Chapter 14: Essentials in Infant Nutrition

EXCLUSIVE BREASTFEEDING (EBF)

(WHO definition) feeding of breastmilk only (including expressed breastmilk and milk from a wet nurse), not allowing the infant to
receive any other food or drink, even water for 6 months. Oral rehydration salts, vitamins and mineral preparations, and medicines are
acceptable.
- EBF during the first 6 months of life, followed by appropriate complimentary feeding while continuing breastfeeding upto 2
years and beyond
- Adequacy of nutririon most especially during infancy is critical in providing the foundation for optimal growth and
development.
- WHO and UNICEF recommend that breastfeeding be initiated within the first hour of life.

COMPOSITION OF HUMAN MILK

1. FATS
- About half of the energy content in breastmilk with about 3.5 g fat/100 ml in the form of:
 LCPUFAs (Long chained polyunsaturated Fatty Acids)
 DHA (Docosahexaenoic acid)
 ARA (Arachidonic acid)
- secreted in small droplets, increasing over thecourse of a feed
FOREMILK HINDMILK
 Secreted at  secreted
the beginning towards the
of a feed end of a feed
 Bluish gray
 creamy white
 Less fat  higher fat
 responsible for
satiety

2. CARBOHYDRATES
- LACTOSE – principal sugar in breastmilk (7 g/100 ml)
- OLIGOSACCHARIDES – provide energy, but playing important roles in immunosuppression

3. PROTEINS (0.9 g/100 ml)

- WHEY PROTEIN – α-lactalbumin
- CASEIN – less in breastmilk, allows for softer, easily digestible curds compared with other milks

4. VITAMINS AND MINERALS

- Normally contains sufficient vitamins for infants – unless mother is deficient
- No Vit D – sunlight exposure for its production
- Iron and zinc – in lower concentration
- Low birth weight (LBW) infants – need suplements before 6 months

5. COLOSTRUM AND MATURE MILK

- first secretion of the human breast in the first 2-3 days after delivery;
- thick and yellow, sometimes greenish due to carotenoid
- produced in small amounts, rich in white cells, protein, minerals and fat soluble vitamins
- Secretory IgA is at its highest level in colustrum
- Infant normally takes about:
 3rd day – 300-400ml/24hrs
 5th day – 500-800 ml/24hrs
- 7th-14th day – transitional milk, slightly bluish
ANATOMY OF THE BREAST
Breast Structures:

 Ducts beneath the areola are filled with milk during a feed, when the oxytocin-triggered “let-down” reflex is active.
 Montgomery’s gland – oily fluid is secreted, protects the skin over nipple and areola during lactation and produces the
mothers unique scent that attracts her baby to her breast.

HORMONAL CONTROL OF MILK PRODUCTION

1. PROLACTIN
- Triggers cells of alveoli to secrete milk
- Increase during pregnancy
- When baby suckles the breast, prolactin increases.
- Nighttime feeding are vital because more is produced at night
- Breastfeeding intervals of no longer than 4 hrs in the daytime and no longer than 6 hrs in the nightime can delay a new
pregnancy.

2. OXYTOCIN
- Triggers contraction of myoepithelial cells around alveoli
- As baby suckles the breast, oxytocin is stimulated
- Oxytocin-induced uterine cramping prevents excessive postpartum bleeding and hastens uterine involution

FEEDBACK INHIBITOR OF LACTATION (FIL)

- Breastmilk contains polypeptide that inhibit alveolar cells from secreting more milk.
- Control of milk production, independent of each breast.
- Occurs when baby’s preferentially suckle on side, the opposite breast lags in milk production.
- Mothers are advised to allow their babies to suckle on both breasts.

STRATEGIES FOR SUCCESSFUL BREASTFEEDING

1. Breastfeeding in the first hour
- About 20-60 minutes after normal vaginal birth
- Newborns have suckling and swallowing reflex triggered by the nipple touching the palate.
- Delay of initiation (1 hour – 7 days), risk of infection-related death

2. Proper attachment and effective suckling

- Chin touching the breast
- Lower lip turned outwards
- Mouth wide open
- More areola seen above that below the baby’s mouth

Mothers can choose from any position to breastfeed her baby. Key points:
- Baby’s body should be straight, head slightly extended at the neck helps chin to be close to the breast
- Baby should face the breast, not held horizontally against the mother’s chest
- Baby’s body should be close to the mother
- Entire body, not just head and neck, shoul be supported

