Transcript Week 7

Infancy
2002
• Growth in infancy
• Physiology of infancy
• GI
• Renal
•
•
•
•
•
Development of feeding skills
Nutrient requirements
Infant formulas
Non milk feedings/solids
Oral health
GROWTH IN FIRST 12
MONTHS
• From birth to 1 year of age, normal human infants
triple their weight and increase their length by 50%.
• Growth in the first 4 months of life is the fastest of the
whole lifespan - birthweight usually doubles by 4
months
• 4-8 months is a time of transition to slower growth
• By 8 months growth patterns more like those of 2
year old than those of newborn.
Weight Gain in Grams per Day in
One Month Increments - Girls
Age
Up to 1
month
1-2
months
2-3
months
4-5
months
5-6
months
10th
percentile
16
50th
percentile
26
90th
percentile
36
20
29
39
14
23
32
13
16
20
11
14
18
Guo et al., J Peds. 1991
Weight Gain in Grams per Day in
One Month Increments - Boys
Age
Up to 1
month
1-2
months
2-3
months
3-4
months
4-5
months
5-6
months
10th
percentile
18
50th
percentile
30
90th
percentile
42
25
35
46
18
26
36
16
20
24
14
17
21
12
15
19
Guo et al., J Peds. 1991
Energy & Protein
• Young infant requires substantial
percentage of energy intake for growth
• Relatively large percentage of
requirement for protein in young infant
is accounted for by protein accretion
Body increment gained, g/day
Energy Used for Growth
Body
Energy Used for
Increment g/d
Growth
Age in Protein
mos.
Fat Kcal/d Kcal/kg/d
0-4
3.12
10.35 153.6
28.4
4-6
6 - 12
2.0
1.9
4.8 78.6
1.4 40.6
10.4
4.5
Body Composition
• BMI and percentage of body weight made up
of fat increase rapidly during the first months
of life
– Fat accounts for 0.5% of body weight at
the fifth month of fetal growth and 16% at
term.
– After birth, fat accumulates rapidly until
approximately 9 months of age
Individual Growth Patterns
– Weight and length at term appear to be
primarily determined by nongenetic
maternal factors
– Birth weigh and birth length weakly
correlate with subsequent weight and
length values
Individual Growth Patterns,
cont.
• Extremes of birth weight and length
tend to regress to the mean, and
genetic factors appear to have a
stronger effect by the middle of the first
year.
• infants who are born small but are genetically
destined to be longer may shift percentiles on
growth grids during the first 3 to 6 months
• larger infants at birth whose genotypes are for
smaller size tend to grow at their fetal rates for
several months before the lag-down in growth
becomes evident
Individual Growth Patterns,
cont.
– African American males and females are
smaller than Caucasians at birth, but they
grow more rapidly during the first 2 years
– Patterns of growth in breastfed infants may
be different from formula fed infants
Assessment of Growth
• Growth Charts
– http://www.cdc.gov/growthcharts/
• Growth Velocity
New Growth Charts
• Data from old charts came from private
study of primarily Caucasian, formulafed, middle-class infants from
southwestern Ohio
• New charts have data from NHANES
and use more sophisticated smoothing
techniques
• 16 new charts provided by gender and
age
New Growth Charts
• Clinical charts for infancy for girls and
boys:
– weight
– length
– weight for length
– OFC
• Choice between outer limits at 3rd and
97th or 5th and 95th percentiles
Physiology - GI Maturation
Genetic Endowment
Biological Clock
Gut Development
Environmental Influences
Regulatory Mechanisms
In utero
• fetal GI tract is exposed to constant passage of fluid
that contains a range of physiologically active factors:
– growth factors
– hormones
– enzymes
– immunoglobulins
• these play a role in mucosal differentiation and GI
development as well as development of swallowing
and intestinal motility
At Birth
• gut of the newborn is faced with the
formidable task of passing, digesting,
and absorbing large quantities of
intermittent boluses of milk
• comparable feeds per body weight for
adults would be 15 to 20 L
Enteral Feeding Requirements
– Coordinated sucking and swallowing
– Gastric emptying
– Intestinal motility
– Secretions: salivary, gastric, pancreatic,
hepatobiliary
– Enterocyte function in terms of enzyme
synthesis, absorption, mucosal protection
– Metabolism of products of digestion and
absorption
– Expulsion of undigested waste products
Human Milk
• complements Immaturities of these
systems as well as their maturation
– Epithelial growth factors and hormones
– Digestive enzymes - lipases and amylase
Motility - Upper GI
• Esophageal motility is decreased in the
newborn
• LES is primarily above the diaphragm
• LES pressure is less for first months
• Gastric Emptying may be delayed
Motility - Intestinal
• Intestinal motility is more disorganized
• Prolonged transit time in upper
intestines may improve absorption of
nutrients
• Rapid emptying of ileum and colon may
reduce time for water and electrolyte
absorption and increase risk of
dehydration
Stooling
• Gasrtro-colonic reflex is active in the
neonate: entry of food into beginning of
small intestine causes reflexive
propulsion toward the rectum
• Passage of stool occurs within 24 hours
for most healthy full term infants.
