Transcript Paediatric Nutrition - Luton & Dunstable Hospital : Welcome

Paediatric Nutrition
Sarah Fuller
Specialist Paediatric Dietitian
Luton and Dunstable Hospital
Outline of talk
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Growth and growth charts
Standard infant formulas – what’s in the milk?
Faltering growth and high calorie formulas
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‘Allergy’ formulas
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CMPI and lactose intolerance – what’s the difference?
First line advice
Pre-term formulas
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First line advice
When to prescribe and when to stop prescribing!
Anti-reflux formulas
Lactose free formulas
Weaning – when to start
The Under 5’s diet – key points
Obesity referrals
The new UK-WHO growth charts
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New growth charts are to be used in use in England, from
May 2009 (for new births only, so any baby who already
has a red book will continue to use the chart already in
that).
They show a pattern of healthy growth for all children.
They are based on breastfed babies and should be used
for all babies, however they are fed.
The new charts are suitable for all ethnic groups.
There is a separate page on the charts for babies born
preterm <37 weeks.
There are no lines between birth and 2 weeks – this is
because babies have very individual weight patterns at this
age.
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Babies should be weighed during this time and if there
is a weight loss of 10% or more the baby should be
examined and feeding reviewed.
The chart no longer has a bold line in the middle. This is
to show that a baby growing normally may be anywhere on
the chart.
Infants and toddlers
What is a normal rate of growth?
• Measure length or height whenever concerned about
weight gain or growth
• Measurements commonly show wide variation
– If worried measure on a few occasions
– Healthy children usually show a stable general pattern over time
• What is a normal rate of head growth?
– Head circumference usually tracks within one centile space
– Fewer than 1% of infants drop or rise through >2 centile spaces
after the first few weeks
Should be carefully assessed
© 2009 Royal College of Paediatrics and Child Health
wwwgrowthcharts.rcpch.ac.uk
Measuring and plotting
What do the Centiles Show?
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91st centile: only 9% of
children would be expected
to be heavier
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50th centile: half of all children
should be above and half
below this line
© 2009 Royal College of Paediatrics and Child Health
www.growthcharts.rcpch.ac.uk
Standard infant formula
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Curds and whey is
cottage cheese!
In milk it refers to
the protein
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Casein
Whey
Standard infant formula
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Whey Based
For infants from birth to one year of age
Protein content is 40% casein and 60%
whey
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same ratio as breast milk and is most suitable
for babies until they swap onto full fat milk
Nutritionally complete and do not require
further vitamin or mineral
supplementation.
E.g. Cow and Gate premium, SMA Gold,
Aptamil First and Heinz Nurture (was
known as Farleys First)
Standard infant formula
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Casein Based - For ‘hungrier’ babies
A higher ratio of casein to whey (80% casein:
20% whey)
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the same as standard cows milk
There is no reason why babies need to swap to
these formulas as they are not higher is
calories, protein or micronutrients
Always encourage parents to keep their babies
on whey based formulas up to one year of age
(can possibly cause constipation in some
babies)
E.g. Cow and Gate plus, SMA White, Aptamil
Extra, Heinz Nurture Hungry baby
Follow on milks
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Higher levels of Fe, Ca, Zn, Vitamins A & C
- but these are in a less bio-available form
Often contain pre and pro-biotics
e.g.‘immunofortis’ a prebiotic mix in
Aptamil
E.g. SMA progress, Cow and Gate (step up,
next step and growing up milk), Heinz
Nurture Growing
Not prescribable
Marketed towards ‘the worried well’ but do
have a place in our local population who
can struggle to wean
Standard infant formula – new research
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Prebiotics and Probiotics – a new trend with all
standard formula manufacturers (except SMA).