3. Skin-to-skin contact
- Ideally at birth, improves maternal affectionate and attachment behaviors
 - Promotes infant self-regulation with shortening of the infants crying time
4. Baby-led feeding
- AKA per-demand feeding or unrestricted feeding
- need to feed as often and for as long as they want, both day and night to ensure adequate milk production and flow
for 6 months of EBF

5. Exclusivity of breastfeeding from birth

- Colostrum as exclusive first feed plays a crucial role in the “microbial ecology” of the newborn’s gut
- Transmission of immunologic memory and interaction
- Antimicrobial substances in breastmilk bind and neutralizr pathogens

LACTATION PROBLEMS AND CONCERNS

1. Sore nipples -
2. Breast fullness
3. Breast engorgement
4. Mastitis
5. Maternal infection
6. Manual expression
7. Cup feeding

BENEFITS OF BREASTFEEDING
1. Benefits to the Infant
a. Breastfeeding boosts immunity and host defense (specifically against respiratory and gastrointestinal infections).
Human milk contains
 Antibodies
 Antimicrobials substances
 Cytokines and chemokines that help mature intestinal IgA-producing cells
 Macrophages (55%-60%), neutrophils (30%-40%), and lymphocytes (5%-10%)
 Immunoglobulin A (highest in colostrum)
 Epidermal growth factor which promotes growth of cells lining the GI tract
b. Breastfeeding prevents atopic disease.
 Protein from cows, goats, and even soya may present as allergens to atopic infants
c. Breastfeeding prevents visual problems.
 Breastmilk is a major source of vitamin A.
o 250 IU per 100 mL by 6 months of age
d. Breastfeeding promotes dental and jaw development.
 Infants nursing from the breast
o Sixty times more energy is used to get milk.
o Oral muscles receive more exercise compared to those drinking from a bottle.
o Such oral stimulation facilities growth of well-formed jaws and straight, healthy teeth.
e. Breastfeeding protects premature and low birth weight babies.
 Milk mothers who deliver prematurely, i.e. preterm milk, contains all the necessary micronutrients
needed for adequate growth, specifically calcium and LCPUFAs.
f. Breastfeeding improves mood and sleep
 Breastmilk contains
o Mood regulators, e.g, casomorphins, produced in the baby’s intestines by the breakdown of
breast milk casein.
o Sleep regulators, e.g. nucleotides.
g. Breastfeeding allows for appropriate weight gain.
 Lipids in breastmilk
 o Provide 50% of the calories in the milk
o Are developed for the easier fat digestion and absorption
o Lessens undesirable fat accumulation and rapid, excessive weight gain.
o High levels of healthier LCPUFAs
h. Breastfeeding protects against overweight and obesity
 Because breastfeed babies can regulate their intake, it prevents them from overeating and gaining too
much weight.
i. Breastfeeding lessens picky eating
 Breastfeeding exposes the infant to a variety of flavors arising from the mother’s diet.
j. Breastfeeding decreases the risk of diabetes.
 Cow’s milk contains cow insulin (similar to human insulin)
k. Breastfeeding and cardiovascular disease
 Lower BP later in life
l. Breastfeeding prevents breathing disorders.
 Increased risk for bottle-fed babies
m. Breastfeeding potentially lessens risk of developing cancers.
 Breastmilk contains
o Lactoferrin
o Human a-lactalbumin made lethal to tumor cells (HAMLET)
n. Breastfeeding promotes cognitive development
 Breastmilk contains long chain polyunsaturated fatty acids (LCPUFAs) which are involved in
o Neurite outgrowth
o Dendritic arborization
o Neuron regeneration after cell injury
o Neurotransmission

2. Benefits to the Mother and the Family

a. Breastfeeding improves postpartum health.
 Suckling at the breast triggers the release of oxytocin, which stimulates uterine muscular contraction.
b. Breastfeeding hastens postpartum weight loss.
 Breastfeeding mothers require ~500 extra calories per day.
c. Breastfeeding helps optimum child spacing.
 Exclusive breastfeeding delays the return of normal ovarian cycles and fertility in most nursing mothers,
d. Breastfeeding is affordable and convenient.
 Families need not spend on costly formula tins, bottles and cleaning gadgets.
 There are no disrupting nighttime rituals associated with mixing, heating and refrigerating
formulas.
e. Breastfeeding protects mothers from developing cancer.
f. Breastfeeding protects against bone and rheumatic problems.

