NIC - Module 2.pdf

Nutrition in Infancy and Childhood Module 2 / Feeding Infants and Young Children  © 1999, Nestec Ltd., CH-1800 Vevey, Switzerland. Printed in Switzerland. All rights reserved. No part of this publication may be reproduced, recorded or transmitted in any form and by any medium w...

Nutrition in Infancy and Childhood Module 2 / Feeding Infants and Young Children  © 1999, Nestec Ltd., CH-1800 Vevey, Switzerland. Printed in Switzerland. All rights reserved. No part of this publication may be reproduced, recorded or transmitted in any form and by any medium whatsoever (electronic, mechanical, photocopying, recording or other) without the written permission of the publisher. The material contained in this publication was submitted as previously unpublished material, except where credit is given to a source of part of the material illustrated. Nestec Ltd. has taken great care to check the accuracy of the information contained in this publication. Nevertheless, Nestec Ltd. cannot be held responsible for any errors or omissions, or for any consequences arising from the use of the information it contains. With particular regard to drugs, the reader must refer to the manufacturer’s recommendations for the dosage, especially if the reader is not in the habit of using the product to be administered or prescribed, or if he has not used it for some time. Edited by Help Medical - 29 avenue Laplace, 94110 Arcueil, France Tel.: 33 1 49 85 80 01 - Fax: 33 1 49 85 80 05 - E-mail: [email protected] 2  Module 2 / Feeding Infants and Young Children Contents Contents Module 2 From Birth Section 1: Breast-Feeding..................................................... Page 15 Section 2: Cow’s Milk versus Breast Milk.......................... Page 15 Section 3: Infant (Starter) Formulas.................................... Page 29 From 4-6 Months of age Section 4: Weaning............................................................... Page 43 Section 5: Follow-up Formulas............................................ Page 53 Section 6: Weaning Foods.................................................... Page 63 From 1 Year to 3 Years of age Section 7: Junior Foods........................................................ Page 77 Subject Index......................................................................... Page 87 3  Important notice The World Health Organisation (WHO*) has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding - in particular the fact that breast-milk provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for, initiation and maintenance of lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breast-feeding. Similarly, mothers should be warned of the difficulty of reversing a decision not to breast-feed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision. If a baby is exclusively bottle-fed, more than one can (450 g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast-milk is not only the best, but also the most economical, convenient and bacteriologically safe food for babies. If a decision to use an infant formula is taken, it is important to give instructions on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can all lead to illness. * See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981. 4  Module 2 / Feeding Infants and Young Children Section 1 - Breast-Feeding Section 1 - Breast-Feeding Objectives When you finish this section, you should be Comment on the advantages of breast milk able to: and breast-feeding, for the mother and the infant State why breast milk is the best source of nutrients for the young infant from birth until 4 to 6 months of age Comment on the changing practices in breast-feeding 5 Additional Information Notes: Protective factors (1) Both nutrients and non-nutrients in human milk may exert beneficial non-nutrient effects. Immunoglobulins are proteins synthe- sized by the immune system. They include all known antibodies. Secretory IgA (sIgA) protect the infant against food allergens and microbial antigens (infection). There is a strong theoretical basis for specu- lating that sIgA in human milk protect the infant against micro-organisms (bacteria, viruses and parasites) present in the gas- trointestinal tract of the mother, through the enteromammary pathway for lymphocytes, and against micro-organisms present in the mother’s respiratory tract, through the bronchomammary pathway. Moreover, the manifestations of infection may be altered by anti-inflammatory pro- perties of human milk. These are due to a number of anti-inflamma- tory agents (catalase, lysozyme, lactoferrin, somatostatin) and to the low content of inflammatory agents. Other components of human milk have been demonstrated as growth factors for various tissues. – Epidermal growth factor from human milk promotes cell proliferation of the gastroin- testinal mucosa. – Insulin-like growth factors stimulate growth of intestinal tissue. In addition, human milk contains a large number of enzymes and hormones. – Lysozyme is an enzyme that cleaves pepti- doglycans from the cell wall of susceptible bacteria. – The peroxidase in human milk catalyzes the oxidation of thiocyanate ions to prod- ucts with bacteriostatic activity. – The bile salt-stimulated lipase in human milk appears to be important in the produc- tion of antimicrobial lipids. 6  Module 2 / Feeding Infants and Young Children Section 1 - Breast-Feeding Breast-feeding Breast-feeding benefits for the baby Breast-feeding is the ideal way to feed an infant. Furthermore, it is practical, economical Breast-feeding is the most efficient and and very rewarding. safest form of nourishment. The nutritional quality is assured; all nutri- Prior to the 20th century, few satisfactory ents are present in the most suitable form; alternatives to breast-feeding existed. If a there is no risk of incorrect dilution. mother died, leaving her baby without a Temperature is finely tuned. source of adequate nourishment, wet nurses There is little chance of bacterial contamina- were available - generally only for the privi- tion of the milk. leged. Breast milk is rich in protective factors: immunoglobulins, lysozyme, lactoferrin, cellular elements (neutrophils, macrophages and lymphocytes), but also antiviral and anti-parasitic proteins, anti-inflammatory agents, growth factors and hormones, growth promoters of intestinal microbial flora, and inhibitors of pathogenic microbial metabolism. Breast-fed babies are less susceptible to infection, particularly gastroenteritis.  Breast-feeding is the ideal way to  For the baby: feed an infant  nutritional quality assured  no risk of incorrect dilution  little chance of bacterial contamination  rich in protective factors  less risk of gastrointestinal infection 7 Additional Information Notes: Protective factors (2) Quite a number of components of human milk, e.g., lactoferrin, monoglycerides and specific fatty acids, are unequivocally effective in inhibiting the growth of or killing micro-organisms. Other molecules - glyco- lipids, oligosaccharides, fatty acids and glycoproteins - block the receptor sites required for pathogenic organisms or bind to toxins. Other factors, identified as glycoprotein components of human milk whey (including lactoferrin) and oligosaccharides, promote the growth of Bifidobacterium species in the large intestine of the breast-fed infant. Lactic and acetic acid produced by these organisms, as well as the low buffering capacity of human milk, result in a distal intestinal pH of approximately 5. This pH is unfavorable to the growth of many enteric pathogens. The number of cellular elements (neutro- phils, macrophages and lymphocytes) is remarkably high in colostrum but much lower in mature milk. – The macrophages and lymphocytes in human milk can synthesize lysozyme, components of complement, lactoferrin, prostaglandin E2 and interferon. – The macrophages in human colostrum have high concentrations of sIgA that are rapidly released during phagocytosis. – Macrophages remain viable at the pH of the intestine, but it is uncertain whether the buffering capacity of human milk permits macrophages to remain viable during pas- sage through the stomach. However, even if the cells fail to survive during passage through the stomach, macrophage products still might exert effects within the intestine. – It seems likely that the leukocytes in human milk provide important protection against infection of the breast. 