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Breast Milk and Infant Formulas

Breast Milk and Infant Formulas. Lori S. Brizee MS, RD, CSP Clinical Dietitian Children’s Hospital and Regional Medical Center. Human Milk and Infant Formulas:. Breast milk Standard Infant Formulas Premature Infant Formulas Specialty Infant Formulas Modular Additives.

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Breast Milk and Infant Formulas

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  1. Breast Milk and Infant Formulas Lori S. Brizee MS, RD, CSP Clinical Dietitian Children’s Hospital and Regional Medical Center

  2. Human Milk and Infant Formulas: • Breast milk • Standard Infant Formulas • Premature Infant Formulas • Specialty Infant Formulas • Modular Additives

  3. Breast Milk Characteristics • First choice feeding for MOST infants • Immunologic factors • Protective against diarrhea causing infections and otitis in infants • Trophic to GI tract • Well tolerated by infants with short bowel • Fatty acids important to brain/visual development

  4. Breast Milk vs StandardMilk Based Formulas • Energy: slightly higher • Protein: Lower, but higher quality (whey and casein) • Renal Solute load: Lower • Carbohydrate: Mainly lactose • Fats: Long chain; DHA/AA (lipases increase absorption)

  5. Common Challenges with Breast Feeding • Baby sided problems • Illness preventing/interfering with early feeding • Anatomic malformations • Sleepy baby • Thrush

  6. Common Challenges with Breast Feeding Sleepy Baby • Sleep cycles • REM sleep-----deep sleep (15 min +/-) ----wake (quiet alert) • If cannot wake, in deep sleep, try again in 15+/- minutes • Watch for hunger cues e.g., sucking on hands

  7. Common Challenges with Breast Feeding Sleepy Baby • Waking techniques • Hold by armpits and dangle • Put feet on hard surface • Spin around • Last resort: stroke palate with finger until sucking, then take finger out and put nipple in.

  8. Common Challenges with Breast Feeding • Mom sided problems • Low milk supply • Frequent feeding, pump after feeding • Medications: Reglan, Domperidone Fenugreek • Sore Nipples • Clogged ducts • Mastitis • Yeast Infection

  9. Breast Feeding: Is baby getting enough? • Regain birthweight by 1 week • Newborn to 2 months gain > 1 ounce per day • Newborn to 4-6 weeks: 2-10 bowel movements per day • Bowel movements are better clue than wet diapers.

  10. Standard Infant Formulas, Milk or Soy Based………..

  11. Formula Brands • Ross • Similac/Isomil/Alimentum • Mead Johnson • Enfamil/Prosobee/Enfacare • Nestle • Good Start • Wyeth • Generic in USA; Gold Brands; SMA • SHS • NeoCate, DuoCal

  12. Milk Based Formulas • Standard 0-12 months • Similac with/without iron • Enfamil with • Good Start Essentials/Good Start Supreme • Wyeth Generic • Standard 0-12 mos with DHA/ARA • Similac Advance with iron • Enfamil Lipil with/without iron • Good Start Supreme DHA/ARA • Wyeth formulas

  13. Milk Based Formulas • Older Infant and toddler formulas • Similac 2 Advance (9-24 mos) • Enfamil Next Step Lipil (9-24 mos) • Good Start 2 Essentials (4 to24 mos) • Wyeth Generic “follow on formulas” • Increased Calcium • Increased protein (Good Start and Enfamil) • Intended to compliment nutrients in solid milk

  14. Milk Based FormulasCharacteristics • Blend of Whey and Casein Proteins (8.2-9.6 % total calories) • Carbohydrate: lactose • Fats: long chain • Meet needs of healthy infant

  15. Soy Formulas • Isomil/Isomil DF /Isomil Advance/Isomil Advance 2 • Prosobee/Prosobee Lipil/Next Step Prosobee • Good Start Essentials Soy/Good Start 2 Essentials Soy • Wyeth All iron fortified

  16. Soy FormulasCharacteristics compared to Milk Based • Higher protein (lower quality) • Higher sodium, calcium, and phosphorus • Carbohydrate: Corn syrup solids, sucrose, and/or maltodextrin; lactose free • Fats: Long chain • Meet needs of healthy infants

  17. Predigested protein based infant formulas

  18. Protein Hydrolysate Formulas • Alimentum Advance • Pregestimil/Pregestimil Lipil • Nutramigen Lipil • Protein Casein hyrolysate + free AA’s • Fat (Alimentum and Pregestimil) Medium chain + Long chain triglycerides; (Nutramigen) Long chain triglycerides • Carbohydrate: Lactose free

  19. Elemental formula for infants

  20. Elemental Infant Formula • NeoCate (SHS) • Protein: Free Amino Acids • Fat: Long chain • Carbohydrate: Lactose Free • Indications for use: Food Allergy or intolerance to peptides or whole protein

