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ANNEX 2. MILKS AND MILK PRODUCTS THAT MAY BE USED FOR INFANT FEEDING AND THEIR PREPARATION

Choice of milk to be used will depend on availability, cost, danger of contamination of the milk during its preparation, and keeping qualities. Relevant properties of the various milks and milk products and the method of their preparation are listed below.

2.1 Fluid Whole Milks

2.1.1 Cow, goat, camel

- Must be brought to the boil, stirring continuously to destroy pathogenic bacteria and to make it more digestible.
- Every effort must be made to obtain milk from a source where adulteration or dilution for financial gain is unlikely.
- Whole milk should be diluted before it is fed for the first one or two months of the baby's life in order to reduce the solute load on neonatal kidneys.

2.1.2 Buffalo, yak, ewe

- Same precautions as for cow's milk.
- The very high fat content can be reduced by boiling the milk, cooling, and then skimming.

Quantities per Feeding- Assuming Five Feedings per Day

- place milk, water, and sugar in a pan
- bring to boil, then cool
- pour into feeding utensil (using clean jug, if necessary)

2.2 Dried Whole Milk

- Keeps well but may become contaminated when can or package is opened.
- Must be prepared with clean boiled water.
- Recommend cheapest recognized commercial brand available.
- The largest quantity that is economically feasible should be bought on pay day.

Quantities per Feeding- Assuming Five Feedings per Day

- mix dry milk powder with sugar
- add a small quantity of boiled, cold water
- mix well until smooth
- gradually add the rest of the water, stirring briskly to avoid lumps

2.3 Dried Skimmed Milk (DAM)

- Low energy and fat content and no vitamin A or D (unless fortified).
- Should only be used when no other milk is available and then extra oil or sugar and supplementary vitamin A must be given.
- It should be explained to mothers that the addition of oil will not cause diarrhoea or indigestion.

Quantities per Feeding- Assuming Five Feedings per Day

- mix dried milk and sugar
- stir oil into the dry mixture
- gradually add cooled boiled water, mixing well with fork until smooth. Do not sieve, since some lumps of milk are)lost on the sieve. If using a feeding-bottle, squeeze lumps through the sieve with a spoon.
- pour into feeding vessel
- keep lid on can of dried milk to avoid contamination and hardening of the milk

(Note: If the dried milk is of the type that mixes easily, it may be placed directly into the feeding vessel together with the sugar and boiled water and be well stirred or shaken.)

2.4 Evaporated Whole Milk and Filled Milk

- Easy to reconstitute.
- Does not keep overnight in a warm atmosphere.
- If not fortified with vitamin A, give a supplement.
- "Filled" milk is milk in which the milk fat has been replaced by another fat such as coconut oil.
- One can evaporated milk (370 ml) a day is needed by a 5 kg baby. The mother should use a can a day, and any remainder should be drunk by sibling or mother.
- Evaporated skimmed milk should only be used when no other milk is available. Extra oil or sugar and vitamin A (unless fortified) must be added.

Quantities per Feeding- Assuming Five Feedings per Day

- add sugar and boiled water to evaporated/filled milk
- stir well to mix

2.5 Yoghurt/Soured Milks

- Use type made from whole milk.
- Must be fed by spoon or suitable traditional implement.
- Lower lactose content than fresh milk.
- Easier to digest and absorb.
- Less likely to support pathological microbial growth and keeps longer than fresh milk without refrigeration.

Quantities per Feeding- Assuming Five Feedings per Day

- place yoghurt in feeding utensil
- add sugar and mix
- add boiled cooled water and mix well

2.6 Sweetened Condensed Milk

- This is quite widely used because it is relatively cheap and the opened can keeps several days (sucrose content approx. 40, per cent).
- However, it should only be used as a last resort if other milk is not available because:

a. the extreme sweetness encourages mothers to overdilute the milk
b. the protein/energy ratio is too low
c. it pre-disposes to dental caries if continued after eruption of teeth
d. it is often low in fat and vitamin A
e. supplementary vitamin A must be given unless the milk is fortified

Quantities per Feedog- Assuming Five Feedings per Day

- mix the condensed milk with a small quantity of boiled, cooled water
- stir vigorously
- gradually stir in the rest of the water

2.7 Commercial Baby Milk Formula

- These are powdered animal milks which have been adapted to human needs, only the addition of clean water being required.
- They are expensive, and as a result overdiluted feeds tend to be prepared.
- Thus, they are inaccessible in sufficient quantities for the target group discussed here, although they may be needed for an immature preterm infant.
- Composition varies with different brands but most approximate to that for dried whole milk ;2.2).
- Health workers should familiarize themselves with the preparation instructions and use of a few of the cheapest reliable brands that are locally available.

2.8 K-Mix 2

- This is a product supplied by UNICEF for beginning the treatment of severe malnutrition. It is not a complete food and should be used in formula feeding as an emergency measure only.
- It contains 17 parts calcium caseinate, 28 parts DSM, and 55 parts sugar, and is fortified with vitamin A.
- It must always be mixed with oil to increase energy content".

