Child nutrition. The alimentary Child nutrition. The alimentary factors & developments of factors & developments of

teeth system and development teeth system and development of diseasesof diseases

Nykytyuk S.ONykytyuk S.O

Human milk is uniquely superior for Human milk is uniquely superior for infant feeding and is species-specific; infant feeding and is species-specific; all substitute feeding options differ all substitute feeding options differ markedly from it. The breastfed markedly from it. The breastfed infant is the reference or normative infant is the reference or normative model against which all alternative model against which all alternative feeding methods must be measured feeding methods must be measured with regard to growth, health, with regard to growth, health, development, and all other short- development, and all other short- and long-term outcomesand long-term outcomes

Epidemiologic research shows that human milk Epidemiologic research shows that human milk and breastfeeding of infants provide advantages and breastfeeding of infants provide advantages with regard to general health, growth, and with regard to general health, growth, and development, while significantly decreasing risk development, while significantly decreasing risk for a large number of acute and chronic diseases. for a large number of acute and chronic diseases. Research in the United States, Canada, Europe, Research in the United States, Canada, Europe, and other and other developeddeveloped countries, among countries, among predominantly middle-class populations, provides predominantly middle-class populations, provides strong evidence that human milk feeding strong evidence that human milk feeding decreases the incidence and/or severity of decreases the incidence and/or severity of diarrhea, lower respiratory infection, otitis media, diarrhea, lower respiratory infection, otitis media, bacteremia, bacterial meningitis, botulism, bacteremia, bacterial meningitis, botulism, urinary tract infection, and necrotizing urinary tract infection, and necrotizing enterocolitisenterocolitis

There are also a number of studies that indicate possible There are also a number of studies that indicate possible health benefits for mothers. It has long been acknowledged health benefits for mothers. It has long been acknowledged that breastfeeding increases levels of oxytocin, resulting in that breastfeeding increases levels of oxytocin, resulting in less postpartum bleeding and more rapid uterine involution. less postpartum bleeding and more rapid uterine involution. Lactational amenorrhea causes less menstrual blood loss Lactational amenorrhea causes less menstrual blood loss over the months after delivery. Recent research over the months after delivery. Recent research demonstrates that lactating women have an earlier return demonstrates that lactating women have an earlier return to prepregnant weight, delayed resumption of ovulation to prepregnant weight, delayed resumption of ovulation with increased child spacing, improved bone with increased child spacing, improved bone remineralization postpartum with reduction in hip fractures remineralization postpartum with reduction in hip fractures in the postmenopausal period, and reduced risk of ovarian in the postmenopausal period, and reduced risk of ovarian cancer and premenopausal breast cancer. In addition to cancer and premenopausal breast cancer. In addition to individual health benefits, breastfeeding provides individual health benefits, breastfeeding provides significant social and economic benefits to the nation, significant social and economic benefits to the nation, including reduced health care costs and reduced employee including reduced health care costs and reduced employee absenteeism for care attributable to child illness. The absenteeism for care attributable to child illness. The significantly lower incidence of illness in the breastfed significantly lower incidence of illness in the breastfed infant allows the parents more time for attention to siblings infant allows the parents more time for attention to siblings and other family duties and reduces parental absence from and other family duties and reduces parental absence from work and lost incomework and lost income

RECOMMENDED RECOMMENDED BREASTFEEDING PRACTICESBREASTFEEDING PRACTICESHuman milk is the preferred feeding for all Human milk is the preferred feeding for all infants, including premature and sick newborns, infants, including premature and sick newborns, with rare exceptions. The ultimate decision on with rare exceptions. The ultimate decision on feeding of the infant is the mother's. Pediatricians feeding of the infant is the mother's. Pediatricians should provide parents with complete, current should provide parents with complete, current information on the benefits and methods of information on the benefits and methods of breastfeeding to ensure that the feeding decision breastfeeding to ensure that the feeding decision is a fully informed one. When direct breastfeeding is a fully informed one. When direct breastfeeding is not possible, expressed human milk, fortified is not possible, expressed human milk, fortified when necessary for the premature infant, should when necessary for the premature infant, should be provided. Before advising against be provided. Before advising against breastfeeding or recommending premature breastfeeding or recommending premature weaning, the practitioner should weigh weaning, the practitioner should weigh thoughtfully the benefits of breastfeeding against thoughtfully the benefits of breastfeeding against the risks of not receiving human milk. the risks of not receiving human milk.

