Artificial and Mixed Feeding Feeding of Toddlers

MIXED FEEDING. TECHNIQUE AND RULES OF GIVING NEW FOOD. SCHEMES OF MIXED FEEDING CHILDREN OF THE FIRST YEAR OF LIFE. THE MILK FORMULAS WHICH ARE USED FOR ADDITIONAL FEEDING. ADDITIONAL FOOD AND FEEDING CORRECTION IN MIXED FEEDING. CHILD NEEDS IN PROTEINS, FATS, CARBOHYDRATES AND CALORIES IN MIXED FEEDING .

When breastmilk is no longer enough to meet the nutritional needs of the infant, complementary foods should be added to the diet of the child. The transition from exclusive breastfeeding to family foods, referred to as complementary feeding, typically covers the period from 6 to 18-24 months of age, and is a very vulnerable period. It is the time when malnutrition starts in many infants, contributing significantly to the high prevalence of malnutrition in children under five years of age world-wide. WHO estimates that 2 out of 5 children are stunted in low-income countries.

Mix-feeding – the feeding of the babies of first 5-6 mo with human milk and formula in which the volume of formula is more than 1/5 of daily volume (or the daily volume of the human milk is less than 4/5).

There are two kinds of mix feeding:

· Mix-feeding closed to breast-feeding

· Mix-feeding close to formula feeding

Mix-feeding closed to breast-feeding  – the feeding of the babies with human milk and formula in which the ratio between them in daily volume are 2:1 (or 2/3:1/3).

Mix-feeding close to formula feeding - the feeding of the babies with human milk and formula in which the ratio between them in daily volume are 1:2 (or 1/3:2/3).

Mix-feeding indication:

In causes of mother's diseases:

1.      Hypogalactia (oligogalactia);

2.      Some diseases in that mother must decreased the quantity of feeding:

a.                mastitis;

b.               anemia of severe degree;

c.                using of medicine (medicament);

d.               erythroderma.

3.      Human milk inferiority (fat's, protein's or carbohydrate's inferiority).

In social and living conditions

1.      Mother is working and can't nurse a baby for all feeding.

2.      Closed children institution in which the amount of donor human milk is not in enough quantity.

In causes of baby's diseases:

Congenital malabsorption syndrome: hypolactasia.

HYPOGALACTIA (OLIGOGALACTIA)

Hypogalactia (oligogalactia) – is decreasing human milk secretion.

Hypogalactia is divided into primary and secondary.

Primary hypogalactia – is very rarely diseases (only 1-3 %). It is connected with neurohumoral disorders in mother's organism or undeveloped breast or carried mastitis during previous deliveries.

Secondary hypogalactia  - can appear in case of

a.     not correct day regimen during pregnancy and delivery;

b.     not correct carrying for breasts (nipple crack, erosion, mastitis);

c.       incorrect mother's nutrition.

There are four degree of hypogalactia:

I-^stdegree – deficiency of the human milk is less than 25 % of the daily requirements;

II-^nd degree – deficiency of the human milk is between 25 and 50 % of the daily requirements;

III^-d degree – deficiency of the human milk is between 50 and 75 % of the daily requirements;

IV^-th degree – deficiency of the human milk is more than 75 % of the daily requirements.

Lactation crisis
• A condition in which a sudden decrease milk supply
• There are 3-6 weeks, 3, 4, 7 and 8 months of lactation
• lasts 3-4 days, not a danger to the child's health.
A child that is growing rapidly, more and more need of milk, with little appetite can not increase gradually, and jumps. In this case, the mother "did not have time to" adapt to the growing demands of the child.
• arise due to temporary changes in hormonal levels.

The main symptoms are lack of breastmilk:
- Inadequate weight gain per month;

Reducing the daily volume of breast milk

- Worry Baby

Symptom "dry diaper", indicating a decrease in daily urine volume (child first months are breastfed should urinate at least six times a day, and the urine should be colorless or pale yellow).

There are two methods of mix-feeding:

· Classic method.

· Interchanging (rotate) method.

Classic method  is used in babies younger than 3 mo. In this method for each feeding the formula is given.

Calculation of feeding (classic method)

For example: the child 2 mo. is in mix-feeding closed to breast-feeding. The weight at birth was 3300 g

The normal weight of the child is 3300+600+800=4700 g

Daily volume is (will use volume method of calculations)

 4700/6=783 ml

Volume for one feeding is 783/6=130 ml

If the child is in mix-feeding closed to breast-feeding that the quantity of human milk must be 2/3 and formula 1/3.

So, the quantity of human milk will be 130:3 ´ 2=86 ml and formula 44 ml.

The feeding schedule (classic method)

Exemplary Menu

6.00 o'clock	86 ml of human milk + 44 ml of Hipp 1
9.30 o'clock	86 ml of human milk+ 44 ml of Hipp 1
13.00 o'clock	86 ml of human milk+ 44 ml of Hipp 1
14.30 o'clock	86 ml of human milk+ 44 ml of Hipp 1
20.00 o'clock	86 ml of human milk+ 44 ml of Hipp 1
23.30 o'clock	86 ml of human milk+ 44 ml of Hipp 1

Interchanging method  is used in babies older than 3 mo. In this method the human milk is given for first and last feeding. In others feeding formula or human milk is given (it depend of kind of feeding).

