How to choose a mixture?
When choosing infant formula, it is necessary to carefully study the label, the inscription on the can (box) about the composition and the plate of the components. Pay attention to:
Squirrels
Carbohydrates
Fats
Osmolarity
Initially, the mixture is given starting with small amounts and brought to full volume in 5-7 days in the absence of signs of intolerance (no allergic manifestations, regurgitation, constipation, diarrhea).
1. For healthy young children, it is better to use mixtures with a lower protein content - in the range of 1.2-1.5 g per 100 ml of liquid product. The higher the amount of protein, the more is the load on the immature kidneys of the child, on his intestines.
Modern formulas should be enriched with a-lactalbumin (lowering the protein in the mixture, i.e. the lower the protein, the more a-lactalbumin), this gives an amino acid composition close to breast milk and a bifidogenic effect. In breast milk, α-lactalbumin is up to 80%.
2. An important aspect is the ratio of whey proteins to casein. The protein component of breast milk substitutes is of great importance for the baby. In most adapted formulas, it is represented by whey proteins (dominant in human milk) and casein (the main protein in cow's milk) in a ratio of 60:40; 70:30; 80:20 (50:50 is acceptable). Whey proteins should prevail over casein proteins.
Whey proteins form a more delicate clot in the baby's stomach than casein, which ensures a higher degree of milk absorption. The group of adapted milk formulas, in which the protein of cow's milk - casein (its share is 80%) dominates, is called casein formulas.
The protein (amino acid) composition of the so-called "whey" mixtures is closer to mother's milk than "casein" mixtures.
Since at the breastfeeding stage, the ratio of whey proteins to casein in breast milk is on average 60% to 40%, ideally, they should correlate in the same way in mixtures. With such a ratio of whey proteins and casein, the child will not have indigestion of the latter, as from cow's milk.
3. The carbohydrate component of the mixture. The only source of carbohydrates in all types of milk is milk sugar - lactose. This carbohydrate is found only in milk and is not found anywhere else. The hydrolytic breakdown of lactose in the intestine proceeds slowly, and therefore the intake of lactose does not cause intense fermentation. The intake of lactose into the intestines normalizes the composition of the beneficial intestinal microflora. Therefore, in a quality product for feeding healthy children, sugar substitutes should not be sucrose (can lead to upset stools, intestinal colic), fructose or glucose, but lactose, which is an essential component of breast milk, and, possibly, dextrinmaltose (due to its addition, manufacturers are trying to achieve a decrease in the osmolarity of the mixture (what is osmolarity, see the end of the article)), the addition of which is justified, since in the first half of the life of children, enzyme deficiencies often occur, including lactase deficiency.
If you look at the composition of adapted milk formulas intended for artificial feeding of healthy children, you will see that most of them, in fact, do not contain other carbohydrates besides lactose. However, it should be noted that children who are weak, born prematurely or with low body weight may have difficulty digesting lactose: they have bloating, and the stool becomes foamy and thin. For these children, you should choose formulas with a lower lactose content.
4. It is necessary to pay attention to the content of fat in the mixture - the most important source of energy for an infant. The most optimal is its amount in the range of 3.4-3.6 g in 100 ml of the reconstituted mixture. Or not less than 3.3 g and not more than 6 g per 100 kcal.
Many children do not tolerate formulas with a large amount of fat. They have difficulty digestion, and the stool may become frequent and runny. Formulas with a high fat content are indicated for children who are weakened, with an insufficient rate of increase in body weight.
It is good if the mixture contains DHA and ARA - they affect the immune response, are responsible for the development of the retina and brain cells.
For the proper growth and development of a child, two of the most important polyunsaturated fatty acids (PUFA) - linoleic (at least 300 mg per 100 kcal) and linolenic, must be present in baby food. The indispensability of linoleic acid has been recognized for a long time. It is necessary for the synthesis of protein in the membranes of brain cells. In human milk, its content is 15%, and at least 10% is recommended in milk replacers. The ratio of linoleic acid to linolenic acid is also important (not less than 8.8). Polyunsaturated fatty acids are found only in vegetable fats. Therefore, breast milk substitutes may contain plant-based raw materials or even be prepared with them. Especially often soy and vegetable oils (sunflower, corn, soybean, rapeseed, coconut, palm) are used for this.
5. If the food of an adult must necessarily contain 8 amino acids, which are the main constituents and structural components of protein molecules (the so-called essential amino acids - methionine, lysine, tryptophan, phenylalanine, leucine, isoleucine, threonine and valine), then in childhood, to irreplaceable amino acids are also added with histidine and arginine, since they are not synthesized in the child's body in quantities that can satisfy its needs. Therefore, enrichment of human milk substitutes with these amino acids provides the best amino acid ratio and improves their biological value.
The free amino acid taurine, which is essential for babies in the first weeks and months of life for the formation of the organs of vision and the brain, is added to the formula of many breast milk substitutes to improve their biological value. In addition, it is involved in the synthesis of bile acids. Taurine is not included in the protein, but is present in human milk in an amount of about 5.0 mg per 100 ml (in the mixture - taurine enrichment at a level of at least 4.5 mg / 100 ml).
6. L-carnitine (at a level of at least 0.8 mg / 100 ml). Carnitine is not an enzyme, as it is sometimes called, but a compound that is synthesized in the body in the liver and kidneys from two amino acids - lysine and methionine with the participation of iron and vitamins C and B6. Especially a lot of it is in the muscles. With a lack of carnitine in the body, long-chain free fatty acids cannot penetrate into mitochondria and be oxidized. Thus, carnitine normalizes fat metabolism.
Lack of carnitine in an adult is quite rare, since an adult gets it from food - beef, chicken, rabbit, cow's milk and eggs. More often, a lack of carnitine occurs in newborns, especially in premature babies; it is caused either by impaired carnitine biosynthesis or by its "leakage" in the kidneys. Symptoms of a lack of carnitine are attacks of hypoglycemia, which are manifested first by short periods of excitation of the central nervous system, and then by its depression, accompanied by weakness, drowsiness, hunger, anxiety, trembling, sweating - up to various mental disorders. In the blood plasma, the content of free fatty acids rises, fat accumulates in the body and muscle weakness (myasthenia gravis) develops.
7. For the normal growth and development of an infant, baby food products must contain a complex of mineral elements (macro- and microelements) and vitamins. Macronutrients such as calcium (at least 50 mg per 100 kcal) and phosphorus (at least 25 mg per 100 kcal) are necessary for a child to form bone tissue. However, with an excess of these minerals in the mixture, they are excreted from the infant's body, giving a huge load on the child's still undeveloped kidneys.
Relatively high phosphorus levels can lead to hyperphosphatemia and, as a consequence, hypocalcemia in infants. It is also known that undigested calcium forms insoluble salts in the intestinal lumen, interacting with fatty acids, which impairs the absorption of fat. With the optimal ratio of calcium and phosphorus in the mixture, the absorption of calcium from the intestine and bone mineralization are improved, and the risk of hypocalcemia is reduced. In addition, the optimal ratio of these minerals can help reduce stool density and prevent the development of constipation in children. Therefore, it is important not only a sufficient amount of calcium and phosphorus, but also their ratio in the mixture, which should approach their ratio in human breast milk (2.20-2.33).