Breastfeeding should begin as soon Breastfeeding should begin as soon as possible after birth, usually within as possible after birth, usually within the first hour. Except under special the first hour. Except under special circumstances, the newborn infant circumstances, the newborn infant should remain with the mother should remain with the mother throughout the recovery period. throughout the recovery period. Procedures that may interfere with Procedures that may interfere with breastfeeding or traumatize the breastfeeding or traumatize the infant should be avoided or infant should be avoided or minimizedminimized

Newborns should be nursed whenever Newborns should be nursed whenever they show signs of hunger, such as they show signs of hunger, such as increased alertness or activity, mouthing, increased alertness or activity, mouthing, or rooting. Crying is a late indicator of or rooting. Crying is a late indicator of hunger. Newborns should be nursed hunger. Newborns should be nursed approximately 8 to 12 times every 24 approximately 8 to 12 times every 24 hours until satiety, usually 10 to 15 hours until satiety, usually 10 to 15 minutes on each breast. In the early weeks minutes on each breast. In the early weeks after birth, nondemanding babies should after birth, nondemanding babies should be aroused to feed if 4 hours have elapsed be aroused to feed if 4 hours have elapsed since the last nursingsince the last nursing

No supplements (water, glucose No supplements (water, glucose water, formula, and so forth) should water, formula, and so forth) should be given to breastfeeding newborns be given to breastfeeding newborns unless a medical indication exists. unless a medical indication exists. With sound breastfeeding knowledge With sound breastfeeding knowledge and practices, supplements rarely are and practices, supplements rarely are needed. Supplements and pacifiers needed. Supplements and pacifiers should be avoided whenever possible should be avoided whenever possible and, if used at all, only after and, if used at all, only after breastfeeding is well establishedbreastfeeding is well established

When discharged <48 hours after delivery, all When discharged <48 hours after delivery, all breastfeeding mothers and their newborns should breastfeeding mothers and their newborns should be seen by a pediatrician or other knowledgeable be seen by a pediatrician or other knowledgeable health care practitioner when the newborn is 2 to health care practitioner when the newborn is 2 to 4 days of age. In addition to determination of 4 days of age. In addition to determination of infant weight and general health assessment, infant weight and general health assessment, breastfeeding should be observed and evaluated breastfeeding should be observed and evaluated for evidence of successful breastfeeding for evidence of successful breastfeeding behavior. The infant should be assessed for behavior. The infant should be assessed for jaundice, adequate hydration, and age-jaundice, adequate hydration, and age-appropriate elimination patterns (at least six appropriate elimination patterns (at least six urinations per day and three to four stools per urinations per day and three to four stools per day) by 5 to 7 days of age. All newborns should day) by 5 to 7 days of age. All newborns should be seen by 1 month of age. be seen by 1 month of age.

Exclusive breastfeeding is ideal nutrition Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and sufficient to support optimal growth and development for approximately the and development for approximately the first 6 months after birth. Infants weaned first 6 months after birth. Infants weaned before 12 months of age should not before 12 months of age should not receive cow's milk feedings but should receive cow's milk feedings but should receive iron-fortified infant formula. receive iron-fortified infant formula. Gradual introduction of iron-enriched solid Gradual introduction of iron-enriched solid foods in the second half of the first year foods in the second half of the first year should complement the breast milk diet. It should complement the breast milk diet. It is recommended that breastfeeding is recommended that breastfeeding continue for at least 12 months, and continue for at least 12 months, and thereafter for as long as mutually desired. thereafter for as long as mutually desired.

In the first 6 months, water, juice, and other foods In the first 6 months, water, juice, and other foods are generally unnecessary for breastfed infants. are generally unnecessary for breastfed infants. Vitamin D and iron may need to be given before 6 Vitamin D and iron may need to be given before 6 months of age in selected groups of infants months of age in selected groups of infants (vitamin D for infants whose mothers are vitamin (vitamin D for infants whose mothers are vitamin D-deficient or those infants not exposed to D-deficient or those infants not exposed to adequate sunlight; iron for those who have low adequate sunlight; iron for those who have low iron stores or anemia). Fluoride should not be iron stores or anemia). Fluoride should not be administered to infants during the first 6 months administered to infants during the first 6 months after birth, whether they are breast- or formula-after birth, whether they are breast- or formula-fed. During the period from 6 months to 3 years fed. During the period from 6 months to 3 years of age, breastfed infants (and formula-fed infants) of age, breastfed infants (and formula-fed infants) require fluoride supplementation only if the water require fluoride supplementation only if the water supply is severely deficient in fluoride (<0.3 ppmsupply is severely deficient in fluoride (<0.3 ppm

Breastfeeding for the first year of Breastfeeding for the first year of life with the supplementationlife with the supplementation

