Nutrition, Breastfeeding

and Infant Feeding

Jacqueline P. Pedroso, M.D.
OB-GYN Ultrasound
Maternal-Fetal Medicine
• Infancy growth period is rapid, critical for neurocognitive development, and
has the highest energy and nutrient requirements relative to body size
compared with other periods of growth.
• Childhood period of growth, during which 60% of total growth occurs
• The major risk period for growth stunting (impaired linear growth) is
between 4 and 24 months of age
• Nutrition and growth during the first 3 years of life predict adult stature
and some health outcomes
• The significant global burden of malnutrition and undernutrition is the
leading worldwide cause of acquired immunodeficiency and the major
underlying factor for morbidity and mortality globally for children <5 yr of
age
• The dietary reference intake (DRI) established by the Food and Nutrition
Board of the Institute of Medicine provides guidance as to nutrient needs
for individuals and groups across different life stages and by gender
• The Estimated Average Requirement is the average daily nutrient intake
level estimated to meet the requirements for 50% of the population,
assuming normal distribution
• The Recommended Dietary Allowance is an estimate of the daily average
nutrient intake to meet the nutritional needs of >97% of the individuals in
a population, and it can be used as a guideline for individuals to avoid
deficiency in the population
• Estimated energy requirement (EER) is the average dietary energy intake
predicted to maintain energy balance in a healthy individual and accounts
for age, gender, weight, stature, and physical activity level
Macronutrients
• The nutrients that provide energy intake in the child’s diet are fats
(∼9 kcal/g), carbohydrates (∼4 kcal/g), and proteins (∼4 kcal/g). They
are referred to as macronutrients.
FATS
• most calorically dense macronutrient, providing approximately 9 kcal/g.
• For infants, human milk/formula are the main dietary sources of fat, whereas
older children get fat from animal products, vegetable oils, and margarine.
• AMDR for fats is 30-40% of total energy intake for children 1-3 yr and 25-35% for
children 4-18 yr of age
• fats provide essential fatty acids and play structural and functional roles;
cholesterol moieties are precursors for cell membranes, hormones, and bile
acids. Fat intake facilitates absorption of fat-soluble vitamins A, D, E, and K.
Both roles are particularly relevant in the context of neurological and ocular
development.
• Diets low in saturated fats and cholesterol and without trans fats are preferred
The current dietary guidelines for children and adolescents recommend that total
fat should account for <30% of total daily energy and saturated fat less than
10%, dietary cholesterol <300 mg/day, with no trans fat.
Proteins
• 4 kcal/g
• Inadequate energy intake and/or inadequate protein intake increases catabolism
of body protein reservoirs (i.e., lean body mass) so as to provide substrate for
energy and free amino acids required to support normal physiologic function
• Protein energy malnutrition impairs brain, immune system and intestinal mucosal
functions
• Human milk contains both the indispensable and conditionally indispensable
amino acids and therefore meets the protein requirements for infants
• Breast milk is considered the optimal source of proteins for infants and is the
reference amino acid composition by which biologic quality is determined for
infants.
• For soy-based infant formula, supplementation with the limiting amino acid
(methionine) is necessary.
Carbohydrates
• 4 kcal/g.
• Essential energy source for erythrocytes and the central nervous
system and a major energy source for all cells
• Diets within the AMDR for carbohydrates and fats minimize the risks
of diabetes, obesity and coronary heart disease.
Fiber
• Nondigestible carbohydrates mostly derived from plant sources, such as whole
grain, fruits, and vegetables, that escape digestion and reach the colon nearly
100% intact
• Dietary fiber might play an important role by diluting toxins, carcinogens, and
tumor promoters; by decreasing transit time, thereby decreasing colonic mucosal
exposure; and by promoting their expulsion in the fecal stream.
• Lack of dietary fiber is associated with constipation and diverticulosis.
• Dietary fiber has a low glycemic index, and may have a beneficial effect on insulin
sensitivity.
• Fiber also binds luminal cholesterol and reduces absorption and/or enterohepatic
circulation of the cholesterol in bile salts (with the intake of more viscous forms
of dietary fiber, such as pectin).
• Soluble fiber types (such as guar gum, oat products, pectin) lower serum
cholesterol, while insoluble fiber may reduce serum triglycerides.
Micronutrients
• Vitamins and trace minerals or micronutrients play an essential role in
growth and development and contribute to a host of physiologic
functions
• Breast milk provides optimal intake of most nutrients including iron
and zinc.
• After 4-6 mo of age, iron and zinc are required from complementary
foods, such as iron-fortified cereal and pureed meats.
• Zinc deficiency affects millions of children and is associated with
increased risk for impaired linear growth (stunting), impaired immune
function, and increased risk for respiratory and diarrheal diseases.
• Vitamin D is absorbed in the skin from sunlight and is also present
naturally in some foods and fortified in all cow milk products,
regardless of fat content, soy milk, almond milk, and orange juice
• American Academy of Pediatrics increased total vitamin D intake
recommendations to 600 IU/day for infants and children. A
supplement was recommended for all breast-fed infants to ensure
sufficient intake.
• Vitamin K prophylaxis at birth is recommended for all newborn
infants.
• The CDC and American Academy of Pediatrics recommend the use of
the WHO charts to monitor growth of all infants and children (breast
and bottle or infant formula fed) from birth to 2 yr of age, and the use
of the CDC 2000 growth charts for children 2 to 20 yr of age.
Breastfeeding
• The American Academy of Pediatrics (AAP) and World Health Organization
(WHO) have declared breastfeeding and the administration of human milk
to be the normative practice for infant feeding and nutrition
• The AAP and the WHO recommend that infants should be exclusively
breastfed or given breast milk for 6 months.
• Breastfeeding should be continued with the introduction of
complementary foods for 1 year or longer, as mutually desired by mother
and infant
• New mothers should be instructed about infant hunger cues, correct nipple
latch, positioning of the infant on the breast, and feeding frequency
Characteristics and Advantages of Human
Milk
• Low renal solute load
• Immunologic, growth and trophic factors
• Decrease illness, infection, allergy
• Improved digestion and absorption
• Nutrient Composition: CHO, Protein, Fatty Acid, etc
• Cost
• Other
Human Milk
• Colostrum
• Higher concentration of protein and antibodies
• Transitions around days 3-5
• Mature by day 10
 Human Milk
• Nutrient composition of human milk is remarkable for its variability,
as the content of some of the nutrients change during lactation,
throughout the day, or differ among women, while the content of
some nutrients remain relatively constant throughout lactation.
Human Milk Compartments

