Top feeding means feeding of milks other than the breast milk in early infancy, should be strictly discouraged. However, it may be necessary in rare instances of true lactation failure, maternal death/serious sickness, or any absolute/relative contraindication for Breast feeding.

Top feeding may be loosely classified as exclusive top-feeding, or supplementary top-feeding along with Breast feeding like in partial lactation failure. Important issues in top-feeding are as follows —

Which milk to use in top feeding? Although many age-appropriate commercial formula feeds are available, prohibitive cost and risk of incorrect dilution by illiterate and poor mothers render them unsuitable for regular use in India. Dried skimmed milk powders or evaporated/condensed milks are also unsuitable for top feeding due to same reasons as well as unbalanced composition.

Skimmed milk powders top feeding have high protein & solute content (risk of dehydration), while condensed milks have excess carbohydrates (risk of diarrhea).

Pasteurized or fresh-boiled cow milk is the most practical top feeding alternative to Breast feeding, if top feeding is unavoidable. Composition of the cow’s milk is nearest to the breast milk except high protein load, which may be reduced by dilution.

It should be diluted with water in 1:1 ratio during first two weeks (longer in pre terms) and in 2:1 ratio during next two weeks. Undiluted cow milk may be used beyond neonatal period in full terms. Sugar may be added (1 tsb/l00 ml) to compensate for carbohydrate loss due to dilution.

Commercial formulas top feeding are specially prepared to bring their composition nearest to BM after dilution and hence, if used at all, should be diluted strictly according to the manufacturer’s instructions.

How much to give in top feeding? Quantity of top milk depends on baby’s age, gestation and weight. As a general rule, top- milk should provide 1 10-120 cal/kg/day. Calculated amount should be divided into 8 rations (3 hourly) during first two month and 6-7 rations (4 hourly) subsequently, to be given during each feed. A term baby normally accepts 50 ml feeds during first 2 weeks, 100 ml between 2-8 weeks and 150-250 ml subsequently.

How to give? Top feeding may be given by bottle, spoon, or indigenously designed utensils like Bondla or Paladi. Although convenient, risk of infection and other complications is maximum with bottle-feeding, which should be avoided as far as possible.

Ten Steps to Successful Lactation

1) A written Breast-feeding policy

2) Training of health-staff in Breast feeding promotional skills

3) Antenatal Counseling towards Breast feeding

4) Initiation of Breast feeding, within 30 minutes of delivery

5) Exclusive Breast feeding & no pre-lacteal feeds

6) Practicing rooming-in

7) Encourage demand feeding

8) No artificial teats/pacifiers to Breast feeding infants

9) Correct Breast feeding practices & continuance of lactation by EBM if the baby is separated from mother for medical reasons

10) Breast-feeding support groups

d) Which precautions to take? Important precautions, necessary to prevent complications of top feeding are—

a) Proper preparation of feeds

• Proper quantity and dilution of feed

• Use of fresh boiled milk diluted formula

• Proper temperature of feed

b) Proper preparation of feeding equipment

• Proper sterilization of feeding bottle/utensils

• Proper teat-hole size to allow drop by drop flow of milk from inverted bottle.

c) Correct technique of feeding

• Semi-upright position to avoid aspiration

• Burping after feeding

d) Early vitamin/mineral supplements, as Vitamin C and iron are deficient in cow milk.

e) How to sterilize feeding bottle/utensils for top feeding? Although bottle feeding is strongly discouraged, proper sterilization is necessary, if unavoidable. Bottle & nipple may be sterilized by boiling or chemical sterilization by dipping for 10 minutes in Milton solution (2% sodium hypochlorite). Other feeding utensils need not be boiled but should be properly cleaned with running or warm water.

* For top feeding, Before boiling, bottle should be properly cleaned with brush and lukewarm salt-water to remove the stickiness. Subsequently, bottle and nipple should be boiled for 15-20 minutes and 5 minutes respectively and left in container itself, till required, to prevent re-contamination.

Complications of Top feeding

Related to the milklformula:

• Under nutrition (over-diluted milk)

• Dehydration (concentrated formula feeds)

• Oral mucosal scalding (hot feeds)

• Constipation (high solute load)

• Allergic problems (high protein content)

• Recurrent respiratory infections (no immune factors) Related to the bottle

• Diarrhea (contaminated bottle)

• Overfeeding or underfeeding

• Aerophagia due to wrong bottle position

• Nipple confusion — difficulty in simultaneous Breast feeding

• Weaning problems (refusal to part with bottle)

• Defective dentition/Caries (sp. with night feeds)

Common Weaning Foods* for Indian Children

Between 4-6 months (1-3 times a day)

• Thickened fruit juices & soups

• Mashed fruits like banana, papaya, cheekoo etc.

• Boiled-mashed vegetables like carrot, potatoes etc.

• Milk-cereal porridge (ragi/ nachni/ suji), kheer etc

Between 6-8 months (3-4 times a day)

• Cereal-pulse combinations like khichri, rice-dal

• Chewable foods, softened in dal like bread, chapati

• Eggs (Not < 6 months due to risk of allergy in later life)

• Non-veg: like mashed chicken, fish, by 7-8 months Between 9-12 months (4-6 times a day)

• All foods eaten by the family, though less spicy.