Dr. Nellie D.

Gundao
FEEDING HEALTHY INFANTS, CHILDREN and
ADOLESCENTS
 Appropriate feeding practices should be established in the
neonatal period and carried out as a continuum from
childhood and adolescence to adulthood.
 Optimal neonatal feeding practices require a multidisciplinary
approach among health care providers, including physicians,
nursing staff, nutritionists, and lactation consultants.

BREASTFEEDING
 Feedings should be initiated soon after birth unless medical
conditions preclude them.
 World Health Organization (WHO), PPS, and other agencies
strongly advocate breast-feeding as the preferred feeding for
all infants.
 Breastfeeding should start early, within 1 hour after birth.
 Breastfeeding should be exclusive for 6 months.
 Appropriate complementary feeding should start from age 6
months with continued breastfeeding up to 2 years and
beyond.

STEPS TO ENCOURAGE BREAST-FEEDING IN THE

HOSPITAL: UNICEF/WHO BABY- FRIENDLY HOSPITAL
INITIATIVES
 Provide all pregnant women with information and counseling Table 1. Selected beneficial properties of human milk compared to infant
 Document the desire to breast-feed in the medical record formula
 Document the method of feeding in the infant's record
 Place the newborn and mother skin-to-skin, and initiate Benefits of Breastfeeding
breast-feeding within 1 hr of birth Baby Mother
 Continue skin-to-skin contact at other times and encourage Reduced
rooming in Assess breast-feeding and continue Allergies Breast/ Ovarian CA
encouragement and teaching on each shift Asthma Osteoporosis
Diabetes Diabetes
MOTHERS SHOULD KNOW Obesity Less worktime missed
 Proper position and latch on Celiac disease
 Nutritive sucking and swallowing SIAS
 Milk production and release IBS
 Frequency and feeding cues Childhood leukemia
 Expression of milk if needed Ear infections
 Assessment of the infant's nutritional status Enhanced
 When to contact the clinician Mother/Baby bonding More sleep
 Refer to lactation consultation if any concerns arise Emotional security Financial savings
Increased IQ scores Increased monthering skills
and confidence
Financial security for family
Table 2. Benefits of Breastfeeding

Patterns of Milk Supply

Day of Life Milk Supply
Day 1 <5ml milk
Day 2-4 Lactogenesis; ↑ milk production
Day 5 Milk present; fullness and leaking felt
Day 6 onwards Breast should feel “empty” after feeding
Table 3. Patterns of Milk Supply