• Aqueous Phase
• Ca, Mg, Ph, Na, Cl, CO2, casein proteins, whey proteins
(lactoalbumin, lactoferrin, IgA, lysozyme, albumin) Lactose,
amino acids, water soluble vitamins
• Colloidal Dispersion
• Caseins, Ca, Ph
• Fat emulsion
• Fat (phospholipid, TG, cholesterol) protein as fat globule
membrane, enzymes, trace minerals, fat soluble vitamins,
macrophages, neutrophils, lymphocytes
Diet, milk production, and milk composition

• There is a great variation in milk composition during a feed, from feed

to feed, and even between breasts.
• The impact of dietary variation and milk composition is unclear.
Overall milk composition remains relatively unaffected by diet
variations although there are reports to the contrary:
• DHA and ARA supplementation, vegan diet, drugs and environmental
contaminants,…..
Breast milk composition and Diet
• DHA levels of breast milk vary with diet. Increased amounts of DHA have been
found in the breast milk of mothers consuming fish or fish oil, and with
supplementation.
• Water soluble vitamins may vary with diet. Diets inadequate in B12 or thiamin
have been associated with case reports of deficiency in infants. High intakes of
Vitamin C, however, does not appear to change the content of breast milk.
• Supplementation of fat soluble vitamins do not appear to alter the content of
breast milk
• Iron supplementation does not appear to alter the iron content of breast milk
Influence of diet on milk composition
• Protein-energy malnutrition impacts milk volume. Composition
remains relatively unaffected
• Water soluble vitamins move readily from serum to milk thus dietary
fluctuations are more apparent
• B12 vegan, case report of beriberi…..
• Fat soluble vitamin content not improved with supplementation
• Fatty acid composition (DHA and ARA) altered by maternal diet and
supplementation
Distribution of Kcals: Breast milk

