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Usually breastfeeding is the best way to feed infants. Nevertheless, there are situations when it may be preferable or it is necessary to replace breast milk with any alternative. In addition to contraindications briefly described above, circumstances arise when, despite all efforts to continue breastfeeding, the mother cannot maintain lactation at a level that fully satisfies the nutritional needs of the child. When it comes to stopping breastfeeding, the risk of feeding the baby with something else should be less than the potential risks associated with continuing to breastfeed. Before you start feeding your baby any other food, and not breast milk, it is extremely important to consider the following questions:
• Feeding should, to the fullest extent possible, provide all the nutritional needs of the infant. No substitute does not fully reproduce the nutrient content in breast milk.
• Breast milk substitutes do not have the properties of breast milk that protect the baby from infection. During preparation, breastmilk substitutes may be contaminated with bacteria, and therefore it is very important that the feeding portions are prepared and given to the baby with good hygiene (see chapter 12). Even when hygiene conditions are good, artificial feeding is significantly more prevalent in gastrointestinal and respiratory infections than breastfed infants.
• Using breast milk substitutes is expensive. A recent study in the United States (88) showed that using any alternative to breast milk during the first year of life costs about $ 800. These costs are borne by individual families, they also entail costs for the local community and affect the level of the entire population. In addition to infant formula, you need to take into account the cost of fuel, water, medical care.
• Women who do not breastfeed lose the benefits of lactational amenorrhea. Among the population, where it is not so easy to have access to contraceptives, this can result in short intervals between the birth of a child and the deterioration of the mother’s health if women do not have easy access to family planning services soon after giving birth.
• Breastfeeding can affect the emotional connection between mother and child, which can lead to insufficient stimulation for the baby. It is necessary to help mothers to ensure that non-breastfed babies receive as much attention as breastfed babies.
Children's nutritional mix of industrial production
The basis of most industrial nutritional infant formula is cow's milk, and these mixtures are designed to replicate the composition of nutrients of breast milk. Therefore, the concentrations of proteins and electrolytes, such as sodium, potassium and chlorine, are lower than in cow's milk, while the levels of some minerals, above all iron and, to a lesser extent, zinc, are higher (table 36). Industrial infant nutritional formulas do not contain non-edible biologically active components of breast milk (protective and trophic factors), and the quality of the proteins and lipids they contain (amino acid and fatty acid profiles) may not be optimal for the needs of the infant (see below). However, industrial-made infant formula feeds are a satisfactory alternative source of nutrition for infants under the age of 6 months, used as the only one. Even after the introduction of complementary foods, the formula continues to play an important role in meeting the needs of the child for energy and nutrients, and in the absence of breastfeeding, it should be the main liquid in the diet in the first 9 months, and possibly longer.
Industrial infant formula is usually produced in the form of powdered milk, which is diluted with water. It is necessary to accurately follow the instructions for preparing the nutrient mixture indicated on the jar or box so that the mixture is not too thick and not too liquid. Over concentration can overload the baby’s body with salts and protein, which can be dangerous, and excessive dilution with water can lead to malnutrition. Health workers should be able to demonstrate to mothers and family members how to properly prepare breast milk substitutes.
The guidelines for the composition of infant formula have been agreed in Codex Alimentarius and are determined in accordance with the energy density of the mixtures, i.e. energy per 100 ml, and the standard is taken as a product with an energy density of 65 kcal / 100 ml. It must be emphasized that when industrial infant formula is recommended as the best alternative to breastfeeding, it is assumed that this mixture meets the standards dictated by Codex Alimentarius (89). However, in some countries, due to the absence or insufficiency of measures to ensure the implementation of national standards, the nutrient mix of industrial production may not meet these standards.
Cow's milk and the milk of other animals
Unmodified cow's milk should not be given to infants as a drink until 9 months of age. If infants are fed infant formula, cow's milk can be gradually introduced into their diet in the age between 9 and 12 months. However, if funds allow, it may be better to continue to feed the baby with the mixture for up to 12 months.
Cow's milk is very different from breast milk, both in quality and quantity of nutrients, and does not contain those trophic and immunological factors that are present in breast milk (table 36). As for nutrients, whole cow's milk contains more proteins and minerals (calcium, sodium, phosphorus, chlorine, magnesium and potassium) and less carbohydrates, essential fatty acids (linoleic and a-linolenic acids) and long-chain polyunsaturated fatty acids , zinc, vitamin C and niacin. Cow's milk not only contains more total protein, but its quality differs from breast milk, and the proteins in it are potentially allergenic to an infant.
Homemade baby food
Sometimes infant formula is used to feed infants based on cow's milk or milk from other animals, such as goats and sheep. In such mixtures, many nutrients are often lacking, and most importantly, iron, which is present in small concentrations and has low bioavailability. Home-made infant formula, if prepared on the basis of unmodified cow's milk, can cause gastrointestinal bleeding (see Chapter 6). They should be given only when there is no commercially available infant formula. The younger a baby is, the more important it is for him to receive infant formula, and not cow’s milk. If there are economic difficulties that limit the availability of infant formula for industrial production, priority should be given to the use of nutrient mixtures in the first months after birth, because these months are most important from the point of view of optimal nutrition and development of the infant.
