Physiologic considerations of
INFANTS
1 Month baby = 1 oz stomach (size of fist)
WEIGHT GAIN
lose 6% in 1st/2nd week of life
DOUBLE birth weight by 5-6 months
5 pounds per year on average
LENGTH
- *50%** increase in 1st year
- *100%** increase in 1st 4 years
- *300%** increase by 13 years
- *RDA**
- *DIETARY intake for Children**
38-42weeks gestation >2500gm
Birth - 6 months
110 kcal/kg/day
6 - 12 months
- *80 kcal/kg/day**
- not a sig difference between GENDER*
- PRETERM / <2500gm*
- *<130 kcal/kg/day**
RDA
for Birth - 6 months
110 kcal/kg/day
Breastfeeding is recommended for this age range
@ 4-6 months of age:
digestive system ready to take complex food/cereal/babyfood
better neck/head control
some teeth
RDA
6 - 12 months
80 kcal/kg/day
not a sig diff between boys/girls <10 y/o
LESS THAN birth -6 months = 110
Master chewing & finger foods
Try CUPS / utensils
RDA
for PRETERMor<2500gm
<130 kcal/kg/day
needs MORE than full term children 110->80
Breastfeeding info
- *PREFERRED** source of nutrition for FIRST 6 MONTHS
- only CONTRAINDICATED if:*
- HIV / Chemo Medication / TB*
Frequency is MORE OFTEN
1-2 hours, more than usual
Bowel Movement = after each feeding
Content of Formulas
WANT TO BE IDENTICAL TO HUMAN MILK
40-50% Carbohydrates
lactose is main source
30-40% Fats
5-10% Protein
Water
Micronutrients
Lactose Deficiency
Lactose Intolerance:
Diarrhea / Ab pain / Bloating
infants < 36 weeks gestation
- *SECONDARY** lactase deficiency:
- *TEMPORARY** decrease in lactase cause by
- *gastroenteritis / malnutrition**
- *Congenital** lactase deficiency:
- *INBORN** error of metabolism = Rare
FAT
Content of Formula
Varies between products, but mainly:
TRIGLYCERIDES
no restriction < 2 y/o
needed for proper neurologic development
Minimum requied in formula = 30% of calories as fat
MAX = 54%
Protein
Content of Formula
Whey Protein
more soluble & remains in solution throughout stomach
20% cows milk vs 50-60% human milk
Casein Products
CURDS –> form micelles
Whey:Casein Ration = 60:40
for HUMAN milk, 20:80 for cows milk
Protein Requirements
Birth - 6 months:
2.2 gm/kg/day
6 months - 1 year:
1.6 gm/kg/day
WATER
Content of Formula
+ RDA for WATER
_NO supplemental water is Necessary_
even once starting baby food
Fluid Maintenance:
100 ml/kg/day for 1st 10kg
PLUS + 50 ml/kg/day for each additional-kg between 10-20kg
Vitamins & Minerals
needed for Infant SUPPLEMENTATION
VITAMIN D
All infants : 400 IU/day
starting within 1st few days of life
IRON
Full-term breastfed: 1 mg/kg/day after 4 months of age
varies by preterm/formula
FLUORIDE
Based on the amount of fluoride present in water source
fluoridated toothpaste
Vitamin D Supplementation
ALL INFANTS
400 IU/day
starting within the first few days of life
- UNLESS receiving at least*
- *>1 liter of fortified formula/day**
IRON SUPPLEMENTATION
for infants
FULL Term + Breastfed
1 mg/kg/day after 4 months of age
Pre-term Breastfed
2 mg/kg/day after 1 month
Partial Breastfed
if 50% HUMAN milk fed –> use ABOVE dosing
Formula Fed:
Iron-fortified formulas supply sufficient iron for first 12 months of life
Fluoride SUPPLEMENTATION
Based on the amount of fluoride present in WATER SOURCE
NOT recommended @ <_6 months_
Fluoridated TOOTHPASTE should be used
<3y/o –> use grain of rice amount
>3 years of age –> pea size apoint
start with first tooth eruption
Milk Comparisons
FDA LIMIT for
Renal Solute Load= 277
Cow’s Milk:
20% Whey : 80% Casein
308 Renal Solulte load
_*DO NOT RECOMMEND COW’S MILK IN*
FIRST YEAR OF LIFE_
Soy-Based Formulas
- *Corn Starch / Tapioca Starch / Sucrose**
- for the CARB – instead of LACTOSE*
recommended if lactase deficient or allergy
NOT recommended for pre-term infants
HIGH concentration of
PROTEIN / MANGANESE
Therapeutic Formulas
Casein-Hydrolysate-Based Formulas
Pregestimil // Nutramigen // Alimentum
= BROKEN-down proteins –> AA’s
so that it is easier to digest
Indicated for patients w/
- *GI Distrubances**
- less palatable*
Therapeutic Formulas
WHEY-Hydroysate Based
Carnation Good-Start
- *MORE Palatable** vs Casein
- maybe more acceptable if need for*
- *GI INTOLERANCE**
Therapeutic Formulas
OTHER CONSIDERATIONS
Premature Infant Formulas
decreased renal solule load –> whey predominant
want to mimic breast milk ratio = 60W:40C
Pre-Thickened Formulas
indicated for GERD
- *Concentrated** Formulas
- *24 vs 27kcal/oz** = HIGHER calorie
- *Human Milk** Fortifiers
- *Adds Calories**, without adding volume
What is COLIC?