• Meconium is passed for the first 2 or 3
days
Stooling, cont.
• In first week of life may pass as many as 9
stools per day, declines to 3 or 4 by second
week
• Later breast fed babies may not even have
daily stools.
• Fetal gut is sterile, but infant exposed to
microorganisms during birth.
• Bacteria may be detected in meconium within
4 hours of birth following vaginal birth
Common GI Symptoms
Common GI Symptoms
&
Infant Stools
Effect of infant formula on stool
characteristics of young infants.
Pediatrics 1995 Jan;95(1):50-4
• 238 healthy 1-month-old infant were fed one of four
commercial formula preparations (Enfamil, Enfamil
with Iron, ProSobee, and Nutramigen) for 12 to 14
days in a prospective double-blinded
(parent/physician) fashion. Parents completed a daily
diary of stool characteristics as well as severity of
spitting, gas, and crying for the last 7 days of the
study period. A breast-fed infant group was studied
as well.
Gut Hormones
• Gastrointestinal peptides are found in venous
cord blood at birth in levels similar to those of
fasting adults
• In fetal distress a number of gut peptides are
elevated which might account for passage of
meconium
• With enteral feeding levels of gut hormones
(motilin, neurotensin, GIP (gastric inhibitory
peptide), gastrin, enteroglucagon, PP pancreatic polypeptide, rise rapidly
Possible Roles for Gut
Hormones in Early Infancy
Motilin
Enteroglucagon
Enteroglucagon,
gastrin, pancreatic
polypeptides
Gastric Inhibitory
polypeptide (GIP)
Increased gut
motility
Tropic to gut
mucosa
Intestinal
mucosal and
pancreatic growth
Stimulus to
insulin release
Gut Hormones Influenced By:
• Choice of breast or formula feeds
• Enteric intake (induces epithelia
hyperplasia and stimulates production
of microvillous enzymes)
• Early enteral feeding (enteral feeding is
strongly encouraged to promote GI
function and differentiation)
Programming by Early Diet
• Nutrient composition in early diet may have
long term effects on GI function and
metabolism
• Animal models show that glucose and amino
acid transport activities are programmed by
composition of early diet
• Animals weaned onto high CHO diet have
higher rates of glucose absorption as adults
compared to those weaned on high protein
diet
Pancreas
• Pancreatic function is relatively deficient
at birth and mature levels of pancreatic
enzymes are not achieved until late
infancy
• Pancreatic amylase activity increases
after 4 to 6 months
Lipase levels do not approach adult
efficiency until about 6 months
Protein Digestion
Factor
In Early Infancy
Compared to Adult levels
Gastric Acid
Trypsin
Chymotrypsin
Pancreatic
Proteases
Intestinal Mucosal
peptidases
Lower production
Activity reduced
Low levels
Low levels
Adequate
Fat Digestion
Factor
In Early Infancy Compensating
Compared to
Mechanisms
Adult levels
Pancreatic
Lipase
Bile Acids
Very low levels
Low levels
Lingual, gastric
and breastmilk
bile salt
stimulated
lipase
Carbohydrate Digestion
Factor
In Early
Infancy
Compared to
Adult levels
Salivary Amylase Lower levels
Pancreatic
amylase
Disacharidases
Compensating
Mechanisms
Stays active in
stomach
Very low levels Breastmilk
amylase
Adequate levels Fermentation
and absorption
in large
intestine
Maturation in First Year
• LES tone increases after 6 months and is associated
with less reflux in most infants
• Gastric acid and pepsin activity do not reach adult
levels until 2 years
• Pancreatic amylase increases by 6 months
Retention of lactase activity is typical until 3 to 5
years.