3. Benefits to the Society and the Environment

a. Breastfeeding reduces risk of child abuse.
b. Breastfeeding improves overall quality of life.
c. Breastfeeding is safe and does not harm the environment.
 Breastfeeding does not leave carbon footprints nor does it generate any industrial waste.
  Contamination may occur when there is a breach from production to distribution of formula and
other feeding accessories.

PROMOTION OF OPTIMAL INFANT AND YOUNG CHILD FEEDING

- The Global Strategy for Infant and Young Child Feeding (IYCF) 2003 was jointly developed by WHO AND UNICEF- to
revitalize world attention to the impact that feeding practices have on the nutritional status, growth and development, health
and thus the very survival of infants and young children.
- IYCF strategy emphasizes that “breastfeeding is an unequalled way of providing ideal food for healthy growth and
development of infants; it is also an integral part of the reproductive process with important implications for the health of
mothers”
- Infants should be exclusively breastfeed for the first six months of life to achieve optimal growth, development and health.

1. Exclusive for Six Months and Continue to Two Years or Beyond

- Exclusive Breastfeeding - Single most cost effective intervention for saving children’s lives and improving
maternal quality of life and health
- Improves survival, enhance intelligence, opportunities for education, resilience against psychosocial stress, social
mobility, protection from adult diseases and alleviation from poverty.
- Protecting breastfeeding ensures each infant the opportunity to achieve the highest attainable state of health.
- Protecting breastfeeding is both an individual and collective responsibility.

2. Infant and Young child Feeding in Emergencies

- Donations of bottles and teats should be refused in emergency situations.
- Any well-meant but ill-advised donations of breast milk substitutes, bottles, and teats should be placed under the
control of a single designated agency.

3. Policies, Health System, and Community Actions

- Respiratory infections and diarrheal diseases are the most important causes of mortality in children under five years
of age, with about 8 million deaths globally each year.
- Republic Act 7600: The Rooming-in and Breastfeeding Act of 1992
 provides incentives to all government and private health institutions in the Philippines that support
rooming-in and breastfeeding
- Executive Order 51: The Philippine Milk Code
 Signed by President Corazon Aquino on October 20, 1986
 Products covered by Milk Code are “breast milk substitutes, including infant formula; milk
products, foods and beverages, including bottle-fed complementary foods, when marketed or
otherwise represented to be suitable, with or without modification, for use as a partial or total
replacement of breast milk; feeding bottles and teats.”
 The coverage of the Milk Code is not dependent on the age of the child but on the kind of product
being marketed to the public.
 The Philippine Milk Code restricts advertising and marketing of artificial breast milk substitutes,
feeding bottles and pacifiers, to protect and promote breastfeeding for safe and adequate nutrition
for infants.
 The Milk Code also bans the use of the health care system for the promotion of the covered
products.
 The Milk Code and its implementing rules also ban donations, samples, and other giveaways by
milk companies to health workers and the general public.

- The Mother Baby Friendly Hospital Initiative (MBFHI)

WHO/UNICEF TEN STEPS TO SUCCESSFUL BREASTFEEDING

 Ste Provision
p
1 Have a written breastfeeding policy that is routinely communicated to all health care staff.
2 Train all health care staff in skills needed to implement the policy.
3 Inform all pregnant women about the benefits and management of breastfeeding.
4 Help mothers initiate breastfeeding within a half-hour after birth.
5 Show mothers how to breastfeed and how to maintain lactation even if they should be separated
from their infants.
6 Give newborn infants no food nor drink other than breast milk, unless medically indicated.
7 Practice rooming-in: allow mothers and infants to remain together 24 hours a day.
8 Encourage breastfeeding on demand.
9 Give no artificial teats or pacifiers to breastfeeding.
10 Foster the establishment of breastfeeding support groups and refer mothers to them upon discharge
from the hospital or clinic.

COMPLEMENTARY FEEDING
- is the process of starting foods when breast milk alone is no longer sufficient to meet the nutritional needs of a growing
infant.
- This feeding practice is important, not only to fill in the nutrient gap of breastmilk at this age but also to train the infant on
appropriate feeding skills necessary for a healthy eating habits in adult life.

6-24 months of age

- Tart age for CF while breastfeeding is continued until two years and beyond.

Birth-2-3 years of age

-critical learning period for oral motor development.

6 months of age
-Child’s eating and drinking habits are initiated
-infant would have attained good head control and truncal stability

2 years
-Oral motor abilities become well established.

