities of carbohydrate are necessary observed:

1. level of sweetness; 2. osmolarity 3. bifidogenity

The carbohydrate that possesses almost
all of these qualities is dextrin-maltose
(a natural polymer of glucose).
As it:
 is easily instant
 facilitates the growth of bifida flora
 gets absorbed more slowly
 low osmolarity

NB) It is especially important for

premature children who are at the risk
of necrotic enterocolitis if they are fed
with high osmolarity level mixes.
 IV. Adaptation of iron and vitamins
The content of iron in cow’s milk and breast milk
is approximatelly the same.

However the level of absorption differs.

In human milk – 50%, in cow’s milk – 10%.

The reason is in low level (4 times less) of

bioactive Fe3+.

As a result low level of lactoferrin is observed.

So, mixes are enriched with organic and inorganic
easily assimilated salts of iron.
Mixes are also enriched with
vitamins D, C, B, A and folic acid,
lysozyme and probiotics
(Lactobacillus, Bifidobacillus).

So, during the first years of child’s life

adapted mixes which according to
main feeding ingredients and
osmolarity to maximum degree
resemble human milk are used.
 The specific group of mixes is represented by the
so-called casein-formulas, in which serum proteins
and casein correlation is 30/70 or 20/80.
In these mixes casein is the main protein.
As for the other components these mixes correspond
to highly adapted mixes.
The level of assimilation of casein-mixes is rather
high, because they undergo previous splitting
(the process of hydrolysis).
They are digested longer and the child
doesn’t feel hungry for a longer period.
It’s especially to use such mixes for
feeding children who often eruct.
 For feeding babies who are more than 6 months
old the so-called “further formulas” or partially
adapted formulas are recommended.

There is always number 2 in the mix’s name.

It means that it should be used for the babies aged
from 6 to 12 months.
In these mixes the carbohydrate component
besides lactose contains also saccharose and starch.
Fat, mineral and vitamin component are in
optimal balance.
Nutritions and caloric value of these mixes is
higher than of the highly adapted ones, that
corresponds to the demands of the babies of
this age.
 The stomach empties more rapidly after human milk
than after whole cow's milk.
During formula feeding number of feedings daily is:

0 - 2 months – 7 times (in 3 hours);

2 - 4 months – 6 times (in 3.5 hours);

4 -12 months – 5 times (in 4 hours).

 Feeding up:

1 feeding up: enter with 5,5-6 months

as vegetable mashed potatoes (pure);
2 feeding up: enter from 6,5-7 months
as 5-10 % milk porridges (buckwheat,
rice, oat porridge, semolina) + 5 % of
sugar.
In the first 10 days give 5 % porridge.
3 feeding up: sour-milk products
(curd, yogurt) from 8 months.
A child is requirement for the basic food components
(g / kg / 24h) during formula feeding

Age Proteins Fats Carbohydrates

0-3 mo 2.0-2.2 6.5

4-6 mo 2.6 6.0 13.0 (12-14)

7-12 mo 2.9 5.5

 Mixed feeding is feeding of a baby with a
combination of both human and formulated milk.

For supplementary feedings

use the same mixes
as for formula feeding
Methods of carrying out of the mixed feeding:
1. The classical method
is used at any form of the mixed feeding

Each feeding the child put to a breast, and then finishes

feeding a dairy mix up to necessary volume.
It allows keeping lactation at mother.
The method uses till 3 months of a life.
 2. Method of alternation – use under condition of when
at mother it is kept ½ and less necessary quantity of milk.

The child is put to a breast through feeding and completely

covers necessary quantity feed female milk; through feeding the
necessary quantity of milk becomes covered by an artificial mix.

The method is used after 3 months of life.

 Feeding of the child from 1 - 3 years old

The child after one year continues to grow intensively,

there is a further development and perfection
of his /her separate bodies and systems in this
connection the high need for a plastic and power
material is still kept.