Calculation of feeding (interchanging method)

 For example: the child 3.5 mo. is in mix-feeding closed to formula-feeding. The weight at birth was 3300 g

The normal weight of the child is 3300+600+800+800+375=5875 gm

Daily volume is  (will use caloric method of calculations)

115kcal ´ 5.875kg=676 kcal/day

700 kcal – 1000 ml of human milk

676 kcal – X ml of human milk

X=956 ml – that is the daily volume

Volume for one feeding is 956/5 = 190 ml

If the child is in the mix-feeding closed to formula-feeding, so the first and last feeding is human milk and other – formula.

The feeding schedule (interchanging method)

Exemplary Menu

6.00 o'clock	190 ml of human milk
10.00 o'clock	190 Hipp 1 +20 ml apple juce
14.00 o'clock	190 ml of Hipp 2 +15 ml of apple juice
18.00 o'clock	185 ml of Hipp 1+5 ml of apple puree
22.00 o'clock	190 ml of human milk

Feeding of Children of Different Age in Hospital.

Feeding Infants:

Breast or Bottle

Brest feeding of a baby is an important time of connection.

Types of breast feeding position:

Some expectant mothers are concerned that breastfeeding will be too hard to learn.

The most important skill for them to master is getting the baby onto the breast correctly.

There are three basic breastfeeding positions.

  Cradle  — Hold your baby in one arm, with its head resting in the bend of your elbow.

The baby's lower arm is tucked out of the way. Its mouth is close to your breast and the two

of you are tummy to tummy. This is the most frequently used position. This position can be

used when you are sitting up in bed with pillows supporting your back or sitting in a chair.

2.Lying down — Lie on your side with your baby also lying on his/her side. You are tummy to tummy with the baby's mouth close to your breast. This position is ideal when you are lying in bed.

3.Football — Place the baby on a pillow at your side. Support its head with your hand. The baby's mouth should be in front of your breast. This position is good for smaller or premature babies who might have trouble nursing.

"Latching on" is the expression breast feeding experts use to describe how a baby grasps the mother's nipple with his/her mouth. It is a skill that a baby must learn with a little help from his/her mother.

First, get the baby to "root" for breast. Rooting is a natural reflex for babies. The baby's mouth opens wide and its head moves quickly from side to side, searching for the nipple. To start a baby rooting, lightly touch a nipple to the baby's lower lip. When the baby's mouth is wide open, lift a breast to its mouth. At the same time, pull the baby close, so he/she can latch onto mother's nipple.

Proper latching onto nipple.                                                                              Wrong latching onto nipple.

BOTTLE FEEDING:

How to prepare baby's formula:

Ø Wash your hands before you begin.

Ø Wash all bottle feeding equipment in hot, soapy water. Rinse well with hot water.

Ø Sterilize bottle feeding equipment for the first three or four months of baby's life. To sterilize, cover items completely with water and boil for five minutes. Cool and remove from water with sterile tongs.

Ø The water for formula should be boiled for five minutes then cooled. Use safe drinking water to prepare the formula.

Ø Mix formula according to package directions. Fill the sterilized bottles. You may prepare up to a 24-hour supply of infant formula at one time.

Ø Store the prepared formula in the refrigerator. When away from home, store it with an ice pack in a cooler. Formula should never be left at room temperature for longer than one hour.

How to warm baby's formula:

Ø Place the bottle in a container of warm water or hold it under warm running tap water. Gently shake the bottle for even warming.

Ø Check the temperature of the formula before feeding a baby. Put a few drops on the inside of your wrist. It should feel slightly cool.

Ø Never microwave formula. Microwaves heat unevenly and a baby's mouth could be burned.

Ø Never prop a bottle. It is a choking hazard and can cause baby bottle tooth decay.

Burping:

Ø Wait until baby stops drinking.

Ø Gently rub or pat baby's back.

Ø Rest baby on your shoulder or lap.

.

Burping the child

Which Formula Suits Your Baby?

Experts agree that breastmilk is the most perfect food for your baby during the first year. But if you choose to use formula, all iron-fortified formulas are patterned after breastmilk and provide all the nutrition your baby needs. Bottle-feeding offers another opportunity for you and other family members to comfort your feedings will let your baby know he's in a secure, loving environment.

A gradual transition from breastmilk to formula is best. Learn how to transition Baby to formula and what formula options are available.

There are several formula choices currently available. To help you decide which formula is best for your baby, talk with your baby. Whether you choose to supplement breastmilk with formula or formula-feed exclusively, the closeness you share during bottle- pediatrician. No matter what formula you choose, rest assured that all iron-fortified formulas provide complete nutrition for your baby.

Milk-based formula

A milk-based formula is recommended by most doctors for healthy, full-term infants. It's made from cow's milk protein with added carbohydrates, fat, vitamins, and minerals. If you suspect your baby has a milk allergy, use this type of formula only under a doctor's supervision.

Formula with DHA & ARA

Now there are formulas enriched with DHA & ARA, nutrients that are also naturally found in breastmilk. Medical studies have shown that these nutrients may play important roles in babies' brain and eye development, and some research suggests that formula-fed babies may benefit from the added DHA & ARA in these enriched formulas.

When choosing a milk-based formula for your newborn, consider iron-fortified. It's the only standard, milk-based formula that provides the combined benefits of easy-to-digest COMFORT PROTEINS® and DHA & ARA, nutrients found in breastmilk that support babies' brain and eye development. Like with all GOOD START SUPREME milk-based formulas, the COMFORT PROTEINS in GOOD START SUPREME DHA & ARA are made using a patented two-step process that starts with 100% whey protein. Then, we break down this gentle protein into smaller pieces to be easy to digest. We call them COMFORT PROTEINS, and only GOOD START SUPREME milk-based formulas have them. Just look for the hearts on the can to know you're providing your baby the very best™.