Breastfeeding for the first year of life with the supplementation Breastfeeding for the first year of life with the supplementation of Vitamin D from birth and iron supplementation as ferrous of Vitamin D from birth and iron supplementation as ferrous sulfate drops or iron-fortified cereal after 4 months of age. sulfate drops or iron-fortified cereal after 4 months of age. Fluoride supplementation may be required after 6 months of Fluoride supplementation may be required after 6 months of age depending on the fluoride content of the city water supply. age depending on the fluoride content of the city water supply. Feeding of iron-fortified commercial infant formula for the first Feeding of iron-fortified commercial infant formula for the first year as an alternative to breastfeeding. year as an alternative to breastfeeding. Delaying the use of whole cow milk until after one year of age. Delaying the use of whole cow milk until after one year of age. Early introduction of whole cow milk protein during infancy may Early introduction of whole cow milk protein during infancy may contribute to iron-deficiency anemia by increasing contribute to iron-deficiency anemia by increasing gastrointestinal blood loss. Whole cow milk has an increased gastrointestinal blood loss. Whole cow milk has an increased renal solute load compared to infant formulas. renal solute load compared to infant formulas. Reduced fat milks should be delayed until after the second year Reduced fat milks should be delayed until after the second year of life. Adequate fat intake is important for the developing brain of life. Adequate fat intake is important for the developing brain and milk is usually the primary source of fat for toddlers. and milk is usually the primary source of fat for toddlers. Delaying the introduction of semi-solid foods until 4 to 6 months Delaying the introduction of semi-solid foods until 4 to 6 months of age or until the infant demonstrates signs of developmental of age or until the infant demonstrates signs of developmental readiness, such as head control and ability to sit with support. readiness, such as head control and ability to sit with support.

TThere is an here is an agreementagreement among among healthcare professionals, infant healthcare professionals, infant food manufacturers and mothers food manufacturers and mothers that that breastfeeding is the best breastfeeding is the best choicechoice for feeding infants during for feeding infants during their first four to six months of lifetheir first four to six months of life

There are several reasons why a There are several reasons why a mother may not breastfeed her mother may not breastfeed her baby:baby: 1.1. Medical or other health reasons Medical or other health reasons

may prevent a mother from may prevent a mother from breastfeeding. breastfeeding.

2.2. The baby with special requirements The baby with special requirements may not tolerate breast milk.may not tolerate breast milk.

3.3. Some social or psychological Some social or psychological reasons can make it more difficult reasons can make it more difficult to breastfeed exclusively.to breastfeed exclusively.

Table 1. Drugs that are contraindicated Table 1. Drugs that are contraindicated during breast-feedingduring breast-feeding

No. No. Drug Drug Reported sign or symptom in infant Reported sign or symptom in infant or effect on lactationor effect on lactation

1.1. BromocriptineBromocriptine Supresses lactationSupresses lactation2.2. CocaineCocaine Cocaine intoxicationCocaine intoxication

3.3. Cyclophos-Cyclophos-phamidephamide

Possible immune supression; Possible immune supression; unknown effect on growth or unknown effect on growth or association with association with carcinogenesis; neutropeniacarcinogenesis; neutropenia

4.4. CyclosporineCyclosporinePossible immune supression; Possible immune supression; unknown effect on growth or unknown effect on growth or association with association with carcinogenesiscarcinogenesis

5.5. Doxopubicin Doxopubicin Possible immune supression; unknown Possible immune supression; unknown effect on growth or association with effect on growth or association with carcinogenesiscarcinogenesis

6.6. Ergotamine Ergotamine Vomiting, diarrhea, convulsions (doses Vomiting, diarrhea, convulsions (doses used in migraine medication)used in migraine medication)

7.7. Lithium Lithium ⅓⅓ to ½ therapeutic blood to ½ therapeutic blood concentration in infantsconcentration in infants

8.8. MethotrexatMethotrexate e

Possible immune supression; unknown Possible immune supression; unknown effect on growth or association with effect on growth or association with carcinogenesis; neutropeniacarcinogenesis; neutropenia

9.9. PhencyclidinPhencyclidine (PCP)e (PCP) Potent hallucinogenPotent hallucinogen

10.10. Phenindione Phenindione Anticoagulant; increased prothrombin Anticoagulant; increased prothrombin and partial thromboplastin time in and partial thromboplastin time in infantinfant

Table 2. Table 2. Drugs that have caused Drugs that have caused significant effects on some nursing significant effects on some nursing

infants and should be given to nursing infants and should be given to nursing mothers with cautionmothers with caution

No.No. DrugDrug Reported sign or symptom in infant or Reported sign or symptom in infant or effect on lactationeffect on lactation

1.1.Aspirin Aspirin (salicylates)(salicylates)

Metabolic acidosis (dose related); may Metabolic acidosis (dose related); may affect platelet function; hemorrhagic affect platelet function; hemorrhagic rashrash