• Fat absorption does not approach adult efficiency
until about 6 months
• Lipase reaches adult levels by 2 years.
Renal
• Limited ability to concentrate urine in
first year due to immaturities of nephron
and pituitary
• Potential Renal solute load determined
by nitrogenous end products of protein
metabolism, sodium, potassium,
phosphorus, and chloride.
Potential Renal Solute Load
Feeding
Human Milk
Milk based formula
Isolated Soy protein
based formula
Evaporated milk
formula
Whole cow milk
Potential
Renal Solute
Load,
mOsm/liter
93
135
165
260
308
Urine Concentrations
• Most normal adults are able to achieve urine
concentrations of 1300 to 1400 mOsm/l
• Healthy newborns may be able to
concentrate to 900-1100 mOsm/l, but isotonic
urine of 280-310 mOsm/l is the goal
• In most cases this is not a concern, but may
become one if infant has fever, high
environmental temperatures, or diarrhea
Water Needs
• Water requirement is determined by:
– water loss
• evaporation through the skin and respiratory
tract (insensible water loss)
• perspiration when the environmental
temperature is elevated
• elimination in urine and feces.
– water required for growth
– solutes derived from the diet
Water, cont.
• Water lost by evaporation in infancy and
early childhood accounts for more than
60% of that needed to maintain
homeostasis, as compared to 40% to
50%
• NAS recommends 1.5 ml water per kcal
in infancy.
Water Needs
Age
Amount of Water (ml/kg/day)
3 days
80-100
10 days
125-150
3 mo.
140-160
6 mo.
130-155
9 mo.
125-145
1 yr.
120-135
2 yr.
115-125
Development of Infant
Feeding Skills
• Birth
– tongue is disproportionately large in comparison
with the lower jaw: fills the oral cavity
– lower jaw is moved back relative to the upper jaw,
which protrudes over the lower by approximately 2
mm.
– tongue tip lies between the upper and lower jaws.
– "fat pad" in each of the cheeks: serves as. It is
thought that these pads serve as a prop for the
muscles in the cheek, maintaining rigidity of the
cheeks during suckling.
– Feeding pattern described as “suckling”
Developmental Changes
• Oral cavity enlarges and tongue fills up less
• Tongue grows differentially at the tip and attains
motility in the larger oral cavity.
• Elongated tongue can be protruded to receive and
pass solids between the gum pads and erupting teeth
for mastication.
• Mature feeding is characterized by separate
movements of the lip, tongue, and gum pads or teeth
Feeding behavior of infants
Gessell A, Ilg FL
Age
1-3
months
Reflexes
Rooting and suck
and swallow
reflexes are
present at birth
4-6
months
Rooting reflex
fades
Bite reflex fades
7-9
months
10-12
months
Oral, Fine, Gross Motor Development
Head control is poor
Secures milk with suckling pattern, the tongue projecting
during a swallow
By the end of the third month, head control is developed
Changes from a suckling pattern to a mature suck with
liquids
Sucking strength increases
Munching pattern begins
Grasps with a palmer grasp
Grasps, brings objects to mouth and bites them
Gag reflex is less Munching movements begin when solid foods are eaten
strong as chewing Rotary chewing begins
of solids begins
Sits alone
and normal gag is Has power of voluntary release and resecural
developing
Holds bottle alone
Choking reflex
Develops an inferior pincer grasp
can be inhibited
Bites nipples, spoons, and crunchy foods
Grasps bottle and foods and brings them to the mouth
Can drink from a cup that is held
Tongue is used to lick food morsels off the lower lip
Finger feeds with a refined pincer grasp
Feeding Interactions
Age
Infant Development
Optimal Caregiver
Behaviors
Recognize and respond to
infant cues, lets infant set
tempo, talks and smiles
0-2 months
Homeostasis
Regulation of state,
cycles of feeding and
sleep, begins to
interact
2-6 months
Attachment
Infant initiates and
responds to social
overtures
Responds to infant,
increased skills at reading
cues, avoids interupting
feedings
6-9 months
Behavioral
organization control,
differentiation between
cause and effect,
beginning of autonomy
Gives opportunities to
explore, make messes,
provides structure & let's
infant decide how fast and
how much to eat.
