Introduction :

Infancy, especially the first 6 months, is a period of rapid growth and high nutrient requirements relative to body
weight. If inadequate total intake or inappropriate choice of food occurs, there is risk of rapid deterioration in
growth and nutritional status, with potential for adverse consequences on neurocognitive development.

Infants are more vulnerable to poor nutrition because of:

- Poor stores of fat and protein .
- Extra nutritional demands for growth - the weight of a term infant doubles by 4 months and trebles by 1 year.
- More frequent intercurrent illnesses that reduce food intake and increase nutritional demands.
1 gm. of Fat = 9 cal
1 gm. of CHO = 4 cal
1 gm. of Protein = 4 cal

Breast-feeding:
Human milk is the ideal and uniquely superior food for infants.

- Colostrum : Its the secretion of the breasts during the latter part of pregnancy & for 2-4 days after delivery.
: Its deep lemon yellow in color & alkaline.
: contains several times the protein of mature breast milk.
: more minerals, Vit. A, GH, and Purgatives .
: but less carbohydrate & fat.
Mature breast milk by the 3rd or 4th week.
: It also contains some high unique immunological factors.
After the first few days of lactation colostrum is replaced by secretion of a transitional form of milk.

Milk
Calories
Carbohydrate
Fat

Protein

Human
- 70/dl
- 7gm/dl
- Lactose
- Unsaturated Fat ( Anti-Oxidant )
- 3.5-3.8g/l
- More lineoleic acid
- 1.1gm/dl
-Easley absorbed
- Whey : Casein ratio 70:30

whey(soluble)
casein(insoluble)
Minerals
- More in Iron and copper
- But can't meet the infant
requirement of Iron after 6
Months
Vitamins
- Vit A : Large amount
- Vit. C & D : More
- But Vit . D should be
supplemented at 4 months
- Vit. K : less
Should be given at time of birth
to prevent hemorrhagic Disease
of new born

Cow
- 67/dl
- 4.8gm/dl
- Fructose (Sweeter than Lactose)
- Saturated Fat ( Oxidant )
- Less
- Less lineoleic acid
- 3.3gm/dl
- Difficult to absorb b\c it contain
more Casein
- Whey : Casein ratio of 18:82
- All of the mineral( Na+ , Ca++, Ph )
are much more except:
Iron and Copper
- Vit . A : Large amount
- Vit. C & D : less

- Vit. K : More

Advantages of breast feedings:

1- Its the natural food for human infants
2- Always available at the proper temperature.
3- Easy : Require no preparation time.
4- Fresh & Sterile not contaminated by bacteria
reduce the chance of GIT disturbances.
5- Economic : Among the lower socioeconomic groups..
6- Allergy & intolerance less common.
7- Contains antibodies against infections, contain high concentration of secretory IgA which prevent
microorganisms from adhering to intestinal mucosa.
8- Contains substances that inhibit the growth of viruses.
9- Macrophages in human milk, may synthesize *complement & lactoferrin.
10- Human milk also contain lactoferrin, 1-*an iron binding protein
increase Iron absorption.
2- inhibits growth of E coli in intestine.
11- lower pH promotes growth of lactobacillus in the gastrointestinal tract (protective against
pathogenic intestinal bacteria)
12- Cow milk easily contaminated. Many infections are milk borne e.g. streptococcal, TB, diphtheria, typhoid,
salmonella & brucellosis.
Advantage to the mother :
1- Bonding : Psychological advantages of breast feeding for both mother & infant.
2- Decrease risk of *cancer breast, ovary and uterus .
3- Contraception (suppressed ovulation)
4- Uterus involution, return the body shape.
Mechanism of milk Production:
The mothers psychological state is important
for milk flow reflex.

Suckling stimulate the sensory

impulses from sensory nerve in the
nipple
Infant reflexes :
rooting, sucking,

swallowing &
satiety reflexes
Formation of
milk in breast

Pituitary Gland
Prolactin

Anterior Lobe

Milk secretion reflex

Inhabit ovulation in Ovary
Posterior Lobe

Flow of milk
Ejection reflex

Increase pressure in
the ducts

Contraction of
myoepithelial cells &
milk Ducts

Oxytocin

Techniques of breast feeding :

- Started as soon as possible after delivery.

Stop BF If she is taking

- Breast feeding on demands, otherwise every 3 hours.

one of these:
- Antithyroid drugs.

- Appropriate care for tender nipples

- Anticancer drugs.

- Avoid addition of bottle feeding .

- Breast milk can be kept in freezer for one month & in refrigerator for 1 day & reused.
- Nursing mothers should not take drugs unless they are absolutely necessary.

- INH
- Metronidazole.
- chloamphinicol .

- Smoking cigarette & alcohol drinking should be discouraged.

- At the feeding time, the infant should be hungry, dry & neither too cold nor too warm.

- sulphonamides .

- The baby should be held comfortable in semi sitting position.

- The mother should also be in comfortable position back is supported, one arm supporting babys body and
head, the other holding the breast.
- The infant should not be pulled from the breast.
- At the end of feeding, the infant should be held erect over the mother shoulder to expel swallowed air
(eructation)
- Both breasts should used at each feeding in early weeks of life to encourage maximal milk production.
*TO CHECK POSITIONING, LOOK FOR:
- Infants neck is straight or bent slightly back.
- Infants body is turned towards the mother.
- Infants body is close to the mothers body.
- Infants whole body is supported .
The most common cause of early failure to
thrive is poorly managed breast engorgement,
which rapidly decreases milk supply.
TO CHECK ATTACHMENT,(Latch On) LOOK FOR:
- Chin touching the breast.
- Mouth widely open.
- Lower lip turned outward.
- More areola visible above than below the mouth.
- slow deep sucks, sometimes pausing breathing between.