Formulas for other needs

A doctor may recommend an alternative type of formula. There are three basic categories of these formulas:

·          Soy-based formulas for babies who need to avoid cow's-milk protein or lactose, or for babies in vegetarian families.

·           Older-baby and toddler formulas designed to provide nutritional insurance for babies and toddlers transitioning to solid foods. For your older baby consider milk- or soy-based. These formulas offer calcium, iron, and other important nutrients to help meet the changing nutritional needs of older babies and toddlers 9 to 24 months old-especially if there's a gap between what they eat and what they need.

·              Specialty formulas for babies with other special needs. If you feel your baby has special needs, talk with your pediatrician and decide which formula type is best for you and your baby.

Complementary feeding should betimely, meaning that all infants should start receiving foods in addition to breastmilk from 6 months onwards. It should beadequate, meaning that the nutritional value of complementary foods should parallel at least that of breastmilk. Foods should be prepared and given in asafemanner, meaning that measures are taken to minimize the risk of contamination with pathogens. And they should be given in a way that isappropriate, meaning that foods are of appropriate texture and given in sufficient quantity.

The adequacy of complementary feeding (adequacy in short for timely, adequate, safe and appropriate) not only depends on the availability of a variety of foods in the household, but also on the feeding practices of caregivers. Feeding young infants requires active care and stimulation, where the caregiver is responsive to the child clues for hunger and also encourages the child to eat. This is also referred to as active or responsive feeding.

WHO recommends that infants start receiving complementary foods at 6 months of age in addition to breastmilk, initially 2-3 times a day between 6-8 months, increasing to 3-4 times daily between 9-11 months and 12-24 months with additional nutritious snacks offered 1-2 times per day, as desired.

Inappropriate feeding practices are often a greater determinant of inadequate intakes than the availability of foods in the households. WHO has developed a that enables programme managers to identify local feeding practices, common problems associated with feeding, and adequate complementary foods. The protocol builds upon available information and proposes household trials to test improved feeding recommendations. WHO recommends that the protocol be used to design interventions for improved complementary feeding, and is included as part of adaptation process of the Integrated Management of Childhood Illness strategy.

Based on new knowledge, WHO is spearheading a global process for developing indicators to assess complementary feeding. WHO in collaboration with partners is coordinating next steps to conduct validations. It is hoped that sufficient information will be available by the end of 2003 to allow for a consensus meeting to agree a new set of global indicators for assessing complementary feeding.

 Feeding your baby in the first year of life is an exciting adventure for parents and babies alike. It's about development, nutrition, exploration, sharing and learning. You can help your baby develop a lifetime of healthy eating habits with the right start.  This pamphlet will help show you when and how to introduce new foods and how to make feeding an enjoyable part of your baby's life.

THE FIRST 6 MONTHS

For the first 6 months of life, breastfed babies will get what they need from their mother's milk. Breast milk has the right amount and quality of nutrients to suit your baby's first food needs. It is easiest on her digestive system, so there's less chance of constipation or diarrhea. Breast milk also contains antibodies and other immune factors that help your baby prevent and fight off illness better.

Babies who are exclusively breastfed should get a daily supplement of vitamin D, which is available as drops.

If breastfeeding is not an option, use a store-bought iron-fortified infant formula for the first 9 to 12 months. The formula should be cow's milk-based.

FEEDING SOLID FOODS

Introducing  solid foods

At 6 months, most babies cannot get everything they need from breast milk or formula alone. Though you can continue to breastfeed until your baby is 2 years and beyond, at 6 months you'll start to introduce your baby to other foods. Your baby is ready to start other foods when he:

· Seems hungry earlier than usual.

· Can sit up without support, and has good control of his neck muscles.

· Holds food in his mouth without pushing it out on his tongue right away.

· Shows interest in food when others are eating, and opens his mouth when he sees food coming his way.

· Can let you know he doesn't want food by leaning back or turning his head away.

There are many ways to introduce solid food. The first foods usually vary from culture to culture and from family to family.

Start with foods that contain iron, which babies need for many different aspects of their development. It's common to start with a single grain, iron-fortified infant cereal such as rice or barley. Meat, poultry, cooked egg yolk and well cooked legumes (beans, lentils, chick peas) are also good sources of iron.

·                     Introduce new foods one at a time, waiting about 3 to 5 days before trying another. That way, if your baby develops a reaction, you'll have a better idea of what food might have caused it.

Feeding Techniques:

· Food is for nutrition, not for rewards, bribing or punishment

· Start with small portions

· Introduce one new food item at a time

· Wait until baby gives permission to put food in his/her mouth

· Use high chair if baby can sit

· Use appropriate utensils

· Reduce distractions

Healthy foods that your family eats are good to start with as long as they are plain, with no added salt, sugar or spices. You can also use commercial baby foods, as long as you check the label to ensure there is no added salt or sugar.

Ø Grain products. At 6 to 9 months, offer your baby up to 30 to 60 mL (2 to 4 tbsp.) of iron-fortified infant cereal, twice a day. Then try other grain products such as small pieces of dry toast or unsalted crackers. At 9 to 12 months, offer other plain cereals, whole grain bread, rice and pasta.