8. Of the 15 trace elements for the growth and development of a growing organism, 9 are of the greatest importance: iron, iodine, zinc, copper, selenium, cobalt, chromium, molybdenum and manganese. Deficiency of iron, iodine, zinc and selenium is widespread in children. The lack of these micronutrients leads to disastrous consequences for the health of the child.
At the same time, there are trace elements, the innate reserves of which are enough for the first 4-6 months of life (copper, iron), and trace elements, the content of which in the body of newborns is extremely insignificant (iodine, zinc, selenium). The latter must be constantly replenished. Taking these data into account, modern mixtures should contain sufficient amounts of iron, zinc, iodine, copper and selenium.
9. Iron is involved in the synthesis of blood hemoglobin, ensures the normal functioning of the immune system and the adequacy of behavioral characteristics. In adults, iron deficiency is associated with an increased response to cooling. Whether this is true for infants is unknown, but it seems likely.
Since pregnancy and childbirth necessarily lead the mother's body to a large loss of iron, it may not be enough in breast milk. Therefore, for weakened anemic children, it is better to choose a mixture with a high iron content (in the range of 0.8-1.2 mg in 100 ml of a liquid product).
10. As for vitamins, they are all very important for the normal growth and development of the baby. But it is especially important to pay attention to the content of vitamins D, E, folic acid, K, group B in breast milk substitutes. Vitamin D promotes the absorption of phosphorus and calcium, is necessary for the normal formation of bones and teeth. Vitamin E acts as an antioxidant, which protects cell structures from free radical damage, and red cells from oxidative damage, and supports the immune system. In this case, the content of vitamin E in the mixture should be in a certain ratio with the level of linoleic acid (1.7). Folic acid is especially needed by children during the period of rapid growth. It is the main participant in the formation of hemoglobin in red blood cells and is necessary for the synthesis of proteins.
The increased content of B vitamins is the prevention of anemia, dermatitis, and digestive disorders.
For children with signs of rickets, formulas fortified with vitamin D are shown.
Vitamin A 250-500 International Units (IU) per 100 kcal, vitamin D 40-100 IU per 100 kcal, vitamin C - at least 8 mg per 100 kcal, the maximum is not indicated, vitamin E - 0.7 IU per 100 kcal, the maximum is also not indicated.
The content of biotin must be at least 1.5 μg per 100 kcal, choline - at least 7 mg per 100 kcal.
11. Osmolarity of the mixture. IMPORTANT! This term is used to denote the saturation of a solution of a mixture with proteins and salts. With a high osmolarity (more than 300 mosm / l), the load on the immature kidneys and intestines of the baby increases, which can increase the risk of their diseases in the future, and sometimes lead to dehydration. Maximum osmolarity 290 mOsm / L.
As emulsifiers: lecithin 0.5 g per 100 ml of the mixture, mono- and diglycerides - 0.4 g per 100 ml of the mixture. Substances that regulate the acidity of mixtures: sodium hydroxide, sodium bicarbonate, sodium carbonate, potassium hydroxide, potassium bicarbonate, potassium carbonate, calcium hydroxide, potassium citrate, sodium citrate, lactic acid, cultures producing lactic acid - the amount of these substances is limited by production practice. Antioxidants: Concentrate of mixed tocopherols - 1 mg per 100 ml in all kinds of formulas, L-ascorbyl palmitate.
In addition, the amount of potassium and sodium should be within the limits not exceeding the standards: sodium - 20-60 mg per 100 kcal, potassium - 80-200 mg per 100 kcal.
There are also so-called "Contaminants": the product must not contain - residual amount of pesticides, hormones, antibiotics, pharmacologically active substances. The product must not contain pathogenic (that is, harmful to health, causing disease) microorganisms, any substances originating from microorganisms that pose a threat to health, other toxic substances in quantities that pose a threat to health.
Summary It is widely believed among neonatologists that increased osmolality of enteral nutrition products for premature infants increases the incidence of gastrointestinal dyskinesia and necrotizing enterocolitis (NEC). This belief was based on the studies by L. Book and T. SantuLLi, published in 1975. The results obtained in the course of these studies on the relationship between hyperosmol nutrition and NEC have been repeatedly cited since the mid-1970s, despite the fact that the osmolality of the studied diet in relevant studies exceeded 500 mOsm / kg. Currently, no prematurity formula or breast milk fortifier has such high osmolality rates. This article analyzes publications devoted to the relationship of enteral nutrition with its tolerance and the risk of developing NEC. Based on the analyzed literature sources, no convincing data on the relationship between hyperosmolar nutrition and its intolerance, as well as the risk of NEC development, have been identified. Currently, the safe level of osmolality of enteral nutrition is in the range of 300-450 mOsm / kg.
Keywords: osmolality, osmolarity, prematurity, enteral feeding, food intolerance, necrotizing enterocolitis
Neonatology: news, opinions, training. 2018.Vol. 6.No. 4.P. 63-69. doi: 10.24411 / 2308-2402-2018-14007
Thanks to the development of medical technologies, pharmacotherapy and progress in the provision of perinatal care in the XXI century. the survival rate of premature babies has increased significantly. But despite the great success achieved in the care of such children, the long-term development of premature babies is still under threat. In the long term, such children are at risk for the development of many chronic diseases: diabetes mellitus, hypertension, etc. It is known that the shorter the gestational age, the higher the likelihood of developing distant neurocognitive developmental disorders. At the same time, the development of neurological disorders in the future is directly related to insufficient weight gain and growth in the postnatal period. In this regard, the problem of adequate nutritional support for premature babies is more urgent than ever. The issue of osmolality of enteral nutrition can rightfully be called the cornerstone in nursing premature babies. The need for a small amount of nutrition to meet all the needs of a premature baby determines the high concentration of nutrients and calories in fortified breast milk and formulas, which, in turn, makes their osmolality higher than unfortified mature breast milk.
There is a widespread historical belief among neonatologists that increased osmolality of food is associated with poor tolerance, as well as with the risk of developing necrotizing enterocolitis (NEC). This stance sometimes leads to refusal of breast milk fortification or delayed initiation of enteral feeding. It should be noted that concerns about the high osmolality of enteral nutrition are related to the peculiarities of neonatological practice in the Russian Federation. Nevertheless, no convincing evidence obtained in randomized clinical trials has been published in Russian literary sources. In order to confirm the existing hypothesis about the relationship between increased osmolality and NEC, or to dispel this myth, an analysis of modern publications devoted to studies of the osmolality of nutrition for premature infants was carried out.
Osmolality and Osmolarity
Incorrect use of medical terminology can lead to misinterpretation of results. Therefore, for a start, you should distinguish between the concepts of osmol l nosti and osmol p nosti. Both indicators describe the amount of dissolved particles in a solution. Osmola R ness indicates the concentration of the solute in osmols per liter of solvent (mOsm / l). This indicator is strongly influenced by temperature and pressure, so it is rather difficult to adequately measure it. Osmola eh The value, which indicates the concentration of the solute in 1 kg of solvent (mOsm / kg water), is not so strongly influenced by these factors and therefore is the preferred indicator for measurement.
Osmolality depends on the osmotically active species dissolved in solution. If we talk about the osmolality of milk or milk substitutes, these particles are electrolytes, oligo- and monosaccharides, amino acids and fatty acids. Substances that increase osmolality include mono- and disaccharides, minerals, electrolytes, amino acids, hydrolyzed protein, and medium-chain triglycerides.
Thus, osmol I amR ness and osmol eh ness - these are completely different indicators, which, however, often replace each other in the literature, which leads to distortion of information.