2.2. Clemastine Clemastine Drowsiness, irritability, refusal to feed, Drowsiness, irritability, refusal to feed, high-pitched cry, neck stiffnesshigh-pitched cry, neck stiffness

3.3. PhenolbarbitoPhenolbarbitol l

Sedation; infantile spasms after Sedation; infantile spasms after weaning from milk containing weaning from milk containing phenolbarbitol, methemoglobinemia phenolbarbitol, methemoglobinemia

4.4. PrimidonePrimidone Sedation; feeding problemsSedation; feeding problems5.5. SulfasalazineSulfasalazine Bloody diarrheaBloody diarrhea

Table 3. Table 3. Drugs of abuse that are Drugs of abuse that are contraindicated during breast-feedingcontraindicated during breast-feeding

NoNo.. DrugDrug Reported sign or symptom in infant Reported sign or symptom in infant

or effect on lactationor effect on lactation

11..

AmphetaminAmphetaminee Irritability, poor sleep patternIrritability, poor sleep pattern

22.. CocaineCocaine Cocaine intoxicationCocaine intoxication33.. HeroinHeroin Irritability, Heroin intoxicationIrritability, Heroin intoxication

44..

Nicotine Nicotine (smoking) (smoking)

Shock, vomiting, diarrhea, Shock, vomiting, diarrhea, rapid heart rate, restlessness; rapid heart rate, restlessness; decreased milk productiondecreased milk production

55..

PhencyclidinPhencyclidinee Potent hallucinogenPotent hallucinogen

Common problems encountered Common problems encountered with brest-feedingwith brest-feeding

Poor Let-Down (Milk ejection Poor Let-Down (Milk ejection reflex)reflex)Poor Weight GainPoor Weight GainMastitisMastitisCracked NipplesCracked NipplesJaundice From Breast- Feeding Jaundice From Breast- Feeding

Artificial feedingArtificial feeding

This is the feeding of infant when he This is the feeding of infant when he gets cow’s or buffalo’s milk or gets cow’s or buffalo’s milk or formula from first days till 4formula from first days till 4thth to 6 to 6thth month of his life. month of his life.

Formula milks are humanized, i.e., Formula milks are humanized, i.e., they come very close to the they come very close to the composition of breast milk.composition of breast milk.However, they are more expensive, However, they are more expensive, so cow’s or buffalo’s milk are quite so cow’s or buffalo’s milk are quite often used.often used.

Composition of cow’s milk versus Composition of cow’s milk versus breast milk.breast milk.(in 100 ml)(in 100 ml)

Human milkHuman milk Cow’s milkCow’s milk

Calories Calories 6767 6767

Water Water 87 %87 % 87 %87 %Carbohydrate Carbohydrate 7.4 %7.4 % 4.4 %4.4 %Lactose Lactose isomerisomer ββ-lactose-lactose αα-lactose-lactose

FatFat 3.5 %3.5 % 3.5 %3.5 %

Human milkHuman milk Cow’s milkCow’s milk

Protein Protein 1.5 %1.5 % 3.5 %3.5 %Lactalbumin:CasLactalbumin:Casein ratioein ratio 60 : 4060 : 40 20 : 8020 : 80

SodiumSodium 15 mg15 mg 60 mg 60 mg (4 times)(4 times)

Phosphorus Phosphorus 15 mg15 mg 90 mg 90 mg (6 times)(6 times)

Calcium Calcium 30 mg30 mg 120 mg 120 mg (4 times)(4 times)

Iron Iron 0.5 mg0.5 mg 0.1 mg0.1 mg

Other advantages of breast milk Other advantages of breast milk versus cow’s milk:versus cow’s milk:

Breast milk is available all the time and is Breast milk is available all the time and is practically free from pathogenic bacteria.practically free from pathogenic bacteria.It needs no time for preparationIt needs no time for preparationIt is available at the optimum temperature.It is available at the optimum temperature.It contains antibodies as IgG and IgA and It contains antibodies as IgG and IgA and protects against certain infections such as protects against certain infections such as E.ColiE.Coli, cholera, polio, tetanus, measles etc. , cholera, polio, tetanus, measles etc. IgA antibodies prevent the microorganisms IgA antibodies prevent the microorganisms to adhere the intestinal mucosa and to adhere the intestinal mucosa and provide local GIT immunity.provide local GIT immunity.

