Mixed feeding of the baby

Artificial and mixed feeding can and should be implemented exclusively for vital indications, i.e. when medical workers, preferably their council, are convinced of the mother’s inability to adequately lactate and the high risk of chronic starvation of the child.

All health workers should be convinced of the absolute non-optimal nature and non-physiological nature of artificial feeding of children in the first year of life, and the risk of both immediate and remote negative consequences of refusing natural feeding. According to the Declaration adopted at the WHO/UNICEF meeting in December 1979 (WHO Chronicle, 1980, No. 4): “Breastfeeding is the natural and ideal way of feeding the infant. Therefore, society has a responsibility to encourage breastfeeding and to protect nursing mothers from any influences that may harm breastfeeding. All women should be provided with information on preparing for breastfeeding and on ways to maintain breastfeeding. All postnatal care should be aimed at maintaining natural feeding for as long as possible... Marketing of breast milk substitutes should be conducted in such a way as not to encourage refusing breastfeeding. Health care resources should never be used to encourage artificial feeding. Therefore, the advertising of breast milk substitutes through health service channels is not acceptable. Artificial feeding should not be openly demonstrated in health care settings."

At the same time, it should be recognized that 4-10% of women in labor are found to be unable to adequately lactate, regardless of the entire range of preventive measures. Therefore, the problem of breastfeeding without the mother's participation 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 native breast milk banks, similar to existing blood banks, and imitation feeding methods (a nipple-pad on the breast with a nipple-"milk pipeline").

It should also be borne in mind that, despite the obvious non-physiological nature and even some significant risks to the quality of life of a child from artificial feeding, modern "substitutes" for breast milk cannot be considered obligatory disabling or dangerous to life. Entire generations of people in the modern civilized world (developed countries of Europe and the USA) grew up almost exclusively or predominantly on artificial feeding and on products - substitutes for breast milk, much less perfect than modern ones. The development of science and technology, art and craft have been preserved, people continued to perform both feats and atrocities, to be happy and unhappy often regardless of what kind of feeding they received in the first year of life. Therefore, it is wrong to talk about the inevitable and total doom of those children whose mothers were unable to breastfeed them.

The history of the creation of artificial food products for infants is rich in dramatic events and searches from attempts to feed with chicken eggs diluted with water to feeding with dog milk and milk of other domestic animals. In our cities, "milk kitchens" were preserved for a long time, where mixtures A, B, C (or No. 2, 3, 5) were prepared as simple dilutions of cow's milk with various cereal decoctions with the addition of 5% glucose to this dilution. Dilutions of cow's milk fulfilled their task - they ensured the survival of many millions of children deprived of their mother's breast in the most difficult war and post-war years. In the 60-80s, the domestic baby food industry was able to master the production of the next generation of mixtures for artificial feeding ("Malysh", "Malutka", "Agu 1 and 2", "Molochko", "Bifillin", "Kislomolochny", "Bebilak 1", "Bebilak 2", etc.). These products consistently approach the best examples of infant formulas produced in the world.

Currently, in fairly developed countries, artificial and mixed feeding is carried out exclusively on the basis of using modern adapted products - dry or liquid milk formulas of industrial production. A wide range of formulas is produced for feeding both completely healthy children and children with special needs (colic, limited lactose tolerance, tendency to regurgitation, allergic reactions, etc.). There are formulas oriented towards children in the first or second half of life, as well as for feeding children with low birth weight. The nutrient composition of formulas is regulated by accepted international or state standards. International standards include the Codex Alimentarius, recommendations of the European Society of Pediatrics, Gastroenterology and Nutrition (ESPGAN) and directives of the European Union countries, and state standards for Russia include SanPiN. The regulations contained in these documents are given below.

Mixtures produced using modern technologies can be based on the processing of cow's milk. In this case, whey proteins are used predominantly with a ratio of about 60:40 to casein. In recent years, mixtures based on goat's milk and vegetable proteins, primarily soy proteins, have become an alternative.

Fats are substantially supplemented by plant carriers of essential polyunsaturated fatty acids or their metabolic precursors (linoleic for ω6- and α-linolenic for ω3-fatty acids). Carbohydrates are represented by 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 microelements.