The osmolality of mature breast milk is close to that of serum and varies from 280 to 310 mOsm / kg, depending on the degree of hydration of the mother. Solutions with an osmolality higher than that of blood serum (285-295 mOsm / kg) are called hyperosmolar solutions.
To measure osmolality, an osmometer is used, the principle of which is based on measuring the decrease in the freezing point of a solution (the more solute in the solution, the lower the freezing point). Laboratory measurement of osmolality is limited by the fact that some substances create an osmotic gradient in vivo and some don't. For example, vitamins and some drugs use transporters to pass through semipermeable membranes and therefore do not create an osmolar gradient in a living organism, but increase osmolality in laboratory measurements. In this regard, the measurement of osmolality in the laboratory does not always reflect what actually happens in the human body.
Safe level of nutritional osmolality for premature babies
Currently, the upper limit of the acceptable osmolality of nutrition for premature babies is not clearly defined. Modern international recommendations for feeding premature babies do not regulate the acceptable limits of osmolality / osmolarity of nutrition. The main standard that determines the rate of osmolality for premature babies around the world are
1976 American Academy of Pediatricians (AAP) recommendations These recommendations were developed for healthy term infants and established an upper osmolality limit for initial mixtures of 400 mOsm / L, which is approximately 450 mOsm / kg. AARP experts concluded that exceeding this level of osmolality may contribute to the development of NEC [ 8 ]. This statement is based on historical opinion rather than strong evidence base. However, these guidelines are a guideline for neonatologists and infant formula manufacturers around the world.
The statement about the influence of hyperosmolar nutrition on the development of NEC is based on 2 studies of the 1970s. The first study was carried out by T. SantuLLi et al. in 1975 and is often cited in the literature as evidence of the link between NEC and direct damage to the intestinal mucosa. The authors analyzed 64 cases of NEC development in newborns. It is important to note that the group of children was comorbid and included newborns, including premature infants with extremely low body weight, as well as children with trisomy and left heart hypoplasia syndrome. A group of term infants with developed NEC received breast milk substitute with an osmolarity of 750 mOsm / L. At the same time, in conclusion of the article by T. SantuLLi et al. argue that indirect mucosal injury, which is based on mesenteric ischemia in response to perinatal stress, is a more important factor than direct injury (due to hyperosmolar nutrition). Despite this, this article formed the basis for the osmolarity standards issued by the AAP in 1976.
The second study (L. Book et al., 1975) examined 16 premature infants weighing<1200 г [ 10 ]. These infants were randomized to receive either a standard prematurity formula with whole bovine protein or an elemental formula. The aim of the study was to study the effectiveness of nutrition and to identify the incidence of NEC. 7 (87.5%) of 8 children who received the elemental mixture, and in 2 (25%) of 8 infants who received standard formula were diagnosed with NEC. This study had several serious limitations. First, it was carried out on an extremely small sample - only 16 children. And secondly, as in the study by T. SantuLLi et al., The studied elemental formula had a very high osmolarity - 650 mOsm / L, while the osmolarity of the standard mixture for premature babies was 359 mOsm / L.
These studies are often cited in the current literature, but none of them demonstrates reliable evidence of a link between osmolality and the development of NEC. Consideration should be given to the heterogeneity of the study populations, including oral administration of drugs during studies. These studies have methodological violations, and in both cases, the osmolality of the diet exceeded 500 mOsm / kg. Currently, no prematurity formula or fortifier has such high osmolarity / osmolality values.
The modern view of the relationship between nutritional osmolality and the development of NEC is described in detail in the article by F. Pearson et al. (2013), which analyzed the main research on this issue. The authors argue that there is no evidence of a causal relationship between dietary osmolality and the development of NEC. None of the studies have shown direct damage to the intestinal mucosa in response to hyperosmolar feeding, and all available modern mixtures have osmolality less than 450 mOsm / kg.
Osmolality of Fortified Breast Milk
There is no doubt that after the addition of fortifiers, the osmolality of breast milk increases. According to the study by W. Janjindamai et al. (2006), the greatest increase in osmolality is observed after 10 min after enrichment, and then, up to 24 hours, the osmolality does not change significantly. In their work, M. de Curtis et al. noted that the increase in the osmolality of fortified milk is likely due to the action of breast milk amylase, which hydrolyzes the dextrin contained in the fortification. Despite a significant increase in the osmolality of breast milk after fortification, in all studied samples this indicator did not exceed 450 mOsm / kg even 24 hours after fortification and was within the limits recommended by the AAP.
Several studies have been published comparing the tolerability of breast milk fortifiers with different osmolality. In a study by N. Kanmaz et al. (2013) studied the effects of different doses of breast milk fortifier on growth performance and metabolic response in preterm infants. In particular, the tolerability of fortifiers with osmolarity of 340, 360 and 380 mOsm / L was assessed. When assessing food tolerance, residual food volume, bloating, stool frequency, no significant differences were found between the groups. Only at 1 a child from the group of moderate enrichment (fortifier with an osmolarity of 360 mOsm / l) was diagnosed with NEC.
A study by J. Kim et al. (2015) showed that in the group of children who received a new fortifier with an osmolality of 450 mOsm / L, the proportion of children who canceled the fortifier due to food intolerance was less than a standard fortifier with an osmolality of 385 mOsm / L.(2 vs 10 %, p= 0.048). The incidence of confirmed NEC was low in both groups, while the proportion of children with NEC was lower in the fortification group with higher osmolality (1.5 vs 3.2%).
Similar results were obtained in the work of P. Singh (2017): there were no differences in the incidence of food intolerance between the groups receiving fortifiers with different osmolality 378.40 ± 34.4, 419.73 ± 30.65 and 451.20 ± 39 , 18 mOsm / kg. NEC developmental episodes were not registered in any group.
Interesting data were obtained in the study by M. Thoene et al. (2016). The incidence of NEC was significantly higher in the group of children who received the liquid fortifier with the lowest osmolality (13 vs 0%, p= 0.0056). The authors of the study concluded that these results may indicate that it is not the osmolality, but the composition of the fortifier, that can influence the frequency of NEC development. In a study by G.M. Chan (2003) showed a decrease in the antimicrobial effect of breast milk against the growth of E. coli, Staphylococcus, Enterobacter and Streptococcus when supplemented with a high iron breast milk fortifier versus a low iron fortification. The study by T. Erickson showed a 76% decrease in the leukocyte content in breast milk, "acidified" to pH 4.5, which could reduce its protective properties. Thus, it is possible that it was the high iron content and acidity of the fortifier that increased the susceptibility of premature infants to infections, which could contribute to the development of NEC.
Authors of the 2016 Cochrane Review, which included 11 randomized controlled trials also confirmed that, despite the low level of evidence due to the randomization methods used and the lack of blinding, breast milk fortification does not increase the incidence of NEC (relative risk 1.57, 95% CI 0.76-3.23).
Influence of food osmolality on the rate of evacuation of food from the stomach in premature infants
Most of the studies that examined the effect of nutritional osmolality on the rate of food evacuation from the stomach did not confirm the existence of a connection between them. So, in the study by M. Siegel (1982), it was not possible to find the effect of the osmolality of food on the rate of evacuation of food from the stomach. This study compared 2 mixtures with osmolality of 279 and 448 mOsm / l. The mixtures differed only in the carbohydrate component: a mixture with an osmolality of 279 mOsm / L contained sucrose disaccharide (6.4 g / 100 ml), and a mixture with an osmolality of 448 mOsm / L contained glucose monosaccharide (6.4 g / 100 ml). The rate of gastric emptying did not differ between groups. Thus, the authors concluded that the osmotic load of nutrition does not significantly affect the rate of gastric emptying in premature infants [ 21 ].