8  Module 2 / Feeding Infants and Young Children Section 1 - Breast-Feeding Breast-feeding benefits for the Changing practices in breast- mother feeding Breast-feeding offers a series of physiologi- In traditional pre-industrial human society, cal benefits. all babies were breast-fed for a long period of In the immediate postpartum period, breast- time. feeding is associated with uterine contrac- tions, which reduce the risk of vaginal bleed- In many developed countries, breast- ing. The uterus also returns more quickly to feeding declined until the beginning of the its pre-pregnancy size. 1970’s. This practice was related to urbaniza- The mother dissipates the energy laid down tion, industrialization, increase in hospital during pregnancy; as a consequence, she births and the availability of suitable substi- returns more quickly to her pre-pregnancy tutes. weight. In developing countries, breast-feeding At the present time the proportion of contributes to a reduction of natural fertility breast-fed babies is increasing markedly in by increasing the length of postpartum highly developed societies (e.g., Northern and amenorrhea, thus postponing a new Western Europe, the U.S.A., Scandinavia, conception. Australia, etc.). This phenomenon is related to an increased Breast-feeding also offers a series of psy- knowledge of food and nutrition, higher edu- chological benefits by creating a very intense cation for women, and social legislation pro- mother-infant bond mediated, in part, by the moting the practice of breast-feeding. close skin contact. As a result, most mothers consider breast- feeding an extremely satisfying and rewarding experience.  For the mother:  Increased knowledge of foods and  close mother/infant bond nutrition  less risk of vaginal bleeding in  higher education for women immediate postpartum period  social legislation  quicker return to pre-pregnancy  … contribute to increase the practice weight of breast-feeding  reduction of natural fertility in postpartum period 9 Additional Information Notes: Average composition of breast milk (100 ml) Nutrient Human Milk Fat g 3.8 Linoleate g 0.51 Protein g 1.2 Carbohydrate g 7.0 Minerals g 0.21 Vitamin A µg RE 53 Vitamin D IU 0.4-10.0 Vitamin E mg 0.2 Vitamin K1 µg 0.3 Vitamin C mg 4.3 Thiamine (B1) µg 16 Riboflavin (B2) µg 43 Niacin (PP) µg 172 Vitamin B6 µg 11 Folic acid µg 0.18 Pantothenic acid mg 0.25 Vitamin B12 µg 0.18 Biotin µg 2.0 Choline mg 1.3 Inositol mg 45 Taurine mg 5.0 Carnitine mg 0.8 Sodium mg 16 Potassium mg 55 Chloride mg 43 Calcium mg 33 Phosphorus mg 15 Magnesium mg 4 Iron mg 0.15 Iodine µg 7.0 Copper mg 0.040 Zinc mg 0.53 Manganese µg traces Source: Nestlé Nutrition Services 10  Module 2 / Feeding Infants and Young Children Section 1 - Breast-Feeding Breast milk as reference Colostrum standard for infant nutrition Colostrum is the term used to denote the Breast milk is the best source of nutrients first milk secreted by the mother’s breasts for for the young infant and the reference the first 3 days after the infant’s birth. It is a standard for good infant nutrition from birth particularly rich source of antibodies and other until 4 to 6 months of age. factors which protect against infectious diar- This means that breast milk provides nutri- rhea. ents in adequate amounts and in the right bal- ance to sustain normal growth and develop- Mineral content of colostrum is relatively ment for the first months of life. high, and concentrations of sodium, potas- Breast milk provides protein, fat, carbohy- sium and chloride are greater in colostrum drate, vitamins, minerals and water in the cor- than in mature breast milk. rect balance to promote healthy growth and These increased concentrations correspond development. to the particular requirements of the newborn due to the immaturity of its renal function Moreover, breast milk can form the basis for with, as a consequence, inadequate reabsorp- sound nutrition for the rest of the first year tion and passage of these minerals into the and even beyond until the end of weaning. urine during the first days of life. Therefore breast milk is the perfect food for the normal, healthy infant. It supplies ade- quate amounts of nutrients in the right Transitional and mature breast balance. milk Major changes in breast milk composition occur in the transition from colostrum to mature milk. These changes are completed by  Breast milk, the perfect food for the about the tenth day after the baby’s birth. normal healthy infant: 10 The milk which is produced between the Average amount g/100 ml time secretion of the colostrum ends - around the third day - and the establishment of 7.0 mature milk secretion on the tenth day is known as transitional milk. 5 3.8 From the tenth day onward, the breasts produce mature breast milk. 1.2 0.21  Colostrum: the first three days Carbohydrate Fat Protein Vitamins  Transitional milk: between the third Minerals Lactose Essential fatty acids: Whey proteins Calcium Phosphorus Vitamin A Thiamin and the tenth day mainly Linoleic acid Sodium Copper  Mature breast milk: from the tenth Zinc day onward 11 Notes: 12  Module 2 / Feeding Infants and Young Children Section 1 - Breast-Feeding Progress Check A Give five reasons showing that breast-feeding is the most efficient and safest form of nourishment for the young infant. B Sum up the protective factors present in breast milk. C Give the three factors which have contributed to the recent increase in the frequency of breast-feeding in industrialized countries. D State the timing difference between colostrum, transitional milk and mature breast milk. Answers on the following page 13 Progress Check Answers A 1. The nutritional quality is assured 2. Temperature is finely tuned 3. There is little chance of bacterial contamination of the milk 4. Breast milk is rich in protective factors 5. Babies are less susceptible to infection (e.g., gastroenteritis) B Immunoglobulins, lactoferrin, lysozyme, cellular elements (neutrophils, macrophages and lymphocytes), antiviral and anti-parasitic proteins, anti-inflammatory agents, growth factors and hormones, growth promoters of intestinal microbial flora, and inhibitors of pathogenic microbial metabolism C 1. Increased knowledge of food and nutrition 2. Higher education for women 3. Social legislation promoting the practice of breast-feeding D 1. Colostrum is secreted by the breasts during the first three days postpartum 2. Transitional milk is secreted from the third to the tenth day 3. Mature milk is secreted after 10 days If you have correctly answered all these questions, proceed to the Objectives for Section 2; otherwise please carefully read this Section again. 