Four important features of appropriate Complimentary Feeding

1. Timely - complementary food should be given at around the age of 6 months, the time when the nutritional needs of infants can
no longer be fully sustained through exclusive and breastfeeding.
2. Adequate - to meet the energy, protein, and micronutrient requirements for growth.
3. Safe - foods are prepared and stored hygienically and fed with clean hands; using clean utensils and not bottles and teats to
minimize the risk of contamination with pathogens.
4. Properly fed - using the child’s signal of appetite and satiety and the appropriate meal frequency and feeding method suitable for
age.

Guiding Principles for Complementary Feeding

1. Duration of Exclusive Breastfeeding and Age of Introduction of Complementary Foods

Practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age while
continuing to breastfeed.
- Breastfeeding-confers the infant protection against gastrointestinal infections and enhances motor development.
- Stores of iron of normal term infants of healthy mothers are adequate and sufficient to sustain iron needs for the first
6 months after birth.
- Low birth weight infants iron reserves at birth and those born to anemic mothers are at risk for developing IDA due
to low iron reserves at birth.
 - Iron supplements of 15 mg/day or 1 mg/kg/day of elemental iron should be started at 2 months of age and iron-
fortified or iron-rich complementary foods should be started at the age of 6 months.
- Zinc in breast milk is low although its bioavailability is high.
- Zinc supplementation given for 1-9 months has reduced mortality in this group.
- Vitamin deficiencies like Vitamin A, riboflavin, Vitamin B6 and B12 are uncommon among breastfed infants except
if the maternal diet is deficient.

2. Maintenance of Breastfeeding
Continue frequent, on-demand breastfeeding until two years of age and beyond
- Breast milk when consumed in an average amount of 700-800 mL by a 12-23-month-old infant provides about 35-
40% of nutritional needs.
- The high fat content of breast milk makes it a very good source of energy and essential fatty acids, and promotes the
conversion of pro-vitamin A, a critical process among vegetarians.
- Milk provides 70% of Vitamin A, 40% of Calcium, and 17% of Riboflavin requirements of a 15-18 month old
infant.

3. Responsive Feeding
Practice responsive feeding applying the principles of psychosocial care.
- Successful introduction of complementary food (CF) depends not only on the kind of food being given but more
importantly on the manner, time, and the person who feeds the child.
- The principles of responsive feeding include the following:
(1) Feed infants directly and assist older children when they feed themselves by being sensitive to their hunger and
satiety cues.
(2) Feed slowly and patiently, and encourage children to eat, but do not force, harass, or be angry at them.
(3) If children refuse many foods, experiment with different food combinations, tastes, textures, and methods of
encouragement.
(4) Minimize distractions during meals if the child loses interest easily.
(5) Always consider feeding times as periods of learning and love, talking to children during feeding and
maintaining eye contact.

4. Safe Preparation and Storage of Complementary Foods

Practice good hygiene and proper food handling
- Bacterial contamination of foods is a major cause of gastrointestinal infections in children especially during the
2nd half of infancy, the period when diarrheal illness is at its peak.
- Strict compliance with personal hygiene and proper food handling during food preparation are important
preventive measures against gastrointestinal infection.
- It has been demonstrated that 35% pf bottle nipples were contaminated with E. coli.
- The recovery of E. coli from feeding utensils is a clear indicator of fecal contamination.
- Care should be taken in the preparation and storage of CF.
- Caregivers and food handlers should wash their hands thoroughly before preparing food and observe
appropriate hand hygiene.
- Only safe water and raw materials should be utilized for cooking and drinking purposes.
- Foods must be cooked well, stored with covers and at safe temperature, and served immediately after
preparation.
- Utensils should be washed and cleaned properly before using them for serving or storage.
- Clean cups, glasses, and bowls, not feeding bottles which are difficult to keep clean, must be used when feeding
children.

5. Amount of Complementary Food Needed

Start at 6 months age with small amounts of food and increase the quantity as the child grows older while continuing to
breastfeed

Table 14.5 Energy needs of Infants from complementary foods

Age (months) Calories from complementary foods (CF) (kcal/day)
6-8 200
 9-11 300
12-23 550

- For non-breastfed infants, energy requirements may be higher because of a higher resting metabolic rate.
- It should be borne in mind that the needs of infants vary depending on their size, age, level of activities, and
state of health.
- A better gauge of adequacy of the child’s food intake is the rate of growth reflected by length/height velocity.