According to the results of a study by A. Ramirez (2006), changes in osmolality (150 vs 310 mOsm / l), volume (10 vs 20 ml / kg) and caloric intake (5, 10 or 20 kcal / 30 ml) did not affect the rate of emptying. stomach, but a simultaneous decrease in osmolality and an increase in food volume increased the rate of gastric emptying by 18% ( R=0,035) .
Similar results were obtained in the study by S. Yigit et al. (2008). The authors concluded that fortification of breast milk does not slow down the evacuation of food from the stomach and does not have a clinically significant effect on food intolerances when using the fortification at the recommended dosage.
Lactose in the diet of premature babies
Another controversial topic of nutritional support in neonatology is the level of lactose in preterm formulas. It is believed that the level of lactase in premature babies is significantly reduced, therefore, a high level of lactose can negatively affect the tolerance of the formula.
It is known that the level of lactase begins to be measured in the fetus with 10 - 12 th week of gestation, but its expression and activity remain low until the 24th week. After this period, the level of lactase begins to increase, up to the 34th week, when its activity reaches the indicators of term babies. Thus, the level and activity of lactase in premature babies allows for good digestion of most of the lactose; About 35% of lactose is fermented by the gut microbiota in the colon and serves as a natural prebiotic. Despite the fact that breast milk for premature babies contains lactose at a concentration of 6.5-7.0 g per 100 ml, primary lactase deficiency in premature babies, breastfed babies is very rare.
R. Tsang et al. (2005) recommend adding lactose (at least 3.16 g / 100 kcal) to the diet of extremely low and very low birth weight premature infants. This conclusion is based on the fact that lactose is the main carbohydrate energy component of breast milk, which has a prebiotic effect and promotes calcium absorption. This recommendation applies to the feeding of all babies born prematurely, including premature babies after discharge from the hospital up to 4-6 months.
According to the ESPGHAN (2010) recommendations for enteral feeding of premature babies, for a baby with body weight<1800 г суточная норма по углеводам составляет 10,5-12 г на 100ккал. Для того чтобы достичь такой концентрации углеводов на 100 ккал смеси со 100% лактозой в качестве источника углеводов, необходимо добавить 8,4-9,6 г лактозы на 100 мл смеси. Такой уровень лактозы значительно превышает уровень лактозы 6,5-7 г/100 мл в грудном молоке.
Given the reduced expression and activity of lactose in premature infants with gestational age<34 нед, содержание лактозы в грудном молоке и ее более высокую осмотическую нагрузку, логично несколько снизить содержание лактозы в смесях для недоношенных по сравнению со стандартными базовыми смесями для доношенных детей. Тем не менее необоснованное снижение лактозы лишает недоношенного ребенка возможности получить все полезные свойства этого углевода, включая пребиотический эффект, влияние на всасывание кальция и миелинизацию нервных волокон. Кроме того, известно, что грудное молоко, содержащее 100% лактозу, оказывает защитное действие в отношении развития НЭК.
In this regard, it is likely that the level of lactose in mixtures should be somewhat reduced, but to such an extent that the varnish the tose remained the main carbohydrate, as in breast milk. The addition of maltodextrin as an additional carbohydrate allows you to control the osmolality of the mixture.
Thus, the use of lactose as the main carbohydrate in combination with maltodextrin is the best option.
Conclusion
The osmolality of the diet varies considerably and depends on the type of feeding, showing higher values in formula and in fortified breast milk. Based on the analysis of publications, no convincing data on a causal relationship between the osmolality of food and its intolerance, as well as the development of NEC, were found. All modern formulas have an osmolality of up to 450 mOsm / kg, which is a safe level of osmolality of enteral nutrition for premature babies.
Conflict of interests . THOSE. Lavrov and M.F. Talyzina - employees of Nutricia LLC, E.V. Groshev and V.V. Zubkov confirm that they have no conflicts of interest or financial support that need to be reported.
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19. Erickson T., Gill G., Chan G. M. The effects of acidification on human milk's cellular and nutritional content // J. Perinatol. 2013. Vol. 3 P. 371-373.
20. Brown J.V.E., Embleton N.D., Harding JE, McGuire W. Muiti-nutrient fortification of human milk for preterm infants // Cochrane Database Syst Rev. 2016. Is. 5. Art. N CD000343.
21. Siegel M. et al. Gastric emptying in prematures of isocaioric feedings with differing osmolalities // Pediatr. Res. 1982. Vol. 16.P. 141147.
22. Ramirez A. et al. Factors regulating gastric emptying in preterm infants // J. Pediatr. 2006. Vol. 149, No. 4. P. 475-479.
23. Yigit S. et al. Breast milk fortification: Effect on gastric emptying // J. Matern. Fetal Neonatal Med. 2008. Vol. 21, No. 11. P. 843-846.
24. Kien C.L., Ault K., McClead R.E. In vivo estimation of lactose hydrolysis in premature infants using a dual stable tracer technique // Am. J. Physiol. 1992. Vol. 263, 5 Pt 1.P. E1002-1009.
25. Auricchio S., Rubino A., Muerset G. Intestinal glycosidase activities in the human embryo, fetus, and newborn // Pediatrics. 1965. Vol. 35. P. 944-954.
27. Kien C.L., Liechty E.A., Myerberg D.Z., Mullett M.D. Dietary carbohydrate assimilation in the premature infant: Evidence for a nutritionally significant bacterial ecosystem in the colon // Am. J. Clin. Nutr. 1987. Vol. 46. No. 3. P. 456-460.
28. Kien C. L., Kepner J., Grotjohn K., Ault. K, McClead R.E. Stable isotope model for estimating colonic acetate production in premature infants // Gastroenterology. 1992. Vol. 102, No. 5. P. 1458-1466.
References
1. March of Dimes, PMNCH, Save the Children, WHO. Born Too Soon: The Global Action Report on Preterm Birth. Eds. Howson C.P., Kinney M.V., Lawn J.E. World Health Organization. Geneva; 2012.
2. Twilhaar E. S., Wade R. M., de Kieviet J. F., et al. Cognitive outcomes of children born extremely or very preterm since the 1990s and associated risk factors: A meta-analysis and meta-regression. JAMA Pediatr. 2018; 172 (4): 361-7.
3. Pearson F., et al. Milk osmolality: does it matter? Arch Dis Child Fetal Neonatal Ed. 2013; 98: F166-9.
4. Waitzberg D.L., Torrinhas R.S. Enteral feeding. In: Encyclopedia of food and health. 2016: 519-23.
5. Fenton T.R. Not all osmolality is created equal. Arch Dis Child Fetal Neonatal Ed. 2006; 91 (3): F234.
6. Agostoni C., et al. ESPGHAN committee on nutrition: Enteral nutrient supply for preterm infant: A commentary. J Pediatr Gastroenterol Nutr. 2010; 50 (1): 85-91.
7. Koletzko B., Poindexter B., Uauy R. Recommended nutrient intake levels for stable, fully enterally fed very low birth weight infants. In: Koletzko B., Poindexter B., Uauy R., eds. Nutritional Care of Preterm Infants. Basel: Karger 2014: 297-9.