ββ-lactose is called Bifidus factor, which -lactose is called Bifidus factor, which promotes the growth of lactobacillus and promotes the growth of lactobacillus and helps to lower the gut pH, thus inhibiting helps to lower the gut pH, thus inhibiting the growth of the growth of E.Coli and yeasts.E.Coli and yeasts.Breast milk contains lactoferrin (an iron-Breast milk contains lactoferrin (an iron-binding whey protein), which inhibits binding whey protein), which inhibits bacterial growth by depriving them of iron, bacterial growth by depriving them of iron, which is necessary for growth.which is necessary for growth.Breast milk contains cystine and tyrosine, Breast milk contains cystine and tyrosine, which are not synthesized by infants but which are not synthesized by infants but they are essential for proper growth and they are essential for proper growth and development.development.Breast milk contains taurine that is Breast milk contains taurine that is synthesized in inadequate amounts in synthesized in inadequate amounts in infants. It is important for normal infants. It is important for normal differentiation of CNS.differentiation of CNS.

Breast milk contains nonspecific factors of Breast milk contains nonspecific factors of immune difence: lisozyme, immune difence: lisozyme, macrofagocytes, neutrofiles, macrofagocytes, neutrofiles, lymphocytes, complement system.lymphocytes, complement system.There are 5 times more essential fatty There are 5 times more essential fatty acids (polyunsaturated: arachidonic, acids (polyunsaturated: arachidonic, docosahexacnoic, linoleic, and α-linolenic) docosahexacnoic, linoleic, and α-linolenic) in breasts milk than in cow’s milk.in breasts milk than in cow’s milk.Breast milk contains ferments (lipase, Breast milk contains ferments (lipase, lactase) and mothers hormones.lactase) and mothers hormones.Breast milk is ‘species specific’ and Breast milk is ‘species specific’ and therefore allergy to breast milk is rare.therefore allergy to breast milk is rare.

Dilution of Cow’s Milk:Dilution of Cow’s Milk:

Child’s AgeChild’s Age Cow’s MilkCow’s Milk WaterWater

First 10 daysFirst 10 days 1 part1 part 2 parts2 parts

10 to 20 days10 to 20 days 1 part1 part 1 part1 part

Up to 2 moUp to 2 mo 2 parts2 parts 1 part1 partIf dilution of cow’s milk is required, If dilution of cow’s milk is required, add 1 TSF of sugar to each ounce of add 1 TSF of sugar to each ounce of water (5 %) – isocaloric formula)water (5 %) – isocaloric formula)

Advances in nutritional Advances in nutritional modifications of infant formulasmodifications of infant formulasProteins: Proteins: their amount is adopted to the their amount is adopted to the needs of infant’s organism. Almoust all needs of infant’s organism. Almoust all formulas contain whey:casein ratio as formulas contain whey:casein ratio as 60:40 and adopted amino acid content. 60:40 and adopted amino acid content.

Amino acidAmino acid BreasBreast milkt milk

Cow’s Cow’s milkmilk

““Vitalact”Vitalact” ““Similac”Similac”

Valine Valine 8.2 8.2 %% 6.66.6 4.6 %4.6 % 6.8 %6.8 %

Lysine Lysine 10.910.955 7.87.8 9.7 %9.7 % 8.4 %8.4 %

Trypto-Trypto-phan phan 2.292.29 1.41.4 2.4 %2.4 % 1.4 %1.4 %

Fats:Fats: long-chain polyunsaturated long-chain polyunsaturated fatty acids are added in amounts fatty acids are added in amounts similar to those in human milk.similar to those in human milk. Infants fed these formulas or Infants fed these formulas or human milk have higher tissue human milk have higher tissue concentrations of long-chain concentrations of long-chain polyunsaturated fatty acids and polyunsaturated fatty acids and reportedly have reportedly have better visual better visual acuityacuity than do infants fed than do infants fed nonsupplemented formulas. nonsupplemented formulas.

Carbohydrates:Carbohydrates: they are presented they are presented by by ββ-lactose, sakcharose, dextrin--lactose, sakcharose, dextrin-maltose, which improve the growth maltose, which improve the growth of Bifidum-bacteria. The total of Bifidum-bacteria. The total quantity of carbohydrates in quantity of carbohydrates in formulas is 7.5 %formulas is 7.5 %

NucleotidesNucleotides and their related products and their related products play key roles in many biological play key roles in many biological processes. Although nucleotides can processes. Although nucleotides can be synthesized endogertously, they be synthesized endogertously, they are considered "conditionally are considered "conditionally essential." Nucleotide concentrations essential." Nucleotide concentrations in human milk are higher than in in human milk are higher than in unsupplemented cow milk-based unsupplemented cow milk-based formulas, and studies in animals and formulas, and studies in animals and human infants suggest that dietary human infants suggest that dietary nucleotides play a role in the nucleotides play a role in the development of the gastrointestinal development of the gastrointestinal and immune systems and immune systems