Ø Vegetables. At 6 to 9 months, offer your baby puried cooked vegetables-yellow, green or orange. At 9 to 12 months, progress to soft, mashed cooked vegetables.

Ø Fruits. At 6 to 9 months, offer purйed cooked fruits, very ripe mashed fruits (such as bananas). At 9 to12 months, try soft fresh fruits, peeled, seeded and diced or canned fruit, packed in water or juice (not syrup).

Ø Meat and alternatives.  At 6 to 9 months, offer purйed cooked meat, fish, chicken, tofu, mashed beans, egg yolk. At 9 to 12 months, mince or dice these foods.

Ø Milk and milk products. At 9 months, you can offer dairy foods like yogurt (3.25% or higher), cottage cheese or grated hard cheese. Wait until your baby is 9 to 12 months old before introducing whole cow's milk (3.25%). After 12 months of age, your baby should not take more than 720 mL (24 oz.) of milk products per day. Too much milk can lead to iron deficiency anemia.

Follow your baby's cues for how much to feed. Start by offering a teaspoon or two, and don't rush. Some babies need to try a food many times before accepting it. If she's not hungry, she'll turn her head and close her mouth. If she's hungry, she'll get excited and open up.

Never trick or coax her to eat more by playing games or offering sweetened foods. Babies who are allowed to follow their own hunger cues are much less likely to overeat later in life.

Trying foods with different textures helps babies learn how to handle foods in their mouth. So it's important to vary both tastes and textures when serving foods.

Your baby's development	How often to feed	Type of food
Sits with support	2-3 times a day*	Purйed, mashed food and semisolid foods
Sits on own	2-3 times a day*	Family foods, small amounts of soft mashed foods without lumps
Crawls	3-4 times a day*	Family foods, ground or soft mashed foods with tiny soft lumps; crunchy foods that dissolve, such as whole grain crackers
Walks	3 meals and 2 snacks a day*	Coarsely chopped foods; foods with more texture; toddler foods; bite-sized pieces of food; finger foods

*Plus breast milk, formula, or whole cow's milk, depending on your child's age

Water and juice

Babies who are exclusively breastfed don't need extra water. When your baby begins to eat other foods, you can start to offer water occasionally.

Babies and children don't need to drink juice. Too much juice, especially apple juice, can cause diarrhea. It can fill up small stomachs and decrease your baby's appetite for nutritious foods. Too much juice can also cause early childhood tooth decay.

When you do offer juice, be sure it is only 100% fruit juice. Always offer it in a cup, as part of a meal or snack. Offer water to babies and young children between meals and snacks if they are thirsty. Limit juice to 120 to 180 mL (4 to 6 oz.) per day.

Foods not recommended 

ü Don't give babies sugary drinks or foods, such as candies, soda/pop or energy drinks.

ü Don't give honey to babies under 1 year old, as there is a risk of infant botulism (food poisoning).

ü To reduce the chance of an allergic reaction, avoid giving egg whites until your baby is 1 year old.

ü If you have a family history of allergies, you may want to wait until your baby is 3 years old before introducing peanuts, tree nuts (such as pecans or walnuts) or shellfish.

How to prevent choking

ü Always supervise babies and children while they are eating. They should be sitting down.

ü Don't feed your baby peanuts, nuts or popcorn.

ü Dice or slice round foods such as wieners or grapes.

ü Grate raw vegetables such as carrots to make them easier to chew.

ü Remove pits from fruits.

ü Cook hard fruits and vegetables to soften them.

ü Spread sticky foods like peanut butter thinly on a cracker or toast rather than bread.

ü Chop or scrape stringy meat and add broth to moisten it.

At around 6 months of age, breast milk may not be sufficient to cover a baby's energetic and nutritional requirements. Furthermore, the baby is at a stage of development where he/she can start to swallow non-liquid food. At this time, food helps support optimal growth, brain development and the building of natural defenses. Several behavioral changes may indicate the baby's readiness for solid foods, including new capabilities and changes in eating behavior.

For instance, the baby may:

· sit with support

· play with toes and begin to grasp feet

· support weight on hands with extended arms

· reach for an object with hand

· show anxiety when seeing a stranger and direct smile towards a familiar face

· begin to hold head up

· progressively develop control of muscles and nervous system.

DEVELOPMENTAL  MILESTONES RELATED TO FEEDING

Age	Physical milestones	Social milestones
Birth to 4 months	·         opens mouth wide when nipple touches lips ·         sucks and swallows	·         recognizes source of milk by about 10 weeks
4 to 6 months	·         sucking strength increases ·         brings fingers to mouth	·         socializes during feeding
6 to 9 months	·         drinks from a cup held by an adult ·         eats soft food from a spoon ·        begins rotary chewing (in a circular motion) ·         enjoys holding food and finger-feeding	·         loves to be included at the table for meals ·         begins to show likes and dislikes for certain foods
9 to 12 months	·         tries to use a spoon ·         starts to finger feeds with a more advanced grasp ·         feeds at regular times	·         is aware of what others do ·         imitates others
12 to 18 months	·         grasps and releases food with fingers ·         holds spoon but use is awkward ·         turns spoon in mouth ·        uses a cup but may dribble	·        wants food that others are eating ·         loves performing ·        understands simple questions and requests
18 to 24 months	·         appetite decreases ·         likes eating with hands ·         likes trying different textures	·         easily distracted ·         prefers certain foods ·         ritual becomes important

Nutritional needs

A recent study by the American Dietetic Association concluded that, on average, babies of 6 to 8 months who are fed with human milk receive less than 50% of the Recommended Daily Allowance (RDA) for iron and zinc, and less than 50% of the Adequate Intake (AI) for manganese, fluoride, vitamin D, vitamin B6, niacin, vitamin E, magnesium, phosphorus, biotin and thiamine. The researchers recommended that infants be given complementary foods to fulfil their nutritional and energy needs, and to encourage exposure to different flavors and textures – and to spoons.