Therefore the balanced diet, which meets

physiological needs of a growing organism, is the major
condition of harmonious development of the child.
 For the rational organization of feeding of
children aged 1-3 years old the division of children
into two subgroups is necessary:

- from 1 till 1.5 years

- from 1.5 till 3 years
For correct construction of a diet of the child it is necessary to
know percentage (%) distribution daily calories on feedings
and need for the basic food components and energy.
A children daily need in energy is
1200 – 1300 kcal for children
from 1-1.5 years and
1400 – 1600 kcal for children
from 1.5-3 years.
 Percentage distribution of daily calories on feedings
1 – 1.5 years 1.5 – 3 years
The first breakfast – 20% A breakfast – 25%
The second breakfast –15% A lunch – 35%
A lunch – 30% A mid-evening snack-15%
A mid-evening snack – 15% A dinner – 25%
A dinner – 20% ----

Requirements for basic foods components (g/kg) and energy (kcal/kg

1 – 1.5 years 1.5 – 3 years
Proteins 3.5 – 4.0 4.0
Fats 3.5 – 4.0 4.0
Carbohydrates 15.0 – 16.0 16.0
Kcal 110 100
Prolonged or severe nutritional deficiency will result
in malnutrition.
Severe protein-energy malnutrition in children usually leads to
marasmus, with a weight less than 60% of the mean for age,
and a wasted, wizened appearance.
Oedema is not present.
Skinfold thickness, and affected children are often withdrawn
and apathetic.

Marasmus in a 3-month-old baby who was unable to

establish breast-feeding because of a cleft palate
In addition, there may be:
 a 'flaky-paint' skin rash with
hyperkeratosis and desquamation
 a distended abdomen and enlarged
liver
 angular stomatitis
 hair which is sparse and
depigmented (redness of the hair)
 diarrhoea, hypothermia,
 bradycardia and hypotension
 low plasma albumin, potassium,
glucose and magnesium.
 Three views of marasmus
Photos show the front and back of the
same child.
The child has severe wasting.
From the front, the ribs show, and there is
loose skin on the arms and thighs.
The bones of the face clearly show.
From the back, the ribs and spine show.
Folds of skin on the child’s buttocks and
thighs look like “baggy pants.”
• This girl is 2 years old. She
weighs 4.75 kg and is 67.4
cm in length.

She is severely wasted.

 Kwashiorkor
a particular manifestation of severe
protein-energy malnutrition in
some developing countries where
infants are weaned late from the
breast and the young child's diet
is high in starch.

Kwashiorkor is another manifestation of severe

protein malnutrition, in which body weight is 60-80% of
expected and oedema is present.
Signs of kwashiorkor
This child has generalized oedema.

Feet, legs, hands, arms and face appear

swollen.

Several patches of discoloured, cracking

skin are visible, but you would have to
undress the child to see if there are
more.

There may be a fissure (large crack) on

the child’s ankle.
This child has scaly patches on
the hands and thighs.

There is also generalized oedema

(swollen legs, hands, arms, and
face).
 Oedema of both feet
Both feet and legs are swollen. Notice
the “pitting” oedema in the lower legs.

This child has oedema of both feet as

well as the lower legs.
She is aged 1 year and 8 months,
weighs 6.5 kg, and is 67 cm in length.
Her weight is increased due to fluid
retention.
Marasmic kwashiorkor

This child has moderate oedema seen

in the feet and lower legs.
At the same time, there is severe
wasting of the upper arms, and the ribs
and collar bones clearly show.
 MALABSORPTION

Disorders affecting the digestion

or absorption of nutrients manifest as:
 abnormal stools
 failure to thrive or poor growth in most but
not all cases
 specific nutrient deficiencies, either singly
or in combination.
Coeliac disease is an enteropathy

gliadin fraction of gluten provokes

a damaging immunological response
in the proximal small intestinal mucosa
 As a result, the rate of migration of
absorptive cells moving up the villi
(enterocytes) from the crypts is massively
increased but is insufficient to compensate
for increased cell loss from the villous tips.

Villi become progressively shorter and then

absent, leaving a flat mucosa.
 Children normally present in the first 2 years of life
with failure to thrive following the introduction of
gluten in cereals.