8. American Academy of Pediatrics: Commentary on breast-feeding and infant formulas, including proposed standards for formulas. Pediatrics. 1976; 57: 278-85.
9. Santulli T. V., et al. Acute necrotizing enterocolitis in infancy: a review of 64 cases. Pediatrics. 1975; 55 (3): 376-87.
10. Book L.S., et al. Necrotizing enterocolitis in low-birthweight infants fed an elemental formula. J Pediatr. 1975; 87: 602-5.
11. Grosheva E.V. Optimization of nutritional supplementation in children with extremely low and very low birth weight. Abstract of Diss. Moscow; 2013. (in Russian)
12. Janjindamai W., et al. Effect of fortification on the osmolality of human milk. J Med Assoc Thai 2006; 89: 1400-3.
13. De Curtis M., et al. Effect of fortification on the osmolality of human milk. Arch Dis Child Fetal Neonatal Ed. 1999; 81: F141-3.
14. Kanmaz H. G., et al. Human milk fortification with differing amounts of fortifier and its association with growth and metabolic responses in preterm infants. J Hum Lact, 2013; 29 (3): 400-5.
15. Kim J. H., et al. Growth and tolerance of preterm infants fed a new extensively hydrolyzed liquid human milk fortifier. J Pediatr Gastroenterol Nutr. 2015; 61 (6): 665-71.
16. Singh P., et al. Comparison of osmolality of human milk after fortification with three different fortifiers. Current Medicine Research and Practice. 2017; 7: 81-3.
17. Thoene M., et al. Comparison of a powdered, acidified liquid, and non-acidified liquid human milk fortifier on clinical outcomes in premature infants. Nutrients 2016; 8: 451.
18. Chan G.M. Effects of powdered human milk fortifiers on the antibacterial actions of human milk. J Perinatol. 2003; 23: 620-3.
19. Erickson T., Gill G., Chan G. M. The effects of acidification on human milk's cellular and nutritional content. J Perinatol. 2013; 3: 371-3.
20. Brown J.V.E., Embleton N.D., Harding J.E., McGuire W. Multi-nutrient fortification of human milk for preterm infants. Cochrane Database Syst Rev. 2016; 5: CD000343.
21. Siegel M., et al. Gastric emptying in prematures of isocaloric feedings with differing osmolalities. Pediatr Res. 1982; 16: 141-7.
22. Ramirez A., et al. Factors regulating gastric emptying in preterm infants. J Pediatr. 2006; 149 (4): 475-9.
23. Yigit S., et al. Breast milk fortification: Effect on gastric emptying. J Matern Fetal Neonatal Med. 2008; 21 (11): 843-6.
24. Kien C.L., Ault K., McClead R.E. In vivo estimation of lactose hydrolysis in premature infants using a dual stable tracer technique. Am J Physiol. 1992; 263 (5 Pt 1): E1002-9.
25. Auricchio S., Rubino A., Muerset G. Intestinal glycosidase activities in the human embryo, fetus, and newborn. Pediatrics. 1965; 35: 944-54.
26. Tsang R. C., Uauy R., Koletzko B., Zlotkin S. Nutrition of the preterm infant. Scientific basis and practical application. 2nd ed. Cincinnati: Digital Educational Publishing Inc., 2005.
27. Kien C.L., Liechty E.A., Myerberg D.Z., Mullett M.D. Dietary carbohydrate assimilation in the premature infant: Evidence for a nutritionally significant bacterial ecosystem in the colon. Am J Clin Nutr. 1987; 46 (3): 456-60.
28. Kien C.L., Kepner J., Grotjohn K., Ault K., McClead R.E. Stable isotope model for estimating colonic acetate production in premature infants. Gastroenterology. 1992; 102 (5): 1458-66.
Feeding a child is the most important factor in ensuring his life, health and harmonious development. Today, neither healthcare professionals nor mothers have any doubts that breast milk is the optimal food product for babies in the first year of life. It is ideally adapted to all the features of the baby's digestion and metabolism, contains all the necessary nutrients and a number of protective factors that are a reliable barrier against various diseases. Milk production may sometimes decrease, but this can be temporary, so you shouldn't buy infant formula right away. However, there are situations when the mother does not have milk, and the child has to be transferred to mixed or artificial feeding. Transfer to artificial feeding
Transfer to artificial feeding is a very crucial moment in your baby's life. You need to know how to do this correctly, which mixture to choose and what to do, so that there are no negative reactions to a new baby food product.
Remember! None even the most modern and expensive artificial formula will not become a full-fledged substitute for breast milk. Therefore, when choosing a mixture, we recommend that you consult with a pediatrician who observes your baby and is well aware of the peculiarities of his development and state of health.
There are different types of infant formula: liquid and dry, fresh and fermented milk, based on cow's milk or on the milk of other animals.
On the banks with mixtures, numbers are written, which mean:
● 1 - "initial" or "starting" for children of the first 6 months of life;
● 2 - "follow-up" formulas for children 6-12 months old;
● "Standard" mixtures - from birth to 12 months - are not marked with numbers.
"Initial" mixes are maximally adapted for children aged 1 to 6 months. When choosing a mixture, pay attention to the protein content: the maximum level is 1.4 - 1.6 grams per 100 milliliters of liquid.
And also find the ratio of the albumin and casein fractions of the protein component. The more albumin (serum proteins) in the mixture, the closer the composition is to breast milk.
It is equally important that the mixture contains a very amino acid - taurine, which affects the central nervous system and vision. But the fat in 100 milliliters of the diluted mixture should be about 3.4 - 3.7 grams. In this case, the ratio of linoleic and α-linolenic fatty acids should be 10: 1 - 8: 1.
As carbohydrates Infant formula uses lactose or a combination of lactose with dextrinmaltose. Many formulas contain saccharides, which, like lactose, serve as a breeding ground for the growth of bifidobacteria in the baby's intestines. But sucrose is not used in mixtures, since the appearance of sugar in the crumbs menu can lead to the development of caries or allergies.
The composition of vitamins and minerals in mixtures is very important. It makes no sense to list everything, young mothers need to look for iron on packages (0.6 - 0.8 milligrams per 100 milliliters), ascorbic acid (5 - 10 milligrams per 100 milliliters), the proportion of calcium and phosphorus (1.5: 1 - 2.0: 1).
What is the osmolality of the mixture?
On the packaging, do not miss the data on the osmolality of the mixture - an indicator of the load on the kidneys and cells of the mucous membrane of the child's small intestine. It should not exceed 290 - 320 mosm / l, as in human milk.The amount of nutrients in the "initial" mixture for a seven-month-old baby is no longer enough, therefore, mixtures of a different composition were provided for children of the second half of the year. In the "next" mixtures more protein (up to 2.1 g per 100 ml), all the necessary set of vitamins and minerals, a fairly high content of iron, calcium, zinc. The latter is due to the fact that by this age the reserves of iron are depleted, the child needs them from the outside.
Formulas "from 0 to 12 months" can be used in the nutrition of children throughout the first year of life. They will help parents out when it is difficult to decide on the use of "initial" or "follow-up" mixtures.