CONDITIONS FOR WHICH HUMAN MILK HAS BEEN

SUGGESTED TO HAVE A PROTECTIVE EFFECT
 Acute disorders
 Diarrhea
Figure 1. Proper breastfeeding and latch on  Otitis media
 Urinary tract infection
ADDITIONAL INSTRUCTIONS FOR BREASTFEEDING  Necrotizing enterocolitis
 Refer to lactation consultation if any concerns arise  Septicemia
 Infants should go to the breast at least 8-12 times/24 hr day  Infant botulism
and night.  Chronic disorders
 Avoid time limits on the breasts; offer both breasts at each  Insulin-dependent diabetes mellitus
feeding.  Celiac disease Crohn's disease Childhood cancer
 Do not give sterile water, glucose, or formula unless  Lymphoma Leukemia
indicated.  Recurrent otitis media
 If supplements are given, use cup feeding, a Haberman  Allergy
feeder, fingers, or syringe feedings.  Obesity and overweight
 Avoid pacifiers in the newborn nursery except during painful  Hospitalizations Infant mortality
procedures.
 Avoid antilactation drugs.
 Maternal Medication:
 Sedating psychotherapeutic
drugs, anti-epileptic drugs and
opioids and their combinations;
may cause drowsiness and
respiratory depression, use a
safer alternative if available
 Radioactive Iodine-131:
resume breastfeeding about
two months after receiving this
substance
 Excessive use of Topical
Iodine or Iodophors
(Povidone-Iodine), especially
on open wounds or mucous
membranes, can result in
thyroid suppression or
electrolyte abnormalities in the
breastfed infant
 Cytotoxic Chemotherapy
requires that a mother stops
breastfeeding during therapy
Breast abcess: breastfeeding
should continue on the unaffected
breast; feeding from the affected
breast can resume once treatment
has started
Hepatitis B (HBV): infants should
be given Hepatitis B vaccine, w/in
the first 48 hours or ASAP
thereafter
Hepatitis C (HCV)
Mastitis: if breastfeeding is very
Maternal conditions painful, milk must be removed by
during which expression to prevent progression
breastfeeding can still of the condition
Figure 2. Algorhythm Of Feeding The Term Infant continue, although Tuberculosis: mother and baby
health problems may should be managed according to
Acceptable Medical Reasons for Use of Breast milk be of concern national tuberculosis guidelines
Substitutes (WHO 2009) Substance use:
A. Infant conditions Indications  Maternal use of nicotine,
Classic Galactosemia- a special alcohol, ecstasy,
galactose-free formula is needed amphetamines, cocaine and
Infants who should Maple-Syrup Urine Disease- a related stimulants has been
NOT receive breast special formula free of Leucine, demonstrated to have harmful
milk or any other milk Isoleucine and Valine is needed effects on breastfed babies
except specialized Phenylketonuria- a special  Alcohol, opiods,
formula Phenylalanine-free formula is benzodiazepines and cannabis
needed (some breastfeeding can cause sedation in both
possible, under careful monitoring) mother and baby
Birth weight <1500g (very low
birth weight) GUIDING PRINCIPLES FOR COMPLEMENTARY FEEDING
< 32 weeks AOG (very preterm) OF THE BREASTFED CHILD
Newborn at risk of  Duration of exclusive breastfeeding and age of
hypoglycemia: due to impaired introduction of complementary foods
Infants for whom breast
metabolic adaptation or increased o Practice exclusive breastfeeding from birth to 6 months of
milk remains the best
feeding option but glucose demand if their blood age, and introduce complementary foods at 6 months of
sugar fails to respond to optimal age (180 days) while continuing to breastfeed.
who may need other
food in addition to
breastfeeding or breast milk  Maintenance of breastfeeding
breast milk for a limited feeding o Continue frequent, on-demand breastfeeding until 2
(example of inc. glucose demand: years of age or beyond
period
Preterm, Small for Gestational Age  Responsive feeding
(SGA) or with history of significant o Practice responsive feeding, applying the principles of
interpartum hypoxic/ischemic psycho-social care
stress, presence of illness and o Feed infants directly and assist older children when they
diabetic mothers) feed themselves, being sensitive to their hunger and
B. Maternal Conditions Indications satiety cues
Maternal conditions that HIV infection: if replacement o Feed slowly and patiently, and encourage children to eat,
may justify permanent feeding is acceptable, feasible, but do not force them
avoidance of affordable, sustainable and safe o If children refuse many foods, experiment with different
breastfeeding (AFASS) food combinations, tastes, textures and methods of
Severe illness that prevents a encouragement
mother from caring for her infant o Minimize distractions during meals if the child loses
Maternal conditions that (e.g. sepsis) interest easily
may justify temporary Herpes Simples Virus type 1 o Remember that feeding times are periods of learning and
avoidance of (HSV-1)- avoid direct contact love - talk to children during feeding, with eye to eye
breastfeeding between lesions on the mother’s contact.
breasts and the infant’s mouth until  Safe preparation and storage of complementary foods
all active lesions resolve o Practice good hygiene and proper food handling by
 o Washing caregivers’ and children’s hands before food o After illness, give food more often than usual and
preparation and eating encourage the child to eat more.
o Storing foods safely and serving foods immediately after
preparation HOW TO PREPARE COMMERCIAL FORMULA
o Using clean utensils to prepare and serve food
o Using clean cups and bowls when feeding children
o Avoiding the use of feeding bottles, which are difficult to
keep clean
 Amount of complementary food needed
o Start at six months of age with small amounts of food and
increase the quantity as the child gets older, while
maintaining frequent breastfeeding.
o The energy needs from complementary foods for infants
with “average” breast milk intake in developing countries
are approximately 200 kcal per day at 6-8 months of age,
300 kcal per day at 9-11 months of age, and 550 kcal per
day at 12-23 months of age.
o In industrialized countries these estimates differ
somewhat (130, 310 and 580 kcal/d at 6-8, 9-11 and 12-
23 months, respectively) because of differences in
average breast milk intake.
 Food consistency
o Gradually increase food consistency and variety as the
infant gets older, adapting to the infant’s requirements
and abilities.
o Infants can eat pureed, mashed and semi-solid foods
beginning at six months.
o By 8 months most infants can also eat “finger foods”
(snacks that can be eaten by children alone).
o By 12 months, most children can eat the same types of
foods as consumed by the rest of the family (keeping in
mind the need for nutrient-dense foods).
o Avoid foods that may cause choking (i.e., items that have
a shape and/or consistency that may cause them to
become lodged in the trachea, such as nuts, grapes, raw
carrots).
 Meal frequency and energy density
o Increase the number of times that the child is fed
complementary foods as he/she gets older.
o The appropriate number of feedings depends on the
energy density of the local foods and the usual amounts
consumed at each feeding.
o For the average healthy breastfed infant, meals of HOW TO PREPARE FRESH MILK
complementary foods should be provided 2-3 times per
day at 6-8 months of age and 3-4 times per day at 9-11
and 12-24 months of age, with additional nutritious
snacks (such as a piece of fruit or bread or chapatti with
nut paste) offered 1-2 times per day, as desired.
o Snacks are defined as foods eaten between meals-
usually self-fed, convenient and easy to prepare.
o If energy density or amount of food per meal is low, or
the child is no longer breastfed, more frequent meals
may be required.
 Nutrient content of complementary foods
o Feed a variety of foods to ensure that nutrient needs are
met. Meat, poultry, fish or eggs should be eaten daily, or
as often as possible.
o Vegetarian diets cannot meet nutrient needs at this age
unless nutrient supplements or fortified products are used
o Vitamin A-rich fruits and vegetables should be eaten
daily. Provide diets with adequate fat content
o Avoid giving drinks with low nutrient value, such as tea,
coffee and sugary drinks such as soda.
o Limit the amount of juice offered so as to avoid displacing
more nutrient rich foods.
 Use of vitamin-mineral supplements or fortified
products for infant and mother
o Use fortified complementary foods or vitamin-mineral
supplements for the infant, as needed.
o In some populations, breastfeeding mothers may also
need vitamin-mineral supplements or fortified products,
both for their own health and to ensure normal
concentrations of certain nutrients (particularly vitamins)
in their breast milk.
 Feeding during and after illness
o Increase fluid intake during illness, including more
frequent breastfeeding, and encourage the child to eat
soft, varied, appetizing, favorite foods.
 TYPES OF MILK FORMULAS FEEDING PERIODS
 Cow’s Milk Protein- Based Formulas  Early Infancy - Nipple feeding.
 Soy Formulas  Late Infancy - Transition to solids.
o Given to infants with galactosemia  Toddler - Modified adult foods.
 Protein Hydrolysate Formulas  Feeding infants and children is a challenge, and there is no
 Amino acid Formulas one right way to nurture a child. It takes education,
o Given to infants with deficiency encouragement, and patience to go through this period, and
The AAP provides the following recommendations for the medical home for the child plays a very important role in
initiating complementary foods supporting the family-infant dyad
(Pediatric Nutrition Handbook, 6th edition):
 Introduce 1 single nutrient ingredient food at a time, and do Equation for a Good Diet
not introduce other new foods for 3- 5 days to observe for Well Balanced Meals & Snacks
tolerance. Although iron-fortified rice cereal is most +
commonly introduced, ethnic and cultural variations should Positive Eating Environment
be respected and understood. There is no good evidence __________________________
that delaying the introduction of other foods such as wheat, = Well Nourished Child
fish, and shellfish affects the overall incidence of atopic
disease in infants and children. PEDIA QUIZ #1:
 Choose foods that provide key nutrients and help meet 1. When should breastfeeding start? 1 hour after birth
energy needs: iron-fortified cereals or pureed meats that are 2. How often does an infant feed per day? 8-12 in 24 hours
rich in protein, iron, and zinc. 3. Antibodies found in breast milk? IgA
 Introduce a variety of foods by the end of the 1st yr, helping 4. In the patterns of milk supply, when is leaking experienced?
to establish healthy eating habits. When offering a new food, Day 5
8-10 attempts to offer might need to be made before the 5. When should complementary feeding start? 4-6 months of
infant accepts the new food. age
 Withhold cow's milk and other milks not formulated for 6-8. Breastmilk is suggested to have a protective effect against
infants during the 1st yr of life. (true or false)…
 Ensure adequate calcium intake while transitioning to 6. obesity-true
complementary foods. 7. mortality- true
 Do not give fruit juices during the first 6 mo of life and limited 8. diarrhea- true
amounts of 100% juices thereafter (4-6 oz/day for ages 1-6 9. Milk recommended for infant with galactosemia? Soy
yr, and 8-12 oz per day for ages 7-18 yr). formula milk
 Ensure safe ingestion to decrease choking hazard and 10. Milk given to infant with cow milk protein allergy?
adequate nutrition when choosing and preparing homemade Hydrolysate formula
foods: mash or puree solid foods; avoid hot dogs, nuts,
grapes, and popcorn in the first 3-4 yr of life; avoid adding
salt or sugar; and ensure nutrient and energy sufficiency

