Mixt and artificial alimentation

of suckling baby
Department of Pediatrics
 Methods of mixt alimentation
• The complementary method is used in the case of hypogalactia: at
each alimentation the infant is putting first of all at breast, after
that the artificial form of supplement is administering. This method
is the most recommendable, being physiologic and contributing to
maintainance and further stimulation of lactation.
• The alternative method is used when the mother can’t apply
enough frequvently the infant to breast, being absent home a
period of time – either being at job, or at studies. In this case it is
recommended the maximal alimentation with squeezed milk, and
the deficit will be compensated with milk formula, replacing one or
more applications at breast with supplement. This method is less
recommended, because the big intervals between the application
on breast influences negatively the lactation, reducing progressively
the milk quantity produced by mother.
 The mixt and artificial alimentation
• The distrophy or insufficient containing of nutrients in foods is the
associated cause of approximatively 50% of world children’s deceases (The
situation of children in world,1998, UNICEF)
• The inadequate nutritional state affects millions inhabitants of planet,
leading to increased suseptibility due to diseases, physical, mental
retardation and even invalidity
• The most vulnerable and sensible are children by little age and pregnant
or breastfeeding mothers
• In Republic of Moldova there is a significant prevalence of statural
retardation, which is meeting at 26% of children under 5 years and 8-9%
children from 5 till 12 years (National Nutrition Study, 1996)
• The nutritional problems bring great damage both to healthy population,
and to country economy. Conformable to WHO studies, the combined
deficiency of iron, iodine and vitamin A can generate the decreasing of
some country economic performances approximately with 5%.
 The natural (breast) feeding
• The natural (breast) feeding satisfies the three fundamental
principles of correct alimentation – alimentation, health and care –
and is the essential factor of child’s protection
• The new-borns with low weight, which benefit in the first 6 months
by alimentation exclusively with breast milk, have intelligence
coefficient (IQ) more than children fed with reconstituted milk
(artificial formulas), this is shown in an americano-norvegian study
– The tests, realized on a lot of 220 three years aged children shown,
that these fed with breast in the first 24 weeks of life have an IQ more
in medium with 11 points than anothers.
– This study confirms the theory, that the breast milk is important for
intelectual development of children.
– The preceeding studies have shown, that the new-borns with normal
weight, fed exclusively with breast milk in the first 6 months of life,
have an IQ more with 3 points than these artificially fed.
 The natural (breast) feeding
• The breast milk ensures perfect feeding and is the unique aliment which
satisfies all needs of child’s growing and development in the first 6 months
of life.
• All substitutes, inclusively the cow’s milk, special formulas, powder milk
and farinaceous foods, are less good for children.
• The breast milk contains sufficient water for little infant, even when the
weather is very warm, droughty. It is not necessary for to quench his
thirst to geve him supplementary water or sugar sweetened drinks. These
can be injurious to health. If we geve him water, or drinks prepared on
water, than the risk of diarrhea or other diseases appearance increases. In
plus the breast will produce less milk.
• Another aliments and liquids become necessary around the age of 6
months. If at monthly weighing of infant less than 6 months age we
establish, that in the absence of some disease he doesn’t gain his weight,
it could be necessary to feed him with breast milk more frequently.
 The natural (breast) feeding
• In conclusion, the breast milk is an ideal food for
new-born and suckling infant.
• But, in the case of breast milk insufficiency, its
absence or contraindications for breast feeding
there is the necessity to feed the infant with
another type of milk, that is to pass at mixt or
artificial alimentation.
• However, before to decide it, you must to be
convinced that the infant is not alimented
adequately and in did needs another type of
milk, supplementary to this maternal.
 Methods of child’s adequate
alimentation estimation
1.The signs of adequate breast-feeding in the first
month of life:
• Glutition heared during sucking;
• Humid swaddling clothes more than 6 in 24 hours;
• Physiologic stool ( as a rule after each alimentation);
• The state of „comparatively empty” breast after
alimentation;
• Satisfactory state of infant between the periods of
alimentation;
• Weight gain 18-30 g/day or 125-210 g/week.
 Methods of child’s adequate
alimentation estimation
2. The symptoms of suckling hunger
• Flat weight (ponderal) curve (no weight gain);
• Rare urine voidings (less than 6 in 24 hours);
• Stool changes (constipations or diarrhea,
unstable stool);
• The infant is anxious, agitated all day, in the
absence of some cause (fever, other
manifestations of disease);
• The infant sucks permanently the fingers.
 Methods of child’s adequate
alimentation estimation
3. Signs which indicate that the infant’s weight doesn’t
increase sufficiently rapid
• The weight gain is under 18 g/day and at 3 sweeks he didn’t
recover his weight at birth;
• He seems to be somnolent , has week crying or whining
and sleeps much;
• He cah have reduced, concentrated voidings, or normal
urinary elimination;
• He has frequent, or very rare stools;
• He can suck permanently;
• He can have anxious sight and wrinkled skin on all body.
The motiv from which an infant can not
receive the necessary milk quantity
From the part of infant From the part of mother