Sour milk instead of powder
Today, so-called adapted fermented milk products are used in the nutrition of infants. For this, special strains of bifidobacteria and lactobacilli are selected, as well as thermophilic streptococcus. Such fermented milk mixtures can be offered to children simultaneously with fresh mixtures from the first weeks of life.It is possible to determine whether the mixture is correctly chosen according to only one criterion: the baby tolerates it well. He eats with pleasure, does not spit up, does not develop allergies, there are no problems with the tummy ...
But, before transferring a child to artificial feeding, be sure to consult your doctor. Health to you and your baby!
Elena BARANAEVA,
Associate Professor of the Belarusian State Medical University
The cow's milk used in the preparation of the formula differs from the mother's in a higher content of protein and mineral salts, a lower level of carbohydrates, fatty acids, and vitamins. Therefore, in preparing the mixture, the manufacturer adapts cow's milk for all constituent substances, bringing its composition as close as possible to that of breast milk. In this article, we provide data on the required content of essential nutrients that SanPin requires and dictates the creators of international standards.
Calorie content
Should be in the 64-72 kcal range.
Squirrels
100 ml of breast milk contains up to 1.3 g of protein in the first 30 days and up to 1.15 g thereafter.
Protein adaptation consists in replacing casein proteins with whey proteins, which form a looser, tender clot in the child's stomach, the predominance of whey proteins contributes to better absorption, copper, etc. In breast milk, casein proteins make up no more than 35% of the total; in cow's milk, casein accounts for about 80%. Therefore, the ratio of whey proteins to casein in baby food should be 3: 2 (60:40). In order to reduce and not add stress on the kidneys of the baby, the amount of casein should not exceed 50% of the total protein content.
Also, the mixture must be enriched with essential amino acids (taurine, histidine, arginine), which are absent in cow's milk. Taurine is one of the most important. It is needed for the structure of the retina, brain tissue. Breast milk contains 5 mg / 100 ml, baby food must contain taurine in the amount of 5-7 mg / 100 ml.
Recently, more and more biologically active compounds - nucleotides (structural units of a protein) - have begun to be added. Content in breast milk - 3.0 / 100 ml. A healthy full-term baby does not need them, but the use is quite justified, since nucleotides regulate various multi-stage processes of tissue formation, especially in conditions of rapid growth. In addition, these biologically active compounds are necessary for the immune system, promote the maturation of intestinal cells and the growth of favorable flora in it.
In nutrition for older children, the protein content increases to 1.8–2.2 g, and the proportion of casein increases to 60%.
Fats
If breastfeeding is impossible, the mixture is the main food of the child in the first 12 months of his life, the health of the baby directly depends on its composition.
In human milk, they are contained in an amount of 3.7-3.9 g / 100 ml. In baby food, the recommended amount is 3–3.8 g. Food for children must necessarily contain vegetable oils, which are the main source of essential fatty acids necessary for the development of the brain, organs of vision, and enhancement of immunity. When adapting nutrition, both partial and complete replacement of animal fat with vegetable oils is allowed. Sunflower, corn, soybean, coconut and palm are more commonly used. On the packaging, they are indicated as linoleic and linolenic acids, their optimal ratio in baby food is 10: 1.
On a note!
- linoleic acid should be 13% (or more than 0.4 g) of the total amount of fatty acids;
- tauric and myristic - no more than 15% of the total amount of fats;
- the ratio of omega-3 to omega-6 fatty acids is normally 1: 5–1: 10.
Emulsifiers
Their presence is important. On the packaging are indicated as lecithin, mono- and diglycerides. They are responsible for the full use and proper consumption of fats in the body, breaking down fat molecules into smaller ones, which contribute to their better absorption.
Lactulose
The recommended content is at least 3.5 g / 100 kcal. Lactulose is the main carbohydrate in human milk, it provides normal intestinal flora, the absorption of calcium, manganese and magnesium. Unlike sugar, it reduces the risk of allergies and tooth decay. Some manufacturers (NAN, Humana, Semper) add dextrinmaltose (maltodextrin) instead of lactulose, which is a close relative of starch, but easier to digest and absorb. It is more correct to use maltodextrin in the nutrition of children over 6-7 months. The optimal ratio of lactulose and maltodextrin is 75:25.
Vitamins and minerals
All mixtures, without exception, are enriched with vitamins and minerals. The amount of vitamins and minerals in baby food should be 15–20% higher than in breast milk, due to their poorer absorption from cow's milk. In the table, we have placed the main vitamins and minerals (the quantities for the subsequent mixtures are indicated in parentheses).
| Recommended content per 100 ml of baby food | Content in breast milk | |
| Minerals: | ||
| Fe, mg | 0,6–1,2 (1–1,4) | 0,5 |
| 5–10 | 6,0 | |
| P, mg | 25 (30–50) | 15 |
| Zn, mg | 0,37–1,1 | 0,12–0,29 |
| 30–50 (40–70) | 28–34 | |
| K, mg | 50–80 (60–90) | 58 |
| Mg, mg | 4–6 (5–7) | 4 |
| Na, mg | 20 (15–30) | 18 |
| Cu, μg | 30–60 (40–100) | 25 |
| Vitamins: | ||
| Folic acid, mcg | 5–10 | 8,5 |
| 4–10 | 5,2 | |
| 50–80 (60–80) | 67 | |
| Beta-carotene, mcg | 25–40 | 23 |
| 0,05–0,07 | 0,05 | |
| 0,4–1,2 (0,6–1,2) | 0,316 | |
| K, mcg | 2,5–5 (2,5–6) | 0,2 |
Only a doctor should prescribe a formula for artificial feeding to a child. But mothers do not hurt to know what they are feeding their babies with.
Today formula for artificial feeding of babies is a high-tech product, and only a doctor should prescribe them to a child. But mothers do not hurt to know what they are feeding their babies with.
They are so different!
All formulas for baby food are divided into adapted, partially adapted and non-adapted. In addition, there are many other classifications - these are dry and liquid (ready-to-eat), fresh and sour (fermented milk), conventional, therapeutic and prophylactic and therapeutic. Also, many manufacturing firms have an age gradation:
for newborns, including premature babies, children with intrauterine growth retardation, "zero" or mixtures with the prefix "Pre" are produced;
starting, or "ones", with gradation for children from birth to six months;
subsequent - from six months to a year and older, the so-called "two" (6-12 months) and "C" (over 10-12 months);
and non-gradual (from birth to one year).
Starting and following mixtures differ in the amount of protein, vegetable fats, lactose (milk sugar), vitamins and minerals. In addition, they differ in caloric content and osmolarity (the amount of acid and alkaline bases required for normal kidney function). For example, 100 g of the Hipp-1 mixture contains 73 kcal, and the osmolarity is 241 mOs-mol / l, while 100 g of the Hipp-2 mixture contains 78 kcal, and its osmolarity is 320 mOsmol / l ... Such changes in the composition of the mixtures are adjusted to the dynamics of changes in the composition of breast milk, to the needs of the crumbs changing with age.
Several groups belong to adapted mixtures.
First group- highly adapted mixtures :
fresh - "Bellakt-1", "PreHipp", "Hipp-1", "Puleva-1", "Nutrilon-1", "Nutrilon Om-neo", "Pikomil-1", "Heinz", "Enfamil- 1 "," SMA "," Gallia-1 "," Tutteli "," Pillty "," Frisolac with nucleotides "," Mamex Plus "," Semper Baby-1 "," AGU-1 "," Nan "," Nutrilak 0-6 "," Humana-1 ".
fermented milk - "Nan fermented milk". These mixtures are the best for a baby in the first six months of life. The mixtures "Alesya", "Tonus", "Nutrilak" are quite close in composition to women's milk.
