INFANT FEEDING PRACTICE

dr. Endang Dewi L, dr., MPH, Sp.A(K)

UKK NUTRISI DAN PENYAKIT METABOLIK
IDAI
 TOPICS
• Breastfeeding in practice
• Infant formula used
• Complementary foods used
 Background
• Infants and young children esp. Sensitive to external
factors (e.g. Nutrition)
• First 2 years = a critical period for :
o Growth and development
o Health in infancy and childhood
o Health in adulthood
 Global strategy for infant and
young child feeding
• 60%of deaths annually among children under five
caused by malnutrition.
• Over two-third of these deaths, which are often
associated with inappropriate feeding practice
 Optimal infant feeding practice

• Exclusive breastfeeding for 6 months

• Complementary feeding with continued
breastfeeding from 6 to 24 months and beyond
o Timely
o Adequate
o Safe
o Appropriately fed

(who global strategy on infant and young child feeding, 2002)

 Exclusive breastfeeding
• Definition
o Giving an infant only breat milk, with the
exception of drops or syrups consisting of
vitamins, mineral supplements, or drugs

o No food or drink other than breast milk, not even

water
Breastfeeding = a normative model
• Breastfeeding = a preferred mode of feeding
considering benefits :
o Nutritional
o Immunological
o Health (morbidity, mortality)
o Developmental
o Economical and ecological

AAP 1997
 Nutritional benefits of breast milk
• Composition changes inthe course of development
(preterm, fullterm infants), singles feeding (foremilk,
hindmilk), in relation to eposure to infection (e.g.
IgA)
o Optimal concentration of nutrients, high
bioavailability, lower intake of calories
o Growth factors – epidermal f=growth factors,
hormons
o Protective factors – immunoglobulins,
lymphocyte, leucocytes, macrophages, lysozym,
bifidus factor etc.
 Breastfeeding = lower morbidity
• Infants • Mothers
o Nonspesific gastroenteritis o diabetes (type 2)
o Necrotizing enterocolitis
o Carcinoma of breast
o Acute otitis
o Carcinoma ovaria
o Infection of lower
respiratory tract
o Sudden infant death
(SIDS)

o Atopic dermatitis
o Asthma in young children
o Obesity
o Diabetes (type 1, 2)
o Child leukaemia
 Breastfeeding technique
• Feed during the first hour of life if possible (initiation
of breastfeeding)
• 5-20 minutes per breast
• 8-12 feedings per 24 hours (Q2-3h)
• Wake infant after 4 hours of sleep
• Avoid flow preferences with artificial nipples,
especially in the first 2 weeks of life
• Recognize that crying is late indicator of hunger

AAP 2005
 Breastfeeding problems
• Flat nipples – nipple shells
• Sore nipples – nipple shields
• Mastitis – continue feeding in most case
• Engorgement – soften breast
• Poor weight gain in the infant :
consider frequent pumping or supplemental nursing
system (SNS)
 Breats milk pumping and storage
• Pumps : handled, electric
• Storage :
o Fresh at room temperature 6 to 8 hours
o Refrigerator up to 5 days
o Freezer with a separate door 3 months
o Deep freezing 6 months

• use thawed breast milk within 24 hours. Never

microwave breast milk for reheating

www.bfmed.org
Breast milk storage
Thawing frozen breast milk
 Infant formula
• Definition
o infant formula is an artificial substitute for human breast
milk, intended for infant consumption
codex standard for infant formula and formulas
for special medical purposed for infant
(CODEX STAN 72-1981)
• Infant formula like no other food is regulated by its
own law, the Codex standard for infant formula and
formulas for special medical purposes for infant
(CODEX STAN 72-1981)
• The act sets upper and lower limits on important
nutrients
• It requires that the formula support normal growth
and that contents are clearly labeled
• Manufacturers are required to follow “good
manufacturing practice”
 Composition of infant formula
• Lactose, glucose, corn syrup, startched
• Lactose 9-14 g/100kcal or 2, 2-3, 3 g/100kJ
• Supply 30-40% of total energy in formula Carbohydrate
• Gelatinized startch 2 g/100ml or 30% from total
carbohydrate
• Min 1,8g/100kcal or 0,45g/100kJ Max 3 g/100kcal,
0,7/100kJ
• Essential and semi essential amino acid equivalent
to breast milk Protein
• Modified → bovine whey bovine casein = 60 : 40
• Lactoglobulin → potentially allergen
• 45-50% total calorie of infant formula
• Made from combination of various plant oil
• Mixture of short chain fatty acids, LCPUFA and PUFA Lipid
• Added with essential fatty aci i.e linoleic and alfa
lipolenic → 5-15 : 1
 Composition of infant formula
Vitamin • Quantity : fulfill the recommended daily allowance
• Quality : same with breastmilk
and mineral • Have maximum and minimum value