6. Food Consistency
Gradually and progressively increase the consistency and variety of food as the infant gets older, adapting to the infants
requirements and abilities
- The consistency of food to be initiated will depend on the neuromuscular development of the infant.
- Start with soft, semi-solid or pureed foods at 6 months and gradually increase the consistency and variety as the
infant’s development advances.
- Single-ingredient foods introduced at intervals of 3-4 days are recommended in order to better detect any food
intolerance.
- When munching (up-and-down mandibular movement) or chewing (use of teeth) appears, finger foods may be
started at about 8 months, lumpy foods at 10 months, and family or table foods at 12 months.
- Ten months is considered the “critical window” for the introduction of lumpy food, which if delayed beyond this age
would increase the risk of feeding difficulties later.

7. Meal Frequency and Energy Density

Increase in the number of times complementary foods (CF) are given as the child gets older
 Appropriate number of feeding is dependent on the energy density of the food as well as the amount consumed at each
feeding.
 Infants (6-8 m.o.) = CF 2-3 times a day
 Infants (9 m.o. onwards) = CF 3-4 times a day
 Snacks or foods usually self-fed and easy to prepare, and eaten between meals are offered 1-2 times a day
as desired.
- If energy density or amount of food per meal is low, more frequent meals may be required.
- Food given more frequently than recommended is not advisable as this could cause displacement of milk intake.
 Can reduce maternal breast milk secretion and will subsequently lead to untimely weaning (for breastfed
infants)
- For the non-breastfed infant, complementary feeding 4-5 times a day with additional nutritious snacks offered 1-2 times a day
would still be appropriate due to higher resting metabolic rate.

Meal freq. and dietary energy density necessary to meet the energy requirements of children 6-24 months
Age
6-8 m.o. 9-11 m.o. 12-23 m.o.
Ave. energy req. (kcal/day) 615 686 894

# of meals req. if energy density is:

0.6 kcal/g 5.1 5.0 5.4
0.8 kcal/g 3.9 3.8 4.1
1.0 kcal/g 3.1 3.0 3.2
Min. energy density (kcal/g) req. if meal freq. is:
3 1.03 1.00 1.08
4 0.77 0.75 0.81
5 0.62 0.60 0.65

8. Nutrient Content
Meat, poultry, fish or eggs should be eaten daily, or as often as possible

Micronutrient Content
- Breast milk contributes a significant amount of proteins and vitamins for infants 6-24 m.o.
- Several nutrients such as Fe, Zn, P, Mg, Na, and Ca are found to be low in breast milk and need to be filled up by CF
- Plant-based complementary foods are deficient to meet the needs for certain micronutrients.
- It is recommended to include meat, fish, or eggs as often as possible.
- Dairy products such as yoghurt and cheese are good sources of calcium.
- Children with family history of allergy or food sensitivity should avoid:
 Cow’s milk until 1 y.o.
 Eggs until 2 y.o.
 Peanuts, other nuts, and fish until 3 y.o.
- Vit. A- rich fruits and vegetables should be eaten daily to prevent vit. A deficiency.
 Vitamin deficiency is one of the prevalent nutritional problems that affect 20% of the Filipino children under 5 years.
- Vegetarian diet cannot meet the nutrient needs of an infant unless nutrient supplement or fortified foods are given.

Fat Content
- Fat plays several important metabolic functions which include:
 Provision of essential fatty acids, namely linolenic (precursor of DHA) and linoleic acid
 Formation of part of the myelin sheath
 Facilitation of absorption of fat-soluble vitamins A, D, E, K
 As source of concentrated energy (9 kcal/g) thus enhancing energy density
 As satiety enhancer
 As precursors for some important hormones
- Diets of infants and young children should contain about 30% to 45% of fats for optimal growth
 Too little can result to an inadequate supple of essential fatty acids
 Too much could predispose to childhood obesity
- If animal fats are taken regularly, additional fats in the diet must be reduced to a min. of 5 g/day.
 Otherwise, 10-20 g/day of fats should be added to the diet of these children