The composition of modern baby food mixtures is enriched with conditionally essential nutrients, which include amino acids (taurine, choline, arginine), nucleotides, inositol, carnitine. Requirements for the composition of baby food products (per 1 l)

Nutrients	SanPiN 2.3.2.560-96	ESPGAN	Alimentary Codex	Directives of the European Union countries
Energy, kcal	600-720	640-720		600-750
Protein, g	15-18	12-20	12.2-27.2	11-20.5
Fat, g	33-38	28-43	22.4-40.8	19.8-48.8
Linoleic acid, g	14-16% of the 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 mcg	1600-3600 IU	1700-3400 IU	1200-4500 IU
Vitamin D	8-12 mcg	256-576 IU	272-680 IU	242-750 IU
Vitamin E	4000-12000 mcg	Minimum 4.5 IU	Minimum 4.8 IU	Minimum 4.5 IU
Vitamin K	25-30 mcg/l	Minimum 25.6 IU	Minimum 27.2 IU	Minimum 24 IU
Thiamine, mcg	350-600	Minimum 256	Minimum 272	Minimum 240
Riboflavin, mcg	500-1000	Minimum 384	Minimum 408	Minimum 360
Vitamin B6, mcg	300-700	Minimum 224	Minimum 238	Minimum 210
Vitamin B-12, mcg	0.2-0.6	Minimum 0.6	Minimum 1.02	Minimum 0.6
Niacin, mcg	3000-5000	Minimum 1600	Minimum 1700	Minimum 1500
Folic acid, mcg	50-100	Minimum 25.6	Minimum 27.2	Minimum 16.3
Biotin, mcg	10-20	Minimum 9.6	Minimum 10.2	Minimum 9
Vitamin C, mg	25-50	Minimum 51.2	Minimum 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	Minimum 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, mcg	20-50	Minimum 22	Minimum 34
Copper, mcg	300-500	128-570,6	Minimum 408	120-600
Iodine, mcg	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 for increasing the physiological value of artificial infant feeding products arise when they are enriched with probiotics and/or prebiotics. 

Probiotics are food supplements containing live bacterial cultures. They are administered to modify the child's own gastrointestinal microbiota to normalize it or to have a positive effect on health.

Cultures are introduced more often through fermented dairy products. Mainly certain strains of lactic acid and bifid bacteria are used. The following are especially often used:

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

Prebiotics are non-digestible or non-metabolizable components of food products that help maintain the most healthy bacteria in the gastrointestinal tract. Most often, these are dietary fibers, oligo- and polysaccharides, and immunoglobulins.

Synbiotics are additives that include a combination of pro- and prebiotics. The presence of pro- and prebiotics gives food products the ability to have greater biological assimilation of nutrients, but mainly increases the degree of resistance of the gastrointestinal tract to pathogenic microorganisms. Pro- and prebiotics cannot replace the main essential nutrients. The advantages of industrially produced mixtures are determined primarily by their multi-component balance in nutrients and only then by the presence or absence of probiotics.

In recent years, the range of products for artificial feeding has been expanding due to non-dairy soy-based mixtures. Soy mixtures began their history as specialized products for children with milk protein and lactose intolerance, but now they are taking the place of physiological food products.

The nutritional value of soy formulas for baby food is in no way inferior to formulas based on cow's milk, but it allows to solve the nutritional issues of many children with atopic heredity and the risk of developing allergic diseases. The industry also produces other milk formulas for "healthy, but slightly special" children. These are hypoallergenic formulas, formulas for children prone to regurgitation, for children prone to unstable stool or intestinal colic, formulas used at risk of anemia. Interest in goat's milk as a basis for adapted formulas has increased. This is due to the fact that goat's milk is better than cow's milk in certain dietary positions. Its protein component does not contain α-Is-casein - the main allergenic protein of cow's milk. The fats of this type of milk have high biological value due to increased concentrations of essential fatty acids and medium-chain fatty acids. Goat milk is an excellent source of easily digestible calcium, phosphorus, iron, and copper.

