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Case Based mostly Pediatrics For Medical College students and ResidentsDepartment of Pediatrics, College of Hawaii John A. Burns College of MedicineChapter II.3. Child FormulasNadine Tenn Salle, MDFebruary 2002

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A 24 yr vintage aboriginal time mother brings her two anniversary vintage son in your appointment for a capable-bodied adolescent examination. She is a superior mom with ready ancestors assist. She is likely to be abiding to endeavor in a single anniversary and has adopted not to breastfeed. Right now she is gluttonous your admonition apropos her toddler’s vitamins.

In a 1986 exercise assertion, the American Academy of Pediatrics (AAP) reaffirmed its position on Four points pertinent to toddler weight reduction program (1):

1. The AAP will abide to boost breastfeeding because the aboriginal anatomy of child diet.

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2. The AAP will abide to project to develop and advance the aerial affection of child formulation inside the USA as a result of truth in some circumstances, breastfeeding will not be utilized or favored.

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3. The AAP will abide to acclaim adjoin sure to purchaser assertion of child formulation.

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4. The AAP will abide to animate the tailor-made complement weight reduction plan affairs for girls, breed and accouchement (WIC) and well being middle nurseries, and functions to carry out accessible a group of formulation.

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The AAP adheres to the attractiveness that pediatricians take supply of a albatross for toddler nutritional vitamins, settle for an obligation to be abreast roughly the comestible needs of every positive usually creating breed as able-bodied as breed with unique comestible needs together with these with metabolic, gastrointestinal, communicable and oncologic ache altitude (1).

Breast milk is advisable to be the perfect comestible for the appellation or abreast appellation toddler as an absolute antecedent of weight reduction program all through the aboriginal six months of existence. Breast milk collected with the accession of particles is often advisable for the introduced six months of an toddler’s pastime (2).

There are injury for the usage of youngster system:

1. As a complement or appearing for breast milk again a mother can not or chooses now to not breast-feed.

2. Breed whose moms are adulterated with bacilli acquainted to be communicable with the help of animal milk (e.G., HIV)

three. Breed whose moms are potential chemotherapy.

4. Breed whose moms are accepting drugs or capsules which is likely to be excreted into animal milk.

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5. Breed who’re clumsy to abide animal milk due to metabolic points (e.G., galactosemia).

Within the coincidence breast agriculture is neither applied nor most popular, there are a cardinal of commercially accessible child formulation that take supply of been formulated to simulate animal breast milk and accommodate an toddler’s comestible necessities. On frequent, a adolescent will alcohol roughly 100 sixty 5 cc of system/kg/day (2.5 ozpound/day) and roughly 30-90 cc (1-Three oz) based on feeding. The caloric agreeable of greatest toddler formulation fastidiously approximates that of animal milk at 2/Three kcal/cc (20 kcal/ounces). Breed are about their very own first-class regulators, correctly aberration with anniversary agriculture needs to be predicted. In the course of the aboriginal 6 months of existence, breed crave 95-one hundred fifteen kcal/kg/day; 8-12% of those energy needs to be obtained from protein, 30-50% from fat and forty-60% from carbohydrates. If these comestible necessities are met, an youngster will about accretion 25-forty grams per day (30 grams = 1 ounce) inside the aboriginal three months and 15-20 grams inside the launched three months. Child formulation are cautioned to actor the comestible settlement of animal milk, nevertheless in absoluteness they accommodate a cardinal of variations inside the protein, fats and carbohydrate content material materials.

Human milk contains about 1.1 g/dL of protein in comparison with 1.5g/dL in first-class prevalent formulation. This represents 6-eight% of an toddler’s absolute caloric consumption. Milk protein could also be disconnected into coaching primarily based on about solubility in acid: whey (acid soluble) and casein (acid insoluble). The whey:casein association of animal milk is 70:30 as in comparison with a affiliation of 18:82 for cow milk. The analytic acceptation of the aberration in whey:casein association amid animal and bovine milk is illustrated again blunt casein-most essential cow milk enters the acerb ambiance of the animal abdomen and paperwork a virtually adamantine acerbate of casein and minerals. This acerbate could also be laborious for an youngster to digest. Thus, the AAP recommends that cow’s milk not be acclimated until afterwards the aboriginal birthday. Tailored toddler’s milk is now fact marketed as a capricious blueprint to carried out cow’s milk; about there are not any right tailored allowances compared to a toddler bistro a counterbalanced weight reduction plan that features milk and juice.

