Berthold Koletzko Katharina Dokoupil
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both breasts during the first days. Initially, the breast produces colostrum, which is rich in anti- bodies that will contribute to protecting your child from infections; a larger amount of milk, with in- creasing protein and fat content, will be produced a few days after birth. Temporary supplementary feeding with water or other liquids should only be offered if it is deemed necessary by the pediatri- cian or other health care professionals.
Breastfeed your baby whenever it wishes to suckle, also at night. In the first weeks, most in- fants take 8–12 meals within 24 h. Breastfeeding promotes a gradual loss of the mother’s body weight and the extra body fat stores that were de- posited during pregnancy. The amount of fat loss increases with the duration of full breastfeeding.
Additional active weight reduction during breast- feeding with the use of restrictive diets is not rec- ommended because it may have undesirable ef- fects on milk composition.
Breastfeeding women should consume a var- ied diet and plenty of liquids. A good supply of iodine (iodized salt, supplements with 100–150 μg/day) and long-chain n–3 fatty acids (200 mg docosahexaenoic acid/day, provided by 1–2 week- ly meals of sea fish including fatty fish) is recom- mended. Breastfeeding women should refrain from smoking and the consumption of signifi- cant amounts of alcoholic drinks. Only very few mothers of babies with proven food intolerances are advised to exclude allergenic foods from their own diets upon individual advice from their pe- diatrician or dietitian. However, the preventive exclusion of certain foods from the maternal diet to reduce the risk of allergies in infants is not jus- tified and not recommended.
Infant Formula
If breastfeeding is discontinued before 1 year of age, a commercial infant formula should be used.
In the first months of life, only infant formula should be used, which can be continued through-
out the first year of life. Follow-up formulas are only appropriate after the timely introduction of complementary feeds into the infant’s diet.
In infants who are not fully breastfed and who have a parent or sibling suffering from allergic diseases, the pediatrician should be consulted re- garding the preventive use of infant formula based on hydrolyzed protein during the first 4–6 months of life.
Manufacturers’ recommendations on the prep- aration of bottles should be carefully followed.
Both too low and too high concentrations of for- mula are detrimental. Milk bottles must always be freshly prepared and fed within approximately 2 h.
Leftovers should be discarded to prevent an in- creased risk of bacterial infections. Frozen and then defrosted breast milk must be handled simi- larly. It is important to keep bottles and nipples clean and dry. Powdered formulas must be pre- pared with fresh and clean drinking water. The use of water filters is not recommended. If the wa- ter contains high levels of nitrate (>50 mg/l; found particularly in domestic wells) or water pipes made of lead are used (found in some old buildings), bot- tled water suitable for preparing infant formula should be used. The suitability of water from do- mestic wells should be assessed in each case.
Infant formulas based on soy protein as well as so-called special formulas are only indicated un- der limited special conditions and should only be used upon the recommendation of a pediatrician or other qualified health care professional. Self- prepared bottle feeds from cow’s milk, the milk of other animals (goat’s, mare’s, and sheep’s milk) and other sources (such as almond milk) pose se- rious risks and should not be used.
Feeding Solid Foods (Complementary Foods or ‘Beikost’)
After 6 months, breast milk alone does not ade- quately meet the nutrient requirement of a healthy baby. For their optimal development, all infants
318 Koletzko Dokoupil
require additional nutrients, such as the trace ele- ments iron and zinc, after the age of 6 months. The introduction of solid foods over time should grad- ually get the child used to an increasing variety of foods and, around the age of about 1 year, to regu- lar family foods. The first complementary foods should be given no later than at 6 months of life but not before the age of 4 months. As the first solid food, a mixture of pulpy vegetables, potatoes and meat can be recommended, which provides iron and zinc with high bioavailability ( fig. 1 ). In about monthly intervals, additional meals consist- ing of cereals with milk and a fruit-grain pap may be introduced. From the age of about 10 months, (initially soft) bread may be offered. Gluten-con- taining cereals (wheat, rye, and barley e.g. in por- ridge, bread, biscuits, and rusks) should initially be given only in small quantities to reduce the risk of developing intolerances (celiac disease). No benefits of a generally low-allergen diet in infancy have been shown. Therefore, the exclusion or de- layed introduction of complementary food prod- ucts considered allergenic is not recommended.
