The Ideal Formula

• An infant formula should contain optimal amounts of

all nutrients in levels that support normal growth but

does not stress the infants still-developing systems.

• The infant formula should minimize feeding problems.

Human milk vs Cow milk-Both are liquid-Quantity and availability of nutrients is different-Both have similar amount of water, calories, calorie source is different (proteins supply 7% of calories in human milk, 20% in cow milk). Lactose supplies 42% in human milk and 30% in cow milk, % of calories from fat is the same.

CHO: lactose in both cases, cow milk<<human milkProteins: cow milk 3X minerals and protein, composition is different

Two fractions: casein and whey .Casein: precipitated at low pH, constitutes 20–30% of human milk proteins .

A heterogeneous group of proteins, molecular weights: 20 000–30 000Whey: contains a large number of proteins, which are derived from both milk and plasma. MainlyWhey: casein ratio: Human milk (60:40), cow milk (20:80)The large amount of curd may cause GI distressa.a. content is inappropriate to the immature enzyme systems

Infant formulas, why? Contents of various milks

Fat: both have similar fat contentLinoleic acid (supplies 7% of calories in human milk, 1% cow milk, Formula 10%)

Cholesterol level is different (higher in human milk)Fat in human milk is different from cow milk in 2 ways: TG types: cow milk, short and long chain FA, in human milk medium chain Degree of saturation: human milk:PUFA, cow milk: butter fatLCPUFALipoprotein lipase

Minerals and electrolytes: several times more in cow milk than human milkCalcium and phosphorus: higher level in cow milk (4-7 times more) and the ratio is differentIron, ZincNa, K and Cl

Infant formulas, why? Contents of various milks

Infant formulas, why? Contents of various milks

Reduced fat cow milkWhole cow milkEvaporated milk

Types, uses and selection of commercial infant formulas

1. Milk based formulas: nonfat cow milk, vegetable oils (corn oil, sunflower, soy oil) and lactose are added. Supplemented with vitamins and minerals, iron and zinc

2. Milk based formulas with added whey protein

Therapeutic Formulas

a. Lactose free formula: for lactose intolerance

b. Soy protein formula: soy protein instead of animal protein (fortified with methionine). Vegetable oil as fat source, corn syrup or sucrose supply the CHO.

• Infanct with CMA: respiratory tract, skin, dairrhea• Minerals and supplements• Lactose free,, no animal protein or fat• High PRSL• Not suitable for premature or LBW infants. Have to add Ca and P

c. Casein hydrolysate fromula: infants with severe GI abnormalities, malabsorption of CHO, protein and fat.Fortified with amino acidsCHO source is corn syrup, conr starch, dextroseFat source: medium chain triglycerides

d. Amino acid based formula: infants who are intolerant to casein hydrolysatee. Whey hydrolysate formula

Therapeutics formulas

LACTOSE INTOLERANCE

Medical Need for LF Formulas

• Lactose intolerance (L I) often a complication of diarrhea.– Secondary lactase deficiency most common

cause of LI.– About 23% of well-nourished infants with acute

diarrhea develop LI.– Incidence greater in malnourished infants.

• Lactose intolerance may cause colic in some infants.

Symptoms Of Lactose Intolerance:

• Nausea (?)• Abdominal pain and distension• Flatulence• Watery diarrhea

Lactose Free Formulas

• LF Formulas appropriate for– Infants with secondary lactase deficiency.– Infants with congenital lactase deficiency.– Children and adults with acquired lactase deficiency.

Corn syrup solids, or corn syrup solids with sucrose instead of lactose

REGURGITATION

REGURGITATION

• Mild regurgitation is a common occurrence in infancy.

• Often considered to be a normal physical phenomenon of early development.

• Usually no serious health risks.• Spontaneously resolves with time.• Often considered as a source of parental anxiety.

SYMPTOMS

•Common symptoms

-Regurgitation

-Esophagitis

-Excessive crying

-Feeding problems

-Respiratory

problems

-Parental anxiety

•Unusual Symptoms

-Failure to thrive

-Respiratory problems

-??? Hematemisis

REFLUX & REGURGITATION

• Reflux: Backward flow of gastric juices out of the stomach up through esophagus.