Lipid constitutes about 50% of the energy in animal milk (5.7g/100 kcal) and on a regular basis youngster blueprint (4.4-6.0g/100 kcal). Absolutely the allocation of lipid in animal and cow milk is triacyl glycerol. Triacyl glycerol consists of a glycerol braveness with three-hydroxyl accumulation esterified to blubbery acids.

Important blubbery acids lineoleic and alpha lineolinic acerbic comedy a acute position in neurodevelopment. About 5-7% of absolute energy in animal milk and 1% of absolute energy in cow milk is lineoleic acid. The majority of lineoleic acerbic instructed succesful is controversial nevertheless it in about agreed it should not be launched than 20%. For this acumen all cow milk primarily based formulation add greens oil (containing practically ample portions of lineoleic and lineolinic) to their preparations. Finest bartering toddler formulation accommodate at atomic 10% of absolute blubbery acids as lineoleic acid.

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The first carbohydrate antecedent activate in every animal milk and formulation is lactose (besides in lactose chargeless methodology). Lactose is a disaccharide that is tailor-made to straightforward sugars, galactose and glucose via a lactase enzyme. Disaccharides crave about-face to straightforward sugars to accredit assimilation through the intestine through a monosaccharide carriage system. The carbohydrate antecedent in soy based totally blueprint is glucose polymers (moreover known as blah abstract solids) and/or sucrose. Sucrose is tailored to easy sugars, fructose and galactose for assimilation (3).

The adamant agreeable of animal milk is appreciable beneath than that of adamant adherent cow milk based totally components, however the bioavailability of animal milk adamant is ample higher. Pointers from the board on weight-reduction plan of the AAP recommends 2-Three mg/kg/day of basal iron. In a appellation toddler, adamant absence is aberrant afore 4-6 months of age as a result of affluence of adamant meals at starting. Adamant absence is nice customary amid accouchement 6 months to three years of age. To compensate for the burning of adamant meals via enhance, comestible adamant cost be offered. Alone breastfed breed may also crave weight reduction program supplementation with adamant (1 mg/kg/day) and diet D (400 IU/day) at four-6 months of age. Accepted formulation (roughly 32 oz. In keeping with day) will accommodated 100% of RDA for vitamins and minerals for appellation infants. Low adamant formulation genuine by the use of the FDA as absolute beneath than 6.7 mg/L of iron, already impartial below than 1.5mg/L of iron, common in an unacceptably aerial bulk of adamant absence and anemia. Over the achieved bristles years, blueprint producers take supply of launched the majority of adamant in low adamant formulation to 4-5mg/L. A useful acumen that adamant causes ache and added agriculture issues has accustomed for the linked bazaar of low adamant absolute formulation. There isn’t any abstracts to abutment this recognition and the AAP recommends iron-fortified formulation.

Signs of cow milk protein abhorrence about immediate amid anniversary Four to 6, nevertheless the acuteness may also curiosity as aboriginal as 48 hours or could current in maturity. The attendance of gastrointestinal affection which embrace blood-soaked stools, diarrhea and airsickness can announce pathophysiological bent accompanying to a specific basic of cow milk formulation. Affection which incorporates flatus, adornment and colic are beneath correct and tough to anon chronicle to tools of cow milk. True cow milk protein allergenicity as right by way of a double-blinded abstraction is current in under than 6% of the citizenry (5,6). Some surveys look as aerial 30% of blueprint fed breed are switched to hypoallergenic formulation on account of a perceived or doubtable protein abhorrence (7). Hypoallergenic formulation are created by way of abundantly hydrolyzing the cow milk protein (generally casein), thereby abbreviation its atomic weight to below than 1250 kDa. Proteins below than 1250 kDa are a great distance below appropriate to aftermath a IgE-mediated allergic acknowledgment (6). Hypoallergenic anatomize casein formulation are succesful in stopping protein allergy. It’s set actually useful to essentially look at cow milk allergic toddler afore beginning these formulation whose glorious cogent draw back is a larger quantity decrease again in comparison with accredited parts. Breastfeeding is alike launched acerb advisable in breed with milk allergy.

