Mixed feeding of a child

Artificial and mixed feeding can and should be implemented only according to vital indications, that is, with the conviction of health workers, preferably their consultation, in the mother's inability to adequately lactate and the high risk of chronic child starvation.

All health workers should be convinced of the unconditional nonoptimality, the non-physiological nature of the artificial feeding of children of the first year of life, the risk of both immediate and remote negative consequences of the refusal of natural feeding. According to the Declaration adopted at the WHO / UNICEF meeting in December 1979 (WHO Chronicle, 1980, No. 4): "Breastfeeding is a natural and ideal way of feeding an infant. Therefore, society is responsible for encouraging breastfeeding and protecting lactating mothers from any effects that may harm breastfeeding. All women should be provided with information related to the preparation for breastfeeding and ways that breastfeeding can be supported. All postnatal care should be aimed at the longest possible maintenance of natural feeding ... Trade in breastmilk substitutes should be carried out in such a way as not to contribute to the rejection of breastfeeding. The resources of the health system should never be used to encourage artificial feeding. Therefore, advertising of breast milk substitutes through the channels of the health service is not permissible. Artificial feeding should not be openly demonstrated in health care facilities. "

At the same time, it should be recognized that 4-10% of women giving birth are diagnosed with inability to adequately lactate, regardless of the whole range of preventive measures. Therefore, the problem of feeding infants without the participation of the mother will always be relevant for pediatrics. The most promising way out of the situation, which causes minimal damage to the child, is the creation of banks of native female milk, similar to existing blood banks, and imitation feeding methods (nipple-lining on the breast with a nipple-"milk pipe").

It should also be borne in mind that, despite the apparent lack of physiology and some even significant risks to the quality of life of a child by artificial feeding it, modern "substitutes" for women's milk can not be considered obligately disabling or life-threatening. Entire generations of people in the modern civilized world (developed countries of Europe and the USA) grew almost exclusively or mainly on artificial feeding and on products - substitutes for women's milk, much less perfect than modern ones. The development of science and technology, arts and crafts have been preserved, people continued to commit feats and atrocities, to be happy and unhappy, no matter what kind of feeding they received in the first year of life. Therefore, it is wrong to talk about the imminent and total doom of those children whose mothers could not raise them with their breasts.

The history of the creation of artificial food for infants is rich in dramatic events and the search for attempts to feed diluted water with chicken eggs until they are fed with canine milk and other domestic animals' milk. "Dairy kitchens" were kept in our cities for a long time, where mixtures A, B, B (or No. 2, 3, 5) were prepared as simple dilutions of cow's milk with various cereal broths with 5% glucose added to this dilution. Cow's milk farming fulfilled its mission - they ensured the survival of many millions of children deprived of their mother's breast during the most difficult military and post-war years. In the 1960s and 1980s, the domestic infant food industry was able to master the production of the next generation of artificial feeding formulas (Malysh, Malyutka, Agu 1 and 2, Molochko, Bifillin, Kislomolokny Bebilak 1 "," Babilak 2 ", etc.). These products consistently bring closer to the best samples of infant formulas, produced in the world.

Currently, in sufficiently developed countries, artificial and mixed feeding is carried out exclusively on the basis of the use of modern adapted products - dry or liquid dairy mixtures of industrial production. A wide range of mixtures for nutrition of both perfectly healthy children and children with special features is available (presence of colic, limited tolerance to lactose, propensity to regurgitate, allergic reactions, etc.). There are mixtures that are aimed at children of the first or second half of life, as well as for feeding babies at birth. The nutrient composition of the mixtures is regulated by the accepted international or state standards. International Codex Alimentarius, recommendations of the European Society of Pediatrics, Gastroenterology and Nutrition (ESPGAN) and directives of the European Union countries, to the state for Russia - SanPiN. The following are the regulations contained in these documents.

Mixtures produced by modern technology can be based on the processing of cow's milk. In this case, predominantly whey proteins are used with a ratio to casein of about 60:40. In recent years, mixtures based on goat milk and plant proteins, especially soybean, have been an alternative.

Fats are significantly supplemented with vegetable carriers of essential polyunsaturated fatty acids or their metabolic precursors (linoleic for ω6- and α-linolenic for ω3-fatty acids). Carbohydrates are lactose and are often supplemented with either glucose polymers or corn syrup. The main advantage of artificial mixtures is a wide range of essential micronutrients - vitamins, salts and trace elements.