14  Module 2 / Feeding Infants and Young Children Section 2 - Cow’s Milk versus Breast Milk Section 2 - Cow’s Milk versus Breast Milk Objectives When you finish this section, you should be State the major differences between cow’s able to: milk and human milk which affect infant nutrition State the reasons why unmodified cow’s milk is unsuitable for infant nutrition Describe the nutrients distribution in mature human milk and in whole cow’s milk State what distinguishes casein from whey protein Explain the significance of the whey/casein ratio 15 Additional Information Evaporated and sweetened condensed milk Evaporated milk, a concentrated form of whole milk, has been widely used for feed- ing infants. When diluted adequately with water, it has the same basic disadvantages as whole cow’s milk. Moreover, it has lost some protein quality and vitamins due to the heating needed for evaporation. Sweetened condensed milk is of excellent protein quality, because it undergoes little heating! Sweetened condensed milk has often been fed to infants. However, it is no longer recommended any more for infant feeding. Its disadvantages are that it con- tains too little fat, linoleic acid and vitamins, and too much carbohydrate (sucrose). GRAMS/100ML ENERGY DISTRIBUTION (PERCENT OF FOOD ENERGY) Mature Full Mature Full Breast Cream Breast Cream Milk Cow’s Milk Milk Cow’s Milk 29% 4.8 43% CARBOHYDRATE 7.0 21% 7% PROTEIN 3.3 1.2 FAT 3.8 3.7 50% 50% MINERALS 0.2 0.7 16  Module 2 / Feeding Infants and Young Children Section 2 - Cow’s Milk versus Breast Milk Whole cow’s milk Food energy Whole unmodified cow’s milk - also called Food energy level full-cream milk - is still used in place of breast Energy level of cow’s milk (about 660 kcal/l) milk. is comparable to that of breast milk (about Without considerable modification, whole 670 kcal/l). cow’s milk is unsuitable for feeding infants from birth to 12 months of age. Food energy distribution As you learned in Module 1, protein repre- Feeding whole cow’s milk to infants causes sents about 7% of the food energy in mature a series of physiologic and nutritional prob- breast milk, fat represents around 50%, and lems: carbohydrate between 40 and 45%. Its energy level is comparable to the energy In whole cow’s milk, protein represents 21% level of breast milk, but the fat in cow’s milk of the food energy, while 50% of the food ener- is poorly absorbed reducing the availability gy comes from fat and 29% from carbohy- of energy, possibly leading to malnutrition. drate. Whole cow’s milk contains excessive amounts of protein, sodium and chloride which cannot be excreted by the immature kidneys and lead to renal solute overload and dehydration. Excess calcium and phosphorus strongly influence intestinal flora and transit, result- ing in constipation. Whole cow’s milk is deficient in essential fatty acids, iron, copper, vitamin C and vita- min E.  Whole cow’s milk is unsuitable for  Food energy: feeding infants:  breast milk: 670 kcal/l  excessive amounts of:  whole cow’s milk: 660 kcal/l - protein  … but less available in cow’s milk due - sodium to poorly absorbed fat - chloride - phosphorus - calcium  deficient in: - essential fatty acids - iron, copper - vitamins C and E 17 Additional Information Notes: Average composition of cow’s milk (100 ml) Nutrient Cow’s Milk Fat g 3.7 Linoleate g 0.07 Protein g 3.3 Carbohydrate g 4.8 Minerals g 0.7 Vitamin A µg RE 34 Vitamin D IU 0.3-4.0 Vitamin E mg 0.1 Vitamin K1 µg 0.7 Vitamin C mg 1.8 Thiamine (B1) µg 42 Riboflavin (B2) µg 157 Niacin (PP) µg 85 Vitamin B6 µg 48 Folic acid µg 0.23 Pantothenic acid mg 0.34 Vitamin B12 µg 0.4 Biotin µg 22 Choline mg 1.2 Inositol mg 8 Taurine mg 0.5 Carnitine mg 1.0 Sodium mg 58 Potassium mg 137 Chloride mg 103 Calcium mg 125 Phosphorus mg 96 Magnesium mg 12 Iron mg 0.1 Iodine µg 21 Copper mg 0.03 Zinc mg 0.38 Manganese µg traces Source: Nestlé Nutrition Services 18  Module 2 / Feeding Infants and Young Children Section 2 - Cow’s Milk versus Breast Milk Protein content Quality of protein One of the major differences among milks We have seen that the protein content in from different species concerns the protein cow’s milk is higher than that in human milk. content which is related to growth rate of the But the quality of protein is also different. young. The proteins in milk are composed of two The composition of mother’s milk - e.g. with protein fractions, whey proteins and casein. regard to protein content - in each species is Breast milk protein is whey protein- adapted to the needs of the young animal. predominant: the average whey/casein ratio The faster a young animal grows, the more in breast milk is 60:40, which means that whey protein it needs to lay down in the newly syn- proteins represent 60% of the total protein thesized tissues, and the richer its mother’s and casein only 40%. milk is in protein. The major whey proteins in human milk are Let us compare growth rates in infants and lactalbumin, lactoferrin and immunoglobulins calves. Normally, an infant doubles its birth IgA. weight in around 4 to 6 months - or 125 to Cow’s milk protein is casein-predominant: 180 days. A calf doubles its birth weight in the average whey/casein ratio in cow’s milk is about 50 days. The faster-growing mammal in the range 20:80, which means that whey requires milk with a higher protein content. proteins represent only 20% of the total pro- tein and casein 80%. Protein represents about 21% of the total energy in whole cow’s milk, while it is only What is the significance of these ratios? The 7% in human milk. whey/casein ratio is important for digestibility The protein content per 100 kcal of whole and determines the essential amino acid pat- cow’s milk is about 5.0 g, while it is only about tern. 1.8 g in breast milk. Thus, the protein content of cow’s milk is about three times that of human milk. The higher protein content of unmodified cow’s milk makes it especially unsuitable for infant nutrition. Excessive protein intake in infants can lead to renal solute overload.  Protein fractions:  cow’s milk: casein-predominant (80%)  Protein content per 100 kcal:  breast milk: whey protein-  human milk: 1.8 g/100 kcal predominant (60%)  whole cow’s milk: 5.0 g/100 kcal  Whey/casein ratio:  Excessive protein content in cow’s  cow’s milk: 20:80 milk  breast milk: 60:40  … especially unsuitable for infant  important for digestibility nutrition.  determines the amino acid content 19 Additional Information Notes: Whey proteins in human milk and cow’s milk The term “whey protein” covers all nitro- gen-containing substances which do not coagulate at acid pH (the latter is known as “casein”). It is not one single protein, but a group of proteins, whose composition pre- sents significant differences between human milk and cow’s milk. Apart from proteins, it also includes a non- protein nitrogen (NPN) fraction, composed of free amino-acids, peptides, etc. The NPN fraction in human milk represents approxi- mately 20% of total nitrogen, and only 5% in cow’s milk. The major whey proteins in human milk are α-lactalbumin (about 40% of total whey pro- teins), lactoferrin (30%) and immunoglobu- lins IgA (15-20%). Serum albumin and lysozyme are also present. The major whey proteins in cow’s milk are ß-lactoglobulin (60% of total whey proteins, not present at all in human milk) and α-lactalbumin (20%). Immunoglobulins are of the IgG type, and lactoferrin and lysozyme are present only in trace amounts. Essential amino acids in human milk and cow’s milk (mg amino acid per g total nitrogen) Human milk Cow’s milk Isoleucine 320 350 Leucine 580 640 Lysine 430 510 Methionine 91 180 Cystine 120 60 Phenylalanine 230 340 Tyrosine 180 280 Threonine 275 310 Tryptophan 140 90 Valine 415 460 Histidine 150 190 Ref.: Paul and Southgate, DHSS 1978 20  Module 2 / Feeding Infants and Young Children Section 2 - Cow’s Milk versus Breast Milk Digestibility of the Amino acid composition protein fractions in milk The amino acid profile of human milk is sig- When milk is acidified, as normally occurs in nificantly different from that of cow’s milk. the stomach, the casein becomes insoluble, coagulates and forms a curd. The watery part The content of some essential amino acids left over is called whey. such as tryptophan and the sulphur-containing Casein is the protein that precipitates and amino acid cystine, is somewhat higher in constitutes the curd protein, whereas whey whey proteins than in casein. proteins are those that remain soluble in the The higher concentrations of these essential liquid. amino acids may be nutritionally advantageous, at least in preterm infants. The large amount of casein in cow’s milk is responsible for the formation of a relatively A formula, for an equal energy value, must poorly digested mass of large pieces of firm, contain an available quantity of each essential rubbery curds when the milk is acidified in the amino acid at least equal to that contained in infant’s stomach. human milk. Breast milk, which is whey-predominant, forms a soft pliable curd when acidified. It is therefore more easily digested by the infant. As a result, infants fed whey-predominant formulas are less prone to develop lactobe- zoars (intestinal milk-bolus obstruction) than infants fed casein-predominant formulas, especially in preterm infants.  