• Regurgitation: Backward flow of undigested food ‘spitting-up’

Recommendation

• Step I Parents Reassurance

• Step II

Feed Thickeners

• Step III

Feed Thickener + Medications

Rational of AR Formula• Regurgitation or spit-up is a common occurrence in

infancy• 15-30% of infants suffer from GER.• Baby can’t thrive on formula that won’t stay down.• AR formula reduces parents’ anxiety. • Iron fortified formula containing CHO blend of

lactose, rice starch and maltodextrin

Galactosemia• It is a metabolic disorder caused by a deficiency in the

activity of the enzyme galactose-1-phosphate uridyl transferase (Type 1).

• As a result, toxic levels of galactose-1-phosphate accumulate in the body.

• Without treatment, this disorder is usually fatal.• Treatment should eliminate galactose and lactose from

the diet.• Soya bean formulas may be indicated for these infants.

NUTRITIONAL NEEDS OF LBW INFANTS

Low-Birth-Weight Infants

• Infants who are born prior to term, i.e., 38-42 weeks, are classified as premature or preterm by the AAP.

• Approximately, 12% of infants are born preterm each year.

• Preterm infants tend to weigh less than term infants (<2,500gm) and are considered LBW.

• The digestive, metabolic and excretory systems of these infants are less mature than those of term infants, and require special care.

• Optimal nutrition that meets the special nutritional needs of LBW infants to achieve post-natal growth that approximates intra-uterine growth without placing undue stress on under developed body systems, often creates a dilemma.

Cont., Low-Birth-Weight Infants

Low-Birth-Weight Formulas

• LBW formulas must be designed to address the most important problems impeding optimal growth in LBW infants:

• LBW infants may not have a fully active sucking reflex, making breast feeding impossible.

• LBW infants have a limited capacity to consume high volumes of formula, and are incapable of complete digestion and absorption.

• Fat absorption in the intestine is less efficient, as bile salts concentrations are reduced.

• LBW infant’s inability to properly absorb, digest, and achieve metabolism of food has severe implications.

• The renal system and liver are not fully developed:– Immature liver: reduced glycogen storage.

– Less developed kidneys will not be able to obtain normal absorption mechanisms.

Cont., Low-Birth-Weight Formulas

• Excessive concentrated feedings are not well-tolerated.

• RSL must be kept within manageable limits. • LBW formulas must be fortified with extra

calcium, magnesium, phosphorus, and LCPUFAs to meet the special nutritional requirements.

• Whey is predominant, CHO mixture, additional calcium and phosphorus is needed

Cont., Low-Birth-Weight Formulas

supplements

The need for vitamin and mineral supplementsBreast fed full term infants-vitamin D-Iron (after 4-6 months)

Formula fed full term infants

Preterm infants

Potential problems with infant formulas• Diarrhea: can lead to failure to thrive or

dehydration. Improper dilution or preparation of the formula

• GI problems: hypersensitivity to cow milk proteins, GI distress

• Tooth decay: bottle feeding beyond 1 year, caries

Infant formula preparation

TIPS IN BOTTLE FEEDINGChoosing the right bottle: variety of types, selection of the appropriate

volumeChoosing nipples or teats:

Type of teat: rubber latex, or siliconShape: Orthodontic- type, nubbin-typeNipple hole

SterilizingAfter a feeding, thoroughly rinse the bottle and nipple under warm water and

leave them on a clean towel by the sink, ready for your next sterilizing session.

Wash all the equipment in hot soapy water, rinse thoroughly in hot water, and remove the milk scum with a bottle brush.

Pad the bottom of a large pan with a towel or dishcloth. Immerse open bottles, nipples, and other equipment in the pan (place bottles on their side to be sure that they are filled with the sterilizing water) and boil for ten minutes with the pan covered. Allow to cool to room temperature while still covered. Remove the bottles and nipples with tongs or a spoon and place the bottles upside down on a clean towel with the nipples and caps alongside. Let the equipment dry.