Other • Colin
• Myocholinol
substance • L-carnitin

• May be added to provide substance ordinarily found in

Optional breast milk
• Sustainability and safety should be scientifically proved
ingredients • Touraine, nucleotides, LC PUFA
 Acceptable medical reasons for use of breast
milk subtitutes (WHO, 2009)
health problems in the infant
Breastfeeding and
Contraindication of BF supplementation
• Galaktosemia (infant
• Very low birth weight
formula without
galactose) (below 1500g)
• Maple syrup disease
(infant formula without • Premature birth (before
leucine, isoleucine and 32nd week)
valine)
• Fenylketonuriae (infant
formula without • Hypogycaemia (hypoxic
phenylalanine) stress, mothers with
diabetes, etc.)
• WHO 2009
 HEALTH PROBLEMS IN THE
MOTHERS
• Contraindications of breastfeeding
o HIV/AIDS infection
o HTLV-1, 2 Infection (India, Africa, Japan)
• Temporary interruption of breastfeeding
o Serious illness (e.g sepsis)
o Herpes simpleks virus 1 infection (HSV 1)
o Varicella
o Active TBC
o Medication in mother (sedatives, antiepileptics, opioids,
radioactive iodine- J-131, cytotoxic chemotheraphy)
• Breastfeeding and management of the problems
o Mastitis, absess of breast
o Hepatitis B, C, TBC (positif tuberculine test)
o Using addictive substances
 Types of formula
1. Standart cow’s milk based formula
2. Soy formula
3. Elemental or hydrolysate formulas (some
hypoallergic)
4. Aminoacid based formulas
5. Other “designer formulas” (lactose-free, special
metabolic formulas, etc.)
 International code of marketing of
breastmilk subtitutes (WHO 1981)
• Art 4 information and education
• Art 5 public and mothers
• Art 6 health care systems
• Art 7 health workers
• Art 9 labelling
 Art. 4.2 information and educational
materials for pregnant women and mothers
• Should be distributed via the health care system
• Benefits and priority of breastfeeding stressed
• Importance of healty nutrition in mother
• Negative impact of supplementation with a bottle
• Health risk related to infant feeding
• Instruction on proper use of infant formula
• Financial consequences of artificial feeding
• No texts, figures idealizing infant formula
 Art. 9 Labelling
• “Important statement” :
o stressing priority of BF
o product use should be consulted with health professional
o Instruction on proper preparation
o Warning against health risk
o No text or figures idealizing BMS
 Risk of artificial feeding
(in developing countries risk are above these levels)

• Increased risk of acute illness :

o Gastroenteritis : 3-4x risk (developing countries 17-25x)
o Acute otitis media : 3-4x risk
o Lower respiration tract infection (e.g pneumonia)
o Bacterial infection requiring hospitalization : 10x risk
o Meningitis : 4x risk (e.g Enterobacter sakazakii)
o Higher mortality from sudden infant death syndrome (SIDS)
 Risk of artificial feeding
• Increased risk of chronic conditions and illness :
o Allergies- atopic dermatitis, asthma
o Type 1 type 2 diabetes
o Obesity
o Crohn’s disease, ulcerative colitis, coeliac disease
o Childhood lymphomas (5-8x risk) leukemia
 Risk of artificial feeding
• Dose related differences mental development :
o Lower scores of mental development test at 18 months
o Difference in mental development and school
perfomance at 3-5 years
o Lower scores in prematures on intelligence tests at 7-8
years
o Deficits in neurological develompent (lack of essential fatty
acids)
o Differences in visual acuity
 Risk of artificial feeding
• Effects on mother :
o Increased risk of anemia due to early return of
menstruation
o Increased risk of new pregnancy
o Higher risk of impaired bonding, abuse, neglect and
abandonment of the child
o Increased risk of breast and ovarian cancer
Complementary food
 Definition
• The process of giving an infant other foods and
liquids along with breast milk or non human milk as
breast milk alone is no longer sufficient to meet the
nutritional requirements
• These foods should complement rather than
replace breast milk
Appropriate complementary feeding
• Timely : introduced when need for energy and
nutrients exceed that provided by BF
• Adequate : should provide sufficient energy, protein
and micronutrients
• Properly fed : active feeding methodes and proper
frecuency according for age
• Safe : should be hygienically prepared stored and
fed
Age of introduction
 Timing of complementary feeding
• Soon after comppeting 6 months of age :
o Breast milk sufficient to promote growth and development
till 6 months
o Energy and nutrient gap appears after 6 months and
widens thereafter
o Infant’s develompent and behavior makes him ready for
others foods :
• Hold objects (e.g biscuit) and takes everythings to
mouth
• Chewing movements start
• Tendency to push solids out decreases
• Eruption of teeth and beginning of biting movements
 Timing of complementary feeding
• Disadvantages of adding foods too soon
o Decrease the intake of breast milk resulting in a low nutrient
diet
o Increase risk of illness esp. Diarrhea
• Disadvantages of adding foods too late
o Growth and development slows down or stops
o Risk of deficiencies and malnutrition
Guiding principles for complementary
feeding infants 6-23 months
AMOUNT OF ENERGY NEEDED
6-8 months 600 kcal/day
9-11 months 700 kcal/day
12-23 months 900 kcal/day
 Fluid needs
Offer plain, clear water several times
per day once infants are eating solids