  21. Premature Infant Breast Milk Additives and Formulas • Enfamil Human Milk Fortifier • Similac Human Milk Fortifier • Powdered breast milk additives • Similac Natural Care Advance • Liquid breast milk additive • Similac Special Care Advance • Enfamil Premature +/- Lipil

  22. Premature FormulasGeneral Characteristics compared to Standard • Increased Protein,Vitamins & Minerals • For infants born at <1.5kg • up to 2000-2500gm • Feeding of infants > 2500 gm • risk of vitamin toxicities • Premature formulas vary in nutrient content

  23. Post Premature Infant formula

  24. “Post” Premature Formulas • NeoSure Advance • EnfaCare Lipil • Standard Dilution: 22 kcal/oz • Protein: between standard and Premature • Vitamins: Higher than standard,significantly lower than Premature • Calcium and Phosphorus: between standard and Premature

  25. Other Specialty Formulas • Portagen (Mead Johnson) • 85% fat MCT, 15% fat Corn oil • Used for infants with chylothorax • Similac PM 60/40(Ross) • Low in Ca, P, K+ and NA; 2:1 Ca:P ratio • Used for infants with Renal Failure • Formulas for Metabolic Disorders • Several condition specific products by Ross and Mead Johnson

  26. Modular Products to Increase Energy/Protein

  27. Modular Products to increase Energy or Protein

  28. Products to Augment Energy and Protein in Breast Milk • Human Milk Fortifiers • For Premature infants less than 2000-2500gm only • Standard Infant Formula Powder • 1 teaspoon to 100mL = 24kcal/oz+/- • Do Not Add CHO or Fat w/o protein: Final product is TOO LOW in protein

  29. Finding Up to Date Information • www.ross.com Similac products • www.meadjohnson.com Enfamil products • www.verybestbaby.com Nestle products • www.wyethnutritionals.com generic products • www.brightbeginnings.com lower cost formulas made by Wyeth • www.shsna.com/html/Hypoallergenic.htm Neocate formulas

  30. When Baby is Not Growing • Normal Weight gain and linear growth • Guo et al J Pediatrics 1991 • Assess Feeding • Number feedings/day • Feeding environment • BF: baby “empties” breasts each feeding • Formula: volume per feeding • Vomiting? Diarrhea? Medical issues that increase needs/decrease intake?

  31. When Baby is Not Growing • Increase number of feedings/day • If baby <6 months d/c solids, increase breast milk or formula • Monitor weight weekly • If no improvement in 1 week consider increasing caloric concentration of breast milk or formula to 24 kcal/oz.

  32. When Baby is Not Growing • In cases of increased need due to medical condition or fluid limit, may need to go higher than 24 kcal/oz • In all cases monitor closely watch for • Signs of dehydration (baby may take less volume of concentrated feed) • Vomiting • Diarrhea

  33. Increasing Caloric Density of Formula • Concentrate formula (decrease water added): • Calculate kcals desired (e.g. 30 oz of 24 kcal/oz formula = 720kcal) • Divide kcals by kcal/oz of liquid or scoop of powder (e.g. 720 kcal divided by 40 kcal/oz liquid conc. = 18 oz liquid conc. Formula). • Add water to make final volume (12 oz water + 18 oz liquid conc. Formula = 30 oz 24kcal/oz formula)

  34. Using Modulars to Increase Calories • Example: Making 30 oz of 30 kcal per oz formula (30oz X 30kcal/oz = 900 kcal) • Start with 24 kcal/oz formula: • 24kcal/oz X 30oz = 720 kcal • 900kcal - 720 kcal = 180 kcal from modulars • Use Polycose and Micro lipid to make up additional kcals (approximately 90 kcal of each)

  35. Using Modulars to Increase Calories continued • Polycose 23 kcal/TBSP • 90 kcal /23kcal/TBSP =3.9TBSP (use 4 TBSP X 23 kcal = 92 kcal; still need 88 kcal) • Microlipid 4.5 kcal/mL • 88 kcal/4.5 kcal/mL =19.55 mL (use 20 mL X 4.5 kcal = 90 kcal) • Final calculation:720kcal + 92 kcal + 90 kcal = 902 kcal/30oz =30.07 kcal/oz

  36. Know What You Are Feeding • Caloric density, protein, fat and carbohydrate vitamin and mineral content. • Osmolality: goal is for <400mOsm/kg H2O; can slowly go up to 700 • Meds/modulars increase osmolality • Renal Solute Load: goal is for less than 300mOsm/l (all infant and pediatric meet this recommendation when concentrated up to 30 kcal/oz.) • Addition of protein will increase Renal Solute Load

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