In the nutrition of an infant deprived of breast milk, it is these adapted formulas that should be used as close as possible in their composition to human milk. They contain all the essential nutrients and are safe to overload the liver and kidneys with excess salt and protein. A serious disadvantage of these products is the lack of protective (immunobiological) properties.
Second group called subsequent mixtures, they are less adapted, these include fresh ones - "Bellakt-2", "Nan 6-12", "Hipp-2", "Semper Baby-2", "Nutrilon-2", "Gallia-2" , "AGU-2"; fermented milk - "Nan 6-12 with bifidobacteria". These mixtures are the best for a child in the second half of life. The amount of protein, as well as the calorie content of these mixtures is higher than in the starting ones. In addition, this type of mixture is enriched with iron, as well as vitamins and minerals necessary for growth and development.
The following fresh mixtures - "Similak", "Nestogen", "Impress" and fermented milk - "Lactofidus", "Agusha" are less adapted and are chosen only if the previous group is not suitable.
But the fresh mixtures "Malyutka", "Malysh", "Vitalakt", "Aptamil", "Milumil", "Milazan", "Solnyshko" and sour milk acidophilic "Malyutka", "Bifilin", "Tonus", "Bifidobakt" are partially adapted mixtures. Therefore, they are selected only when it is impossible to feed with adapted mixtures.
There is also a group of unadapted mixtures for children - these are fresh mixtures, or rather sterilized milk, fortified milk and fermented milk mixtures, which include bio-kefir, bifitat, biolact, acidolact, "Totoshka-2", "Evita", "Narine". In the nutrition of children at the present stage, they should only be used in emergency situations.
How do milk formulas try to bring them closer in composition to human milk?
In the production of adapted mixtures, cow's milk is used, less often goat's. The adaptation process of cow's milk in the composition of the mixture includes a decrease in the amount of protein, a decrease in the amount of calcium salts. Also, the fat component is changed in milk - refractory fatty acids are removed from it, and essential omega-3 and omega-6 fatty acids are additionally introduced. The carbohydrate component is changed by increasing the carbohydrate content of lactose (milk sugar) and dextrinmaltose - they contribute to the growth of beneficial intestinal microflora, especially bifidobacteria.
We will tell you in more detail how this is done.
It is important for the health of the baby that the mixture contains a complete protein with a set of essential amino acids. Modern highly adapted breast milk substitutes should contain the amino acid taurine, which is not sufficiently synthesized in the child's body, but is necessary for normal development - the maturation of the brain and retina. It is very good if the mixture contains nucleotides that activate the baby's lymphocytes, contribute to the formation of intestinal functions, the growth of bifidobacteria, the absorption of iron in the intestine (mixtures "NAN", "Lactose-free NAL", "Frisolak", "Mamex Plus", "CMA", " Nanny "," Enfamil "," Similak formula plus 1-2 ").
It is necessary to highlight mixtures with an improved protein component - "NAS" and "Mamex Plus". In them, 70% of the protein component is represented by a modified fraction of whey proteins, the amino acid composition is close to breast milk. These mixtures significantly reduce the metabolic load on the kidneys of the child, contain nucleotides and the trace element selenium (read more about it below).
Also, a child needs energy in the process of growth and development, and a significant part of it is extracted by the body from the breakdown of fats. Some fatty acids essential for health cannot be synthesized in a child's body.
Their food source is vegetable oils: for medium-chain fatty acids - coconut, for linoleic - sunflower and corn oil, for linolenic - soybean, for long-chain - linseed oil. Vegetable oils are added to the mixture, thereby ensuring the approximation of the fatty acid composition of the milk mixture to the fatty acid composition of human milk.
The ratio of long-chain fatty acids of the omega-6 and omega-3 series in mixtures for the first half of life should be 15: 1, and for the second half of life - 10: 1. To improve the assimilation of fat, the milk mixture should include:
natural emulsifiers (lecithin, mono- and diglycerides), which help to better "dissolve" fats in the intestine;
carnitine - a vitamin-like compound that improves the oxidation of fats in the tissues of the child;
as well as phospholipids, which are structural elements of biological membranes and ensure uniform evacuation of food from the stomach, intestinal motility, and bile outflow.
The own fat of cow's milk, represented mainly by refractory fatty acids, is partially or completely extracted.
A mixture that is properly balanced in terms of fat is especially needed by children, who have a history of cardiovascular accidents in their relatives. For them, mixtures should be selected based on skimmed cow's milk with the addition of vegetable oils, of which coconut is the best. An example of such mixtures are "NAS", "Nutrilak", "Hipp", "Similak", "Enfamil", "Nutrilon", "Webi", "Gallia", "Mamex plus".
The mixtures, enriched with medium-chain triglycerides (MCT), are intended for children with the syndrome of impaired intestinal absorption, diseases of the pancreas, liver and biliary tract, when the processes of breakdown and absorption of fats in the small intestine are impaired. MCTs can be absorbed directly into the bloodstream, bypassing the lymphatic system and without requiring emulsification. An example of such a specialized blend is Portagen, it contains all the necessary nutrients, and as a source of fat - medium chain triglycerides, which make up more than 80% of the total fat. MCTs are part of specialized mixtures based on protein hydrolysates (Alfare, Nutrilon Pepti-TCS, Pregestemil, Nutrilon Omneo), which are intended for feeding babies with food allergies.
For constipation, mixtures containing a fatty component enriched with palmitic acid in a special position are desirable, contributing to the formation of soft, digested stools, similar in consistency to that of breastfeeding (mixtures "Nan", "Nan fermented milk", "Nestogen").
In addition to the energy function, carbohydrates in adapted mixtures should contribute to the development of physiological microflora in the intestine. So, lactose promotes calcium absorption and has a bifidogenic effect, i.e. supports the growth of bifidobacteria, lowers the pH in the large intestine. Often, lactose is combined with a low molecular weight polymer of glucose - dextrinmaltose, which is absorbed more slowly than lactose, causing a slow increase in glycemia. As a result, the feeling of hunger occurs in infants later, hence the calm behavior between feedings and the possibility of lengthening the intervals between them. Instead of dextrinmaltose, malt extract or molasses can be added to the mixture.
In order to promote the correct formation of bifidoflora in children who are bottle-fed, a mixture of prebiotic fibers (oligosaccharides) has been developed, which in its composition and properties reproduces the prebiotic effect of breast milk oligosaccharides. Prebiotic fibers have a beneficial effect on stool formation, making it softer and preventing constipation. Such an effect is possessed by the mixtures "Nutrilon Omneo", "Samper Bifidus", "Mamex", which makes it possible to use these mixtures for infants with functional disorders of the gastrointestinal tract (colic, flatulence), symptoms of partial lactase deficiency, after intestinal infections.
With artificial feeding, there is a problem of overfeeding children with carbohydrates, which leads to overweight, decreased immunity, allergization, and increases the load on the child's pancreas. Therefore, an important requirement for modern adapted mixtures is the content of oligosaccharides ("Mamex Plus", "Nutrilon Omneo"), as well as restriction of carbohydrates, the content of which should not exceed 12 g per 100 kcal. An example of such mixtures are Nan, Nutrilak, MamexPlus, Gallia, Nutrilon, Hipp pre or 1.