Difficulties of breastfeeding Psychologic factors

Rare alimentations Absence of confidence

The child is not fed in night Troubles, stress

Short breastfeedings Absence of appetite

Wrong position Repulsing of the infant

Partial consumption Tiredness

Using of suckling bottles

Early introducing of weaning foods

 Hypogalactia
Hypogalactia – diminished capacity of breast secretion in the lactation
period . It can appear in any period of lactation.

Classification:
• In function of principal cause we distinguish primary and secondary
hypogalactias;
• In function of onset periods we distinguish precocious hypogalactias
(they are manifesting in the first 10 days after birth) and belated
• In function of milk insufficiency degree to the infant’s necessities there are
distinguish 4 degrees:
– deficit under 25%
– deficit under 25%-50%
– deficit under 50%-75%
– deficit under 75%
 The causes of primary hypogalactia
1. different primary neuroendocrine disorders
2. hipoplasia of mammary gland
3. not argumented and abusive using of
hormonal preparations
4. administration of oral contraceptives.

The most frequently spread hypogalactias are,

usually, secondary.
The causes of secondary hypogalactia
• belate putting at breast of baby after birth;
• rare putting at breast of baby;
• incorrect position of putting at breast;
• negative psychoemotional factors, stress;
• unfavourable socioeconomic factors;
• extragenital pathologies, viral infections, severe renal,
hepatic diseases, anemias, cardiovascular diseases at
mother;
• medication with the drugs suppressing lactation:
Adrenalin, Noradrenalin, Gastrocepin, Cimetidin, Ranitidin,
Famotidin, Atropin, Parlofen, Linestrol, Levodopa,
Progesteron, oral contraceptives, Ergotamin, laxative
preparations, saluretics, Phenobarbital, diuretics etc.
 Incorrect practices, performed
anteriorly, of natural alimentation
• Belate putting at breast after birth (at 6 – 12 hours),
especially in women with pathology (e.g.-anemia);
• Administration of 5% glucose solution until the
moment of lactation appearance at mother;
• Excessive breastfeeding only in the first month after
birth;
• The breast milk as basic aliment only in the first 4 – 4,5
months;
• Complete stopping of breastfeeding at 10 – 11 months;
• Breastfeeding strictly on hours;
• Nocturnal pauses between alimentations.
Incorrect practices, performed anteriorly, about the
alimentation with other produces than breast milk
• Introducing at the age of 2 – 3 months of cow’s milk diluted with rice or
other croups bopiling water (or diluted kefir) with the addition of 5% sugar
sirup;
• Tea or water with sugar for breast fed infants;
• Juice of legumes or “fruits” (water with jam) at 1 month;
• Introducing in alimentation of integral cow’s milk or integral kefir at the
age of 3 months;
• Introducing of fruits at 2 months;
• Introducing in alimentation in 3 months of egg yolk and in 4 months of
white cow’s cheese ;
• Using in alimentation of sugar sirup and salt solution;
• Introducing in alimentation of croups gruels with sugar and butter from 4
months.
• The recommendation to introduce in alimentation of infants suffering by
anemia and/or rickets the gruel and other solid aliments until the age of 4
months was alarming.
 Mixt and artificial alimentation
• The mixt alimentation is the type of
alimentation, when the infant, besides breast
milk also receives during the day an another type
of milk –adapted or not-adapted milk formula,
the ratio between them being different.
• If the infant receives breast milk less than 1/5
from daily ratio, the remainder constituting the
milk formulas, it is considered that he is on
artificial alimentation.
 Milk formulas
• Adapted formulas are some milk formulas, elaborated
scientifically and ecquilibrated after the containing of
nutritive ingredients for maximal appropiation of
alimentary factor by the breast milk containing. They are
made in industrial mode and differ after more criteria (a
classification of adapted milk formulas is exposed below).
• Non-adapted formulas are some milk formulas prepared in
home conditions, representing the milk of a lot of
mammals, especially the cow’s milk, (also of she-goat,
buffalo cow etc.) and their dilutions.