FEEDING SKILLS BIRTH TO 36 MONTHS

Age (mo) Feeding/Oral Sensorimotor
Nipple feeding, breast or bottle
Hand on bottle during feeding (2-4
mo)
Birth to 4-6 Maintains semiflexed posture during
feeding
Promotion of infant-parent
interaction
Feeding more in upright position
Spoon feeding thin, pureed foods
Suckle pattern initially suckle
suck
6-9 (transition Both hands to hold bottle
feeding) Finger feeding introduced
Vertical munching of easily
dissolvable solids
Preference for parents to feed
Cup drinking
Eats lumpy, mashed food
9-12 Finger feeing for easily dissolvable
solids
Chewing includes rotary jaw action
Self-feeding; grasps spoon with
whole hand
12-18 Holds cup with 2 hands
Drinking with 4-5 consecutive
swallows
Holding and tipping bottle
Swallowing with lip closure
Self-feeding predominates
>18-24 Chewing broad range food
Up-down tongue movements precise
Circulatory jaw rotations
Chewing with lips closed
One-handed cup holding and open
Fig. 3. Recommended well balanced diet
cup drinking with no spilling
24-26 Using fingers to fill spoon
Eating wide range of solid food
Total self-feeding, using fork
Dr. Nellie D. Gundao
Feeding School-Age Children and Adolescents

Fig. 4. PSPGHAN Food Guide Pyramid