Bad attachment may lead to nipple sore and milk

engorgement

Types of breast feeding :

1- Exclusive Breast Feeding :
WHO recommendation for the first 6 months ( no even drop of water )
2- Absolute Breast Feeding :
Breast Feeding + Water

Unrelieved engorgement can result

from :
- Long intervals between feeding .
- Improper infant suckling .
- Sore nipples (improper positioning,
attachment).
- Maternal or infant illness.
- Nursing from one breast.

The mother may complain that her baby pass red urine ( which is Uric acid ) TTT by increase water intake.
3- Supplementation :
More formula milk + Less breast feeding .
4- Complementary breast feeding :
Start with breast feeding then shift to formula milk at the same feeding session .
Failure of breast feeding :
- Working mother.
- Incompetent mother.
- Indifferent and busy mothers
- Depressed mother.
- deception, fraud.
- low vegetables and fruits.

3 possibilities should be excluded

before assuming that a mother
cannot produce sufficient milk:
- Error in feeding technique
- Maternal factors related to diet, rest
& emotion.
- Physical disturbance of the infant

- low fiber diet.

- lack of exercise.
- Unhealthy mother, chronic diseases, anemia, Breast infection.
- Junk foods excessive fats, high sugar, corn syrup high fructose, additives and preservatives Decrease appetite.
Complication of Breast Feeding:
Mother
- Sore/cracked nipples: treat with warm compresses, massage, frequent feeds, proper latching technique.
- Breast engorgement (usually in first week): continue breastfeeding and/or pumping
- Mastitis (usually due to S. aureus): treat with cold compresses between feeds+ Antibiotics .
Infant
- Breastfeeding jaundice (first 1-2 weeks)
- Poor weight gain: consider dehydration or failure to thrive
- Oral candidiasis (thrush).

Contraindication to Breast Feeding:

- Acute maternal infection may contraindicate BF if the infant does not have the same infection (AIDS, HCV etc)
- CMV, rubella V, hepatitis B V, herpes simplex V have been demonstrated in breast milk
- Mothers with septicemia, active TB, typhoid fever, breast Cancer & malaria, substance abuse, severe neurosis or
psychosis should not BF their babies.
- Infant disorder e.g. galactosaemia.
- Family history of atopy.
Appropriate Feeding:
- Exclusive breast feeding for the first 6 months.
- After 6 months complementary foods are added thereafter through at least the 1st year of life.
- Breast milk and/or formula can be used exclusively (no other foods are necessary) until 6 months of age.
- Some vitamin supplementation may be necessary (e.g., vitamin K given at birth,
vitamin D at 4 months to prevent rickets).
Weaning :
- Start at 4-6 months.
- Iron enriched cereals (e.g., rice cereal) should be started first because they are less allergenic.
- New foods can be added gradually (only one to two new foods per week to determine hypersensitivity and/or food
intolerance).

Egg yolk can be given at 7 mo.

- Pureed yellow/orange vegetables (e.g., carrots, squash) should be added next. But the egg white&honey after 1st yr.
- Pureed green vegetables should be introduced after yellow/orange vegetables because they have more bulk.
- Vegetables with high nitrite contents (e.g., beets, spinach, turnips) should be avoided.
- Vegetables are generally offered before fruits b\c the sweet taste of fruits may cause infants to reject other foods.
- Pureed fruits and juices, pureed meats, fish, poultry, and egg yolk can be introduced after the infant demonstrates
tolerance to pureed vegetables.
- Avoid desserts, since these have no significant nutritional value and their sweet taste may cause infants to reject
other foods.

Some Important Points :

Fluid and caloric maintenance:

- Avoid egg whites until 12 months because of the risk of allergy.

- 100 cc/kg/day for the first 10 kg,

- Whole cow's milk is not recommended before 9 months of age.

- 50 cc/kg/day for the next 10 kg,

- Vegetarian diet NOT recommended for the first 2 years of life.

- 20 cc/kg/day thereafter.

- Avoid peanuts and raw, hard vegetables until 3-4 years old, because of the risk of aspiration.
- 2% or skim milk is NOT used (fat is needed for neural development esp. *lineoleic acid , whole milk contains 4%
fat) skim milk contains no fat).
- *Micronutrients are lack in Cow milk, they are essential for brain development
- The CHO source in soy based formula is glucose polymers and/or sucrose.
- Soya based formula : free of cow's milk protein
: free of lactose.
: Never used in preterm infants .
Indicated in : galactosaemia, Hereditary lactose intolerance, and vegetarian families .
- Corn syrup can lead to obesity, hyperglycemia, Liver dis.
- Is the infant Suckling effectively ? (that is, slow deep sucks, sometimes pausing).
- Determining the adequacy of milk supply:
Feeds 8 times per 24h- Baby satisfied after feed- no constipation
Sleep 2- 4 hours between feeding - gaining weight properly Normal amount of urine 6 or more per 24 h
Vegetarian risk of developing Vit.b12 deficiency.
Goat Milk risk of developing Folic acid deficiency
- Exclusively breastfed infants may require diet supplementation with iron at 6 months , Vit.D at 4 months, fluoride
(after 6 months if not sufficient in water supply)
*Symptoms of cow milk protein allergy:
- Typically begin between week 4 to 6, but the sensitivity may occur as early as 48 hours or may
present in adulthood.
- The presence of gastrointestinal symptoms such as bloody stools, diarrhea and vomiting can
indicate pathophysiological intolerance related to a specific component of cow milk formula.
- Symptoms such as flatus, fussiness and colic are less likely and difficult to directly relate to
components of cow milk.