• On the whole globe there is a great lot of adapted milk
formulas, on the commodity market of RM being
commercialized more than 30. All commercializaed
formulas in our republic are, as a rule, imported.
 The choice of milk formula
• The choice of milk formula for mixt or artificial infant’s
alimentation is based, first of all, on appreciation of
suckling baby’s health state and his peculiarities of
development
• Don’t forget about the family material possibilities: the
formulas with the high degree of adaptation are surely
more expensive, requiring an significant financial effort
from the part of parents
• However, all pluses and minuses are estimating in each
case appartly, especially when there are a special
indications for the administration of one or another
formula
• It’s good when the choice of milk formula takes into
consideration certain rules.
 The rules of milk formula choice for
mixt/artificial infant’s alimentation
• The pediatrician must be consulted supplementarly about the
problem of milk formula necessity and its choice;
• If the infant has still received a milk formula, has good tolerated it
and is developing corresponding to the age, it is necessary to
concretize which formula is it and to recommend its further
administration;
• It is necessary to take into account the infant’s age;
• The formulas with high degree of adaptation are preferable,
especially in the first 6 months of life;
• The data, exposed on lable (quantitative and qualitative content of
ingredients, the terms of valability) will be thoroughly studied;
• The milk formula must contain taurine – an aminoacid, which
takes part at the forming of nervous system tissues and eye’s retina
ochiului, and has an important role especially in the establishment
of some defense functions etc.;
 The rules of milk formula choice for
mixt/artificial infant’s alimentation
• It is recommended that the selected formula must contain also carnitine
– a biologic active substance, important for good function of proteic,
lipidic and energetic metabolism in the cell;
• The milk formula must contain also the unsaturated fatty acids, which are
indispensable for adecquate development of brain and eye retina;
• For milk formula it is preferable the preponderant containing of milk
serum proteins and less casein, for to appropiate the content of
aminoacids to that of breast milk and for better digestion of proteins;
• The individual tolerance to selected formula will be appreciated, and at
the appearance of intolerance signs (allergic eruptions, meteorism, more
frequent regurgitations, abdominal pains, modified stools) the evaluation
of infant’s health state will be performed and, if there are not another
explanations of indicated signs, a new formula will be select. It must to
take into account that is not good to pass from one formula to another
each 1 – 2 days. The adaptation to new produce lasts in medium no less
than 3 – 5 days.
• If special indications are present, the dietetic formula will be selected.
 The rules of milk formulas administration
in the mixt or artificial alimentation
• If the infant still receives breast milk, even small quantity, he will be fed
with milk formula only after breastfeeding;
• The milk formula will be given at beginning with teaspoon, learning the
infant to drink the milk from cup;
• The milk formula will be fresh prepared, using boiled water, conformable
to indicated technology;
• The dosage will be strictly respected (the ratio milk-powder / water
volume) for avoid the indigestion or subalimentation;
• All dishes used for milk formula preparation and alimentation of infant will
be kept in ideal cleanliness (they will be washed, scalded in boiling water
and even boiled);
• The use of suckling bottles for artificial or, especially, mixt alimentation of
infant, will be avoided: the mixt alimented infant refuses soon the breast,
the suckling bottles more hardly are subdued to the cleanliness and
desinfection, can provoke an intestinal infection and have negative
influence on the correct forming of bite and infant’s dentition.
 The establishment of artificial
alimentation ratio
The alimentary ratio can be calculated after good known “classical”
methods: volumetric and energetic.