Curds:  Whey-predominant protein:  cow’s milk: firm, poorly digested  better digestibility  breast milk: soft, easily digested  more favorable amino acid composition  Essential amino acids content in formulas … at least equal to that in breast milk, for an equal energy value. 21 Additional Information Detailed fatty acid composition in human milk and cow’s milk Fatty acids Human milk Cow’s milk saturated 4:0 butyric 3.0 6:0 caproic 1.0 8:0 caprylic 0.19 1.0 10:0 capric 1.1 3.0 12:0 lauric 4.8 2.0 14:0 myristic 7.2 10.7 16:0 palmitic 23.4 26.3 18:0 stearic 8.0 12.1 mono unsaturated 16:1 palmitoleic 3.4 4.5 n-9 18:1 oleic 35.3 33.3 poly unsaturated n-6 18:2 linoleic 13.4 2.0 18:3 γ-linolenic 0.17 20:4 arachidonic 0.45 0.1 n-3 18:3 α-linolenic 0.94 1.0 20:5 EPA 0.18 22:5 DPA 0.17 22:6 DHA (cervonic) 0.30 Source: Nestlé Nutrition Services 22  Module 2 / Feeding Infants and Young Children Section 2 - Cow’s Milk versus Breast Milk Fat and fatty acids Carbohydrates The fat in breast milk provides the infant Carbohydrates (CHO) in human milk and with important component fatty acids as cow’s milk are mainly present as the free dis- essential fatty acids and acts as the carrier of accharide lactose, and there is no significant the fat-soluble vitamins required for normal difference between human and bovine lactose. growth, development and maintenance. Besides lactose, there are small amounts of The fatty acids in cow’s milk are largely oligosaccharides, either bound to other mono- saturated or monounsaturated and include saccharides such as fructose, or to nitrogen- rather small amounts of the essential fatty containing substances (N-acetylglucosamine, acids linoleic and α-linolenic acid compared to sialic acid). The oligosaccharides in human human milk. milk may represent up to 15% of total carbo- hydrates,whereas they do not exceed 2 to 5% Fat absorption in the infant depends very in cow’s milk. much on the absorption of long chain saturat- ed fatty acids, such as palmitic and stearic Carbohydrates are important determinants acids. of the composition of the intestinal flora. Although the palmitic acid level in cow's milk is similar to that of breast milk, its absorption is poor, due to differences in triglycerides structure. As a result, the fat in cow's milk is poorly absorbed.  Essential fatty acids  Carbohydrates:  … less linoleic and α-linolenic acid in  mainly lactose cow’s milk than in breast milk  oligosaccharides: – up to 15% of total CHO in human milk  The fat in cow’s milk is poorly  – do not exceed 2-5% in cow’s milk absorbed 23 Additional Information Notes: 24  Module 2 / Feeding Infants and Young Children Section 2 - Cow’s Milk versus Breast Milk Mineral content In contrast, cow’s milk contains excessive amounts of minerals necessary to cover the Another major difference between mature requirements of the fast-growing calf. breast milk and cow’s milk concerns mineral With the exception of iron and copper, levels and renal solute load. cow’s milk contains considerably more of all the minerals than breast milk. Minerals are present in breast milk at levels The excessive mineral levels in unmodified compatible with the infant’s body weight, cow’s milk, along with the high protein con- physiologic maturity and requirements for tent, contribute to a high renal solute load healthy growth, with no risk of renal solute which can lead to renal solute overload, dehy- overload. dration and acidosis. These two characteristics of unmodified cow’s milk make it especially unsuitable for infant nutrition.  Cow’s milk mineral content  Both excessive mineral and protein  … excessive for the infant content in unmodified cow’s milk  … can lead to renal solute overload, dehydration and acidosis 25 Notes: 26  Module 2 / Feeding Infants and Young Children Section 2 - Cow’s Milk versus Breast Milk Progress Check A Why is whole cow’s milk unsuitable for feeding infants? B How does the food energy distribution compare in mature human milk and in whole cow’s milk? C Protein content in milks is related to …… D How do the protein content compare in mature human milk and in unmodified cow’s milk? E The whey/casein ratios in mature human milk and unmodified cow’s milk are …… and …… F What are the advantages of a whey-predominant protein? Answers on the following page 27 Progress Check Answers A – Whole cow’s milk contains excessive amounts of protein, phosphorus, calcium, sodium and chloride, resulting in excessive renal solute load and poor digestibility – Whole cow’s milk is deficient in essential fatty acids, iron, copper, vitamin C and vitamin E – The fat in cow’s milk is poorly absorbed B – Mature human milk: 7% from protein, 50% from fat, 43% from carbohydrate – Unmodified cow’s milk: 21% from protein, 50% from fat, 29% from carbohydrate C Growth rate in the young D The protein content in mature human milk is about 1.8 g per 100 kcal, and about 5.0 g per 100 kcal in unmodified cow’s milk E 60:40 and 20:80 F Better digestibility and a more favorable amino acid composition If you have correctly answered all these questions, proceed to the Objectives for Section 3; otherwise please carefully read this Section again. 28  Module 2 / Feeding Infants and Young Children Section 3 - Infant (Starter) Formulas Section 3 - Infant (Starter) Formulas Objectives When you finish this section, you should be Describe the major steps leading from able to: whole cow’s milk to a modern infant formula Describe a starter formula and provide the rationale behind its composition Describe the various types of starter formulas Describe how to prepare the formula 29 Additional Information Notes: Developments in artificial feeding The following developments have made rou- tine artificial feeding possible: the availability of safe water the improvement of general sanitation the development of methods for the preservation of cow’s milk the establishment of standards for han- dling and storing fresh cow’s milk the availability of easily cleaned and steril- ized glass bottles and rubber nipples improved education leading to the aware- ness that bacteria cause disease the development of methods for the treat- ment of cow’s milk in order to improve its digestibility advances in pediatric and nutritional knowledge greater purchasing power Totally unsuitable breast milk substitutes In areas where rice is a dietary staple, rice gruel is often used to feed the infant. – In other areas, cassava flour may form the basis of an infant’s diet. – In some parts of Latin America, some chil- dren are fed a mixture of cornstarch and water, which indeed looks like milk. – Sugared teas can be mistakenly used as significant sources of fluid and energy, even in industrialized countries. Such substitutes provide some food ener- gy, but nutritionally they lack the basic nutri- ents needed for proper growth and develop- ment. 30  Module 2 / Feeding Infants and Young Children Section 3 - Infant (Starter) Formulas Breast milk substitutes Adaptation of cow’s milk for infant feeding Infants grow most rapidly during the first 6 months of life. From a nutritional point of The difference in protein level is one of the view, this period is critical. major nutritional differences between breast Breast-feeding is best for babies and also milk and full cream cow’s milk. beneficial for mothers, but not all babies are Since the protein level in the latter is too breast-fed, for various reasons. high, the first process used in adapting it for Breast-feeding may be unsuccessful, med- infant feeding has been to dilute it with water, ically inappropriate or stopped early, or a to reduce protein and mineral content, and to mother may simply choose not to breast-feed. add to the solution adequate quantities of car- bohydrates and lipids, to reach the same In situations where breast-feeding does not caloric density as in human milk. occur, infants can grow normally and thrive on appropriate breast milk substitutes that are Whereas in the first attempts to adapt properly prepared. cow’s milk, sucrose