Where there is no commercially produced infant formula fortified with iron, fresh animal milk or dry milk should be modified in accordance with the following recipes, and iron supplements should also be given. Other micronutrients (such as zinc, which can be sprinkled with food) are being developed, and in the future they may be a way to improve the micronutrient density of home-made infant formula.
Modified animal milk
Since cow's milk contains more dissolved substances than breast milk, to reduce their concentration, it must be diluted with boiled water. This adversely affects the energy density, so you need to add sugar.
For home-made infant formula, the WHO recommends the following recipe (60):
• Boil 70 ml of water.
• Add 130 ml of boiled cow or goat milk to get 200 ml of the mixture.
• Add 1 tsp topless (5 g) sugar.
This recipe can also be used if the milk is prepared from canned whole milk powder. Milk should be prepared according to the instructions on the label, and then modified in accordance with the above recipe.
Goat milk is modified in the same way as cow milk. But sheep milk has a very high protein content, and therefore it needs to be diluted more. To modify sheep's milk, use the following recipe:
• Boil 100 ml of water.
• Add 100 ml of boiled sheep milk to make 200 ml of the mixture.
• Add 1 tsp topless (5 g) sugar.
As in cow's milk, goat and sheep's milk contains little iron and vitamin D, as well as little folate compared to breast and cow's milk. While goat's milk contains relatively little vitamin A, sheep's milk contains more of it than cow's.
Unmodified goat and sheep milk should not be given to children under 1 year old, and even then it can be given only if measures are taken to prevent the deficiency of minerals and vitamins, along with measures to ensure microbiological safety.
Unsuitable Breast Milk Substitutes
It is not recommended to give to children up to a year skimmed and half-melted milk. All fat has been removed from skimmed milk, and about half the fat from half-skimmed milk does not provide enough energy for a growing infant. Sweetened condensed milk is also not recommended due to its high sugar content. Sometimes, instead of dairy mixes, they give fruit juices, sugar water, and diluted liquid cereals from cereal products, but giving them as an alternative food is not recommended due to the incompleteness of their nutritional properties.
Bottles and Cups
When babies cannot be breastfed, one method of feeding babies is to use bottles and nipples. However, cup feeding is becoming increasingly popular, and it is especially recommended in areas with low hygiene, as well as for feeding children in special conditions.
Both the bottle and the nipple can be harmful because:
• bottle feeding increases the risk of diarrhea (in conditions of low hygiene), diseases of the teeth and inflammation of the middle ear, and can change the dynamics of the oral cavity;
• bottle feeding increases the risk that the infant will not receive enough stimulation and attention during feedings;
• Bottles and nipples should be thoroughly washed with a brush and then sterilized by boiling, which takes time and fuel consumption;
• often sweetened solids are added to bottle blends, which increases the risk of dental caries, as is the practice of dipping nipples and pacifiers into honey or sugar;
• Bottles can cause “nipple confusion,” which can damage the frequency and intensity of breastfeeding.
An alternative method of feeding infants who cannot breastfeed is cup feeding. This method is especially recommended for children who need to start breastfeeding later, and in situations where hygienic treatment of bottles and nipples is difficult. Proper cup feeding allows the baby to regulate food intake; no need to “pour” milk into the baby’s mouth
Case for cup feeding:
• less risk of improper attachment to the chest;
• the child uses the language when feeding;
• feeding from the cup is carried out by the child himself, distributing food intake by time and quantity;
• cups are safer than bottles, as they are easier to wash with soap and water;
• the cups are smaller than the bottles they carry with them, so there is less opportunity for the growth of bacteria;
• for cup feeding, the mother or another person caring for the child should hold the baby or have more contact with it, which creates more psychological stimulation for the baby than when feeding from a bottle;
• Feeding from a cup is better than feeding from a cup with a spoon, because feeding with a spoon takes more time and the mother can stop feeding before the baby is full.
Feed the baby from the cup as follows (90):
• Hold the child on your lap in a sitting position vertically or semi-upright.
• Support the baby’s back and neck with one hand.
• Hold a small cup of milk to the child’s lips.
• Tilt the cup so that the milk barely reaches the baby’s lips. The cup fits easily on the child’s lower lip, and the edges touch the outside of the child’s upper lip.
• The baby quickens and opens his mouth and eyes. A small child will begin to take milk in the mouth with his tongue. A full-term or older child sucks or sips milk, spilling some.
• DO NOT pour milk into the baby’s mouth. Just bring the cup to the lips of the child and let him drink it.
• When children eat, they close their mouths and refuse to eat more. An infant who has not had enough may eat more next time, or it may be necessary to increase the frequency of feedings.
• Do not try to get a child to drink a certain amount. Let him decide when he has enough to eat.
• Measure your baby’s food intake for 24 hours, and not after each feeding.
Dummies are used throughout the world, and some health workers and non-specialists believe that they are harmless or even necessary and useful for the development of a child (91). However, as in the case of the nipple, pacifiers can lead to a decrease in breast sucking time and thus interfere with on-demand feeding, which leads to inhibition of production of breast milk. They can change the bite and affect speech development. In addition, dummies can often be infected with Candida albicans, and some babies who use dummies may develop candidal stomatitis, which may not respond to treatment until the dummy is thrown away. Finally, soothers can affect the care of the child, since those who care for the children give them in return for their time and attention. If soothers are used, they should not be dipped in sweet foods, such as jams and honey, as this threatens the development of dental caries (see Chapter 11).
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