For a new-born in the 7 days of life can be used Finkelstein formula:

L=(N-1)x70 or 80,
where :
L- daily quantity of milk;
N- number of life days
• The coefficient 70 is using for suckers born with the weight under
3250 g, and 80 - for suckers born with the weight over 3250 g.

From 7th – until 14th day of life can be used Apert formula:
V=1/10 from infant’s weight + 200
 The volumetric method
After 14th day of life the alimentary ratio can be calculaed using
volumetric method in the following manner:
• From the age of 2 weeks until 6-8 weeks:
• V=1/5 from infant’s weight.

• From the age of 6-8 weeks until 4 months:

• V=1/6 from body weight.

• From the age of 4 months until 6 months:

• V=1/7 from body weight.
• After 4 months the alimentary ratio will constitute 900-1000 ml
until the age of 1year, without to exceed usually the quantity of 1
litre.
 The energetic method
If the energetic method, more exact, but more
pretentious, will be used, we will follow from
the following energetic necessities at
kilo/body.
• I trimester – 120 kcal/ kg/day
• II trimester – 115 kcal/ kg/day
• III trimester – 110 kcal/ kg/day
• IV trimester – 100 kcal/kg/day
 Classification of milk formulas
After the degree of adaptation:
• Non adapted (“Classic”)
• Partially adaptated
• Adaptated (“humanized”, maternized”)
• Special formulas (therapeutic, dietetic)

• After age, in which they are indicated:

• From start (complete)
– for prematures
– for term new-borns
• For continuing (diversifying)

• After the technological peculiarities of preparing:

• Sweet
• Acidulated (fermented)
 Classification of milk formulas
After the sourse of proteins:
• From cow’s milk
• From soya (“vegetal milk”)
• From meet (rarely used in this goal)

After compositional peculiarities:

• Lactose- free or with reduced quantity of lactose
• Low fat or fat free
• With increased contain of lipids
• With increased contain of proteins
• With increased contain of oligoelements, vitamins etc.
• Gluten- free
• Without phenylalanine
 The advantages of adaptated milk formulas

1) They are the formulas superiorly to these classic;

