Neonatal Growth and Nutrition
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Transcript Neonatal Growth and Nutrition
Pediatric Nutrition I
Nutrition of Neonates and Infants
– Prior to 1 year of age
– Growth Rates and Nutritional Goals
– Nutrient Requirements
Energy, Protein, Minerals, Vitamins
Absorptive/Digestive Immaturity
– Human Milk
– Infant Formulas
Growth rates are most rapid in the first six
months of human life
Nutrient requirements on a weight basis are
highest during the first six months
Rapid organ growth and development occurs
during the last trimester and first six months
The detrimental effects of nutritional
insufficiencies are magnified during periods of
rapid organ growth (I.e., vulnerable periods for
brain growth)
Provide sufficient macro- and micronutrient
delivery to promote normal growth rate and body
composition, as assessed by curves which are
generated from the population
Curves exist for:
– Standard anthropometrics: weight, length, OFC
– Special anthropometrics: arm circumference, skinfold
thickness
– Body proportionality: weight/length, mid-arm
circumference: head circumference ratio
Body composition measurements (e.g. DEXA,
PeaPod) are not standardized yet
GIRLS
Birth to 36 mo
BOYS
Birth to 36 mo
Term
infants require 85-90 Kcal/kg/d if
breast-fed, 100-105 Kcal//kg/d if
formula
Differences
are due to increased
digestibility and absorbability of
breast milk
– Presence of compensatory enzymes
(lipases)
(Continued)
Energy
requirements are 20% higher
in premature infants due to:
– Higher basal metabolic rate
– Lower coefficient of absorption for fat
and carbohydrates
Energy
requirements decrease to 75
Kcal/kg/d between 5-12 months
Basal Metabolism
Gross
Metabolizable
Energy
Energy
Intake
Intake
Thermic Effect of Feeding
Activity
Energy Stored “growth”
Tissue Synthesis
Energy Excretion
Diseases of infancy that increase BMR
(cardiac, neurologic, respiratory) affect
energy requirements
Diseases that increase nutrient losses
(malabsorption due to cystic fibrosis,
celiac disease, short bowel syndrome)
increase the need for energy delivery,
although the BMR is normal
Late gestation and infancy is the time of
highest protein accretion in human life
Protein requirements range from 1.5 g/kg/d
(healthy breast-fed infant) to 3.5 g/kg/d
(septic, preterm infant)
Amino acid synthesis is incomplete in the
premature; taurine and cysteine are
additional essential amino acids because of
immaturity of enzyme systems
Preterm
infants:
15 g/kg/d
Toddlers:
6 g/kg/d
Adolescents:
4 g/kg/d
Nutrient
Term
Preterm
5-12 Month
Neonate
Neonate
Infant
Na (mEq/kg/d)
2-3
4-7
1-2
K
1-2
2-4
1-2
Ca (mEq/kg/d)
60
150
40
Iron (mEq/kg/d)
1
2-4
0.7
0.4
0.3
(mEq/kg/d)
Zinc (mEq/kg/d)
0.2 - 0.5
Water-soluble vitamins (B, C, folate, etc.)
are rarely a problem in newborns and
infants; babies are born with adequate
stores and/or all food sources have
adequate amounts
Fat-soluble vitamins (A,E,D,K) may present
significant problems because of relatively
poor fat absorption by newborn infants
(especially premature infants)
K: Needs to be given at birth to prevent
hemorrhagic disease of newborn; adequate
thereafter due to synthesis by intestinal
bacteria
D: Low amounts in breast milk; infants
born in winter in north and infants who are
clothed at all times (minimal sun exposure)
have been identified with rickets
AAP now recommends 400 IU/d for all infants
(Continued)
A: Essential for normal structural collagen
synthesis and retinal development
deficiency in premature infants contribute
to fibrotic chronic lung disease
E: Antioxidant that protects against
peroxidation of lipid membranes; preterms
have poor antioxidant defense and are
subjected to large amounts of oxidant
stress; vitamin E deficiency causes severe
hemolytic anemia
Rapid transit time
+
Immature digestive capabilities
=
Reduced nutrient retention
Primary sources of CHO in newborn
and infant diet are disaccharides (esp.