 No definitive research has shown any benefit
 However, they are found in breast milk
Change in protein – SMA Gold has reduced the
total protein level, closer to breast milk and altered
the quality of the protein
 Potential long term benefits from this – public
health impact, lower blood pressure and weight
gain mirroring that of breast fed babies (Lien,
2007 & Lawson, 2007)
Lipil - Mead Johnson's special blend of DHA
(omega-3 fatty acid) and ARA (omega-6 fatty
acid), long chain polyunsaturated fatty acids that
are important building blocks for baby's brain and
eye development
Faltering growth
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Up to 5% of babies
Most common in the second 6 months of
life
Early, effective intervention is key to
prevent prolonged periods of malnutrition
If concerned measure the OFC & length
as well
Don’t use the birth centile – babies will
settle to a weight centile ~12 weeks
High calorie formulas
Standard infant formula is 67Kcal and 1.5g
protein per 100ml
High calorie formula from birth to 8kg or 1yr
 SMA High Energy:
 Milk based nutritionally complete tube and sip
feed
 91kcal per 100ml and 2.0g protein per 100ml
 Infatrini:
 Milk based nutritionally complete tube and sip
feed
 100kcal per 100ml, 2.6g protein per 100ml
 Lower osmolarity than SMA High Energy
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High calorie formulas
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Indications for use:
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Fluid restrictions e.g. in cardiac babies
(usually restricted to 100120ml/kg/day)
Catch up growth e.g. in FTT
Increased energy requirements e.g. CF,
respiratory diseases, prematurity
High calorie formulas/sip feeds
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1-6 yr or 8kg – 20kg
Paediasure: 101kcal, 2.8g protein per 100ml
Paediasure Fibre: 101kcal, 2.8g protein,
0.73g fibre per 100ml
Fortini: 150Kcal, 3.4g protein per 100ml
Fortini multi fibre: 150Kcal, 3.4g protein,
1.5g fibre per 100ml
Tube feeds
1-6years and 8-20kg
 Nutrini: 100Kcal, 2.8 g prot/100ml
 Nutrini energy: 150Kcal, 4.1gprot/100ml
 Nutrini low energy: 75Kcal, 2.1g
prot/100ml
7-12years and 21-45kg
 Tentrini: 100kcal, 3.3g prot/100ml
 Tentrini energy: 150kcak, 4.9g prot/100ml
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Can be prescribed an adult feed after this
Multi fibre varieties available in all these feeds
Faltering growth
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Please monitor !!!!
CMPI and Lactose intolerance
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CMPI = Cow’s Milk Protein Intolerance.
~5% of all newborns can have CMPI.
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Symptoms: Diarrhoea, vomiting,
constipation, blood in stools, eczema,
refusal of milk, FTT
Treatment – 1st line: Nutramigen 1.
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80% of these will grow out of it by 1y,
95% by 3y
IF FTT as well, Neocate LCP.
Refer to Dietetics for milk free weaning
advice.
Lactose intolerance
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Lactose is the sugar in milk
Broken down by the enzyme
lactase – produced in the tips
of the gut villi
Diagnosed by the presence of
reducing substances in the
stool
Primary lactose intolerance
mostly in Asian and AfroCaribbean populations
Secondary lactose intolerance
after gut trauma (i.e. from
rotavirus or CMPI depending
on symptoms)
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Treatment 2 – 6 weeks on
Lactose free formula and
milk/lactose free diet
Colic and lactose intolerance
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Colic ~ 1 in 5 babies
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intensity of crying: the baby's face is red and
flushed, the crying is intense and furious, and there
is little, or nothing, you can do to comfort them,
body posture – the baby may clench their fists,
draw up their knees, or arch their back.
‘Colief’ Drops: Helps compensate for a possible
lactase deficiency in the infant’s digestive system
– Prescribable
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Add to the baby’s usual milk (breast milk or
formula) will reduce the level of lactose by up to
70% by breaking down lactose into glucose and
galactose, before the baby is fed.
Hydrolysed infant formulas
Potential
Antigenicity
High
Protein Breakdown
Intact protein
(e.g. normal infant formula)
Incomplete proteins
(partially digested
e.g. Aptamil Pepti)
Large peptides
(e.g. Pepti Junior)
Small peptides
(e.g. Nutramigen 1)
Low
Amino acids
(e.g. Neocate LCP)
Hydrolytic Stages of an
antigenic protein molecule
Hydrolysed milks
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For those suspected of being allergic, intolerant (e.g.
CMPI) or mal-absorbing
E.g. Nutramigen 1&2/Pregestimil (Casein based,
95% <1000 Daltons), Pepti-junior (Whey based,
63% <1000 Daltons).
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Cost ~£9/400g tin and are lactose free
Nutramigen has LCT whereas Pregestimil has MCT
Note! If >6m babies may not tolerate hydrolysed
formulas due to their bitter taste. They can be
flavoured with milkshake or syrups. BUT, this will
increase the osmolarity.
Nutramigen 2 has 2g fructose added (puree apple =
19g)
Nutrini Peptisorb – NEW!!! Semi-elemental,
1Kcal/ml, 1-6 years or 8-20Kg. Contains some MCT
fat and small amounts of lactose.
Extensively hydrolysed milks
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Some babies may still be intolerant to Hydrolysed
formulas. Cost ~£25/400g tin
 Neocate – standard conc. 15% (71Kcal, 2g
prot/100ml), osmolarity is 360mosm/kg
 Neocate Advance – standard conc. 25%
(100Kcal, 2.5gprot/100ml) osmolarity
610mosm/kg. >1y of age. Complete in 600ml.
 Neocate Active – standard conc. 21%
(100kcal, 2.8g prot/100ml) osmolarity
520mosm/kg extra Ca, Fe and P. 1 – 10y.