Feeding Interactions, cont.
Age
9-12 months
13-18 months
Infant Development
Optimal Caregiver
Behaviors
Consistently responds Recognizes boundaries
to parent's gestures
between playing and
eating
Organizes patterns Does not bribe, coax, beg
teases, jokes and
or force child to eat
provokes
Energy Requirements
• Higher than at any other time per unit of
body weight
• Highest in first month and then declines
• High variability - SD in first months is
about 15 kcal/kg/d
• Breastfed infants many have slighly
lower energy needs
• RDA represents average for each half of
first year
Energy Requirements, cont.
• RDA represents additional 5% over
actual needs and is likely to be above
what most infants need.
• Energy expended for growth declines
from approximately 32.8% of intake
during the first 4 months to 7.4% of
intake from 4 to 12 months
Mean Daily Energy and
Protein Intakes
Intake
Energy
Kcal
Kcal/Kg
Protein
g
g/kg
Infant
Adult
464
116
2500
36
10.4
2.6
93.8
1.3
Mean Daily Energy and
Protein Intakes
Intake
Energy
Kcal
Kcal/Kg
Protein
g
g/kg
Infant
Adult
464
116
2500
36
10.4
2.6
93.8
1.3
Energy Intakes by Breastfed and
Formula Fed Boys (kcal/kg)
Age in Mos.
1
2
3
5
6
Breastfed
115
104
95
89
86
Formula
120
106
95
95
92
1989 RDA: Energy and
Protein
Age in
Months
0–6
6 - 12
Reference
Weight (kg)
6
9
Energy
Protein
(kcal/kg/day) (g/kg/day)
108
2.2
98
1.6
From National Academy of Sciences: Recommended dietary
allowances, Ed 10, Washington, DC, 1989, National
Academy Press.
2002 Energy DRI
2002 Protein DRI
2002 Carbohydrate DRI
2002 Fat DRI
Distribution of Kcals
Breastmilk
Formula
% Protein
6
9
% Fat
52
48
% Carbohydrate
42
42
Protein
• Increases in body protein are estimated
to average about 3.5 g/day for the first 4
months, and 3.1 g/day for the next 8
months.
• The body content of protein increases
from about 11.0% to 15.0% over the first
year
Essential Fatty Acids
• The American Academy of Pediatrics
and the Food and Drug Administration
specify that infant formula should
contain at least 300 mg of linoleate per
100 kilocalories or 2.7% of total
kilocalories as linoleate.
LCPUFA: Background
n-6
n-3
18:2
Linoleic
18:3
Linolenic
18:3
 linolenic
20:5
EPA
20:4
Arachidonic
22:6
DHA
LCPUFA: Background
• Ability to synthesize 20 C FA from 18 C FA is
limited.
• n-3 and n-6 fatty acids compete for enzymes
required for elongation and desaturation
• Human milk reflects maternal diet, provides
AA, EPA and DHA
• n-3 important for neurodevelopment, high
levels of DHA in neurological tissues
• n-6 associated with growth & skin integrity
Formula supplementation with long-chain
polyunsaturated fatty acids: are there
developmental benefits? Scott et al. Pediatrics,
Nov. 1998.
• RCT, 274 healthy full term infants
• Three groups:
– standard formula
– standard formula with DHA (from fish oil)
– formula with DHA and AA (from egg)
• Comparison group of BF
Outcomes at 12 and 14
months
• No significant differences in Bayley,
Mental or Psychomotor Development
Index
• Differences in vocabulary
comprehension across all categories
and between formula groups for
vocabulary production.
Outcomes at 12 and 14
months
• No significant differences in Bayley,
Mental or Psychomotor Development
Index
• Differences in vocabulary
comprehension across all categories
and between formula groups for
vocabulary production.