and starch were the only However, all foods are not nutritionally suit- available carbohydrates, and milk fat (butter) able as breast milk substitutes. the most commonly used source of lipids, In certain circumstances, because of socio- technological developments have enabled the economic conditions or cultural food customs, use of better adapted food ingredients, includ- breast milk substitutes which are nutritionally ing lactose, maltodextrins, glucose polymers unsuitable are given to infants. as carbohydrate sources, and refined veg- Very often the consequence of these prac- etable fats of adequate fatty acid composition tices is infant and child malnutrition. as lipid sources. Modern infant (starter) formulas are the only products specially designed as breast milk substitutes: – They are usually formulated to closely approximate the composition of breast  Qualitative adaptation of cow’s milk milk. for infant feeding: – They meet all nutritional requirements dur- + Fat + CHO ing the first 4 to 6 months of life. 12 10 4.8 7.0 7.0 8 g per 100 ml 6 3.7 2.4 4 3.7 3.8 1.8 3.3 2 1.6 1.6 1.2  Infant formulas are the only products 0 0.7 0.3 0.3 0.2 Cow’s milk Dilution Adaptation Human milk specifically designed as breast milk (Formula) substitutes. minerals proteins lipids carbohydrates 31 Additional Information Notes: Importance of medical advice Infant feeding should always be super- vised by a health professional. The medical advisor should always be aware of social circumstances when giving advice on infant feeding, even in industrial- ized countries. For example, if formula feed- ing has been chosen in order to allow the mother to return to work, an older child or another family member may be left respon- sible for preparing the bottle and feeding the baby, and may not do it correctly. Thus, both mother and caregiver should be informed of the proper use of the formula. 32  Module 2 / Feeding Infants and Young Children Section 3 - Infant (Starter) Formulas Starter formulas Main categories of starter formulas are: whey-adapted formulas The term “starter formula” is used to casein-predominant formulas describe a formula which is intended to cover, acidified formulas by itself, all the nutritional needs of the infant hypoallergenic formulas during the first 4 to 6 months of life. Nutrient levels in starter formulas are regu- lated by national or international legislations such as the European Directive, or in their absence by the Codex Standard for Infant Formula. Composition of starter formulas generally  Starter formulas: mimics composition of human milk.  cover all nutritional needs of infants Although they could be used, as human milk, to 4-6 months of age until the end of the first year of life, pediatri-  nutrients levels are regulated for cians nowadays recommend, at weaning time instance by Codex or EC Directive switching to follow-up formulas (see section 6).  Composition of Starter Formulas (main criteria) Codex (1981) EC Directive (1991) Energy - 60 to 75 kcal/100 ml Protein: cow’s milk protein 1.8 to 3 g/100 kcal 1.8 to 4 g/100 kcal protein hydrolysates 2.25 to 3 g/100 kcal whatever the source soya protein isolates 2.56 to 3 g/100 kcal Lipids 3.3 to 6 g/100 kcal 4.4 to 6.5 g/100 kcal linoleic acid min 300 mg/100 kcal 300 to 1 200 mg/100 kcal α-linolenic acid - > 50 mg/100 kcal Carbohydrates - 7 to 14 g/100 kcal lactose - min 3.5 g/100 kcal sucrose - max 20% of total CHO Iron 1 to 2 mg/100 kcal 0.5 to 1.5 mg/100 kcal Calcium/Phosphorus ratio 1.2 to 2.0 1.2 to 2.0 Vitamin D 40 to 100 IU/100 kcal 40 to 100 IU/100 kcal Ref.: - Commission Directive of 14 May 1991 on infant formulae and follow-on formulae (91/321/EEC) Ref.: - Codex STAN 72-1981 33 Additional Information Notes: Differences between casein-predominant and whey-adapted formulas Although the protein source is different, the growth effects of casein-predominant or whey-adapted formulas are quite similar. Serum concentrations of threonine and branched-chain amino acids are greater when infants are fed whey-adapted formu- las, but the implications of these findings are unknown. Serum concentrations of methionine, tyro- sine and phenylalanine are greater when infants are fed casein-predominant formu- las. High levels of those amino acids have been associated with pathological condi- tions, but at concentrations far higher than those observed in routine infant feeding. For preterm infants, the greater cystine content of whey-adapted formulas may be an advantage. Furthermore, lactobezoars may be more common when casein-predom- inant formulas are used in those infants. Specialities (therapeutic formulas) Specialities are a broad group with specific properties useful when feeding infants with special dietary needs. They include: formulas designed to meet the special needs of low birth-weight (LBW) infants; lactose-free formulas; formulas designed to provide nutritional support to infants with diarrhea; formulas containing hydrolysed protein for feeding of infants who are allergic to cow’s milk; thickened (AR) infant formulas as regards the reduction of regurgitation. 34  Module 2 / Feeding Infants and Young Children Section 3 - Infant (Starter) Formulas Whey-adapted formulas Acidified formulas Whey-adapted starter formulas have whey An acidified formula is one which has been protein added to cow’s milk protein to achieve biologically acidified by a micro-organism. a whey/casein ratio ≥ 1 and an amino acid The type of lactic acid produced is impor- pattern closer to that found in mature breast tant. For example, only the L-form of lactic milk. acid is metabolized and therefore acceptable in infant feeding. The D-form of lactic acid is Generally these formulas have mineral con- not metabolized and can cause metabolic aci- centrations similar to those of breast milk. dosis, an abnormal metabolic condition. These formulas are the most modern and scientifically advanced infant formulas. The benefits of an acidified formula are a finer, more digestible curd, and a reduced risk of formula contamination. Casein-predominant formulas Acidified formulas are therefore indicated in infants presenting with poor digestion and in The main source of protein in casein-pre- situations where hygiene may be poor and the dominant formulas is cow’s milk protein. risk of contamination of the formula is high. Because cow’s milk protein contains more casein than whey protein, these infant formu- las are called “casein-predominant” formulas Hypoallergenic formulas and their whey/casein ratio is < 1. The proteins in hypoallergenic formulas Due to their slower gastric passage, they have been moderately hydrolysed and satisfy the baby for a longer period of time and processed by a protease (an enzyme with are often appreciated for their satiating splits proteins), to reduce the allergenicity of effects. milk proteins. The benefit of such formulas is a reduction in the number of symptoms of potentially allergic origin, such as eczema, rhinitis, urticaria, etc. The benefit is more pronounced in infants whose parents are themselves allergic.  