Additional fluids needed :

400-600 ml/day in temperate climates
800-1200 ml/day in hot climates

Without additional water

dehydration becomes a threat
Guiding principles for feeding breasfed and
non breastfed children, 6-23 months (2)
Breastfed child Non breastfed child

Practice responsive feeding Practice responsive feeding

Safely prepare and store CP Safely prepare and store CF

Start with small amounts of food at 6 Provide adequate amounts of food.

month. Increased quantity of food as Increase quantity as child gets older
child gets older

Increase food consistency and variety Increase food concistency and variety
as infant gets older as infant gets older
Food consistency
Increased food cnsistency and
variety as infants gets older

Infants can eat pureed, mashed

and semisolid food from 6
months

By 12 months, family food

suitable
Guiding principles for feeding breasfed and
non breastfed children, 6-23 months (3)
Breastfed child Non breastfed child
Frequency of feeding : Frequency of feeding :
Min # “meals”/day CF = Min # “meals”/day =
- 2-3 for children 6-8 m - 4-5 for children 6-8 m
- 3-4 for children 9-23 m - 4-5 for children 9-23 m

Nutrient content of foods : Nutrient content of foods : feed

Feed a variety daily
- Meat, poultry, fish or eggs
- Vitamin A rich fruits and
vegetables
variety
- Meat, poultry, fish or eggs
- Vit A rich fruits & vegetables
- Milk and milk products from
acceptable sources
 Amounts of food to offer
Age Texture Frequency Amount of food an
average child will
usually eat at each 1
meal
6-8 months Start with thick 2-3 meals/day plus Start with 2-3
porridge well mashed frequent breastfed tablespoon per feed
foods continue with depending on the increasing
mashed family foods childs appetite 1-2 gradually to ½ of a
snacks may be offered 250 ml cup
9-11 months Finely chooped or 3-4 meals plus ½ of 250 ml
mashed foods and breastfeds depending cup/bowl
foods that baby can pick on the child appetite
up 1-2 snacks may be
offered
12-23 months Family foods, chooped 3-4 meals plus ¾ to 1 of a 250 ml
or mashed if necessary breastfeds depending cup/bowl
on the child appetite
1-2 snacks may be
offered
The 1st test feedings
Iron fortified infant rice cereal as
1st food

Should be a single food (not

combination), nutritious, smooth
texture and thin consistency

Best to offer after feeding some BM

or formula, except who repeatedly
no interest → offer before
Precautions when introducing solid food
Home prepared beets, carrots, collard greens,
spinach and turnips :
- High in nitrates → methemoglobin
- Should not be fed babies <6 months

Honey :
- May contains C. Botulinum → causing infant
botulism

Cow’s milk :
- Infant <1 years should not get cows milk → low in
Fe, high in Na, K, Cl and other minerals
 Variety of foods
• Start at 6 months with small amounts of food,
increase quantity with age, maintaining frequent
breast feeding
• Increase food consistency & variety with age
o Can feed mashed & semi solids (e.g porridge) at 6 months
o Can feed finger foods by 8-9 months
o By 12 months family foods can be eaten
• Combine foods (e.g rice and legumes) to provide
good mixture of amino acids
Safety issues regarding feeding infants :
Honey and corn syrup, are the only food sources
in infants diet of clostridium botulinum spores,
which lead to botulism. They should not be fed to
infants less than 1 years of age

Cook eggs and chicken well to avoid salmonella

Small, hard, round and sticky solid food may

lead to choking and aspiration
AAP: spesific reommendation
Home prepared spinach, beets, turnips,
carrots, collard greens not recommended
due high nitrate levels →
methemoglobinanemia

Canned food with high salt levels and sugar

are unsuitable for preparation of infant
foods

Honey not recommended for infants

younger than 12 months → botulism
 Advantages and disadvantages of
commercial complementary foods
• Comfortable directly • Lower nutritional value
• Saves time : be sensitivity (compared to fresh
satiety cues food)
• Feed patiently :
encourage but do not • Similar consistence
force does not suit
• If child refuses : developmental needs
experiment food of the infant
combination tasted
• Costs money
• Minimize distraction
during meal • Burden for the
• Talk to child during environment
feeding contain eye (production, transport,
contact adverts, wasted)