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Artificial Feeding • Artificial feeding means giving the infant other feedings than breast milk during the period when he would naturally receive human milk. • Although artificial feeding has been improved as regard it's sterilization & the indigestibility of cow's milk protein yet we should stress the fact that breast feeding is generally superior to artificial feeding. Types of artificial feeding : 1- Fresh animal milk. 2- Dried animal milk. 3- Condensed & evaporated animal milk. 4- Milk substitutes e.g. soya bean milk Indications of artificial feeding : 1- The presence of any contraindication to breast feeding. 2- As a complimentary or supplementary feeding. 3- Death or absence of the mother. 4- Twins. 5- Particular diseases e.g allergy, lactose intolerance or galactosemia. Cow's milk" is in the root of most dietary problems in children. The problems associated e` it lie in it's composition. It is high in saturated fatty acids, sodium, and phosphate, yet low in long chain fatty acids. 4 major reasons support the recommendation not to provide whole cow's milk before I yr of age. 1-Cow's milk may create a potential for intolerance to whole milk protein. 2-An increased incidence of iron deficiency anemia. 3-From the metabolism of cow's milk, a high level of solute results that stresses renal excretion. 4-Cows milk is more difficult to digest, and the nutrients are not ideally balanced for infants Fresh animal milk - Contaminated e`microorganisms. -Form a large curds in the stomach & is slowly digested In addition, some diseases are more frequent in cow's milk fed infants ( & to a lesser extent, formula fed infants ), e.g. - acute & chronic diarreoha, - RTIs, - OM, - allergy ( asthma, eczema & cow's milk allergy - infantile rickets, - neonatal tetani & - osteomalacia. Cow's Milk Protein Allergy ( CMPA): Prevalence : 1-3 % 30% of atopic children. Common manifestations: recurrent diarrhea, repeated vomiting, recurrent bronchitis, and asthma. Uncommon Manif: thrombocytopenia, nephrotic syndrome & pulmonary hemosidrosis. Infants e` documented milk allergy have more visits to physicians because illness during the 1st yr of life than do control infants e`out milk allergy & experience a significantly greater number of hospital admissions. Heating or even boiling, may denature only a small fraction of milk proteins. However, that fractions are less responsible for allergies than are the fractions that resist heat, so heating of milk or formula does not make it less allergenic. CL/m of CMPA: GIT : - Vomiting - GERD - Colic - Malabsorption - Colitis. - GI bleeding. - Constipation. -Obstruction . Resp : Rhinorrhea. Sinusitis. Cough. Serous OM. Wheezing. Pulmonary infilterates. Heiner's syndrome. Dermatologic : Eczema. Urticaria. Angiodema. Contact dermatitis. Hematological Anemia Thrombocytopnia. Others : Anaphylaxis Shock Conjunctivitis. Typs of fresh animal milk 1) Raw cow`s Milk . 2) Pasreurised Milk. 3) Homogenized milk . 4) Humanized milk . 5) Evaporated & condenced milk . 6) Goat's Milk . 1)- Raw cow`s Milk: This is not advised for infant feeding because : o o o Vis supra Contaminated e`microorganisms. Form a large curds in the stomach & is slowly digested 2)- Pasreurised Milk: Pasteurization is done by heating milk at 65 oc for 1/2 hr followed by rapid cooling. Pasteurization has 2 actions: a-it destroys pathogenic bacteria but not spores, so; Pasteurized milk should be boiled when used to infants. b-It modifies the casein so that curds become small & less tough & easier in digestion. 3)- Homogenized milk : By passing milk through fine holes under pressure to break large fat globules, so butter will not separate. 4)- Humanized milk : Humanization means; modification of cow's milk so to be as similar as possible to human milk by : 1- dilution of of boiled milk with an equal volume of water & the adding 5 gms sugar to each 100 ml of the mixture. 2- Addition of weak acid e.g. lemon juice. 3- Peptonization : partial predigetion of proteins. 5)- Evaporated & condenced milk : It is milk, w` is concentrated by removal of water to 1/3 or 1/2 it's size. Advantages : -Can keep in it's can for months without refrigeration. -Casein curds, formed are smaller & softer. -Lactalbumin becomes less allergic than that of fresh milk. • Evaporated milk is diluted 1 in 10 by volume. • Each feed should be prepared at a time & there is no need for boiling. 6)- Goat's Milk : advantages : a – is more digestible than cow's milk. b- Less allergenic, so, can be used to replace cow's milk in infant's allergic to cow's milk. c- contains more EFAs. Disadvantages: a-low folic acid content, megaloblastic anemia. b-Goat's are esp. susceptible to brucellosis & thus the milk should be well boiled before feeding. c-It's caloric value is low. Dried Milks Are cow's milk dried by either : - Roller method : where milk is poured on heated roller. - Spray method : where milk is dried by spray in hot rooms to lose it's water content & solid particles settle in bottom. Advantages of dried milk: 1- Sterile. 