Composition of goat milk (according to literature data from recent years)

Nutrients	Contents in 100 ml	Nutrients	Contents in 100 ml
Energy, kJ	289	Minerals:
Protein, g	3.56	Calcium, mg	133.5
Amino acids:		Phosphorus, mg	110.7
Alanine, 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, mcg	1.40
Leucine, g	0.315	Manganese, mg	0,016
Lysine, g	0.291	Vitamins:
Methionine, g	0.082	Vitamin A, IU	185
Phenylalanine, g	0.156	Vitamin A, p. e.	56
Proline, g	0.369	A-retinol, p.e.	56
Serine, 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
Valin, g	0.242	Pyridoxine, mg	0.045
Fats		Vitamin B-12, mcg	0.065
Total fat, g	4.24	Biotin, mcg	0.3
Saturated fats, g	2.67	Vitamin C, mg	1.29
Monounsaturated fats, g	1.11	Vitamin D, mcg	0.3
Polyunsaturated fats, g	0.15	Vitamin D, IU	12:00
Ω6 fatty acids, g	0.11	Vitamin E, A-equiv.	0.09
Ω3-fatty acids, g	0.04	Vitamin E, IU	0.135
Trans fatty acids, g	0.12	Vitamin E, mg	0.09
Cholesterol, mg	11.40	Folic acid, mcg	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" formulas have already appeared and proven themselves well. For children from 1 year old, the formula "Nanny" (Vitacare, New Zealand) is intended, for children in the first half of the year - "MEmil Kozochka 1", for the second half of the year - "MEmil Kozochka 2" (Enfagroup Nutrisinal). Industrial correction of goat milk brought these products to a high nutritional value, and the biological properties of the components of goat milk gave them not only good tolerance, but also a therapeutic effect in relation to 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 precisely orient adapted formulas to the child's age. An example is the line of NAN (Nestle Nutrition) milk formulas: preNAN - for premature babies, NAN-1 - for healthy children from 0 to 6 months, NAN-2 - from 6 months, NAN-3 - from 10 months, "Instant Milk" and "Klinutren-Junior" - from 1 year.

It is advisable to use only one formula at a time for mixed feeding and no more than two formulas for artificial feeding. Acidified formulas can be combined with fresh or sweet ones, taking up 1/3-1/2 of the daily food volume.

If it is necessary to switch to mixed feeding relatively early, i.e. before 3-5 months of life, it is advisable to increase the number of times the baby is put to the breast to stimulate lactation, and after putting the baby to the breast, provide partial supplementary feeding with formula for several days, and then return to the original number of feedings with full supplementary feeding. With a stable but limited volume of lactation, when the daily volume of breast milk is 250-400 ml, it is possible to alternate putting the baby to the breast with feeding with formula.

For mixed, and especially artificial, feeding, a two-stage system of approximate calculation of nutrition is advisable. The first stage is determining the volume of nutrition based on the volumetric method, the second stage is choosing products (mixtures) that provide the necessary amount of ingredients in a given volume.

The calculated approaches are a guideline for the initial nutritional prescription. It should then be adjusted according to the body weight curve and the child's individual response to the proposed diet.

Regarding the feeding regime and volume per feeding, there is some discrepancy between the domestic and American-European approaches. Domestic pediatricians prefer a slightly higher frequency of feeding while limiting the daily volume of food, not exceeding 1 liter during the entire first year of life. It is possible that both approaches are equally valid.

After 3 months of life, children on artificial feeding can receive not only sweet, but also sour mixtures. It is desirable that the latter account for no more than 1/3 of the total volume of mixtures and that initially balanced industrial products are used to prepare sour mixtures.

Artificial feeding of children in the first year of life

Age	American and European schools	National school
Approximate number of feedings per day
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 feeding, 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, it is necessary to take into account the almost exhaustive needs of the child for enrichment of industrial food products with salts and vitamins. Indications for correction for fluorine may remain, and for iron-poor formulas - for iron. Increased osmolarity of formulas may be the basis for the emergence of an increased need for liquid. It is advisable to compensate for it with unsweetened water after feeding or in the interval between feedings.

The introduction of complementary foods during artificial feeding is necessary first of all to stimulate the skills of chewing and swallowing thick food, later (after 8-9 months) complementary foods will supplement milk nutrition in proteins, carbohydrates and energy. The displacement of milk formulas rich in micronutrients by thick complementary foods (vegetable purees and porridges) of home preparation can worsen the degree of balance of the diet. This requires calculating the provision.

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