Major lactose bent which embrace lactase absence and galactosemia, happens roughly in 1:one thousand infants. Accent lactose bent by way of unfavourable is a great distance added normal and roughly gives with abiding diarrhea. The lactase agitator is amid on the bearded tip of the civil and seems to be introduced accessible than sucrase that is set off added inside the crypt. An communicable diarrhea may also account denuding and the lactase agitator could booty as much as a anniversary to sincerely recuperate. A low lactose or lactose chargeless blueprint may additionally bathroom down carbohydrate malabsorption (and consecutive deepening of diarrhea via an osmotic mechanism) all through the an infection. The lactose chargeless cow-milk primarily based formulation are advisable to leisure principally accent lactase deficiency. The destructive to lactose absolute formulation is the barter of its carbohydrate supply. As a substitute of lactose, a blah abstract secure and/or sucrose is used.

Soy formulation abutment the advance of accustomed appellation breed through the aboriginal yr of existence. Soy formulation could be acclimated in lieu of cow milk blueprint and in blueprint fed breed whose mother and father urge for food their accouchement to hook up with a vegetarian weight reduction program. Phytate in soy blueprint in accession to the absence of lactose abate the assimilation of divalent cations together with iron, calcium and zinc contained in the stomach lumen. Supplementation of soy blueprint with iron, calcium and zinc has abundantly affected these troubles (8,9). Phytogens in soy formulation settle for the abeyant for hormonal pastime at analytical credibility in growth. The AAP has acclaimed that sure animal abstracts does not abutment these apropos (10).

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Abstract of formulation:

Cow’s milk primarily based formulation:. . . . Indications: Appellation or abreast appellation toddler.. . . . Protein: whey-major; carnitine and taurine usually added.. . . . Carbohydrate: lactose.. . . . Fats: vegetable oils.. . . . Manufacturers: Enfamil with iron, Similac with iron, Good Begin (100% whey protein, correctly could also be acclimated for constipation), Lacto-free (makes use of blah abstract and/or sucrose), Similac PM 60/40 (60:forty association of whey to casein, below Ca, P, Okay for cardiac and renal victims).

Soymilk based totally formulation:. . . . Indications: Lactose absence or galactosemia, austere vegetarians, IgE recommended acknowledgment to cow milk protein.. . . . Protein: 2.2g/dl of protein from a bulb supply, cysteine and taurine as able-bodied as an added methionine introduced.. . . . Carbohydrate: blah abstract (glucose polymer), sucrose.. . . . Fats: vegetable oils.. . . . Manufacturers: Isomil, ProSobee.

Casein Hydrosylate formulation:. . . . Indications: Milk or soy protein intolerance, colic.. . . . Protein: casein hydrolysate (hypoallergenic).. . . . Carbohydrate: glucose oligosaccharides tailored cornstarch.. . . . Fats: MCT, blah oil.. . . . Manufacturers: Pregestimil, Nutramigen, Alimentum (multiplied MCT fats focus; for cystic fibrosis victims).


1. The American Academy of Pediatrics recommends what anatomy of weight reduction plan for infants?

2. What’s an tailor-made affluence of blueprint for an toddler?

3. Again is adamant supplementation appropriate for an toddler?

4. Again evaluating breast milk vs. Cow’s milk based totally formulation, which has a greater: a) kcal/cc? B) Absorption of casein protein? C) Carbohydrate content material? D) Fats content material materials?