20% of infants experience this
Insoluble Crying
= worse in evening
Gassy / Hernia / Sensitivity to milk protein ???
usually subsides by _3 months of age_
needs a LOT of patience
Considerations for CONSTIPATION
- DO NOT USE*
- *Low-Iron Formulas**
Honey - botulism risk
Plain Water? - NO NUTRITIONAL USE
JUST GIVE THEM MORE FORMULA
NO DRUG THERAPY
see a doctor if been going for too long
Formula Warming
Bring to
ROOM TEMPERATURE
AVOID use of microwave
can have HOT SPOTS –> burn mouth
Sterilization of nipples/bottle
Full Term Baby & 1 month old
Stomach Capacity
“SIZE of THEIR FIST”
Full Term
20 - 90mL = 1-3oz
1 month
90 - 150mL = 3-5oz
Problems with Feeding:
GERD
- *do NOT add CEREAL** to formula
- may WORSEN the GERD*
Recommend:
formulas that THICKEN in the stomach
Monitoring if
Problems with Feeding:
Weight
use a weight curve
Height
Head Circumference
HYDRATION STATUS
# Wet Diapers (weight)
TEARS
soft fontanelle
How MUCH to feed the baby?
◦Birth – 2 weeks:
2-3 ounces/feed
◦3 weeks – 2 months:
4-5 ounces/feed
◦2 months onward:
~ 6 ounces/feed
◦Birth to 6 months ~ 110 kcal/kg/day
◦6 months – 12 months ~ 80 kcal/kg/day
How OFTEN to feed the baby?
- *Healthy**, term infants = Q4 HOURS
- preterm = q 2-3 hours*
FEED ON DEMAND!
until they are satisfied
Nightime feedings may stop after 1-2 months
during _illnesses –> frequency will VARY_
constipation –> MORE frequent
vomiting –> LESS frequent
DIARRHEA –> fluid/electrolyte replacement
HOW TO PREPARE FORMULA?
LIQUID CONCENTRATE
HOW TO PREPARE FORMULA?
POWDERED FORMULA
30 days after can is open
1 tbsp = 1 scoop
POWDER NEEDS MORE WATER
Water for Baby Formulated
- *Nursury Water** = Distilled Water
- NOT sterile, has 0.7 ppm Fluoride*
Tap Water
usually contains fluoride, not sterile
no need to use distilled water, just use TAP
Ready-to-Feed Formula
NO PREP NEEDED
- *Expensive but CONVENIENT**
- use within 48 hours of opening*
- *unopened bottle** can be
- *kept at room temperature!**
Pharmacist Recommendations
for Baby Formula
Typically switching formulas
–> DOES NOT make a difference
- *Calculate calories / Fluid amount**
- may be using too much or too little, based on STOMACH SIZE*
Review PRODUCT PREP
When to SEE MD
baby formula
no improvement in a FEW DAYS
weight loss / dehydration
BLOOD in stool
INCREASED Vomitting
Regular Milk for babies?
NO COW’S MILK UNTIL > 1 yo
no need for supplementation or switching until after 12 months
- *Whole milk = INCREASED RENAL SOLUTE LOAD**
- risk of DEHYDRATION / GI Blood loss*
- *iron deficiency**
AAP MILK Recommendation for
AFTER 1 YEAR OF AGE
for those 1 - 2 years
use WHOLE MILK
EXCEPT: Overweight / risk of obesity (FH, too)
use 2% milk
AFTER 2 YEARS OLD:
ALL USE 1% MILK
What FORMULA is NOT RECOMMENDED?
- *ORGANIC** / Home-Made
- other* Animal-milk-based formulas
due to:
dehydration / contamination / decreased nutrients
Formula chart
GOOD START = WHEY
Infant Weight Gain Considerations
◦Loss of about 6% of body weight during 1st – 2nd week of life
◦25-35 gm per day in 1st 3 months of life
1 oz
◦15 gm per day in the next 8 months
◦Double birth weight by 5-6 months
◦2-9 years old: 5 lb per year on average