% Protein 6

% Fat 52

% Carbohydrate 42
Protein:

Predominant protein of human milk is whey. Casein/whey ratio is

between 40:60 and 30:70
• Casein: proteins of the curd (low solubility at pH 4.6)
• Whey: soluble proteins (remain soluble at pH 4.6)
Lactalbumin
Lactoferrin
Secretory IgA
Lactoglobulin
Carbohydrate
• Predominant carbohydrate of breast milk is lactose (7.3 g/dl)
• Oligosaccharides (1.2 g/dl)
• Prebiotics: nondigestible CHO that enhance the growth of “favorable”
bacteria and contribute to the unique GI bacterial characteristics of BF infant
(bifidobacteria)
Fat
• 2.5- 4.5% Fat (provides approx 50% of calories)
• Contained in membrane enclosed milk fat globules
• Core: TG (98-99%of total milk fat)
• Membrane: phospholipids, cholesterol, protein
• DHA/ARA: wide variations
DHA/ARA concentration variation in human milk

• DHA: 0.1-1.4%
• ARA: 0.31- 0.71%

• DHA lowest in populations with high meat intake and highest in populations
with high fish intake
Breast milk and establishment of core
microbiome
• Definition: Full collection of microbes that naturally exist within the
body.
• Alterations or disruptions in core microbiome associated with chronic
illness: Crohns disease, increased susceptibility to infection, allergy,
NEC, etc
Microbiome
• Beneficial effect for the host:
• Nutrient metabolism
• Tissue development
• Resistance to colonization with pathogens
• Maintenance of intestinal homeostasis
• Immunological activation and protection of GI integrity
Human milk and microbiome
• Core microbiome established soon after birth
• Core microbiome of breastfeeding infant similar to core microbiome
of lactating mother
• Components of breast milk supporting establishment of microbiome
• Prebiotics,probiotics
AAP Policy Statement: Breastfeeding and the use of
human milk
• AAP statement includes 15 recommendations on Breastfeeding
healthy term infants including:
• Establish peripartum policies and practices supporting breastfeeding
• Place infant skin to skin after delivery until first feeding is accomplished
AAP Policy Statement:Recommendations continued