Protein Content
- The rapid growth rate and metabolism of infants and young children during the first 6-24 months (w/ limited gastric capacity,
and a decreased capability to consume large amounts of solid foods) necessitates that high calorie-dense food be provided to
sustain their metabolic needs.
- The Food and Nutrition Institute recommends that protein intake of infants 6-12 months and children 1-3 years be given at 14
g and 28 g respectively.
- Besides the potential milk allergy, the concern for infants fed cow’s milk, is the high conc. of protein and minerals (Na, Ca,
K, P) in cow’s milk
 Has the potential to increase renal solute load
 Increased solute load in infants could result to dangerous fluid imbalance of hypernatremic dehydration => can be
averted by ensuring adequate fluid intake is provided, especially during illness and excessive fluid losses (diarrhea)
- Protein content of 1.45-1.60 g/dL in cow’s milk has been modified to approximate that of human milk (0.9-10.0 g/dL).
- The ratio of whey to casein in cow’s milk has been changed in some formulas from 18:82 to closely mirror that in human
milk (60:40).
- The whey protein in cow’s milk is predominantly beta-lactoglobulin
 In human milk it is predominantly alpha-lactalbumin
- Infant formulas cannot duplicate the immunologic and anti-infective properties of breast milk.
- Soy formulas are lactose-free and serve as alternatives for infant feeding, especially recommended for those who have lactose
intolerance or lactase deficiency, cow’s milk allergy, galactosemia, or are vegetarians.

Beverages with Low Nutrient Value

- Low-nutrient value drinks should be discouraged (e.g. tea, coffee, and sugary drinks such as soda).
 These satisfy the appetite of the children but are devoid of proper nutrients for proper growth
- Limit the amount of juice taken (240 mL as advised by the American Academy of Pediatrics) so as to avoid displacing more
nutrients.

9. Use of Vitamin-Mineral Supplements or Fortified Products for Infant and Mother

Use fortified complementary foods or vitamin-mineral supplements for the infant as needed
 - CF that are not fortified especially if they are plant-based, lack the key nutrients (Fe, Zn, Ca) necessary to sustain the needs
of growing infants from 6-24 months.
- The quantity of the animal source food that can be consumed by infants may be insufficient to meet the gaps, alternatives that
may be adopted include:
 Food fortification => can be achieved by mixing products that contain concentrated amounts of vitamins and minerals
like sprinkles, crushable tablets, or fat-based spreads to the foods prepared at home; fortified infant foods lessen the need
for infant formula
 Vitamin-mineral supplementation
- Maternal malnutrition
 can affect the conc. of vitamins in breast milk
 it may be easier and less expensive to feed and provide them with vitamin-mineral supplements or fortified products
 a single dose of 200,000 IU of vit. A after delivery (not later than 6-8 weeks), supplemented with thiamine, riboflavin,
vit. B6, Vit. B12, iodine, and selenium is necessary as the levels of these micronutrients can easily be affected by the
maternal diet.
 Levels of folate, calcium, iron, copper, and zinc remain relatively high in breast milk despite low maternal reserves
(supplementation is still recommended)

10. Feeding During Illness

Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, varied,
appetizing, favorite foods
- Need for fluids is often higher than normal
- Sick infants appear to prefer breast milk to other foods  frequent breastfeeding is highly recommended
- Continued consumption of CF is recommended to maintain nutrient intake and enhance recovery.
- For non-breastfeeding infants who refuse the quantity of water needed, it may be necessary to restrict foods that are high in
renal solute load during the illness such as fish, cheese, chicken, beef, and liver
- After the illness, child needs greater nutrient intake to compensate for nutrient losses during illness and to allow for catch-up
growth.

Reference: Fundamentals of Pediatrics, Competency-based, Vol. 1,

Questions:

What are the 4 signs of good attachment:

- Chin touching the breast
- Lower lip turned outwards
- Mouth wide open
- More areola seen above that below the baby’s mouth

Which of the following statements is untrue?

A. Infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health.
B. The Milk Code and its implementing rules ban donations, samples, and other giveaways by milk companies to health workers
and the general public
C. Protecting breastfeeding is an individual and not collective responsibility.
D. Donations of bottles and teats should be refused in emergency situations.

At what age does oral motor abilities become well established?

A. 6 years
B. 3 years
C. 2 years
D. 1 year

These formulas serve as alternatives for infant feeding and are recommended for infants who have lactose intolerance, cow's milk
allergy, galactosemia, or are vegetarians.
 A. Cow's milk
B. Soy milk
C. Breast milk
D. Skim milk Answer: Soy milk

(family feud)
Name benefits of breastfeeding to the society and the environment

- reduce risk of child abuse

- improves overall quality of life
- safe and does not harm the environment

Or
Benefits of breastfeeding to infants (mas damo)