The composition of modern mixtures for infant nutrition is enriched and conventionally with essential nutrients, which include amino acids (taurine, choline, arginine), nucleotides, inositol, carnitine. Requirements for the composition of baby foods (per 1 liter)

Nutrients	SanPiN 2.3.2.560-96	ESPGAN	Codex Alimentarius	Directives of the countries of the European Union
Energy, kcal	600-720	640-720		600-750
Protein, g	15-18	12-20	12.2-27.22	11-20.5
Fat, g	33-38	28-43	22.4-40.8	19.8-48.8
Linoleic acid, g	14-16% of total fatty acids	3.2-8.2	Minimum 2.0	1.8-9.0
Carbohydrates, g	70-75	54-86		42-105
Vitamin A	500-800 μg	1600-3600 IU	1700-3400 IU	1200-4500 IU
Vitamin D	8-12 μg	256-576 IU	272-680 IU	242-750 IU
Vitamin E	4000-12000 μg	At least 4.5 IU	Minimum 4.8 IU	At least 4.5 IU
Vitamin K	25-30 μg / l	Minimum 25.6 IU	At least 27.2 IU	At least 24 IU
Thiamine, μg	350-600	Minimum 256	Minimum 272	Minimum 240
Riboflavin, μg	500-1000	Minimum 384	Minimum 408	Minimum 360
Vitamin B6, μg	300-700	Minimum 224	Minimum 238	Minimum 210
Vitamin B-12, μg	0.2-0.6	Minimum of 0.6	Minimum 1.02	Minimum of 0.6
Niacin, μg	3000-5000	Minimum 1600	Minimum 1700	Minimum 1500
Folic acid, μg	50-100	Minimum 25.6	Minimum 27.2	At least 16.3
Biotin, μg	10-20	Minimum 9.6	At least 10.2	Minimum 9
Vitamin C, mg	25-50	A minimum of 51.2	At least 54.4	Minimum 48
Choline, mg	50-80		Minimum 47.6
Inositol, mg	20-30
Calcium, mg	450-650	Minimum 320	Minimum 340	Minimum 300
Phosphorus, mg	250-400	160-648	Minimum 170	150-675
Magnesium, mg	40-70	32-108	At least 40.8	30-112.5
Iron, mg	3-12	3.2-10.8	Minimum 1.0	3-11.3
Zinc, mg	3-5	3.2-10.8	Minimum 3.4	3-11.3
Manganese, μg	20-50	Minimum 22	Minimum 34
Copper, μg	300-500	128-570.6	Minimum 408	120-600
Iodine, μg	30-50	Minimum 32	Minimum 34	Minimum 30
Sodium, mg	200-300	128-432	136-408	120-450
Potassium, mg	500-700	384-1044	545-1360	360-1087.5
Chlorides, mg	600-800	320-900	374-1020	300-937.5

New opportunities to increase the physiological value of artificial products for feeding children arise when they are enriched with probiotics and (or) prebiotics. 

Probiotics are food additives containing live bacterial cultures. They are introduced to modify the microbiota of the child's gastrointestinal tract to normalize it or have a positive effect on health.

Cultures are injected more often through fermented dairy products. They use mainly certain strains of lactic acid and bifidum bacteria. Especially often used:

• Lactobacillus reuterii;
• Lactobacillus rhamnosis GG;
• Lactobacillus acidophilus;
• Lactobacillus casei;
• Lactobacillus bifldus LA 7.

Prebiotics are indigestible or nonmetabolized by the child's body components of food products, which help maintain the most health-friendly bacteria of the gastrointestinal tract. Most often - food fibers, oligo- and polysaccharides, immunoglobulins.

Synbiotics are additives that include a combination of pro and prebiotics. The presence of pro- and prebiotics gives food products the possibility of greater biological assimilation of nutrients. But mainly increases the degree of resistance of the gastrointestinal tract to pathogenic microorganisms. Pro- and prebiotics can not substitute for themselves the essential essential nutrients. Advantages of the mixtures produced by the industry are determined primarily by their multicomponent balance in nutrients and, after that, the presence or absence of probiotics.

In recent years, the range of products for artificial feeding is expanding due to non-dairy mixtures based on soy. Soy mixtures began their history as specialized products for children with intolerance to milk protein and lactose, but now take the place of physiological foods.

The nutritional value of soy mixtures for infant formula is not inferior to mixtures based on cow's milk, but it allows solving the nutrition problems for many children with atopic heredity and the risk of allergic diseases. The industry also produces other milk mixtures for "healthy but slightly special" children. These are hypoallergenic mixtures, mixtures for children prone to regurgitation, for children prone to unstable stools or intestinal colic, mixtures used at the risk of anemia. An increased interest in goat milk as a basis for adapted mixtures. This is due to the fact that for certain dietary positions, goat's milk is better than cow's milk. Its protein component does not contain α-Is-casein, the main allergenic protein of cow's milk. Fats of this type of milk have a high biological value due to increased concentrations of essential fatty acids and medium chain fatty acids. Goat's milk is the pre-eminent source of well-assimilable calcium, phosphorus, iron, copper.