• Supplements (water, glucose water, formula) should not be given unless

medically indicated
• Avoid pacifier during initiation (? Recent OHSU report)
• 8-12 feedings at the breast every 24 hours during early weeks
• All newborn breastfeeding infants should be seen by HCP at 3-5 days and
again at 2-3 weeks of age
• All breast feeding infants should receive 200 (changed to 400) IU Vitamin D
AAP Policy Statement: Breastfeeding and the use of human
milk: Pediatrics 115 #2 2005
• Human milk is species specific and uniquely superior for infant feeding
• Exclusive breastfeeding is the reference or normative model against which all
alternative methods must be measured in regards to growth, development and
health
• Research provides strong evidence that human milk feeding decreases the
incidence and/or severity of a number of infectious diseases (meningitis, Otitis
media, UTIs, Respiratory tract infections, NEC, diarrhea)
AAP Policy Statement: Breastfeeding and the use of
human milk:
• Contraindications to breastfeeding
• Galactosemia
• Maternal use/exposure to certain radioactive or chemotherapeutic agents
• Maternal abuse of “street drugs”
• Active HSV lesions of breast
• Maternal HIV (in USA)
 AAP Policy Statement: Breastfeeding and
the use of human milk:
• Some studies suggest decreased incidence of SIDS, diabetes (type 1 and 2),
leukemia, obesity, hypercholesterolemia, and allergy (asthma and atopy)
• Breastfeeding has been associated with slightly enhanced performance on tests
of cognitive development.
Nipple Pain
• Poor infant positioning and improper latch are the most common
reasons for nipple pain beyond the mild discomfort felt early in
breastfeeding.
• If the problem persists and the infant refuses to feed, consideration
needs to be given to nipple candidiasis. If present the mother should
be treated with an antifungal cream that is wiped away before
feeding, and the infant treated with oral medication.
Engorgement
• Breasts may become engorged: firm, overfilled, and painful as the
pattern and volume of milk production is adjusting to the infant’s
feeding schedule.
• Incomplete removal of milk as a result of poor breastfeeding
technique or infant illness can cause engorgement
• To reduce engorgement, breasts should be softened prior to infant
feeding with a combination of hot compresses and expression of milk.
Between feedings a supportive bra should be worn, cold compresses
applied, and oral nonsteroidal antiinflammatory medications
administered.
Mastitis
• 2-3% of lactating women and is usually unilateral, manifesting with
localized warmth, tenderness, edema, and erythema after the second
postdelivery week
• Organisms implicated in mastitis include Staphylococcus aureus,
Escherichia coli, group A streptococcus, Haemophilus influenzae,
Klebsiella pneumoniae, and Bacteroides spp
• Oral antibiotics and analgesics, while promoting breastfeeding or
emptying of the affected breast, usually resolve the infection.
Inadequate Milk Intake
• Signs of insufficient milk intake include: lethargy, delayed stooling,
decreased urine output, weight loss >7% of birth weight, hypernatremic
dehydration, inconsolable crying and increased hunger.
• Caused by insufficient milk production, failure of established breastfeeding,
and health conditions in the infant that prevent proper breast stimulation
• Parents should be counseled that breastfed neonates feed 8-12 times a day
with a minimum of 8 times per day.
• Late preterm infants (34-36 wk) are at risk for insufficient milk syndrome
because of poor suck and swallow patterns or medical issues.
Jaundice
• Breastfeeding jaundice – insufficient fluid intake in the first week of life
• Breast milk jaundice causes persistently high serum indirect bilirubin in a
thriving healthy baby that becomes evident later than breastfeeding
jaundice, but which generally declines in the 2nd to 3rd wk of life
• Persistently high bilirubin levels may require changing from breast milk to
infant formula for 24-48 hr and/or treatment with phototherapy without
cessation of breastfeeding.
• Breastfeeding should resume after the decline in serum bilirubin.
• Parents should be reassured and encouraged to continue collecting breast
milk during the period when the infant is taking formula.
Collecting Breast milk
• Good hand washing and hygiene should be emphasized.
• Expressed breast milk can be frozen and used for up to 6 mo. Milk
should be thawed rapidly by holding under running tepid water and
used completely within 24 hr after thawing. Milk should never be
microwaved.
Human Milk Substitutes
• Early evidence of artificial feeding
• Majority of infants received breast milk
• Maternal BF
• Wet nurses
• Wealthy women
• Orphans, abandoned, “illegitimate”
• Prematurity or congenital deformities
Wet Nurses
• Work demands, societal needs, vanity, health requirements, social diversion
• Proper selection: Questionable character-- Infant would suck in her vices
• Wet Nurse Industry: emerging infant mortality/abuse
• Impact of industrial revolution: Wet nurses made better money in factories
Human Milk Substitutes: Infant Mortality
• Artificial feeding in first weeks of life associated with 100% mortality
• 19th century infant mortality with “hand feeding” was 88%
• Foundlings: 80%
• In Dublin Foundling hospital 1775-96: 99.6%
Interesting Milestones in Infant Nutrition

• 1784: Underwood recommends cows • 1845: Pratt patents rubber nipple

milk as alternative to breast feeding • 1856: Borden patents condensed milk
• 1800: glass feeding bottles • 1883: Meyenberg patents evaporated
• 1838: Simon determines protein goats milk
CM>BM • 1885: Meigs analyses human milk
Historical timeline
• 1900 • 1920
• Pasteurization of milk
in US
• Association between
bacteria and diarrhea
• 1912
• U.S Children’s Bureau
• Public Health and
Pediatricians efforts to
improve infant/child
health and decrease
mortality
• Intro evaporated milk
• Cod liver oil prevents
rickets
• Curd tension of milk
altered
• Increased availability of
refrigeration
• Vitamin C isolated
• Vitamin D prepared in
pure form
• Improved sanitation
Historical timeline