Whey-adapted formulas:  whey/casein ratio ≥ 1  amino acid pattern  Acidified formulas:  mineral concentrations  finer, more digestible curd  … similar to content of breast milk  less risk of formula contamination  Casein-predominant formulas:  Hypoallergenic formulas:  cow’s milk alone is protein source  moderate protein hydrolysis  whey/casein ratio < 1  to reduce the allergenicity of milk  slower gastric passage proteins 35 Additional Information Notes: 36  Module 2 / Feeding Infants and Young Children Section 3 - Infant (Starter) Formulas Hazards of formula feeding Improper dilution also makes formula feeding hazardous. Feeding young infants with infant formula Often parents do not know how to use or other substitutes for breast milk involves infant formula and do not realize the impor- some hazards. Some parents - often the poor- tance of proper formula reconstitution. est - have little or no education and may be They may overdilute or underdilute with illiterate. disastrous results on the infant. – Overdilution will cause the infant to be Poor hygiene makes formula dangerous. undernourished. If only contaminated water is available, the – Underdilution will put the infant at risk of mother must know how to make the water renal solute overload and constipation. safe and have the equipment to do so. – In addition to clean water, good sanitation Overfeeding: is necessary when preparing the formula, ie In more affluent societies, the baby may be utensils, bottles, nipples and caps should be overfed. Some parents feel that a fat baby is a washed, rinsed and sterilized to destroy path- healthy baby. Furthermore, they feel that a fat, ogenic bacteria. apparently healthy baby indicates that they – Non-boilable bottles, cups and spoons are good parents. should not be used. A possible result of overnutrition, where the If the correct hygiene steps are followed, baby is urged to drain the last drop from the the danger of contamination will be mini- bottle, is obesity. mized. Parents must be taught that overfeeding their infants is an undesirable practice, and to allow the baby to determine when it has had enough.  Hazards of formula feeding:  If the correct hygiene steps are  contamination followed, the danger of  underdilution contamination will be minimized  overdilution  overfeeding 37 Additional Information Notes: 38  Module 2 / Feeding Infants and Young Children Section 3 - Infant (Starter) Formulas Preparing the formula Make sure bottle, nipple and cap At feeding time, add correct number are perfectly clean. If not, wash them thoroughly. of level scoops. Put clean bottle, nipple and cap in water Replace scoop in tin. Close tin. and boil for 10 minutes. Cap bottle. Shake well. Boil clean drinking water, allow to cool. Attach nipple, feed baby immediately. Do not keep leftovers. Pour correct amount into bottle. After the feed, wash bottle, nipple and Cap until feeding time. cap thoroughly. Keep covered until boiled. 39 Notes: 40  Module 2 / Feeding Infants and Young Children Section 3 - Infant (Starter) Formulas Progress Check A Which two “manipulations” are necessary to adapt whole cow’s milk to an infant formula? B Give the four types of starter formula C What are the advantages of whey-adapted formulas? D What are the advantages of casein-predominant formulas? E State some hazards of feeding formula to young infants Answers on the following page 41 Progress Check Answers A – Dilution with water, to reduce protein and mineral content. – Addition of carbohydrate and fat, to obtain an energy content similar to that of breast milk. B – Whey protein-adapted – Casein-predominant – Acidified – Hypoallergenic C Better digestibility and a better amino acid profile D A better satiating effect E Poor hygiene, improper dilution, overnutrition and obesity If you have correctly answered all these questions, proceed to the Objectives for Section 4; otherwise please carefully read this Section again. 42  Module 2 / Feeding Infants and Young Children Section 4 - Weaning Section 4 - Weaning Objectives When you finish this section, you should be State what weaning is able to: State the two objectives of weaning State when weaning usually starts State the nutritional recommendations for weaning 43 Additional Information Notes: 44  Module 2 / Feeding Infants and Young Children Section 4 - Weaning Weaning Objectives of weaning Weaning may be defined as the process by The primary objective of weaning is to com- which the infant makes the transition from an plement breast milk or breast milk substitutes all-milk diet to a completely diversified diet. when these no longer satisfy nutritional needs or support growth and development. Weaning starts when the first solid (or semi- Solid foods become necessary as energy solid) food is introduced into the infant diet needs increase with infant growth and and lasts until breast- or bottle-feeding is increased activity. It is not possible to meet replaced by the cup. these increased energy needs with liquid feeds alone. There is no typical model of weaning Moreover some nutrients, such as iron, are because it can differ from one child to another. not supplied in sufficient quantities in breast milk or cow’s milk but can be provided by weaning foods. A second objective is to introduce new tastes and textures in the form of solid foods, to make the transition to the adult mode of feeding.  Weaning  Weaning objectives:  … infant goes from an all-milk diet to  to complement milk diet to satisfy a completely diversified diet nutritional and energy needs for growth  to introduce new tastes and textures in solid foods 45 Additional Information Hazards associated with weaning Weaning foods are well accepted by the infant at around 4 to 6 months of age. The ability to swallow Feeding and sanitary practices vary greatly from coarser foods at around 9 months leads to the intro- one population to another. duction of foods from the family table. The baby – In some countries, mothers traditionally have may wish to feed himself at this time and should be used inadequate and unsuitable weaning foods. encouraged to do so. These include sugar water, barley water, rice water, Delayed weaning may thus result in delayed social corn starch and other cereal gruels and paps, which development and possibly failure to establish good provide limited energy and little or no protein, and eating habits. lack many more essential nutrients. Therefore, they are nutritionally inappropriate as weaning foods. Furthermore, the great monotony of these weaning diets increases the risk of specific deficiencies. – In more privileged households, infants may be overfed with high energy foods, and obesity may result. Another hazard involved is weaning too early. The newborn infant has a poorly developed swal- lowing reflex, and hence may have difficulties accepting food from a spoon. Moreover, early weaning may result in diminished lactation in the breast-feeding mother, as it is the frequency of suckling which determines the amount of breast milk secreted. Additionally, early weaning may result in the devel- opment of allergic reactions and food intolerance. There are also hazards associated with weaning too late. As the infant grows and becomes more active, ener- gy needs increase. Consequently, breast milk or infant formula may no longer supply all the nutri- ents required for healthy growth and development. Undernutrition and growth failure may occur unless weaning foods are fed to the infant. Furthermore, weaning should start when the infant’s neuromuscular development has pro- gressed to a stage compatible with feeding wean- ing foods. It is at this time that lifelong eating habits develop, and the feeding of appropriate weaning foods in correct amounts at this time is important. Missing this stage may influence lifelong eating habits. 46  Module 2 / Feeding Infants and Young Children Section 4 - Weaning Timing of weaning Weaning too early or too late are both unde- sirable. Breast-feeding or infant formula feeding Too early weaning may lead to: alone may not ensure adequate nutrition for – decline in sucking intensity causing failure the first full year, and usually not beyond the of breast-feeding first 6 months, even under favorable circum- – increased risk of infectious diarrhea stances. – increased risk of allergic reactions and food intolerances Weaning therefore usually starts at about – protein excess, overfeeding and obesity 4 to 6 months of age and is usually completed – psycho-affective difficulties related to between 12 and 24 months of age, but some- frustration and developmental immaturity times as late as 36 months. Too late weaning may lead to: – undernutrition and growth failure Timing for the start of weaning is usually – delayed social development and failure to dependent upon pediatric recommendations, establish good eating habits the mother’s occupation and availability, the satisfaction of the infant’s needs and local cul- tural practices. Sometimes it is the nutritional status of the mother and the adequacy of breast milk volumes which will determine when weaning starts.  