5. What’s the analytic acceptation of the whey:casein association in cow milk?

6. What’s the capital anatomy of carbohydrate in breast milk? Cow’s milk primarily based components? Soy primarily based methodology?


1. Breastfeeding and the usage of animal milk. American Academy of Pediatrics. Project Accumulation on Breastfeeding. Pediatrics 1997;100(6):1035-1039.

2. Corridor RT, Caroll RE. Child feeding. Pediatr Rev 2000;21(6):191-two hundred.

3. Greer FR. Formulation for the advantageous appellation toddler. Pediatr Rev 1995;16(3):107-113.

4. Blecker U, Sothern MS, Suskind RM. Iron-fortified youngster formulation. Pediatr Rev 1999;20(10):359.

5. Oldaeus G, et al. Allergenicity screening of “hypoallergenic” milk-primarily primarily based formulation. J Abhorrence Clin Immunol 1992;ninety(1):133-135.

6. Oldaeus G, et al. Cow’s milk IgE and IgG antibiotic responses to cow’s milk formulation. Abhorrence 1999;fifty 4(4):352-357.

7. Schrander JJ, et al. Cow’s milk protein bent in breed below 1 12 months of age: a -to-be epidemiological take a look at. Eur J Pediatr 1993;152(8):640-644.

8. Mimouni F, et al. Bone mineralization within the aboriginal yr of pastime in breed fed animal milk, cow-milk parts, or soy-primarily primarily based components. J Pediatr 1993;122(3):348-354.

9. Hertrampf E, et al. Bioavailability of adamant in soy-based completely blueprint and its aftereffect on adamant nutriture in infancy. Pediatrics, 1986;78(4):640-645.

10. American Academy of Pediatrics. Board on Vitamin. Soy protein-primarily primarily based formulation: pointers to be used in youngster feeding. Pediatrics 1998;100 and one(1 Pt 1):148-153.

Solutions to questions

1. Breastfeeding is wanted aboriginal and basic apart from decrease again it is not at all times sensible, tailored or medically contraindicated.

2. From a applied standpoint, whether or not it is breast milk or child parts, a efficient appellation child is the standard regulator of the affluence and affluence of their comestible consumption. Nonetheless, decrease again we’re scientists at coronary heart; throughout the aboriginal 6 months of exercise about ninety five-115 kcal/kg/day is recommended.

three. In a appellation toddler, adamant absence is aberrant afore four-6 months of age due to the affluence of adamant meals at supply. To compensate for the burning of adamant meals by growth, comestible adamant price be furnished to by myself breastfed infants. Adamant adherent formulation can assume adamant absence in blueprint fed infants. Pointers from the Board on Weight loss program of the AAP acclaim 2-Three mg/kg/day of basal iron.

4a. They’re in regards to the equal. Animal milk consists of about 2/three kcal/cc (20 kcal/oz.). The standard youngster blueprint usually charcoal abutting to this vary.

4b. Whey:Casein of animal milk is 70:30 compared to a association of 18: eighty two for cow milk. Please accredit to the argument to evaluation the analytic acceptation of this contour distinction.

4c. The carbohydrate agreeable is in regards to the equal.

4d. Lipids combination roughly 50% of the power in animal milk (5.7 g/100kcal) and unusual toddler blueprint ( g/100kcal).

5. The analytic acceptation of the aberration in whey:casein affiliation amid animal and bovine milk is illustrated returned blunt casein-fundamental cow milk enters the acerb ambiance of the animal abdomen and paperwork a virtually adamantine acerbate of casein and minerals. This acerbate could also be robust for an child to digest. Thus, the AAP recommends that cow’s milk not be acclimated until afterwards the aboriginal birthday.

6. Lactose is the capital carbohydrate in beastly milk. The lactose absorption of animal milk is 7g/dL, cow milk contains 5 g/dL. Lactose is delivered to good prevalent youngster blueprint to perform the absorption of animal milk. Soy formulation don’t accommodate lactose; they accommodate sucrose, glucose polymers, or a admixture of the two.

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College of Hawaii Division of Pediatrics Residence Web page

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