• 1940 • 1960
• Homogenized milk widely • Further advances in
marketed technology and packaging
• Commercially prepared
infant formula becoming
increasingly popular
Interesting Milestones in Infant Nutrition

• 1911: MJ introduces Dextri-maltose

• 1915: SMA
• 1920: Franklyn (Similac)
• 1929: MJ markets Sobee, hypoallergenic
• 1930-60: Concentrated liquid, hydrolysed, elemental, and ready to feed formulas
introduced
• What now?
Infant Formula - History, cont.
• 50s and 60s commercial formulas replaced home preparation
• 1959: iron fortification introduced, but in 1971 only 25% of infants
were fed Fe fortified formula
• Cow’s milk feedings started in middle of first year between 1950-
1970s. In 1970 almost 70% of infants were receiving cow’s milk.
Formula Composition

• Breast Milk as “gold standard”

• Attempt to duplicate composition of breastmilk
• ? Bioactivity, relationship, function of all factors present in breast milk
• ? Measure outcome: growth, composition, functional indices
Formula Categories
• Standard
• Cows milk base
• Soy base
• Elemental
• Hydrolysates
• Amino acid pased
• Other Specialty Products
• Metabolics
• PM 60/40
• Low fat/MCT
• Premature feeding products
 Formula Brands
• Ross
• Similac/Isomil/Alimentum
• Mead Johnson
• Enfamil/Prosobee/Enfacare
• Nestle
• Good Start
• Wyeth
• Generic in USA; Gold Brands; SMA
• SHS
• NeoCate, DuoCal
Distribution of Kcals