Weaning  Too early weaning:  … usually starts at about 4 to  may interfere with breast-feeding 6 months of age  can result in allergic reactions and food intolerance  Too late weaning  … may result in undernutrition and growth failure 47 Additional Information Notes: Practical considerations Ideally, the first weaning food should con- sist of a soft, semi-solid cereal pap, with a high energy density. According to pediatric recommendations, gluten-free cereals (rice, corn) should be preferred for this first pap. It is recommended to proceed as follows: – Prepare the food to be tested under hygienic conditions (wash hands, clean cooking utensils); – Offer 1 to 2 spoons of mashed food during a feed; – Some babies will accept the trial better after having satisfied their hunger with half the feed or bottle; – Place a small amount of food on the spoon; – Since the child is used to its mother’s milk at 37°, the temperature of the first food offered should be either room temperature or warm; – If the child refuses it, persevere but never force the baby to swallow. Studies on the development of taste suggest that after 15 to 20 contacts with a new taste, a child will accept a food without problems. When the food is well-accepted, the amount can progressively be increased. The time taken to introduce semi-solid foods is variable; for some children the meal is accepted in 1 or 2 days, while for others, it takes a week before a liquid meal can be replaced by a solid meal. Usually, one milk feed is replaced by weaning food during the fifth month. – A second milk feed may be replaced around the sixth month. – By the eighth or ninth month, a third milk feed will have been replaced by weaning food. At this age, the infant will receive a wide range of foods. 48  Module 2 / Feeding Infants and Young Children Section 4 - Weaning Introduction of complementary An important point to emphasize is that all foods in the weaning diet new foods should be introduced one at a time and gradually in order to enable recognition of There are several pediatric recommenda- food allergy and intolerance reactions. tions such as those of the Committee on A 3-day to 5-day interval should be main- Nutrition of the European Society for tained between introduction of each new food. Paediatric Gastroenterology, Hepatology and This will enable the infant to adapt to the new Nutrition (ESPGHAN) and the WHO. taste and texture. This interval is also important to assess any Weaning foods should not be introduced reaction to the new food. The infant may earlier than 4 months nor later than develop an untoward reaction after the intro- 6 months. duction of a new food. It may be a rash, or By the age of 6 months, weaning foods excessive gas, or some other reaction. should not represent more than 50% of the If only one new food is given at a time, it is total daily energy intake. easy to identify the causative agent and the Milks should be given in a quantity of not mechanism of the reaction. The single new less than 500 ml daily. food can be eliminated and then tried again at Gluten should not be introduced before 4 a later age. months of age. Postponement to 6 months may be advisable. It is also important, for the same reasons, to Avoid foods which may contain high start feeding new foods in small amounts. amounts of nitrates such as spinach and A small spoonful can be given first, and this beets during the early months. amount increased daily for 3 to 5 days to Introduction of highly allergenic foods such determine tolerance. as eggs and fish should be delayed. The same procedure should be followed as In infants with a family history of atopy, each new food is added. highly allergenic foods should be strictly avoided during the first year.  Recommendations for introduction of complementary foods in the weaning diet from 4 to 6 months of age no gluten before 4-6 months weaning foods to be introduced one at high nitrate-containing foods to be a time and gradually avoided during the early months energy intake by the age of 6 months: delay introduction of highly allergenic not more than 50% from weaning foods foods not less than 500 ml per day of breast milk or formula 49 Notes: 50  Module 2 / Feeding Infants and Young Children Section 4 - Weaning Progress Check A Weaning is the process by which …… B When does weaning usually start? C State the two objectives of weaning. D State the main nutritional recommendations for weaning. E Why should all new foods be introduced one at a time and gradually? Answers on the following page 51 Progress Check Answers A Weaning is the process by which the infant makes the transition from an all-milk diet to a completely diversified diet. B Weaning usually starts between 4 and 6 months of age, when the first solid (or semi-solid) food is introduced into the infant’s diet. C – The primary objective of weaning is to complement breast milk or breast milk substitutes when these no longer satisfy nutritional needs or support growth and development. – A second objective is to introduce new tastes and textures in the form of solid foods. D – Weaning foods should not be introduced earlier than 4 months nor later than 6 months. – Weaning foods should not represent more than 50% of the total daily energy by the age of 6 months. – Milk diet should be given in a quantity of not less than 500 ml daily for the remainder of the first year. – Delay introduction of highly allergenic foods such as eggs and fish. – Gluten should not be introduced before 4 months of age. Posponement to 6 months may be advisable. – Avoid foods which may contain high amounts of nitrates such as spinach and beets dur- ing the early months. – In infants with a family history of atopy, highly allergenic foods should be strictly avoid- ed during the first year. E – to enable the infant to adapt to the new taste and texture – to enable assessment of any untoward reaction to the new food – to identify the causative agent and the mechanism of the reaction (allergy or food intol- erance) If you have correctly answered all these questions, proceed to the Objectives for Section 5; otherwise please carefully read this Section again. 52  Module 2 / Feeding Infants and Young Children Section 5 - Follow-up Formulas Section 5 - Follow-up Formulas Objectives When you finish this section, you should be State why cow’s milk is unsuitable during able to: the first year of life State the importance of the use of follow-up formulas in the weaning diet State the most important nutrients in follow-up formulas Describe and justify the two types of follow-up formulas 53 Additional Information Notes: Official definitions of follow-up formulas The Joint FAO/WHO Codex Alimentarius Commission (1988) defined a follow-up formula as “a food intended for use as a liquid part of the weaning diet for the infant from the 6th month on and for young children”. The term “young children” means children from the age of more than 12 months up to the age of three years (36 months); “infants” means children under the age of 12 months. The statement also says that these “prod- ucts are not breast-milk substitutes and should not be presented as such”. Similarly, the Commission of the European Communities (1991) has defined such formulas, called follow-on formulae, as “foodstuffs intended for particular nutrition- al use by infants aged over 4 months and constituting the principal liquid element of a progressively diversified diet of this catego- ry of persons”. 