The second problem associated with carbohydrates is lactase deficiency, which is quite common in immature, premature babies who have undergone hypoxia. With such a transient lactase deficiency caused by immaturity, it is advisable to feed the child with mixtures with a reduced lactose content - low-lactose, and if the lactase deficiency is pronounced (the child has bloating, anxiety, screaming, frequent loose stools with an abundance of gas) - lactose-free.
Casein mixtures are less adapted in terms of protein composition. They are prepared from dry cow's milk without the addition of demineralized milk whey. Their main protein component is hard-to-digest casein.
In partially adapted mixtures ("Baby", "Malysh", "Aptamil", "Vitalakt", "Milu-mil", "Miyaazat," Solnyshko ", etc.) there is no whey and the fatty acid composition is not fully balanced, and not only lactose is used as a carbohydrate component, but also common sugar and starch.
What vitamins and minerals should milk formulas contain?
Any adapted breast milk substitute, according to the recommendations of the FAO / WHO Codex Alimentarius Commission, must contain at least 11 minerals - calcium, potassium, magnesium, phosphorus, manganese, iron, copper, zinc, iodine, sodium, chlorides. There are mixtures that additionally contain fluorine, chromium, molybdenum, and selenium.
Also, according to the recommendations of the same commission, 15 vitamins, including A, E, K, B, C, B, folic acid, biotin, choline, inositol, niacin, should be added to the composition of the adapted mixtures.
In this regard, when artificial feeding with adapted formulas, children should not be additionally prescribed vitamins, including vitamin D and mineral supplements.
Of great importance is the presence in the adapted mixtures of a physiological ratio of calcium and phosphorus of about 2: 1 (as in breast milk). This promotes good absorption of these microelements, which is necessary for the growth of bone tissue, teeth, and for the metabolism of an infant.
Correction of adapted mixtures with iron is important. The average iron content in modern adapted mixtures is 0.7–0.8 mg per 100 ml of a properly prepared mixture. This level of iron is found in the mixtures "Nan", "Nan fermented milk", "Nestogen", "Hipp 1 and 2", "Frisolak", "Nutrilak 0-12", "Nutrilon-1", "Humana 1", "Samper Baby -1 "," Heinz ". This level of iron in mixtures is preferable, especially in the first half of a child's life, since an increased intake of iron can have a negative effect on the absorption of other trace elements.
The fact is that up to 3 months of age, hematopoiesis in a child occurs due to reserves of endogenous (own) iron. Not absorbed iron increases the vital activity of gram-negative opportunistic microflora, therefore, up to 4 months of age, children are not recommended to prescribe iron-fortified mixtures.
For children with a risk of anemia, there are special adapted mixtures fortified with iron (up to 1.0-1.2 mg in 100 ml of the mixture) - these are "Gallia 2", "Leri1", "SMA with iron", "Similak with iron" , "Enfamil with iron".
In modern mixtures, metal complexes are not associated with lactoferrin, therefore they are absorbed worse than from mother's milk. Currently, it is planned to release mixtures with lactoferrin, which will improve the absorption of iron from the mixture.
In the nutrition of children of the second half of the year, it is preferable to use the following formulas - No. 2 with a higher iron content: 1.1-1.4 mg per 100 ml of the finished mixture.
When choosing a formula for artificial feeding in iodine-deficient areas and in unfavorable environmental conditions, it is necessary to take into account the iodine content in them. It is known that the trace element iodine is the most important "nutrient of the intellect". It is an integral part of the hormones produced by the thyroid gland. These hormones regulate the maturation of the central nervous system in a baby's first year of life. According to modern research, a baby in the first 6 months of life should receive up to 110 mcg of iodine per day, in the second half of the year - about 130 mcg. The largest amount of iodine (more than 100 μg / l of the finished product) is contained in the mixtures "Nan", "Nestogen", "Nan fermented milk", "Nan 6-12", "Enfamil", "SMA", "Frisolak", "Nutrilon". These mixtures are well balanced in terms of zinc, manganese and other trace elements.
Domestic mixtures "Nutrilak" contain iodine (65-74 mcg / l of the finished product) in an insufficient amount, and the mixture "Vinnie" is included in the group of the lowest-dose in terms of iodine. Children of the second half of life need to take into account the iodine content in complementary foods of various production. For children from 6 months of age, Nestlé produces a mixture of Nan 6-12 with bifidobacteria with an iodine content of 140 μg / l.
It is important to take into account the content of an irreplaceable trace element in the mixture - selenium, which, together with iodine and iron, contributes to the development of intelligence, memory, and participates in the antioxidant defense of the body. Selenium reduces the risk of developing viral and bacterial infections, malignant neoplasms, myocardial dystrophy, a decrease in the production of thyroid hormones, and liver dysfunction. Selenium-containing mixtures: Nan, Pre-Nan, Nutrilak, Nutrilon, Mamex Plus.
With artificial feeding, the baby needs extra fluids. Between feedings it is necessary to drink boiled water, it is better to use baby water for this. The daily volume of fluid is generally equal to the volume of one feeding plus 10 ml. In the hot season, with dyspeptic disorders, an increase in temperature in an infant, the volume of fluid should be increased.
What is the difference between fermented milk mixtures?
In the diet of children deprived of mother's milk, there should be formulas containing pre- and pro-biotics. Probiotics are understood as various types of living microorganisms that have a positive effect on human health by normalizing the intestinal microbiocenosis. Prebiotics are selective compounds that promote the growth of probiotic microorganisms. One of the options for such products is fermented milk mixtures.
Fermented milk mixtures contain lactic acid, which contributes to gentle curdling of protein, better assimilation of fat, the formation of vitamins of group B and C. Fermented milk mixtures are slowly evacuated from the stomach, increase the secretion of the gastrointestinal tract, are easier to digest, reduce fermentation in the intestine, and contribute to the normalization of microflora -intestinal, suppressing and displacing disease-causing microbes. Fermented milk mixtures are recommended for food intolerances and food allergies to cow's milk proteins, primary and secondary lactase deficiency, disorders of intestinal motor function (diarrhea and constipation), intestinal infections, etc.
Preference should be given to liquid fermented milk adapted mixtures - "Agusha-1 fermented milk" and "Agusha-2 fermented milk". But there are also dry adapted fermented milk mixtures. So, the milk mixture "Gallia Lactofidus" with bifidobacteria and lactase has biological acidification and is intended for feeding children from birth to 1 year. The mixture is highly adapted, contains complete proteins, fats, carbohydrates, minerals, vitamins, enriched with taurine, carnitine, contains oligosaccharides, i.e. all the necessary ingredients for the normal development of the baby. The use of such a mixture is recommended for functional disorders of the gastrointestinal tract (colic, constipation, flatulence, regurgitation), partial lactase deficiency, intestinal dysbiosis. When diluted with water, the mixture takes the form of a finely dispersed suspension. This is normal and is associated with the fermentation process of milk.
A good therapeutic and prophylactic mixture is Nan Fermented Milk, which can be used from birth. For children from 6 months to 1 year old, for the prevention and treatment of dysbiosis, you can use adapted mixtures with bifidumbacteria "Nan 6-12", "Nutrilak Bifi", "Semper-bifidus", which have bifidogenic properties.
Paretskaya Alena,
pediatrician, member of the Association of Consultants
on natural feeding, member of the IACMAC association,
nutritional specialist for young children.