Vitamins and mineralsVitamins and minerals

Breast Breast milkmilk

Cow’s Cow’s milkmilk

Fortified Fortified formulasformulas

Vitamin Vitamin EE

0.63 mg0.63 mg%% 0.180.18 0.4-0.60.4-0.6

Vitamin Vitamin CC 4.2 mg%4.2 mg% 1.51.5 4.5-5.04.5-5.0

PotassiuPotassiumm 55 mg%55 mg% 140140 70-9570-95

SeleniuSeleniumm

15 to 20 15 to 20 µg/L µg/L

2 to 8 2 to 8 µg/L µg/L

11 to 15 11 to 15 µg/L µg/L

OsmolaliOsmolality ty

260 260 mosm/Lmosm/L

420 420 mosm/Lmosm/L

320 320 mosm/Lmosm/L

For infants 0 to 12 For infants 0 to 12 monthsmonthsWhey Whey proteins:casein = proteins:casein = 60:4060:40Close to breast milk Close to breast milk spectrum of amino spectrum of amino acidsacidsContains taurine.Contains taurine.Milk fats – 74 % and Milk fats – 74 % and plant fats – 26 %plant fats – 26 %Linoleic : α-linolenic Linoleic : α-linolenic ratio is optimal for ratio is optimal for absorption 9.9:1absorption 9.9:1Osmolality is equal Osmolality is equal 270 mosm/L270 mosm/L

The level of The level of proteins is 2.2 %proteins is 2.2 %Whey Whey proteins:casein = proteins:casein = 40:6040:60Inriched with Inriched with bifidum-bacteriabifidum-bacteriaFortified with Fortified with vitaminsvitamins

Biologically Biologically hydrolyzed casein hydrolyzed casein and whey proteinsand whey proteinsBiologically Biologically hydrolyzed lactosehydrolyzed lactoseIron fortified (0.8 Iron fortified (0.8 mg/100 ml)mg/100 ml)Contains Contains Bifidobacterium Bifidobacterium Lactis 2Lactis 2101077/1 g/1 g-6 : -6 : -3 = 7.9:1-3 = 7.9:1Osmolality 270 Osmolality 270 mosm/Lmosm/L

It doesn’t contain It doesn’t contain lactoselactoseOnly whey Only whey proteins are proteins are present, 20 % of present, 20 % of them are amino them are amino acidsacidsContains Contains nucleotides and nucleotides and selenselenIron and Iodine Iron and Iodine fortifiedfortifiedContains taurine, Contains taurine, inositol, L-inositol, L-karnitine.karnitine.

For infants withFor infants withHypergalactosaemiHypergalactosaemia a Lactose intoleranceLactose intoleranceStrong allergy to Strong allergy to cow’s milk proteinscow’s milk proteinsVegetarian babiesVegetarian babies

For premature and For premature and low-birth-weight (less low-birth-weight (less than 2500 g) babiesthan 2500 g) babiesProteins – 2.3 %Proteins – 2.3 %Whey : casein ratio = Whey : casein ratio = 70:3070:30Proteins are particly Proteins are particly hydrolyzed hydrolyzed (oligopeptids)(oligopeptids)Contains lysine, Contains lysine, cystine, tryptophan, cystine, tryptophan, L-histidine, and L-histidine, and taurine.taurine.Polyunsaturated fatty Polyunsaturated fatty acids (arachidonic, acids (arachidonic, docosahexacnoic, docosahexacnoic, linoleic, and α-linoleic, and α-linolenic) are presentlinolenic) are present

For ‘hungry’ babiesFor ‘hungry’ babiesFor infants with For infants with often regurgitationoften regurgitationContains 77 % of Contains 77 % of caseincaseinIron, Iodine, Vit. D, Iron, Iodine, Vit. D, A, E and C A, E and C enriched.enriched.

NAN NAN H.A.1H.A.1NAN NAN H.A.2H.A.2For children with For children with strong family allergystrong family allergyContains 100 % of Contains 100 % of whey proteins, which whey proteins, which are hydrolyzed to are hydrolyzed to oligopeptids (80 %) oligopeptids (80 %) and aminoacids (20 and aminoacids (20 %)%)

AlfaréAlfaréHypoallergenic Hypoallergenic elemental diet for elemental diet for children with children with malarbsorption malarbsorption syndrome, diarrhea, syndrome, diarrhea, for tube feedingfor tube feedingContains hydrolyzed Contains hydrolyzed whey proteins: 80 % whey proteins: 80 % of oligopeptids and of oligopeptids and 20 % of aminoacids 20 % of aminoacids Hydrolyzed lactoseHydrolyzed lactoseShort-chain fatty Short-chain fatty acidsacids