To cover all these energy needs and to ensure adequate intake of minerals, trace elements and vitamins for growth and optimal development of the baby, certain simple solid foods should be introduced as a complement to breast milk.

At Stage 1, the infant's digestive system is not yet fully developed, and the stomach in particular is still small. So Stage 1 foods must be presented in a nutrient-dense form so as not to overload the digestion process and ensure digestive comfort.

Sugar intake

There is no specific nutritional or metabolic need for the addition of sugars to baby foods, as ingredients containing natural carbohydrates / sugars already provide enough energy for use as weaning food. The immediate effect of high intakes of added sugar is a fast increase of blood glucose level and insulin secretion, while scientific evidence points to dental and weight problems in the long term. It is also worth noting that, contrary to popular opinion, there is no medical reason to favour the use of fructose as a substitution for sucrose.

Salt (sodium) intake

In the body, sodium plays an essential role in regulating fluid volume and blood pressure. However, babies have a limited renal capacity, meaning they can not so easily conserve fluids and excrete solute load. Consequently, their intake of salt (sodium) needs to be moderate. Healthy infants progressively increase their ability to excrete sodium. Studies have shown that a high sodium intake is associated with higher blood pressure, which in turn is a major risk factor for cardiovascular and cerebral diseases. The Scientific Advisory Committee on Nutrition (SACN) recommends target salt levels for children depending on their age.

In brief

ü breast milk or milk formula is still the most important part of baby's diet

ü the first solid food is the complement that provides required energy and nutrient intake

ü the first solid food is the vehicle for a baby to get accustomed to flavours, textures, and a spoon.

The baby's daily intake should respect the following recommendations:

ü total energy needs of approximately 550-700 kcal/day

ü total protein needs of 9-13 g/day

ü fats of 35-55% of total energy (about 31g/day) with balanced n-3:n-6 ratio (4-10)

ü no specific requirement on carbohydrates, only that non-milk-intrinsic sugars (added sugars) should be below 10% of total daily energy intake

ü no gluten / only one ingredient containing gluten

ü low or no added salt

ü low or no added sugars

ü avoid allergenic ingredients

ü only gentle first ingredients.

The main specialized products are recommended for women during pregnancy and lactation to stimulate lactation
• Dry milk and soy mixture:
- "Femylak" ("Nutritek", Russia) - dry vitaminized milk formula enriched with polyunsaturated fatty acids and taurine;
- "Enfa-mama" ("Mead Johnson", U.S.) - same with taurine;
- "Mom Dumil plus« ("International Nutrition", Denmark) - the same with taurine;
- "Olympic" (JSC "Istra", "Nutricia") - vitaminized dry mix based on soy protein;
- Dry mixture enriched with the addition of lactogenic - ("Milky Way" LLC "Vitaprom" Guni food RAMS) - vitaminized dry mixture from milk and soy protein isolate enriched with herbal extracts halehi.
Means for improving lactation

Juices, beverages, teas, teas

• Fruit juices and drinks ("hippies", Austria
"Nestle", Germany) - juices and drinks enriched with vitamins and iron;
• Tea for pregnant and lactating women ("hippies" Austria, "Kruger", Poland) - soluble herbal teas with the addition of herbs, fruit and powdered sugar;
• Infusions and decoctions of food and spice and flavoring vegetables and herbs (home cooking) - infusions and decoctions of lactogenic vegetables and herbs.

Stimulation of lactation

"Apilaktin", "Laktohon"
("Leovo nutria" Russia, Kazakhstan) - based on the products of bees and spicy-flavoring plants.
Vitamin and mineral complex, multivitamin, mineral
substances ("Centrum", "belly", etc.)

Mixed feeding
• - is it feeding infants, which it receives and milk and an artificial mixture, the amount of which is greater than or equal to 20% of the total daily amount of food and less than 80%

Types of mixed feeding

• close to the breast: prevalence of breast milk in the diet of the child, but no more than 80%;
• close to the artificial: the predominance of artificial mixtures, but not more than 80%;
• mixed: identical value of breast milk and artificial mixtures

Mixed feeding

Supplementation

• a correction of the amount of food the child infants with insufficient breast milk
(Additional input milk mixture)
• always given after the mother's breast;
• the number of mixture supplementation determined by the difference between the required age for the number of breast milk and its actual number in checkweighing.

Disciplines supplementation

• Held after applying baby to the breast;
• Takes into account the amount of milk that the child received from his mother, and you want to get your child to one feeding;
• Breast milk should be saved for the child as long as possible;
• supplementation should be administered after all feedings or individual, as well as separate feedings;
• You must leave at least 2-3 feedings breasts
(if rarely attachment to the breast lactation quickly fades.)

Methods supplementation

• The classic method (applied to 3 months.):

Baby weighed before and after suckling;

    * The difference of these parameters set intake quantity of milk;
* Finish feeding each child an artificial mixture to the proper volume.
Advantages of the method:
- Frequent application of the child to the breast stimulates lactation;
- Relieves stress on the digestive system, as the baby gets human milk and mix.