Bayley Scales at 12 months
Human Std.
AA +
Milk
Formula DHA
DHA
MDI
108
105
105
104
PDI
100
105
98
101
MacArthur Communicative Development
Inventories at 14 Months of Age
Human Std
AA +
Milk formula DHA
DHA
Vocabulary
Comprehension
101
100
98
92
Vocabulary
production
97
101
99
91
Conclusion
“We believe that additional research
should be undertaken before the
introduction of these supplements into
standard infant formulas.”
PUFA Status and Neurodevelopment:
A summary and critical analysis of the
literature (Carlson and Neuringer, Lipids, 1999)
• In animal studies use deficient diets
through generations - effects on
newborn development may be through
mothering abilities.
• Behaviors of n-3 fatty acid deficient
monkeys: higher frequency of
stereotyped behavior, locomotor activity
and behavioral reactivity
Vitamins and Minerals
• Need for minerals and vitamins
increased per kg compared to adults:
– growth rates
– mineralization of bone & increases in bone
length
– Increased blood volume
– energy, protein, and fat intakes
Vitamins and Minerals
• Focus on nutrients with controversies
and/or recent research:
– Vitamin K
– Vitamin D
– Iron
– Fluoride
Vitamin K: AAP, 1993
• Vitamin K deficiency may cause
unexpected bleeding (0.25% to 1.7%
incidence) during the first week of life in
previously healthy-appearing neonates
Vitamin K: AAP
• Late HDN, a syndrome defined as unexpected
bleeding due to severe vitamin K deficiency in infants
aged 2 to 12 weeks, occurs primarily in exclusively
breast-fed infants who have received no or
inadequate neonatal vitamin K prophylaxis.. The rate
of late HDN ranges from 4.4 to 7.2 per 100 000 births
based on reports from Europe and Asia. When a
single dose of oral vitamin K has been used as
neonatal prophylaxis, the rate has decreased to 1.4
to 6.4 per 100 000 births
AAP Recommendations
• 1. Vitamin K1 should be given to all
newborns as a single, intramuscular
dose of 0.5 to 1 mg.
• 2. Further research on the efficacy,
safety, and bioavailability of oral
formulations of vitamin K is warranted.
AAP Recommendations
• 3. An oral dosage form is not currently
available in the United States but ought to be
developed and licensed. If an appropriate oral
form is developed and licensed in the United
States, it should be given at birth (2.0 mg)
and should be administered again at 1 to 2
weeks and at 4 weeks of age to breast-fed
infants. If diarrhea occurs in an exclusively
breast-fed infant, the dose should be
repeated.
AAP Recommendations
• 4. The conflicting data of Golding et al
and Draper and Stiller and the data from
the United States suggest that
additional cohort studies are unlikely to
be helpful.
Cochran Protocol: Vitamin K for preventing
haemorrhagic disease in newborn infants
• Vitamin K deficiency can cause
bleeding in an infant in the first weeks of
life. This is known as Haemorrhagic
Disease of the Newborn (HDN) or
Vitamin K Deficiency Bleeding (VKDB).
Cochran Protocol: Vitamin K for preventing
haemorrhagic disease in newborn infants
• HDN is divided into three categories: early, classic
and late HDN. Early HDN occurs within 24 hours post
partum and falls outside the scope of this review.
• Classic HDN occurs on days 1-7. Common bleeding
sites are gastrointestinal, cutaneous, nasal and from
a circumcision. Late HDN occurs from week 2-12.
• The most common bleeding sites in this latter
condition are intracranial, cutaneous, and
gastrointestinal (Hathaway 1987 and von Kries
1993).
Cochran Protocol: Vitamin K for preventing
haemorrhagic disease in newborn infants
• Vitamin K is necessary for the synthesis of
coagulation factors II (prothrombin), VII, IX and X in
the liver.
• In the absence of vitamin K the liver will synthesize
inactive precursor proteins, known as PIVKA’s
(proteins induced by the absence of vitamin K).