Formula

% Protein 9

% Fat 48

% Carbohydrate 42
Formula Feeding
• Parental preference is the most common reason for using infant formula.
• Infant formula is used as a supplement to support inadequate weight gain in b
• Ready-to-feed products generally provide 20 kcal/30 mL (1 oz) and approximately
67 kcal/dL breastfed infants.
• Although infant formulas are manufactured in adherence to good manufacturing
practices and are regulated by the U.S. Food and Drug Administration (FDA),
there are still potential safety issues. Powder preparations are not sterile, and
although the number of bacterial colony-forming units per gram of formula is
generally lower than allowable limits, outbreaks of infections with Enterobacter
sakazakii have been documented, especially in premature infants and can contain
other coliform bacteria but have not been linked to disease in healthy term
infants.
• Care must be taken in following the mixing instructions to avoid over- or
underdilution, to use boiled or sterilized water, and to use the specific
scoops provided by the manufacturer as scoop sizes vary.
• Parents should be instructed to use proper handwashing techniques when
preparing formula and feedings for the infant
• Once prepared, all bottles regardless of type of formula should be used
within 24 hours.
• Formula should be used within 2 hours of removal from the refrigerator
and once a feeding has started, that formula should be used within an hour
or be discarded.
• Prepared formula stored in the refrigerator should be warmed by placing
the container in warm water for ~5 min.
• Formula feedings should be ad libitum, with the goal of achieving
growth and development to the child’s genetic potential.
• The usual intake to allow a weight gain of 25-30 g/day will be 140-200
mL/kg/ day in the first 3 months of life.
Cow Milk Protein Based Formulas
• contain a protein concentration varying from 1.8 to 3 g/100 kcal or (1.45-1.6
g/dL), considerably higher than in mature breast milk (1.5 g/100 kcal).
• The whey : casein ratio varies from 18 : 82 to 60 : 40; one manufacturer markets a
formula that is 100% whey. The predominant whey protein is β-globulin in cow
milk and α-lactalbumin in human milk.
• fat provides 40-50% of the energy in cow milk–based formulas.
• All infant formulas are supplemented with long-chain PUFAs, docosahexaenoic
acid (DHA), and arachidonic acid (ARA) at varying concentrations
• A Cochrane review concluded that routine supplementation of milk formula with
long chain PUFAs to improve the physical, neurodevelopmental, or visual
outcomes of term infants cannot be recommended based on the current
evidence
• Carbohydrates comprise 69-75g/L of cow milk–based formula. LACTOSE
Soy Formulas
• Soy protein–based formulas on the market are all free of cow milk–based protein
and lactose and use sucrose, corn syrup solids, and/or maltodextrin to provide 67
kcal/dL.
• The protein is a soy isolate supplemented with l-methionine, l-carnitine, and
taurine to provide a protein content of 2.45-2.8 g per 100 kcal or 1.7-1.8 g/dL.
• The fat content is 5.0-5.5 g per 100 kcal or 3.4-3.6 g/dL. The oils used in both cow
milk and soy formula include soy, palm, sunflower, olein, safflower, and coconut.
DHA and ARA are also added
• Indications:galactosemia and hereditary lactase deficiency, because soy–based
formulas are lactose-free; and situations in which a vegetarian diet is preferred.
• The routine use of soy protein– based formula has no proven value in the
prevention or management of infantile colic, fussiness, or atopic disease.
Protein Hydrolysate Formula
• Protein hydrolysate formulas may be partially hydrolyzed, containing
oligopeptides with a molecular weight of <5000 Da, or extensively
hydrolyzed, containing peptides with a molecular weight <3000 Da.
• Because the protein is not extensively hydrolyzed, these formulas should
not be fed to infants who are allergic to cow protein
• Extensively hydrolyzed formulas may be more effective than partially
hydrolyzed
in preventing atopic disease.
• Extensively hydrolyzed formulas are recommended for infants intolerant to
cow milk or soy proteins. These formulas are lactose free and can include
medium-chain triglycerides, making them useful in infants with
gastrointestinal malabsorption as a consequence of cystic fibrosis, short
gut syndrome, prolonged diarrhea, and hepatobiliary disease.
Amino Acid Formulas
• Amino acid formulas are peptide-free formulas that contain mixtures
of essential and nonessential amino acids.
• They are designed for infants with dairy protein allergy who failed to
thrive on extensively hydrolyzed protein formulas.
• Neither breastfed nor formula-fed infants require additional water
unless dictated by high environmental temperature
• Whole cow milk should not be introduced until 12 mo of age
• For cultural and other reasons, such as parental preference, goat milk is
sometimes given in place of formula although this is not recommended.
• Goat milk has been shown to cause significant electrolyte disturbances
and anemia because it has low folic acid concentrations.
Complementary Feeding
• The AAP, WHO, and European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition Committee on Nutrition all recommend
exclusive breastfeeding for the first 6 months.
• The complementary foods should be varied to ensure adequate
macro- and micronutrient intake. In addition to complementary foods
introduced at 6 mo of age, continued breastfeeding or the use of
infant formula for the entire 1st year of life should be encouraged.
• Overconsumption of energy-dense complementary foods can lead to
excessive weight gain in infancy, resulting in an increased risk of
obesity in childhood.
Feeding Practices
• The period starting after 6 mo until 15 mo is characterized by the acquisition of self-feeding skills
because the infant can grasp finger foods, learn to use a spoon, and eat soft foods.
• Bottle weaning should begin around 12-15 mo and bedtime bottles should be discouraged
because of the association with dental carries.
• Sugar-sweetened beverages and 100% fruit juice should also be discouraged from being used in
bottles in all infants at all times.
• Cups without a lid can be used for no more than 4-6 oz/day of 100% fruit juice for toddlers.
• In the 2nd year of life, self-feeding
• The 2 yr old child should progress from small pieces of soft food to prepared table foods with
precautions.
• The child is not capable of completely chewing and swallowing foods, and particular attention
should be paid to foods with a choking risk.
• The AAP discourages eating in the presence of distractions such as television, tablets, mobile
devices, and other screens, or eating in a car where an adult cannot adequately observe the child.
• Toddlers need to eat 3 healthy meals and 2 snacks daily.
• A daily vitamin D intake of 600 IU/ day for all infants beginning in the
first few days of life, and for children and adolescents who are
ingesting <1000 mL/day of vitamin D-fortified milk or formula.
• Toddlers and preschool children often fail to meet the recommended
servings of fruits, vegetables, and fiber, whereas intakes of food with
fat and added sugar are high