• Rotating methods basis:
• - used after 3 months.;
• - per child feeding is breast milk (sucks both breasts), the second - just mix the following - again, breast milk, etc.;
• - convenient method for the mother;
• - breast feeding should not be less than 3, the first and the last   breast

• Technology of supplemental feeding

• finish feeding with a spoon,
• Carefully and precisely follow preparation technology mix: mixture must be sterile, heated to 35-40 ° C,
• unacceptable overfeed or undernourish child;
• Every 2 weeks to control body weight.
supplemental feeding with spoon

Mixtures that are used for feeding children with mixed feeding

•

Adapted : Sweet - " Baby ", " Malish " Detolakt "," Vitalakt "," Nan "," Nutrilon "," Humana "" Lazana "," Nestozhen "; sour - acidophilus " Baby , "" Malish "" Vitalakt "
• not adapted ( simple ): mixture № 1,2,3, " dill ", acidic - A - yogurt , kefir B -, B - yogurt , " Biolakt ", " Narine " " Baldyrhan " and others .

What kind of mixture you choose?

A mixture of selected

Artificial feeding

The daily requirement infants in basic food ingredients (1 kg) in mixed feeding
• Protein 4 months to 2.0 - 2.5 g 3.5 - 4.0 g
• 4-9 months 3.0 - 3.5 g 3.5 - 4.0 g
• 9-12 months 3.0 - 3.5 g 3.5 - 4.0 g
• Fats up to 4 months 6.5 - 6.0 g 6.5 - 6.0 g
• 4-9 months 6.0 - 5.5 g 6.0 - 5.5 g
• 9-12 months 5.5 - 5.0 g 5.5 - 5.0 g
• Carbohydrate during the year 12.0 - 14.0 g

Energy needs for children who are in mixed feeding
• close to the natural:
• 1-6 months - 115 kcal / kg / day;
• 7 - 12 months - 110 kcal / kg / day;
• close to artificial:
• 1 - 6 months - 125 kcal / kg / day;
• 7 - 12 months - 120 kcal / kg / day.

• Diet for mixed feeding are:
- Individual,
- Depending on the amount of milk in the mother.
• It is advisable to stick to the "free" principle
- Breastfeed on demand baby
finish feeding milk mixture.

With a significant decrease in the number of breast milk feeding regime should be fixed in time as in artificial feeding. Because artificial mixtures trapped in the belly of the child longer than

.

• Supplemental different from foods: foods injected to displace breast-feeding, and supplementary feeding - Recovery breastfeeding.
• Unlike supplemental foods should be given only after the attachment of the child to the breast.

When mixed feeding supplementary feeding best given with a spoon or bottle with a teat with a small hole to take the child stopped breastfeeding

Feeding with a spoon

• When mixed feeding for 2 weeks earlier than natural, is correction of food: fruit, vegetable and berry juices, fish oil and vegetable oil, egg yolk, homogenised vegetables and fruits. Start feeding at 1 month earlier, ie
4 months. age.

Organization and principles of nutrition for children older than one year

•
Features food Toddlers

• Nutrition children aged 1 to 3 years as a transitional stage features infant feeding with a gradual approach to diet adult.
• There is the further development and improvement of all functions of the child's body, especially the digestive system: salivary glands, the walls of the esophagus, stomach, and intestines;
• increases the activity of digestive enzymes;
• gradually increasing the capacity of the stomach - from 250 ml of a child 1 years of age to 300-400 ml by the third year of life;

Up to 2.5 - 3 years of life in children already well developed masticatory apparatus: there are 20 milk teeth, 8 of which erupt to one year of age, and 12 - after. Thanks chewing enhanced production of digestive juices, food is better absorbed.

Chewing apparatus child older than one year

• It should gradually replace liquid and semi-liquid food more dense and solid.
• Without this skill in the future baby will not reveal much desire for products such as fresh fruits, raw vegetables, meat slices, etc.

Recommended food for children older than one year

Children over 1.5 years of age with the advent of native deciduous teeth are able to chew soft pieces of food the size of 2-3 cm (salads, vegetables, salad, vegetable stew, goulash, meatballs, sausages, pasta dishes).
The range of products for infants should be varied, with the right combination of products of animal and vegetable origin.
Food for children older than one year

The recommended range of products for children aged 1 to 3 years:
• bread, rye, wheat flour,
• cereals, pasta, potatoes, vegetables, different, fresh fruits, dry pastry
• sugar, egg, milk, cheese, meat, fish, sour cream, salt, tea, coffee drink.

Candies for children

• • Sometimes it is expedient to provide food garlic green onions with antibacterial and anti-inflammatory effect.
• You need to give children fruit and vegetables that are designed specifically for baby food, especially in autumn and winter.

The main source of valuable protein and essential amino acids, minerals, trace elements and many B vitamins are: milk and dairy products, meat and by-products, fish and fish products, eggs.