• HDN is caused by low plasma levels of the vitamin Kdependent clotting factors. In the newborn the
plasma concentrations of these factors are normally
30-60% of those of adults. They gradually reach adult
values by six weeks of age
Cochran Protocol: Vitamin K for preventing
haemorrhagic disease in newborn infants
• The risk of developing vitamin K
deficiency is higher for the breastfed
infant because breast milk contains
lower amounts of vitamin K than formula
milk or cow's milk
Cochran Protocol: Vitamin K for preventing
haemorrhagic disease in newborn infants
• In different parts of the world, different
methods of vitamin K prophylaxis are
practiced.
Cochran Protocol: Vitamin K for preventing
haemorrhagic disease in newborn infants
• Oral Doses:
• The main disadvantages are that the
absorption is not certain and can be
adversely affected by vomiting or
regurgitation. If multiple doses are
prescribed the compliance can be a
problem
Cochran Protocol: Vitamin K for preventing
haemorrhagic disease in newborn infants
• I.M. prophylaxis is more invasive than
oral prophylaxis and can cause a
muscular haematoma. Since Golding et
al reported an increased risk of
developing childhood cancer after
parenteral vitamin K prophylaxis
(Golding 1990 and 1992) this has been
a reason for concern .
Brousson and Klien, Controversies
surrounding the administration of vitamin K
to newborns; a review.
CMAJ. 154(3):307-315, February 1, 1996.
• Study selection: Six controlled trials met the selection
criteria: a minimum 4-week follow-up period, a
minimum of 60 subjects and a comparison of oral and
intramuscular administration or of regimens of single
and multiple doses taken orally. All retrospective case
reviews were evaluated. Because of its
thoroughness, the authors selected a meta-analysis
of almost all cases involving patients more than 7
days old published from 1967 to 1992. Only five
studies that concerned safety were found, and all of
these were reviewed
Brousson and Klien, Controversies
surrounding the administration of vitamin K
to newborns; a review.
CMAJ. 154(3):307-315, February 1, 1996.
• Data synthesis: Vitamin K (1 mg, administered
intramuscularly) is currently the most effective
method of preventing HDNB. The previously reported
relation between intramuscular administration of
vitamin K and childhood cancer has not been
substantiated. An oral regimen (three doses of 1 to 2
mg, the first given at the first feeding, the second at 2
to 4 weeks and the third at 8 weeks) may be an
acceptable alternative but needs further testing in
largeclinical trials.
Brousson and Klien, Controversies
surrounding the administration of vitamin K
to newborns; a review.
CMAJ. 154(3):307-315, February 1, 1996
• Conclusion: There is no compelling
evidence to alter the current practice of
administering vitamin K intramuscularly
to newborns.
Vitamin D
• Vitamin D requirements are dependent on the
amount of exposure to sunlight.
• Rickets has been reported in some high risk U.S.
infants with dark skin
• American Academy of Pediatrics recommends
supplements of 10 mg (400 IU) per day for breastfed
infants.
Vitamin D, cont.
• Pediatric Nutrition Handbook states that for white
infants adequate exposure to sunlight to produce
vitamin D is 30 minutes per week clothed only in a
diaper, or 2 hours per week fully clothed with no hat.
These exposures are mediated by time of year as
well as latitude.
Iron Fortification of Infant Formulas
Pediatrics, July 1999 v104 i1 p119
• During the first 4 postnatal months, excess fetal red
blood cells break down and the infant retains the iron.
This iron is used, along with dietary iron, to support
the expansion of the red blood cell mass as the infant
grows. The estimated iron requirement of the term
infant to meet this demand and maintain adequate
stores is 1 mg/kg per day.
• Infants born prematurely and those born to poorly
controlled diabetic mothers are at higher risk of iron
deficiency
Iron Absorption In Infancy
Percent
Study
Reported
Absorbed
Human Milk
48%
Hallberg et al
Human Milk – in 21%
Abrams et al
5 to 7 month
olds who are
also eating solid
foods.
Iron Fortified
6.7%
Hurrel et al
Cow’s milk
based Formula
Infant Cereals
4 to 5%
Fomon et al
Iron
• Iron absorption from soy formulas is
less
• Also consider: gastrointestinal bleeding
associated with exposure to cow milk
protein or infectious agents
Iron Fortification of Formula
• “The increased use of iron-fortified infant
formulas from the early 1970s to the late
1980s has been a major public health policy
success. During the early 1970s, formulas
were fortified with 10 mg/L to 12 mg/L of iron
in contrast with nonfortified formulas that
contained less than 2 mg/L of iron. The rate
of iron-deficiency anemia dropped
dramatically during that time from more than
20% to less than 3%.”