2- Easily stored, easily handled & can be mad fresh for each feed. 3- Relatively constant composition. 4-The process of drying render the curds more easily digestible. 5- It can be kept for sometime in open tin & so does not require refrigeration. 6- Fortified e` adequate amounts of vits & minerals. 7- Some are fortified e` : LCPUFA, taurine, carnitine, or nucleotides. Preparation : All dried milks are prepared to be diluted 1 in 8, so that in using them a liquid milk is made by adding one leveled measure of the powder (4 gm) to each ounce of previously boiled water (30 cc). Types of dried milk : 1-Full cream (dried whole) milk . 2-Half- cream milks . 3-Skimmed milks . 4-Humanized milks . 5- Special types of milk . A) Acidified milks B) Butter milk . C) Protein milk . D) Milks used for special purposes . Types of dried milk : 1- Full cream (dried whole) milk : These are simple powders of dried whole milk. It has a high fat content (4%). It should not be used before the 1st yr of life. 2- Half- cream milks : the fat content is ~ 2%. 3-Skimmed milks : fat content is < 0.5 % . not suitable for feeding of normal infants . for feeding of infants e` fat intolerance e.g. : -prematures & LBW babies. -Infants e` PCM. -Infants e` recurrent diarrhea & those recovering from G.E. 4-Humanized milks : These milks are modified to be so near as possible to human milk.: -Protein is modified so that it does not form large curds. -Fat is finely dispersed e` substitution of some of milk fat e` vegetable oils containing more LCPUFA. -The ca/p ratio is adjusted. -Vit D & iron are added. These milks are indicated in the feeding of : •normal infants. •Large prematures (2-2.5 kg) •Infants e` mid degree of malnutrition. A)-Acidified milks : - chemical acidification; by addition of weak acid such as lactic acid. - biological acidification : by fermentation by bact. action such as lactobacillus . Advantages : • requires less Hcl for gastric digestion. • Acidity increases the efficiency of gastric Hcl barrier against macrorganisms, • Acidification modifies casein so that it yields a small easily digested curd. • Acidification enhances ca & iron absorption. • Acidified milks may be; full cream, 1/2 cream or skimmed. Indications : -Infants e` GIT upset & recurrent diarreohea. -~~ recovering from GE. -~~ e` PCM. -Prematures & LBW. 5- Special types of milk : B) Butter milk : is lik acidifie skimmed milk. C) Protein milk : Is prepared by the addition of milk curd or dry casein to butter milk . It is rich in protein, low in fat & very low CHO content. It is indicated for : - prematures & LBW. - Debilitated infants. - Infants e` diarrhea D) Milks used for special purposes : 1- Lactose free milk . 2- Hypoallergenic milks : - evaporated goat's milk. - non-milk powder in w` proteins are derived from soya beans . -casein or whey hydrolysates. 3- Low salt milks : for infants e`; CHF, CHD, acute nephritis & nephrogenic D.I. 4-Anti-regurgitation formulas : are thickened formulas used for reducing regurgitation in infants e` GERD. 5- Phenylallanine free milk : for PKU. 6- Elemintary formulas . These are milks producd to manage serious dietary problems; e` malabsorption. They contain purified chemical elements ( free glucose, aas, EFA & medium chain triglycerides). Amount of milk needed by the infant: 1- Age (rough method ): age Amount of milk/feed In days Age in days x 10 In wks Age in wks x 10 + 70 In mo Age in mo x 10 + 100 The weight method ( caloric method): Total caloric req/day = 110 x wt amount of milk req/day = caloric value of milk used /100 ml Total caloric req. x 100 amount of milk req /feed = amount of milk req /day no. of feeds Combined feeding 1- Complemetary milk : in each feed the infant is given the breast, then the feed is completed by the artificial milk. 2- Supplementary milk : means complete substitution of one or more of the breast feeds by the artificial milk. In complementary milk, the following, precautions should be considered; 1- the artificial feed is given only after both breasts have been completely emptied. 2- The artificial feed should not be sweetened . 3- The holes through w` the artificial feed flows should not be large. 