     With the lack of animal protein children are stunted and overall development.
Milk and milk products in baby food

The value of milk

• Cheese and a variety of children's cheese, pasta and other products - nutritional foods high in protein and minerals, especially calcium and phosphorus.
• young children a day to 40-50 grams of cheese, 3-5 grams of cheese, 5-10 g sour cream or cream.
• These products are used within 1-2 days, respectively, in a binary number.
• sour milk every day appointed

Meat in baby food

• Mainly used beef, veal, lean pork, poultry (chicken, turkey), rabbit meat, offal (liver, tongue, brain).
• Children over 1.5-2 years - sausages "Milk", some varieties of cooked sausage ("Drug", "dietary", "Children").
Fish in baby food
Proteins fish easily digested and absorbed by the body. The diet include several species of low-cost sea and river fish: perch, cod, hake.
Not recommended for young children, smoked, salted, dried fish and canned fish (except for special canned baby food).
Fish in baby food

• • • In the diet include meat or fish daily. Child aged 1-3 years to 60-70 grams per day of meat and 20-30 g of fish. During the week the child can get 2-3 fish (70-100 g) and meat 4-5 times (in 100-120 g).
• Meat - a source of iron, which is important for the prevention of anemia. Perhaps the use of meat and fish in one day, but by a lesser amount.

Eggs - products of high nutritional value.

• Children over 1 years old needs not only the yolk, but the whole egg. On the day a child 1-3 years should consume 1/2 eggs (or one egg every other day) in cooked or baked form

• Adverse reactions in children - a rash, itchy skin, which encourages the use of restriction or exclusion of eggs from the diet.

Eggs

Fats in the diet of children

• Fats - an important source of energy (calories) and fat-soluble vitamins A, E and D.
• Use butter and vegetable oils (sunflower, corn, olive oil).
• As a result of heat treatment, the beneficial properties of fat lost, because butter is better to use slices of bread or put in the finished dish.

• Vegetable oil added to salads, salads, vegetable stews and more.

• For children aged 1-3 years is prescribed daily 15-20 grams of butter and 6-7 grams of vegetable oil.

• Sunflower oil

Bread in the diet of children

• must be different varieties - from rye and wheat flour, preferably coarse.
• Bread - healthy product, rich in vegetable proteins, carbohydrates (polysaccharides), dietary fiber (cellulose) that a positive effect on digestion and vitamin B.
• Every day, a child aged 1-3 years should be given up to 20 g and 40-50 g rye wheat bread.

Sugar in the diet of children

• Sugar must include the child's diet.
• It is easily absorbed, improves the taste of many dishes.
• Excess sugar is bad for children: this leads to obesity, diseases related to metabolic disorders (diabetes, diseases of the musculoskeletal system).
• The need for child 1-3 years in sugar of 30-40 grams per day.
• With pastry can be given candy, fruit candy, fruit candy, honey, jam, jam (only 10-20 grams per day).
Chocolate and chocolate candies consumed young children is not recommended (increased arousal of the nervous system andis one of the strongest allergens).
Sweets in the diet of infants

Vegetables, fruits, berries in baby food

Vegetables, fruits, berries in baby food
• Vegetables, fruits, berries - are important components of nutrition.
• They should be used in the daily diet of fresh, baked and boiled.
• Rich in carbohydrates, minerals, trace elements and water-soluble vitamins, among which the most important are ascorbic acid (vitamin C) and bioflavonoids (vitamin P).
• Nuts - a natural concentrate of many biologically valuable substances.
• 10 grams of nuts (walnuts, hazelnuts, almonds) contain 1/10 of the daily requirement of micronutrients such as iron, copper, fluoride, nicotinic acid, perydoksyn, tocopherol, linoleic acid, most of the essential amino acids, vegetable fat.

Nutritional requirements in cystic fibrosis

l Patients with CF require more calories (120-150% of usual dietary needs for their age)

                For example, a boy aged 7-10 years needs about 1970 kcal / day, but in CF with additional 20-50% of the calorie content may rise to 2360 - 2950 kcal / day

                (Severe lung pathology may make the greater needs)

A diet rich in fat and energy

• A diet rich in fat and encouraged regular meals and "snacks"
• Various food - from different groups:
  protein: eggs, fish, meat, beans and mole. products
  carbohydrates: potatoes, bread, rice, pasta, cereal
  Fruits and Vegetables
• Add more butter, milk, sour cream, cheese and butter to increase the calorie content
• Fried food is not contraindicated

High calorie diet - Ukrainian food

"Soup" - soup, Cabbage, rosolnyk (increase calorie content may lard, vegetable oil, which is added during cooking and sour cream)
Once, sausage, meatballs, burgers, pies will kaloriynishymy if they fry
Dairy products -
Milk, yogurt, sour cream

Recommendations for dosing Creon

l Babies - 5000 units of lipase to feeding - with fruit puree before each feeding

l Children 1-3 years - 20 000 of staple food, 10, 000 - with "snack"

l Preschoolers - 20-30 000 with the main meal 10-20 000 with "snack"

l Students - 40-60 000 with the main meal 20-30 000 with "snack"

l Teens - 50-80 000 with the main meal 20-30 000 with "snack"
Creon is applied for 10-15 minutes before meals or just before eating.

l The dose may vary depending on the nature of the food you eat
Since the age of 3 years, children should be taught to swallow capsules
The capsules should not be chewed
and should not be confused with food

Some products do not require enzymes

l Only for the exclusive consumption of simple carbohydrates, such as:
Fruit (except avocados)
drinks: fruit juice / lemonade / sweet carbonated water (but milk needs)
boiled sweets
jam, jam, honey
Vegetables (except peas / beans / potatoes)

Salt

· Higher demand due to sodium loss in sweat

· Add more salt to food

· Especially in the hot season, or if the children are too young

· Check the level of sodium in the urine of children who do not grow well

· Infant formula and breast milk contain enough salt, so you need to add salt to food babies

Fat-soluble vitamins

· Fat-soluble Patients with CF are at risk of deficiency of fat-soluble vitamins

· Vitamins A, D, E and K

· Even with adequate nutrition children with CF can not get enough of these vitamins. Therefore, you need to add them separately.