Complete in 600ml
 Nutramigen AA – NEW!!! 17.5% cheaper,
more Na (high levels when concentrated) and
Ca. Lower osmolarity than Neocate.
Hydrolysed formulas – non
vegetarian
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Neocate, Neocate Advance,
Neocate Active
Animal ingredients:
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L-Tyrosine is derived from 2 sources, one
is from chicken feathers
One of the vitamins is “carried on” trace
amounts of hydrolysed fish skin gelatine
Hydrolysed formulas – non
vegetarian
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Nutramigen and Pregestimil
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Not vegetarian or Halal approved.
They use pork enzyme to break down the
protein.
This equates to: In a standard concentration of
feed there is 0.0125% pork enzyme in 100ml of
feed.
Aptamil Pepti and Pepti junior
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Not Halal approved. No animal ingredients.
However animal (calf) rennet is used in the
processing of the feed.
Hydrolysed formulas – non
vegetarian
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World Health Organisation, July 2001.
A seminar held by the Islamic Organisation for
Medical Sciences attended by leading religious
spokesmen
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‘Transformation which means the conversion of a
substance into another substance, different in
characteristics, changes substances that are
judicially impure or are found in an impure
environment, into pure substances, and changes
substances that are prohibited into lawful and
permissible substances’
‘Necessities overrule prohibitions’ – Dire need for
specialist infant formula
Elemental feeds
Nutritionally complete liquid diet containing
a mix of essential and non-essential amino
acids, carbohydrates, fats, vitamins,
minerals, trace elements with added flavourings
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Elemental 028 Extra
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From 1 year of age, but higher osmolarity so we use
>5y
89Kcal, 2.5g protein per 100ml
Emsogen – as Elemental 028, but with MCT fats
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88kcal, 2.5g protein per 100ml
Soya formulas
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Soya e.g. Infasoy, Wysoy, Perjomin
Can be given from 6 months.
Babies with a family history of atopic disease
(asthma, eczema, hay-fever etc…) should be
given a hydrolysed formula
Ideally should be used after 1 year, but can
be used from 6m. (BDA Consensus
statement, 2009)
Potential long term risks if used <1y – high
levels of Phytoestrogens result in longer and
heavier periods in females and reduced
fertility in males
OK in Galactosaemia
Allergy advice
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Refer to a Paediatric Dietitian for specific
tailored advice
Useful to know…
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90% of ‘may contain’ labels don’t actually
contain the allergen they warn about
Use the ingredient list not the free from
advertising (this can be wrong)
Foods made in the EU now have the 12
greatest allergens labelled by law
Restricted diets often lead to poor bone
health so we will request a Calcium and
Vitamin D supplement for patient or
mother if breastfeeding
Lactose free formulas
Hydrolysed formulas usually don’t contain lactose
e.g. Nutramigen, Neocate etc...
 ‘Enfamil-O-lac’ or ‘SMA LF’– tastes better as it is
not hydrolysed, just lactose free
 If >1y - Soya as lactose free.
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Should not advise the pre-made soya milks under
the age of 2years old as they have the same calorie
content as semi skimmed milk.
Can be used over 2y if the child's diet is
nutritionally adequate, ensure that the ones fortified
with Ca are purchased.
Note: these feeds will have extra Ca as lactose
aids the absorption of Ca.
Express delivery!
What about the little ones?
Pre-term or low birth-weight formulas
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Very difficult to meet the energy and protein
requirements in premature babies especially if they
have restricted fluids due to reflux or CLD
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Can need volumes up to 200ml/kg/day
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Term baby needs 150ml/kg/day
Adult needs 30-35ml/kg/day
They can be given SMA High Energy or Infatrini if
their needs require
A combination of EBM and formula may be used to
help meet their requirements
Breast milk fortifier – increases the level of protein,
energy, Ca, P, vitamins and minerals
Pre-term or low birth-weight formulas
- Assists with catch-up growth
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Nutriprem 1:
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150 – 200ml/kg/day until the infant reaches 18002000g
80Kcal, 2.4g protein per 100ml
Higher levels of nearly all vitamin and minerals –
especially Ca, Fe, Phosphate
Nutriprem 2:
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A post discharge formula or if over 2000g
Used until 6 months of corrected age
75Kcal, 2g protein per 100ml
Higher levels of nearly all vitamin and minerals –
especially Ca, Fe, Phosphate
Pre-term or low birth-weight formulas
- Assists with catch-up growth
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Nutriprem breast milk fortifier:
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A breast milk powder supplement for low birth
weight babies and born before the sucking
reflexes have been established (34-36weeks of
gestation)
1 sachet (2.1g) to 50ml or 2 to 100ml
 Extra energy, protein, CHO, vitamins &
minerals
 EBM ~ 66-70KCal and 1.8g protein
 Fortified EBM ~ 86Kcal and 2.6g protein
Not ACBS but may be provided from a
Neonatal Unit
Pre-term formulas – when to prescribe
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Not to term babies that are low
birth weight (these need a term
formula ? High energy formula)
Prescribable until 6 months of
corrected age (not actual) –
unless otherwise directed by a
Dietitian.