Other commercial infant formulasOther commercial infant formulasFormula Formula Protein Protein

sourcesourceCarbohy-Carbohy-drate s.drate s. Fat sourceFat source

For full-term and premature infants with no For full-term and premature infants with no special nutritional requirementsspecial nutritional requirements

SMA SMA (Wyeth)(Wyeth)

Nonfat cow's Nonfat cow's milk, reduced milk, reduced mineral whey: mineral whey: whey/casein whey/casein ratio: 60:40ratio: 60:40

LactoseLactose Oleo, Oleo, coconut, coconut, oleic (saf-oleic (saf-flower) and flower) and soy oilssoy oils

Enfamil Enfamil (Mead (Mead Johnson)Johnson)

Nonfat cow's Nonfat cow's milk, deminer-milk, deminer-alized whey: alized whey: whev/casein whev/casein ratio: 60:40ratio: 60:40

LactoseLactose Soy, coconut Soy, coconut oilsoils

Similac Similac (Ross)(Ross)

Nonfat cow's milk; Nonfat cow's milk; whey/ casein ratio: whey/ casein ratio: 18:8218:82

LactoseLactose Soy and Soy and coconut oils, coconut oils, mono- and mono- and diglyceridesdiglycerides

Baby Baby formula formula (Gerber)(Gerber)

Nonfat cow's milk; Nonfat cow's milk; whey/ casein ratio: whey/ casein ratio: 18:8218:82

LactoseLactose SoySoy

FOR MILK PROTEIN-SENSITIVE INFANTS (‘MILK FOR MILK PROTEIN-SENSITIVE INFANTS (‘MILK ALLERGY’), LACTOSE INTOLERANCE, ALLERGY’), LACTOSE INTOLERANCE,

GALACTOSEMIAGALACTOSEMIAProsobee Prosobee (Mead (Mead Johnson)Johnson)

Soy protein isolateSoy protein isolate Corn syrup Corn syrup solids. solids. Lactose and Lactose and sucrose sucrose freefree

Soy and Soy and coconut oilscoconut oils

Isomil Isomil (Ross)(Ross)

Soy protein isolateSoy protein isolate Corn svrup, Corn svrup, sucrosesucrose Lactose Lactose freefree

Soy and Soy and coconut oilscoconut oils

Nursoy Nursoy (Wyeth)(Wyeth)

Soy protein Soy protein isolateisolate

Sucrose (liquid Sucrose (liquid formula). Corn formula). Corn syrup solids syrup solids (powdered (powdered formula)formula)

Oleo, coconut, Oleo, coconut, oleic, and soy oleic, and soy oilsoils

FOR INFANTS WITH MALABSORPTION SYNDROMEFOR INFANTS WITH MALABSORPTION SYNDROME RCF (Ross RCF (Ross CarbohydraCarbohydrate Free) te Free) (Ross)(Ross)

Soy protein Soy protein isolateisolate Absent Absent Soy and Soy and

coconut oilscoconut oils

Portagen Portagen (Mead (Mead Johnson)Johnson)

Sodium Sodium caseinatecaseinate

Corn syrup Corn syrup solids, sucrose, solids, sucrose, lactoselactose

MCT (coconut MCT (coconut source) and source) and corn oilcorn oil

Pregestimil Pregestimil (Mead (Mead Johnson)Johnson)

Casein Casein hydrolysate hydrolysate and L-amino and L-amino acidsacids

Corn syrup Corn syrup solids, solids, modified modified tapioca tapioca starchstarch

Corn oil, MCTCorn oil, MCT For infants For infants with with ddisacchaisaccha--ridase ridase deficiencies, deficiencies, malabsorptiomalabsorption svndromes, n svndromes, cystic cystic fibrosis.fibrosis.

Specialty formulasSpecialty formulasFormula Formula

(manufacturer)(manufacturer) Indication for useIndication for use Comments Comments

Lonalac Lonalac (Mead (Mead

Johnson) Johnson) PowderPowder

For children with For children with congestive congestive

cardiac failure, cardiac failure, who require who require

reduced sodium reduced sodium intake.intake.

For long-term For long-term management, management,

additional sodium additional sodium must be given. must be given.

Supplement with Supplement with vitamins C and D and vitamins C and D and iron. Na = 1 mEq/Liron. Na = 1 mEq/L

Similac PM Similac PM 60/ 40 (Ross) 60/ 40 (Ross)

PowderPowder

For newborns For newborns predisposed to predisposed to

hypocal-cemia and hypocal-cemia and infants with impaired infants with impaired renal, digestive, and renal, digestive, and

cardio-vascular cardio-vascular functions.functions.