substituting successfully the human milk in the first
months of life .
2) The concentrations of lipids, glucides, proteins and
minerals from adapted formulas are appropiated to
these from human milk.
3) The glucides are represented exclusively by lactose.
4) The adapted formulas bring for child’s kidneys an
osmotic charge and H+ near ti human milk.
5) Through their using we avoid the hunger due to lipids
restriction, the thirst due to glucides excess,
metabolic hepatorenal overloading.
The advantages of adaptated milk
formulas
1) The decreased level of cazein in adapted formulas leads to
correction of the ratio- serum proteins /cazein, appropiating
them to human milk .
2) The adapted formulas have the contain of essential
aminoacids near to that in human milk (due to addition of
demineralized serum).
3) The ratio saturated fatty acids/unsaturated fatty acids from
adapted formulas is near to that in human milk (45/55),
realised through the addition of vegetal fats.
4) The adapted formulas are supplemented with vitamins and
iron, conformable to recommended dietetic ratio.
 High degree adaptation formulas
• These formulas have on basis cow’s milk serum proteins,
containing a lot of biologic active substances (taurin, lecitin,
cholin, inozitol) , specific for breast milk and which have a
great importance for the growing and development of
suckling baby. These formulas can be given in artificial
alimentation beginning from new-born period. The numeral
„0” and the prefix „Pre-„ indicate, that the respective formula
is este predestinated for artificial/mixt alimentation of
premature new-borns, and the numeral ”1” – for the suckling
babies from the birth until 4-5-6 months.
 I . High degree adaptation
formulas
• Nutrilon(Russian Federation)
• Neonatal ( Holland)
• NAN (Switzerland)
• Alfare(Switzerland)
• Alprem(Switzerland)
• Prehipp (Austria)
• Hipp -1(Austria)
 II. Medium degree adaptation
formulas
• In this group enter the formulas containing
the protein of cow’s milk – casein. Unlike the
milk formulas with high degree of adaptation,
these are recommended for artificial/mixt
alimentation of infants with the age 5-6
months and more. The numeral „2” indicates,
that the respective formula is recommended
for the infants in the second half of first year
of life.
 Medium degree adaptation
formulas
• Similac (USA)
• Similac cu Fe (USA)
• Impress (Germany)
• Enfamil (Hollanda/USA)
• Enfamil with Fe(Holland /USA)
• Enfamil – 2(Holland /USA)
• Nutrilon 2 (Russian federation)
 III. Partially adapted formulas
• These formulas don’t contain above named
biologic active substances ( taurin, cholina, a
lot of fatty acids ), although the cow’s milk
protein is subdued to some industrial
processing.
 III. Partially adapted formulas
• Maliutca (Ucraina, Federaţia Rusă)
• Malîş (Ucraina, Federaţia Rusă)
• Detolact(Ucraina)
• Vitalact, Vitalact M (Ukraine)
• Milumil (Germany)
• Milazan(Germany)
 IV. SPECIAL (dietetic) milk
formulas
SPECIAL (dietetic) milk formulas are classifying
in function of especial content.
1. Formulas with low lactose content, or
lactose free:
• NAN lactose free (Switzerland)
• Similac-Izomil(USA)
• Similac Aldolac(USA)
• Nutrilon with low lactose content (Russian
Federation)
 SPECIAL (dietetic) milk formulas
2. Adapted formulas without milk, containing soya protein, indicated for infants
with intolerance to cow’s milk protein, lactose, also suffering by
galactosemia:
• NAN soya
• Bona Soya
• Nutri-Soya
• Peptidi-Soya
• Soya-Semp
• Tuteli-Soya
• Humana SL
• Humana-Soya
• Enfamil-Soya
 SPECIAL (dietetic) milk formulas
3. Adapted formulas containing hydrolysate of cow’s milk serum protein.
These formulas are indicated to infants, suffering by allergy to cow’s milk
and lactose, infants with severe degree of prematurity, infants with cystic
fibrosis, malabsorption syndrome, also for infants in the pre- and
postoperatory period:
• Alfare
• Pepti-Junior
• Portagen
• Puleva -1
• Humana HA 1 – from birth
• Humana HA -2 – from 5 months age
• Hipp HA 1 – from birth
• Hipp HA 2 – from 4 months age
 SPECIAL (dietetic) milk formulas
4. Iron enriched adapted formulas
• Detolact
• Nestogen
• Nutrilon 2
• Similac + Fe
• SMA + Fe
• Semper-Bebi 1, Semper-Bebi 2
 SPECIAL (dietetic) milk formulas
5. Adapted formulas for premature babies, with
hypotrophy, or with flat ponderal curve:
• Alprem
• Pre NAN
• Neonatal
• Hipp pre
• Enfalac ( USA)
 SPECIAL (dietetic) milk formulas
6. Adapted formulas, recommended for infants with
frequent regurgitations or vomiting
• Nutrilon –AP
• Similac Izovoc
• Semper Lemolac ( Sweden)
• Frisovom (Holland)
 SPECIAL (dietetic) milk formulas
7. Adapted formulas, recommended for infants with
intestinal dismicrobism
• NAN acidulated (acidophilic)
• Bifidus ( firm „Semper” Sweden)
• NAN with bifidobacteries („ Nestle”,
Switzerland).
 SPECIAL (dietetic) milk formulas
9. Adapted gluten-free formulas for infants with celiac
disease
• NAN without lactose (lactose free)
• SOYA-Semp
• Hipp 1
• Humana HN
• Humana HN MCT
 SPECIAL (dietetic) milk formulas
10. Adapted formulas without phenylalanin for infants
with phenylketonuria
• Phenyl Free
• Similac-Lofenalac