54  Module 2 / Feeding Infants and Young Children Section 5 - Follow-up Formulas Milk diet during weaning concluded that cow’s milk is not a suitable food for infants during the first year of life. Up to 4 to 6 months of life, human milk or starter infant formula is the exclusive source of Starter infant formulas are not optimal nutrients for the infant. either, as they contain too much fat and not Once the weaning process starts, new enough calcium. In some circumstances, they foods, with a different nutritional profile, are may even be too low in protein or iron (low introduced in the diet. The “formula” part iron starter formulas). needs to be adjusted so that the overall diet remains well balanced and ensures optimal growth and development. Follow-up formulas Neither cow’s milk nor starter infant formu- la are suitable as the liquid part of the weaning Follow-up formulas are designed to be a diet. liquid part of the weaning diet intended for use from 4 to 6 months onward. Cow’s milk is not suitable Cow’s milk contains too much protein, sodi- Follow-up formulas contain larger quantities um, saturated fats and not enough esssential of those nutrients which many weaning foods fatty acids,vitamin D and iron. cannot provide in adequate amounts. According to the ESPGHAN Committee on The most important of these nutrients are Nutrition, the median protein intake of infants protein, calcium, iron and linoleic acid. fed cow’s milk is 20-100% higher than that of infants fed infant formulas or follow-up formu- The quantities of most other minerals and las between 6 and 12 months of age, and it is vitamins specified for follow-up formulas are 2 to 3 times higher than the calculated “safe similar to those specified for starter formulas. level of protein intake”. Moreover, consumption of pasteurized Daily intake of follow-up formula should be cow’s milk leads to increased gastro-intestinal not less than 500 ml, or about 40% of the blood loss. As a result, the incidence of iron infant’s energy intake, especially to provide deficiency anemia at 12 months of age is sub- sufficient calcium, iron and linoleic acid. stantially higher in cow’s milk fed infants. ESPGHAN as well as the American Academy of Pediatrics (AAP) have therefore  During the first year of life, cow’s milk  Follow-up formula: is not suitable:  liquid part of the weaning diet  too much protein, sodium,  for use from 4-6 months onwards saturated fats  to provide calcium, protein, iron  not enough essential fatty acids, and linoleic acid in adequate vitamin D, iron amounts  not less than 500 ml a day, or about 40% of the daily energy intake  Starter formulas are not suitable either, once the weaning process starts 55 Additional Information Feeding practices and recommendations for Therefore, here too, a moderate protein follow-up protein content of follow-up formulas formula is indicated. “Feeding pattern one” is typical for the English- “Feeding pattern three” is mainly found in many speaking industrialized countries and Scandinavia. developing countries, among a large and vulnerable Milk consumption in these countries is high. group of infants. Pediatricians recommend that mothers avoid feed- The weaning diet is made up of local foods of low ing more than 900 or 1000 ml of milk or formula per nutritional quality, such as cereals and fruits. The day. Weaning foods are rich in protein. quantity as well as the quality of protein and the Therefore, a moderate protein follow-up formula or levels of calcium and iron in these foods are low. even a low protein formula is advisable to maintain Therefore, these nutrients need to be provided by infant protein intakes at appropriate levels. A high the follow-up formula. protein formula or cow milk would be undesirable. However, as the weaning foods are inexpensive and the formula is relatively expensive for these popu- “Feeding pattern two” is found in contries, where lations, consumption of formula falls off rapidly. milk consumption falls off rapidly once the weaning Accordingly, ESPGHAN recommends a high protein process begins. follow-up formula - 4 to 4.5 g/100 kcal - to provide Pediatric recommendations for this group are to the minimum protein requirements. avoid feeding less than 500 ml of milk or formula Thus, high protein follow-up formula is recom- per day. The weaning diet is relatively rich in pro- mended in areas where feeding pattern three is the tein. rule. Recommended Follow-Up Formula Weaning diet Feeding patterns 1 2 3 Volume of formula or milk consumption high low low Level of protein in weaning foods high high low Follow-up formula moderate moderate high recommended protein protein protein 56  Module 2 / Feeding Infants and Young Children Section 5 - Follow-up Formulas Protein content Calcium There are two types of follow-up formulas: Most weaning foods contain only low The first type, with a moderate protein amounts of calcium, and in a poorly available level, is designed to be part of a reasonably form. Follow-up formulas are a major source well-balanced weaning diet containing good of calcium in the weaning diet. quality protein in the form of meat, eggs and fish. In order to supply sufficient available calci- The second type, with a high protein level, um for the skeletal growth, the daily intake of is designed to supplement a poor quality follow-up formula should be no less than low-protein weaning diet. 500 ml. A high protein formula should provide the older infant with the minimum daily require- A follow-up formula should contain at least ment of protein in two or three feeds. 90 mg calcium per 100 kcal. The protein content of follow-up formula must take into account the nutritional wean- ing habits of the population concerned and the prescribing habits of local physicians. The protein composition of follow-up for- mulas will therefore vary from country to country, depending on local feeding practices.  Two types of follow-up formulas  Calcium content at least 90 mg/  moderate protein level 100 kcal  high protein level  … according to local feeding practices 57 Additional Information Notes: 58  Module 2 / Feeding Infants and Young Children Section 5 - Follow-up Formulas Fat Iron The fat content of most weaning foods is Iron is low in most weaning foods, in all low, as is the percentage of energy provided weaning patterns. Even when iron is present, by fat: 12% of energy at 4 to 7 months of age, its bioavailability from these diets is low. and 25% of energy at 8 to 12 months. At weaning time, the iron reserves present Therefore, the fat content of a follow-up at birth have been depleted and the infant now formula should be higher than 3.3 g/100 kcal, depends on dietary sources. and provide at least 35% of the total energy in the formula (approximately 4.0 g/100 kcal). For these reasons, the amount of iron in fol- low-up formulas should be higher than that in As is the case with starter formulas, a mini- starter formulas. mum level of 0.3 g of linoleic acid per 100 kcal, with an upper limit set at 20% of total fatty acids, is fully adequate.  Composition of Follow-up Formulas (main criteria) Codex (1987) EC Directive (1991) Energy 60 to 85 kcal/100 ml 60 to 80 kcal/100 ml Protein 3 to 5.5 g/100 kcal 2.25 to 4.5 g/100 ml Lipids 3 to 6 g/100 kcal 3.3 to 6.5 g/100 kcal linoleic acid min 300 mg/100 kcal min 300 mg/100 kcal Carbohydrates - 7.0 to 14.0 g/100 kcal lactose - min 1.8 g/100 kcal sucrose - max 20% of total CHO Iron 1.0 to 3.0 mg/100 kcal 1.0 to 3.0 mg/100 kcal Calcium min 90 mg/100 kcal min 80 mg/100 kcal Vitamin D 40 to 120 IU/100 kcal 40 to 120 IU/100 kcal Ref.: - Commission Directive of 14 May 1991 on infant formulae and follow-on formulae (91/321/EEC) Ref.: - Codex STAN 156-1987 59 Notes: 60  Module 2 / Feeding Infants and Young Children Section 5 - Follow-up Formulas Progress Check A A follow-up formula forms the basis for sole infant nutrition when used from birth to 6 months: true or false? B A follow-up formula is designed to provide protein, calcium and other nutrients (especially …… and …… ) since weaning foods may not be relied on to provide these …… in …… amounts. C Why does the composition of follow-up formulas differ in various countries? D Describe the two types of follow-up formulas Answers on the following page 61 Progress Check Answers A False B Iron, linoleic acid, nutrients, adequate C The composition of follow-up formulas varies from country to country, depending on local weaning habits. D – The first type of follow-up formula, with a moderate protein level, is designed to be part of a reasonably well-balanced weaning diet containing good quality protein in the form of meat, eggs and fish. – The second type, with a high protein level, is designed to supplement a poor quality low- protein weaning diet. If you have correctly answered all