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If still concerned re: growth/weight
then can change to a high calorie infant
formula and refer to Dietetics
‘Crying over spilt milk’, anti-reflux formulas
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Enfamil AR and SMA Staydown
 Designed to thicken on contact with stomach acid
and therefore prevent regurgitation.
 Should not be used with Ranitidine as this makes
the feed ineffective.
 ESPGAN, 1996: recommend the use of this type of
formula for the first line treatment of mild reflux.
 These formulae can be used in conjunction with
other standard treatments for reflux
 Enfamil AR is available on prescription
 These are made up differently, cool boiled water
needs to be left to stand for 1 hr before powder is
added – to prevent the milk thickening too early
Weaning
When to wean?
 Not before 17 weeks
 No later than 6 months
 BLISS recommend premature babies be weaned
between 5-7 months actual age not corrected
age
In April 2001, the WHO issued recommendations to
endorse exclusive breastfeeding until six months
of age.
In May 2003, the Department of Health issued
guidelines recommending that babies are weaned
at 6 months of age.
Weaning cont…
Go by development rather than age:
 Greater strength and stability of the
trunk, shoulder and neck muscles
 Independent head control
 Tongue thrust mechanism
 Fine motor co-ordination of muscles e.g.
Lips and hands
 Increased demand for feeds especially at
night
Start teeth cleaning as soon as teeth
appear with a smear of toothpaste
twice a day
Weaning continued
Weaning cont…
Risk of early weaning
 Kidney immaturity (hypernataemia)
 Gut immaturity (tolerance problems)
 Increase risk of infection and disease such as:
 Diabetes
 Obesity
 Allergy and intolerance
 Reduced absorption of nutrients in breast milk
Risk of late weaning
 Poor weight gain
 Anaemia
 Food refusal / faddy eating when older
 Miss developmental cues
Baby led weaning
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Gives the control to the infant
Claims that giving puree is unnatural and
babies should be weaned onto hand-held
solid foods
May reduce ‘fussy eating’
Claims that introducing puree could delay
the development of chewing skills.
But if the child is exclusively weaned onto
solids from 6m there may be a limit to the
amount of food and therefore nutrients that
are swallowed and absorbed as only foods
the baby can ‘grasp’ will be offered
Not enough research to date
The Healthy Childs Under 5’s
diet the key points
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Only offer milk and water as a drink with snacks
Offer drinks from a open top cup at 6 months and
the bottle should be gone by 12 months!
Sugar free snacks e.g. breadsticks, fresh fruit,
vegetables, cheese etc…
Don’t add salt or sugar in cooking or onto foods
Vitamin supplements e.g. healthy start vitamins,
Abidec, Dalavit etc…
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From 6m if breastfed
From 1y if on blue top milk
Only to stop prescribing when 5y old!
Healthy Under 5’s scheme – in all children’s
centres and many nurseries in Luton and
Bedfordshire.
Obesity
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Should measure both Ht
and Wt.
Concern when Wt is 2
centiles above Ht
Being on the 98thC for Ht
and Wt does not make you
obese – just tall and in
proportion!
Many South-Asian children
will be on or <0.4thC
BMI charts and ranges are
different in children a BMI
of 15kg/m2 for a 6y old is
on 50thC, but 0.4th C for a
16y old
New growth charts are
multi-centre, mixed race
and show how well children
should grow
Measuring and plotting
What do the Centiles Show?
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91st centile: only 9% of
children would be expected
to be heavier
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50th centile: half of all children
should be above and half
below this line
© 2009 Royal College of Paediatrics and Child Health
www.growthcharts.rcpch.ac.uk
Childhood obesity referrals
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Simple i.e. no co-morbidities or underlying
conditions (Diabetes), allergy, behavioural
problems etc…
Available schemes – run by active Luton
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Mini-MEND 2-4y
MEDN 5-7y
MEND 7-13
Contact Suliman Rafiq. NHS Luton,94 Inkerman
Street, Luton, LU1 1JD
Complex obesity who want to make lifestyle
changes or those who have attended MEND and
need further advice – refer to Dietetics.
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Any questions?
Paediatric Dietitian, Dietetics Department, Luton &
Dunstable Hospital, Lewsey Road, LU4 0DZ
Tel: 01582 49 71 62
Fax: 01582 49 73 61