Composition of goat's milk (according to recent literature)

Nutrients	Content in 100 ml	Nutrients	Content in 100 ml
Energy, kJ	289	Minerals:
Protein, g	3.56	Calcium, mg	133.5
Amino acids:		Phosphorus, mg	110.7
Alanin, g	0.119	Magnesium, mg	13.97
Arginine, g	0.119	Potassium, mg	204.4
Aspartate, g	2.209	Sodium, mg	49.8
Cystine, g	0.045	Chlorides, mg	127.0
Glutamate, g	0.627	Iron, mg	0.049
Glycine, g	0.049	Zinc, mg	0.299
Histidine, g	0.090	Copper, mg	0.045
Isoleucine, g	0.209	Selenium, μg	1.40
Leucin, g	0.315	Manganese, mg	0.016
Lysine, g	0.291	Vitamins:
Methionine, g	0.082	Vitamin A, ME	185
Phenylalanine, g	0.156	Vitamin A, r. E.	56
Proline, g	0.369	A-retinol, p. E.	56
Serin, g	0.180	Thiamine, mg	0.049
Threonine, g	0.164	Riboflavin, mg	0.139
Tryptophan, g	0.045	Niacin, mg	0.278
Tyrosine, g	0.180	Niacin, n. Eq.	1,008
Valine, g	0.242	Pyridoxine, mg	0.045
Fats		Vitamin B-12, μg	0.065
Total fat, g	4.24	Biotin, μg	0.3
Fat saturated, g	2.67	Vitamin C, mg	1.29
Fat monounsaturated, g	1.11	Vitamin D, μg	0.3
Polyunsaturated fats, g	0,15	Vitamin D, IU	12.00
ω6-fatty acids, g	0.11	Vitamin E, a-equ.	0.09
ω3-fatty acids, g	0.04	Vitamin E, ME	0.135
Trans fatty acids, g	0.12	Vitamin E, mg	0.09
Cholesterol, mg	11.40	Folic acid, μg	0.598
Organic acids, mg	130.0	Pantothenic acid, mg	0.311
Dry residue, g	0.82	Choline, mg	15.0
		Inositol, mg	21.0

Several "goat" mixtures have already appeared and have proved themselves well. For children from 1 year, a mix of "Nanni" (Vitacare, New Zealand), for children of the first half-year - "Mamil Kozochka 1", the second half-year - "Mamil Kozochka 2" (Enfagroup Nutrishinal) is intended. The industrial correction of goat's milk brought these products to a high nutritional value, and the biological properties of goat's milk components gave them not only good tolerability, but also a therapeutic effect on various diseases of the gastrointestinal tract and allergic diseases associated with intolerance to cow's milk proteins.

There is a tendency to more and more accurate orientation of the adapted mixtures to the age of the child. An example is the NANL Nutrition Line: preNAN for preterm infants, NAN-1 for healthy children from 0 to 6 months, NAN-2 for 6 months, NAN-3 for 10 months, Milk soluble "And" Clinic-Junior "- from 1 year.

It is desirable to use at the same time only one mixture with mixed feeding and not more than two mixtures with artificial. Acidified mixtures can be combined with fresh or sweet, occupying 1 / 3-1 / 2 of the daily volume of food.

If necessary with respect to the early transition to mixed feeding, i.e., before 3-5 months of life, it is advisable to increase the number of attachments to the breast to stimulate lactation, and after applying a few days of incomplete supplementary feeding with the mixture, and then return to the initial number of feedings with full complementation. With a stable but limited amount of lactation, when the daily volume of breast milk is 250-400 ml, you can alternate applying to the breast with a mixture of feeds.

For mixed, and especially artificial, feeding two-step system of rough calculation of nutrition is expedient. The first stage is the determination of the volume of food on the basis of the volumetric method, the second stage is the choice of products (mixtures) that provide the required quantity of ingredients in a given volume.

Estimated approaches are a guide for the initial purpose of nutrition. In the future, it must be corrected in accordance with the body weight curve and the individual response of the child to the proposed diet.

Regarding the feeding regimen and volume for one feeding, there is some inconsistency between the domestic and US-European approaches. Domestic pediatricians prefer a somewhat higher frequency of feeding, with a daily diet limited to 1 liter during the first year of life. It is possible that both approaches are equally eligible.

After 3 months of life, children on artificial feeding can receive not only sweet, but also acidic mixtures. At the same time it is desirable that the latter should not contain more than 1/3 of the total volume of mixtures and for the preparation of acidic mixtures, initially balanced products of industrial production are used.

Artificial feeding of children of the first year of life

Age	American and European schools	Domestic school
Approximate number of feedings during the day
The first week of life	6-10	7-8
1 week - 1 month	6-8	7-8
1-3 months	5-6	7-6
3-7 months	4-5	6-5
4-9 months	3-4	6-5
8-12 months	3	5
Volumes of mixtures per feed, ml
First 2 weeks	60-90	70
3 weeks - 2 months	120-150	100
2-3 months	150-180	120
3-4 months	180-210	160
5-12 months	210-240	200

When correcting mixed and artificial feeding, one should take into account the almost exhaustive needs of the child for enriching with the salts and vitamins of industrial food products. The indications for fluoride correction may be preserved, but for iron-poor mixtures, by iron. Increased osmolarity of mixtures can be the basis for the emergence of increased fluid demand. It is advisable to compensate it with unsweetened water after feeding or in the interval between feedings.

The introduction of lures for artificial feeding is necessary primarily to stimulate the skills of chewing and swallowing thick food, later (after 8-9 months), the lure will supplement milk nutrition by protein, carbohydrates and energy. The displacement of micronutrient rich milk mixtures with thick lures (vegetable purees and porridges) of home preparation can worsen the degree of balance of the diet. This requires the calculation of security.

[1], [2], [3], [4], [5], [6]