Beverages
When 3 meals per day of complementary feeding are given, children should be offered water; avoid providing sugary drinks or adding sugar to the water. Prior to reaching 3 solid food meals per day, no liquid in addition to breast milk or infant formula is needed, except in cases of fever, vomit- ing, or diarrhea. Cow’s milk should regularly be offered as a drink only after the first year of life to avoid potential adverse effects, for example on iron absorption.
Further Advice and Information
Do not hesitate to ask your pediatrician if you have any further questions on the feeding of your infant.
1 2 3 4 5 6 7 8 9 10 11 12
Vitamin
Breast milk or infant formula
(follow-on formula) Milk cereal pap
Age (months)
Bread + milk Bread + milk Snack Snack
Vegetable potatoe meat pap Cereal fruit
pap Vitamin D, fluoride
Fig. 1. Recommended feeding concept in the first year of life. Modified from Ernọhrungskommis- sion der Deutschen Gesellschaft für Kinder und Jugendmedizin (DGKJ) [1] .
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 316–319 DOI: 10.1159/000375275
4
2 Koletzko B, Bauer CP, Brửnstrup A, Cre- mer M, Flothkửtter M, Hellmers C, Kers- ting M, Krawinkel M, Przyrembel H, Schọfer T, Vetter K, Wahn U, Weissen- born A: Sọuglingsernọhrung und Ernọhrung der stillenden Mutter. Aktu- alisierte Handlungsempfehlungen des Netzwerks Gesund ins Leben – Netz- werk Junge Familie, ein Projekt von IN FORM. Monatsschr Kinderheilkd 2013;
161: 237–246.
References 1 Ernọhrungskommission der Deutschen Gesellschaft für Kinder und Jugendme- dizin (DGKJ); Bührer C, Genzel-Boro- viczény O, Jochum F, Kauth T, Kersting M, Koletzko B, Mihatsch W, Przyrembel H, Reinehr T, Zimmer P: Ernọhrung gesunder Sọuglinge. Empfehlungen der Ernọhrungskommission der Deutschen Gesellschaft für Kinder- und Jugend- medizin. Monatsschr Kinderheilkd 2014; 162: 527–538.
4 Annexes
Infants and children with growth faltering often need an enhanced intake of energy and nutrients.
Increasing the energy density, i.e. the amount of energy per food portion or per millilitre of a liq- uid food, can increase the total energy intake even when the total amount of food taken remains lim- ited. Such an increase in energy density can be achieved by using one or several elements of a stepwise approach.
Elements of a Stepwise Approach to Increase Energy and Nutrient Supply
(1) Analysis of needs, diet and feeding situation (2) Individual, professional counselling on di-
etary choices and on feeding practice (3) Offer meals and snacks more frequently, in-
cluding a small late meal before going to bed (4) Preferential choice of energy-dense foods,
drinks and snacks
(5) Enrichment of formula and home foods with glucose polymers and/or oils
(6) Use of drinkable supplements (sip feeds) (7) Tube feeding (nocturnal/continuous) (8) Parenteral nutrition
Infants: Options for Increasing Energy Density of Expressed Human Milk or Infant Formula
Increased Concentration of Infant Formula The use of 15% powder instead of 13% increases the energy density by 15%. The concentration should be increased stepwise according to indi- vidual tolerance. Concentrations >17% (+30%
energy density) should usually be avoided.
Disadvantage: The increased formula density increases renal solute load and may reduce toler- ance.
Addition of Glucose Polymers
Glucose polymers (dextrin maltose or glucose polymer mixtures) can be added with stepwise in- creasing concentrations from 1 up to 4 g/100 ml, which adds ∼ 3.9–15.6 kcal/100 ml milk/formula.
The concentration should be increased stepwise according to individual tolerance.
Disadvantage: The supply of essential nutri- ents per kilocalorie is reduced and may not al- ways be sufficient, particularly for catch-up growth.
Addition of Glucose Polymer-Fat Mixtures to Infant Formula
Preparations of glucose polymers with either veg- etable oil (e.g. soybean oil) or medium chain tri-
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 320–321 DOI: 10.1159/000375193