Iron Fortified Formula: Iron
Deficiency
• 9-30% of current US sales are low-iron
formulas
• Iron deficiency leads to reduction of
iron-containing cellular protein before it
can be detected as iron deficiency
anemia by hct or hgb
• Permanent effects of Fe deficiency on
cognitive function are of special
concern.
Iron in Formula
• Infant formulas have been classified as
low-iron or iron-fortified based on
whether they contain less or more than
6.7 mg/L of iron.
– Current mean content of low iron formula is 1.1 to 1.5 mg/L
of iron and high iron is 10 to 12 mg/L.
– One company recently increased to 4.5 for low iron.
– European formulas are 4-7 mg/l
– Foman found same levels of iron deficiency at 8 and 12 mg/l
Iron Deficiency Prevalence
at 9 Months
1.1 mg iron per L plus
supplemental foods
12-15 mg iron per L
28-38%
0.6%
Iron Deficiency in
Breastfeeding
• At 4 to 5 months prevalence of low iron stores
in exclusively breastfed infants is 6 - 20%.
• A higher rate (20%-30%) of iron deficiency
has been reported in breastfed infants who
were not exclusively breastfed
• The effect of iron obtained from formula or
beikost supplementation on the iron status of
the breastfed infant remains largely unknown
and needs further study.
GI Effects Attributable to
Iron
• Double blind RTC have not found
effects.
• Most providers know that, but parents
often want to change to low iron…..
• “yet it may remain temptingly easier to
prescribe a low-iron formula, achieve a
placebo effect, and ignore the more
insidious long-term consequences of
iron deficiency.”
AAP Iron Recommendations
1. In the absence of underlying medical factors
(which are rare), human milk is the preferred
feeding for all infants.
2. Infants who are not breastfed or are partially
breastfed should receive an iron-fortified
formula (containing between 4.0-12 mg/L of
iron) from birth to 12 months. Ideally, iron
fortification of formulas should be
standardized based on long-term studies that
better define iron needs in this range
AAP Iron Recommendations
3. The manufacture of formulas with iron
concentrations less than 4.0 mg/L should be
discontinued. If these formulas continue to be
made, low-iron formulas should be
prominently labeled as potentially nutritionally
inadequate with a warning specifying the risk
of iron deficiency. These formulas should not
be used to treat colic, constipation, cramps,
or gastroesophageal reflux.
AAP Iron Recommendations
4. If low-iron formula continues to be
manufactured, iron-fortified formulas should
have the term "with iron" removed from the
front label. Iron content information should be
included in a manner similar to all other
nutrients on the package label.
AAP Iron Recommendations
• Parents and health care clinicians
should be educated about the role of
iron in infant growth and cognitive
development, as well as the lack of data
about negative side effects of iron and
current fortification levels.
Foman on Iron - 1998
• Proposes that breastfed infants should have
supplemental iron (7 mg elemental) starting
at 2 weeks.
• Rational:
– some exclusively breastfed infants will have low
iron stores or iron deficiency anemia
– Iron content of breastmilk falls over time
– animal models indicate that deficits due to Fe
deficiency in infants may not be recovered when
deficiency is corrected.
Fluoride
• Fluoride Recommendations were changed in
1994 due to concern about fluorosis.
• Breast milk has a very low fluoride content.
• Fluoride content of commercial formulas has
been reduced to about 0.2 to 0.3 mg per liter
to reflect concern about fluorosis.
• Formulas mixed with water will reflect the
fluoride content of the water supply. Fluorosis
is likely to develop with intakes of 0.1 mg/kg
or more.
Fluoride, cont.
• Fluoride adequacy should be assessed
when infants are 6 months old.
• Dietary fluoride supplements are
recommended for those infants who
have low fluoride intakes.