lactose)
Disaccharides must be broken into
component monosaccharides to be
absorbed
– Lactose = glucose + galactose (lactase)
– Sucrose = glucose + fructose (sucrase)
– Maltose = glucose + glucose (maltase)
Intestinal
lactase concentrations are
low at birth and are not inducible
Amylase,
necessary for breaking
down starches, are not adequate
until > 4 months
Sucrase, Maltase, Isomaltase
Glucose Uptake
Salivary Amylase
Zymogen Granules in Pancreas
Pancreatic Amylase
Lactose
Gluco-amylase
10 Wks
20 Wks
22 Wks
24 Wks
24 - 28 Wks
85 % of ingested protein is absorbed in
spite of functional immaturities:
– Reduces stomach acidity
– Low pancreatic peptides levels
(chymotrypsin caroboxypeptidases)
Compensation is by trypsin and brush
border peptidases
Adult:
Term
95%
infant: 85-95%
Preterm
infant: 50 - 90%
(dependent on source of fat)
Low
levels of intestinal lipases
Small
bile salt pool
Committee
on Nutrition of the AAP
strongly recommends breastfeeding
for infants
The
rates of breastfeeding have risen
recently, but the attrition rate is high
(Continued)
The goal of the AAP and NIH Health People
2010 is to have 75% women breastfeed, with a
continuation rate of 50% at 6 months
It is necessary to breastfeed for at least 12
weeks to achieve the immunologic and
disease preventative benefits of breast milk
Physician’s role is to support, counsel and
trouble-shoot
Health
Nutritional
Immunologic
Neurodevelopmental
Economic
Environmental
Studies
in developed countries
– Reduced prevalence of:
Diarrhea
» Otitis media
» Lower respiratory infection
» UTI
» NEC (in preterms)
» SIDS
»
Protection
of infant from chronic
diseases:
– Insulin dependent diabetes mellitus
(OR 0.61)
– Inflammatory bowel disease
– Allergic disease
– Childhood lymphoma (OR 0.91)
– Obesity (OR 0.75-0.87)
Protection
of mother from:
– Pregnancy
– Postpartum hemorrhage
– Bone demineralization
– Ovarian cancer
Complete human nutrition for 6 months
– Iron at 4 months
– Vitamin D in northern climates, covered
infants and mothers, vegetarians (vegans)
Energy is more accessible than from
formula
– Compensatory lipases better fat
retention
– But, BF babies grow slower too
Amino
acid spectrum matches
infant need; lower protein and
solute load
Faster
reflux
gastric emptying less
Better
visual acuity (early)
— Role of DHA?
Higher
IQ (debatable)
— Independent of nursing
— Components in human milk which
may potentiate the effect:
»
»
DHA
Growth factors
25%
reduced risk of obesity if BF
— Adjusted OR: 0.75-0.89
—Dose response (Koletzko et al)
—
Rate of Adolescent Obesity
—12% if BF < 1month
—2% if BF 12 months
—“Small” effect compared to OR if
parents are obese (4.2), low physical
activity (3.5) or TV (1.5)
Reduced cost of feeding
— No formula cost (-$855/year)
— Increased maternal consumption (<+$400)
— Net savings of >$400/child
Reduced health care costs due to:
— Lower incidence of childhood illness
Reduced income loss due to:
— Less days lost to cover childhood illness
Galactosemia in infant
Illicit drug use by mother
Certain maternal infectious diseases
— Active TB
— HIV (US only)
— Not CMV
Certain maternal medications
— Anti-neoplastics, isotopes, etc
— How about SSRI's?
Promotes adequate growth, but not brain and
immunologic development compared to human
milk
New formulas contain LC-PUFAs
Soon to be added: prebiotics; probiotics
Most are cow-milk based, although soy-protein
based and fully elemental formulas are
available
(Continued)
Cow’s milk (not formula) is contraindicated in
the first year of life
— High solute load can lead to azotemia
— Inadequate vitamin D and A
— Milk fat poorly tolerated
— Low in calcium; can lead to neonatal seizures
— Gastrointestinal blood loss/sensitization to cowmilk protein
Feed humans human milk
— It is species specific
If not human milk, CMF or Soy formulas
with iron are indicated
Hypoallergenic formulas are highly
specialized, expensive and overused