Clinical manifestation
 general irritability,
 abnormal stools,
 abdominal distension and
 buttock wasting

In later childhood:
 anaemia (iron and/or folate deficiency)
 growth failure
 CASE HISTORY of COELIAC DISEASE
This 2-year-old had a history of poor growth
from 12 months of age.
His parents had noticed that he tended to be
crotchety and had three or four foul-smelling
stools a day.
A jejunal biopsy at 2 years of age showed
subtotal villous atrophy and he was started on a
gluten-free diet.
Within a few days, his parents commented that
his mood had improved and within a month he
was a 'different child'.
He subsequently exhibited good catch-up
growth
Coeliac disease causing wasting of the
buttocks and distended abdomen.
 Normal jejunal
histology is shown
for comparison

Lymphocytic infiltration
and villous atrophy
confirming coeliac
disease
Management
• All products containing wheat, rye and
barley are removed from the diet and this
result in resolution of symptoms.
• The gluten-free diet should be adhered to
for life.
• The incidence of small bowel malignancy
in adulthood is increased in coeliac
disease although a gluten-free diet
probably reduces the risk to normal.
 Specific transport defects (rare)
There are many such defects, each limited to a specific
carrier protein.

Glucose-galactose malabsorption results in

severe, life-threatening diarrhea from the introduction of
milk feeds and affected children are only able to tolerate
fructose as their dietary carbohydrate.

Acrodermatitis enteropathica results from a

congenital defect in zinc transport in the small intestine.
Affected children present in infancy with a symmetrical
erythematous rash mainly affecting mucocutaneous
junctions around the mouth and anus. Plasma zinc is very
low, as are the activities of zinc-dependent enzymes such
as alkaline phosphatase in plasma.
• CYSTIC FIBROSIS

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 CONSTIPATION
• In healthy infants there is a wide range in bowel frequency.
• Breast-fed infants may not pass stools for several days.
• In young children, constipation, which is the painful passage of hard,
infrequent stools, is common.
• It often follows an acute febrile illness or a transient superficial anal
fissure.
• Most such cases resolve with mild laxatives and extra fluids.
• Occasionally, following such events, or perhaps in association with
forceful potty training, the use of uncomfortable lavatories on holiday or
at school, or psychological family stress, more protracted constipation
results.
• Children may refrain from defaecation for fear of the associated pain.
• The rectum becomes full and overdistended, and with time the
sensation of needing to defaecate is lost.
• For mild cases, where faeces are not palpable per
abdomen, dietary fluid and fibre should be increased.
• For more severe cases, when the faeces are palpable per
abdomen, the first aim of management is to evacuate the
overloaded rectum completely.
• Following1-2 weeks of stool softeners (lactulose or
docusate), large doses of powerful oral laxatives (sodium
picosulphate or senna) and high volumes of oral
polyethylene glycol solutions (Klean-Prep) are given daily
until the stools are liquid.
• Advice about improving the dietary fluid and food intake is
given.
• This is followed by daily evening doses of a stimulant
laxative (e.g. senna), combined with regular postprandial
visits to the lavatory, and a star chart is introduced to record
and reward progress.
Hirschsprung's disease
• The absence of ganglion cells
from the myenteric and
submucosal plexuses of part of
the large bowel results in a
narrow, contracted segment.

• The abnormal bowel extends from

the rectum for a variable distance
proximally, ending in a normally
innervated, dilated colon.

• In 75% of cases, the lesion is confined to the recto-

sigmoid, but in 10% the entire colon is involved.
 Presentation is usually in the neonatal period with intestinal
obstruction heralded by failure to pass meconium within the
first 24 h of life.
Abdominal distension and later bile-stained vomiting develop.

Occasionally infants present with severe, life-threatening

Hirschsprung's enterocolitis during the first few weeks of
life, sometimes due to Clostridium difficile infection.
 • In later childhood, presentation is with
chronic constipation, usually profound, and
associated with abdominal distension but
usually without soiling.
• Growth failure may also be present.

Management is surgical and usually involves

an initial colostomy followed by anastomosing
normally innervated bowel to the anus.
Dental caries

Prop feeding infants when put to sleep with a

bottle containing milk or other fermentable liquids
places them at high risk of severe dental caries
and should be discouraged