4- A humanized milk is usually chosen as it has the nearest comp. to breast mlk. Supplementary Feeding : Indications : 1-working mother 2-twins 3-if milk flow is insufficient particularly late in the afternoon. N.B. follow the same precautions (24) as in complimentary feeding. Complementary feeding & introdyction of solid foods ( WEANING ) Weaning is a gradual replacement of breast milk by other foods. Breast milk or formula will meat all nutrient needs for the 1st 4-6 months. There is no need to supplement with water, juice or cereal at this time. From this time solids can be introduced, to increase the intake of nutrients such as; iron & as part of the education process of learning to eat. Starting weaning 4-6 mo helps introduction of new food before the development of milk addiction, while delayed weaning may be a cause of marasmus & nutritional edema. Babies have a critical or sensitive period for the introduction of solids around 6-7 mo. & missing this period might cause feeding difficulties later. Since the infant's GIT accepts a relatively large undigested molecules ( preclosure), babies fed solids early are more prone to allergic problems in later life. Weaning should be ended by 1.5-2 yrs of age when all breast feeds are replaced by foreign feeds. Why not before 4-6 mon? 1-Breast milk or infant formula supplies all of baby's nutritional needs for at least the 1st 4 to 6 mo of life. 2-Starting solids too early can cause food allergies. 3-The intestinal tract is not as fully developed during the 1st few mons and introducing solids at this time can be too much to handle 4- Unintentional overfeeding may develope, since younger babies can not offer you signals when they are full, such as turning away or showing disinterest. 5- Babies has inability to swallow solids correctly before 4 to 6 months of age and this can potentially cause choking. 5- an early introduction of food other than breast milk can cause an earlier cessation of breast-feeding Aim of weaning : 1-Growth of the baby requires more food items, minerals & vits., w` cannot be supplied by milk alone after 4-6 mo. 2-To train GIT to digest starch & other solid foods. 3-To educate the child independence by using spoon & cup. There are no strict rules for carrying weaning. However the following precautions should be followed : 1-Postpone weaning in hot weather & in infants convalescent from acute illness particularly GE. 2-Weaning should be gradual : only one new food is introduced at a time. The new food is introduced gradually beginning e` small quantities to be increased gradually. Next food is given every 1-2 wks. 3-Any food added should be mashed or semisolid, strained or pursed. 4-The food is introduced in lovely presentation e.g. colored spoons & plates. How to carry on weaning : 5-The infant is born e` " the extrusion reflex", he extrudes any solids that are placed in his mouth, so it is not logic to give solids before age of 4-6 mo. Infants often push foods out of their mouth e` their tongue rather than back until they learn to swallow efficiently. This must be explained to the mother since she often feels that the baby is " spitting up" so discontinues the food. 6-There is no point in forcing any particular food when an infant definitely dislikes it. 7-Avoid preserved & canned foods. 8-The food addition should be planned & timed according to the abilities of the family. •Rice cereal is the best 1st introductory solid food for babies as rice is : -the grain least likely to cause an allergic reaction. -it is well tolerated by most babies -has a low protein content suitable fore young infants. •Other cereals designed specifically as starting cereals for infants are oatmeal or barley. •All commercial cereals designed for infants contain added minerals & vits. Weaning foods: Pursed fruits & vegetables are generally recommended after cereals. Introduce one at a time, about a week apart, and watch for symptoms of food allergies or sensitivities Start with 1 tsp per day and gradually increase to 1 to 2 Tbsp per day Do not add sugar, salt, or margarine to infant fruits or vegetables Wheat : is considered a common allergen in many countries & is therefore not recommended before 6 mo of age. •If the family has a history of allergies, it is wanted to delay introducing wheat products until 9 mo or a year Yogurt : if the baby is on a cow's milk based formula, and tolerates it well, yogourt can be started at the age of 6 mo. If the baby is breast fed , yogurt is introduced at 11-12 months Use plain yogurt or yogurt mixed with fruit, but avoid fruit yogurts that contain seeds Egg white : is the protein most commonly associated e` food sensitivity. Therefore whole egg is not recommended before 12 mo of age. Egg yolk, on the other hand , is usually introduced at 8-9 mo of age – the same as meats for mot babies •single ingredient juices, such as white grape, apple, or pear, are ideal 1st juices for the baby. •Orange juice may be a problem fore some babies because of sensitivity to citrus fruit; therefore, orange juice is introduced after 6 mo. Of age. •Interestingly, in some countries citrus allergies virtually nonexistent and orange juice is one of the 1st foods introduced to babies at 4 mo. of age. Juices : Troubles that may occur during weaning: 1-GE : due to either forced feeding or excessive eating of new diet. 2-Abdominal distension & colic : due to excessive CHOs & sweats. 3-PCM : due to either insufficient amount of diet or dependence on CHOs e` protein deficiency. 