· Can be used together with enzymes

Therapeutic nutrition Cystic fibrosis

In order to increase the daily caloric intake to the basic food added:

Klinutren Junior, Klinutren, Frezubin (for probe feed or via gastrostomy)

Complete and incomplete Alfaro Frisopep, Frisopep AU

Humana HN mit MST. Therapeutic nutrition with middle branches triglycerides from birth. Impressions

l For the treatment of diarrhea of various origins in complex forms of bowel disease

l Lack of pancreatic function

l Acute and chronic diseases of the hepatobiliary system

l Celiac disease, cystic fibrosis

l Laktazna failure

Age recommendation: for all ages (children from birth, older children and adults)

Ingredients:

l Protein is represented mainly casein (90%), 1.9 g/100 ml of

l Carbohydrates - mostly dextrin

l 50% Fat presented middle branches triglycerides (SLT), which do not require emulgation  bile and are absorbed directly into the portal vein system.

l Low lactose content (0.5 g/100 ml - 5.6%)

l Does not contain gluten

l Banana pectin has a pronounced effect absorbent and reduces signs of diarrhea

l Dietary fiber banana fiber have a prebiotic effect, stimulating growth natural flora and accelerate the recovery of the intestinal mucosa

l Energy kkal/100 in 61 ml

study:

"Efficacy of mixtures «Humana HN mit MCT" in patients with CF "
(the duration of the study in 2010 to 2011.)

Methods and Materials

• 11 patients, 8 (72.3%) male 3 (27.3%) female

• the age of 4 months. to? 1 year 5 months.

• Length using a mixture of 3 to 6 months

• The mixture used in  7-(63.6%) patients - as the main product

• in 4 (36.4%) - as foods

• Indications for assignment:

• The low number or absence of breast milk in the mother (three patients (27.3%) - breastfeeding, 8 (72.3%) - artificial feeding)

• Disorders of defecation in the background replacement therapy PF

• The good tolerability of cow's milk protein

Methods and Materials

All have:

pancreatic insufficiency, confirmed the level of EF-1

malnutrition and art

All children received basic therapy, including CF Creon drug at a daily dose of 4,500 to 10,000 U / kg lipase

Criteria for evaluating the effectiveness of treatment

• Organoleptic properties

• The presence or absence of dyspepsia (regurgitation, vomiting, defecation disorders with steatorrhea)

• Dynamics available at the time of the appointment of a mixture of dyspepsia

Results

• All children are willing to eat a mixture of failures posseting, vomiting, blurred nature of feces was observed (100%)

• four (36.4%) patients refused to use hydrolyzed mixture on a background introduction to their diet «Humana HN mit MST"

Conclusions: Mix «Humana HN mit MST"

• He has good taste

• Outstanding tolerated by patients with genetically determined ZSNPZ

• Has a positive influence on the correct eating behavior, because it is delicious!

• by:

• high content of protein (casein)

• 50% medium chain triglyceride content

• low content of lactose

• balanced electrolyte composition

• absence of gluten

• Recommended for use in patients with CF as primary and secondary food

Hypercaloric application on food

l May be useful (but expensive)

l Used in addition to the usual food

l They can be useful when a child is ill

l Most of them also require enzymes

In contrast, the same amount of calories contained in? Glass of milk and a piece of cake

References

а) Basic

1. Manual of Propaedeutic Pediatrics / S . O . Nykytyuk , N . I . Balatska , N . B . Galyash , N . O . Lishchenko , O . Y . Nykytyuk – Ternopil : TSMU , 2005. – 468 pp .

2. Kapitan T. Propaedeutics of children's diseases and nursing of the child : [Textbook for students of higher medical educational institutions] ; Fourth edition, updated and

    translated in English / T. Kapitan – Vinnitsa: The State Cartographical Factory, 2010. – 808 pp.

3. Nelson Textbook of Pediatrics /edited by Richard E. Behrman, Robert M. Kliegman; senior editor, Waldo E. Nelson – 19^th ed. – W.B.Saunders Company, 2011. – 2680 p.

b) Additional

1. Denial Bernstein. Pediatrics for medical Students. – Second edition, 2012. – 650 p.

2. Jam W. Ball, Ruth G. Bindler Pediatric Nursing. Caring for Children. -  Third edition, 2011. – 984p.

3. Mary W. Lieh-Lai, Michael Fiore and K. Jane Lee. Pocket pediatrics for PDA .

4. Guidelines on HIV and infant feeding 2010 . Principles and recommendations for infant feeding in the context of HIV and a summary of evidence . World Health Organization , 2010.

5. www.bookfinder.com/author/american-academy-of-pediatrics

6. www . emedicine . medscape . com

7. http :// www . nlm . nih . gov / medlineplus / medlineplus . html

Prepaired by Nykytuyk S.

browningfattle.blogspot.com

Source: https://tdmuv.com/kafedra/internal/pediatria2/classes_stud/en/med/lik/ptn/Propaedeutic%20pediatrics/3/Theme%2016%20Mixed%20feeding..htm

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