Quantities per Feeding- Assuming Five Feedings per Day

- a supply of water (1 or 2 litres) should be boiled each day and be kept in a clean covered container)
- stir oil) into the dry K Mix 2
- slowly add cooled boiled water, mixing well with fork until smooth
- pour into feeding vessel

ANNEX 3. GRUELS THAT CAN BE USED TO FEED YOUNG INFANTS

3.1.4 Additions to basic root/tuber gruel

Use double the quantities given in 3.1.2

- Supplement both gruels with sources of vitamin A and ascorbic acid (see annex 4) or fresh mashed fruits and vegetables.
- Fresh gruel should be prepared at least twice a day.

3.2 Weights of Household Measures of Some Foods

Below are given the weights of different foods contained in three types of utensils commonly found in low-income homes. These are not standard so the quantities are only approximations. The actual weights contained by local utensils should always be checked using local foods.

3.3 Nutritive Value of Gruels

Approximate nutritive content of gruels

* With 40 g sugar replacing 25 g oil. the energy content is 510 kcal for basic cereal gruel, and 440 kcal for basic root/tuber gruel.

ANNEX 4. SUPPLEMENTARY MINERALS AND VITAMINS FOR FORMULA-FED INFANTS

The easiest way to provide the extra minerals and vitamins needed by babies fed unfortified formula is to use a fluid-vitamin/mineral preparation. Several brands are available, and the mother can be taught to give the child the required number of drops.. These should be placed directly in the child's mouth.

4.1 The Content of One Such Preparation per 0.2 ml (Amount Advised per Day) is:

4.2 Vitamin A

Several vitamin-A preparations are available both in an oil and water-miscible base. These can be added to the formula or given directly to provide about 400 microg vitamin A (1200 I.U.) daily.

Where a vitamin preparation is unavailable, a purée of cooked green leafy vegetables can be mixed into the formula. About 10 grams of the purée daily will suffice. Alternatively, red or yellow fruit or vegetable may be substituted.

Note: Some of those foods containing vitamin A will also contain vitamin C.

4.3 Vitamin C (Ascorbic Acid)

Ascorbic acid can be obtained in tablet form and dissolved in formula to provide about 20 - 30 mg per day. This amount can also be obtained from the juice of one orange daily. If orange juice is used, it should be diluted to about half strength with boiled or safe water.

ANNEX 5. HELPFUL INFORMATION FOR THE HEALTH WORKER

5.1 Recommended Nutrient and Fluid Requirements (FAO/WHO 1974)

5.2 Approximate Nutritive Value of Food per 100 g Raw Edible Portion

The food items indicated in this sable represent the most commonly used commodities. The nutritive values have been rounded, and most have been derived from "Food Composition Tables for Use in East Asia," (FAO, Rome, 1972).

5.3 How to Estimate the Relative Costs of Formula Feeds

5.3.1 To compare the costs of different brands of milk of similar nutrient content, calculate the cost of 1 kg of each brand of milk using the formula:

Cost of 1 kg milk

** These foods are usually rich in vitamin A (carotene) and iron.

5.3.2 To determine which type of milk is most economical, compare the relative costs of 10 9 protein from each type milk using the formula:

Cost of 10 9 protein

5.3.3 To calculate the cost of the amount of milk needed each week, using the results of 5.3.2:

Cost of milk per week

5.4 Details of Some Foods That Might Be Used in Infant Feeding

5.4.1 Milk products:

- Amasi. A soured milk used in southern Africa.
- Acid milks. One teaspoon 85% lactic acid (U.S.P.), or white vinegar (4%), or 4 tablespoons lemon juice is added to 1 litre whole milk.
- Cottage cheese. Rennet is added to boiled, cooled milk from cows, ewes, goats, or camels. To preserve, salt is added and the chesse soaked in milk whey.
- Kareeshah. Similar to cottage cheese. Can also be made by adding a few drops of lemon juice to boiling milk and straining the resulting curds through muslin or cheesecloth.

* Milk protein requirement g/kg/day for ages 0 - 3 months. use 1.85 g/kg/day for ages 3 -6 months.

- Lebneh. Yoghurt is strained through muslin to reduce water content, and salt is added. Keeps well if salted and kept covered by olive oil.
- Leban (yoghurt). Milk is boiled and cooled to blood temperature. A little stirred yoghurt is added and the mixture stirred and then well wrapped to keep warm. It is then left undisturbed for 5 - 6 hours. Yoghurt becomes sourer the longer it is kept. It has been used for feeding young infants.

5.4.2 Soybean products

- Natto. Soaked, boiled soybeans are fermented for two days wrapped in straw or pinewood.
- Tofu. Soaked soybeans are ground to a paste and heated. Water is added. The liquid is filtered and gypsum added. The resulting curd is moulded into cakes that are eaten fresh, dried, smoked, or fermented.
- Miso. Fermented rice and soybean.
- Tempeh. Thin slices of fungus-digested soybean.
- Tahu Soft, white cottagecheese like soybean curd.

5.4.3 Other products

- Kishk (kishkeh). Bulgur wheat is soaked for several days in yoghurt and sour milk. It is then sun-dried and milled to a flour. This is fried in fat for a few minutes, water is added, and the gruel simmered for a few minutes.
- Wheat-bread gruel. Slices of brown wheat bread are soaked in water overnight, then mashed and cooked for a few minutes with sugar and a little water.
- Ketjap. Fermented Preparation of rice and wheat.
- Coconut milk. The coconut is grated and mixed with about 1/2 litre of hot water and sieved to remove the fibrous residue.

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