4-Allergy : may follow administration of certain foods e.g. fish, banana, strawberry…etc. N.B. Foods e` high allergic potential that should be avoided during early infancy (1st yr) include: fish, raw cow's milk, egg white, nuts & various food additives. Honey and Corn Syrup Do not feed infants or toddlers less than 2 years of age honey or corn syrup Honey and corn syrup has been linked with infant botulism. • Never try to force any food. The child learns to enjoy his food, all meal times should be play & fun e` no troubles. •All new foods will be refused in the beginning. With introducing any new foods, small quantities should be offered at 1st to allow the child to taste for the food. •Food intake varies from day to day & from one meal to another. •The child needs to eat more frequent than the adults; besides the three meals, several snacks should be offered in the day. •The child should not be served on the communal pot but his portion should be served on a plate & an attempt be made to make him finish his entire portion . Routine feeding instructions : When offering a new type of food, always feed it for several days in a row before starting another new food. This makes it easier to detect food allergies, which can present with diarrhea, vomiting, coughing, hives or a rash. Do not offer mixed ingredient foods until you are sure that the baby isn't allergic to any of the individual ingredients. Don't feed your baby cow's milk, honey or egg whites until your baby is at least one year of age. Also, do not give carbonated or caffeinated drinks, candy or other foods that your baby may choke on. Food For Baby's First Year Birth Breast milk Iron fortified formula Mixed Infant cereal (plain from spoon) : -rice -barley -oats Vegetables (unsalted , strained): carrots, squash, green beans, green peas. Fruits ( unsweetened, strained) : Apple sauce, banana, peaches, pears. Other infant cereals : Wheat, mixed grains, high protein Mashed vegetables and fruits. Mild cheese. Cottage cheese. Fruit juices ( unsweetened – dilute adult juices to half strength) Apple, pear, grape and orange. Offer in a cup. Limit juice to 4 oz. Each day. 4-6 mo 6-7 mo 7-9 mon 8-9 mo Strained meats, liver or chicken. Egg yolk. 10-12 Finger foods : Toast squares, cooked vegetables (strips or slices, peeled soft fruit (wedges or slices), small tender pieces of meat. Food from family table ( feeds self) -vegetables, fruit, cereal, pasta, noodles, bread, beans, fish, meats, chicken and cheese. Continue breastfeeding Drink whole milk Whole egg Weaned from bottle. One year 4 – 5 Months At this age, breast milk or formula is the only food that your baby needs and he should be taking 4-6 feedings each day (24-32 ounces), but you can start to familiarize your baby with the feel of a spoon and introduce solid foods. Cereal is the 1st solid you should give your baby w` can be mixed e` breast milk, formula or water and feed it e` a spoon (not in a bottle). Start by feeding one tablespoon of an ironfortified Rice cereal at one feeding and then slowly increase the amount to 3-4 tablespoons one or two times each day. 6 -7 Months While continuing to give 4-5 feedings of breast milk or formula and 4 or more tablespoons of cereal each day, you can now start to give well-cooked, strained, or mashed vegetables or commercially prepared baby foods. Start with one tablespoon of a mild tasting vegetable, such as green beans, peas, squash or carrots and gradually increase to 4-5 tablespoons one or two times each day. Start fruits about a month after starting vegetables and again, gradually increase to 4-5 tablespoons one or two times each day. You can also begin to offer fruit juices. Start by mixing one part juice with two parts of water and offer it in a cup. 8 - 9 Months You can now start to give more protein containing foods. These include well-cooked, strained or ground plain meats , mild cheese, or egg yolks . .You can also start to offer soft table foods and finger foods at this age. 10 -12 Months Your baby's diet will begin to resemble that of the rest of the families, with 3 meals and 2 snacks each day and will include : 1- 3-4 feedings of breast milk or formula. 2-iron fortified cereal. 3- vegetables and fruits. 4- protein foods (2-4 tablespoons each day). 5- fruit juice (2-6 ounces in a cup each day). 6- finger foods (snacks that can be eaten by children alone) . It is important to offer a variety of foods to encourage good eating habits later. 12 Months and Beyond You may now give the baby homogenized whole cow's milk. Do not use 2%, low fat, or skim milk until the child is 2-3 years old. The child should now want to feed himself with his fingers and a spoon and should be able to drink out of a cup. The next few months will be time to stop using a bottle. As with weaning from breastfeeding, you can wean from a bottle by stopping one bottle feeding every four or five days and then gradually reducing the amount in the bottle when reaching one each day.
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