Low calcium, Low calcium, potassium, and potassium, and

phosphorus. phosphorus. Relatively low Relatively low

solute load. Na — solute load. Na — 7 mEq/L7 mEq/L

Lofenalac Lofenalac (Mead (Mead Johnson)Johnson)

For infants and For infants and children with children with phenylketonuria.phenylketonuria.

111 mg 111 mg phenylalanine phenylalanine per quart of per quart of formula formula

Phenyl-free Phenyl-free (Mead (Mead Johnson)Johnson)

For children over For children over 1 year of age 1 year of age with with phenylketonuria.phenylketonuria.

Phenylalanine Phenylalanine free. Permits free. Permits increased increased supplementation supplementation with normal with normal foods.foods.

PKU 1 (Milupa)PKU 1 (Milupa) For infants with For infants with phenylketonuria phenylketonuria (Available as PKU (Available as PKU 2 for children 2 for children over 1 year of over 1 year of age.)age.)

Phenylalanine- Phenylalanine- and fat-free. and fat-free. Contains Contains vitamins,mineralvitamins,minerals, and trace s, and trace elementselements

Low Methionine Low Methionine Diet Powder Diet Powder (Product 3200K) (Product 3200K) (MeadJohnson)(MeadJohnson)

For infants with For infants with homocystinuriahomocystinuria

Nutritionally Nutritionally complete, but complete, but requires monito-requires monito-ring of amino ring of amino acid levelsacid levels

Sunlight as a source of vitamin Sunlight as a source of vitamin DD

Adequate supplies of Adequate supplies of vitamin Dvitamin D33 can be can be

synthesized with sufficient synthesized with sufficient exposure to solar exposure to solar

ultraviolet B radiationultraviolet B radiation

Melanin, clothing or Melanin, clothing or sunscreens that absorb sunscreens that absorb

UVB will reduce cutaneous UVB will reduce cutaneous production of vitamin Dproduction of vitamin D33

What are the causes for What are the causes for deficiency of Vitamin D?deficiency of Vitamin D?

Reasons of vitamin DReasons of vitamin D deficiencydeficiencyEnvironmental conditions where sunlight Environmental conditions where sunlight exposure is limited like indoor exposure is limited like indoor confinement or working indoors during confinement or working indoors during daylight hours may reduce source of daylight hours may reduce source of vitamin D;vitamin D;Inadequate daily consumption - aInadequate daily consumption - a lack of lack of vitamin D, calcium and phosphorous in the vitamin D, calcium and phosphorous in the diet, have trouble digesting milk products, diet, have trouble digesting milk products, people who are lactose intolerant;people who are lactose intolerant;

Reasons of deficiency vitamin DReasons of deficiency vitamin D Problem of malabsorption called Problem of malabsorption called steatorrhea, in which the body is unable to steatorrhea, in which the body is unable to absorb fats. The result of this problem is absorb fats. The result of this problem is that Vitamin D, which is usually absorbed that Vitamin D, which is usually absorbed with fat, and calcium are poorly absorbed.with fat, and calcium are poorly absorbed.This poor absorption can be a result of This poor absorption can be a result of digestive disorders. digestive disorders. Liver, kidney failure (Liver, kidney failure (congenital or acquired congenital or acquired disorders) - due to tubular acidosis in which disorders) - due to tubular acidosis in which there is an increased amount of acid in the there is an increased amount of acid in the body;body;Dark PigmentationDark Pigmentation

EtiologyEtiology

1.1. Lack of sunshine due to:Lack of sunshine due to: 1) Lack of outdoor activities1) Lack of outdoor activities 2) Lack of ultraviolet light in fall and 2) Lack of ultraviolet light in fall and winterwinter 3) Too much cloud, dust, vapour and 3) Too much cloud, dust, vapour and smokesmoke

EtiologyEtiology

2. Improper feeding:2. Improper feeding: 1) Inadequate intake of Vitamin D1) Inadequate intake of Vitamin D

Breast milk 0-10IU/100mlBreast milk 0-10IU/100ml Cow’s milk 0.3-4IU/100mlCow’s milk 0.3-4IU/100ml Egg yolk 25IU/average yolkEgg yolk 25IU/average yolk Herring 1500IU/100gHerring 1500IU/100g

2) Improper Ca and P ratio2) Improper Ca and P ratio

EtiologyEtiology

3. Fast growth, increased 3. Fast growth, increased requirement (relative deficiency)requirement (relative deficiency)

4. Diseases and drug:4. Diseases and drug: Liver diseases, renal diseasesLiver diseases, renal diseases Gastrointestinal diseasesGastrointestinal diseases AntiepilepticAntiepileptic GlucocorticosteroidGlucocorticosteroid