Fluoride Supplementation Schedule
Age
Fluoride Concentration in Local
Water Supply, ppm
< 0.3
0.3-0.6
>0.6
6 mo. to 3 y
0.25
0.00
0.00
3-6 y
0.50
0.25
0.00
6 y to at
1.00
0.50
0.00
least 16 y
American Dental Association, American Academy of
Pediatrics, American Academy of Pediatric Dentistry,
1994.
AAP: Breastfeeding and the
Use of Human Milk, 1997
• Formal evaluation of breastfeeding by
trained observers at 24-48 hours and
again at 48 to 72 hours.
• No supplements should be given unless
a medical indication exists.
• When discharged at <48 hours, should
have FU visit at 2 to 4 days of age,
assessment at 5 to 7 days, and be seen
at one month.
AAP: Breastfeeding and the
Use of Human Milk, 1997
• Human milk is the preferred feeding for
all infants
• Breastfeeding should begin as soon as
possible after birth
• Newborns should be nursed 8 to 12
times every 24 hours until satiety,
usually 10 to 15 minutes per breast.
(Crying is a late indicator of hunger.)
AAP: Breastfeeding and the
Use of Human Milk, 1997
• “Exclusive breastfeeding is ideal
nutrition and sufficient to support
optimal growth and development for
approximately the first 6 months after
birth….It is recommended that
breastfeeding continue for at least 12
months, and thereafter for as long as
mutually desired.”
AAP: Breastfeeding and the
Use of Human Milk, 1997
• Vitamin D and iron may need to be given
before 6 months of age in selected groups of
infants (vitamin D, when mothers are deficient
or infants not exposed to adequat3 sunlight,
iron for those with low iron stores or anemia.)
• Fluoride should not be administered to infants
during the first 6 months after birth. From 6
months to 3 years only if water supply is
severely deficient.
AAP: Breastfeeding and the
Use of Human Milk, 1997
• “Should hospitalization of the
breastfeeding mother or infant be
necessary, every effort should be made
to maintain breastfeeding preferably
directly or by pumping the breasts.”
Infant Formulas: AAP
• Cow’s milk based formula is
recommended for the first 12 months if
breastmilk is not available
AAP: Cow’s Milk in Infancy
• Objections include:
– Cow’s milk poor source of iron
– GI blood loss may continue past 6 months
– Bovine milk protein and Ca inhibit Fe
absorption
– Increased risk of hypernatremic
dehydration with illness
– Limited essential fatty acids, vitamin C,
zinc
– Excessive protein intake with low fat milks
Infant Formulas - History
• Cow’s milk is high in protein, low in cho,
results in large initial curd formation in
gut if not heated before feeding
• Early Formulas
– from 1920-1950 majority of non-breastfed infants
received evaporated milk formulas boiled or
evaporated milk solved curd formation problems
– cho provided by corn syrup or other cho to
decrease relative protein kcals
Infant Formula - History,
cont.
• 50s and 60s commercial formulas replaced
home preparation
• 1959: iron fortification introduced, but in 1971
only 25% of infants were fed Fe fortified
formula
• Cow’s milk feedings started in middle of first
year between 1950-1970s. In 1970 almost
70% of infants were receiving cow’s milk.
Soy Formulas
• First developed in 1930s with soy flour
• Early formulas produced diarrhea and
excessive gas
• Now use soy protein isolate with added
methionine
Addition of DHA & ARA
• 2001: FDA approves as GRAS
• 2002: Ross & Mead Johnson introduce
products with DHA and ARA
• Cost: 15-20% above standard formulas
Formula Regulation
• Regulation is by the Infant Formula Act of
1980, under FDA authority
• Nutrient composition guidelines for 29
nutrients established by AAP Committee on
Nutrition and adopted as regs by FDA
• Nutrient Requirements for Infant Formulas.
Federal Register 36, 23553-23556. 1985. 21
CFR Part 107.
Cow’s Milk Based Formula
• Commercial formula designed to approximate
nutrients provided in human milk
• Some nutrients added at higher levels due to
less complete digestion and absorption
Protein:
Predominant protein of human milk is whey &
predominant protein in cow’s milk is casein
– Casein: proteins of the curd (low solubility at pH
4.6)
– Whey: soluble proteins (remain soluble at pH 4.6)
– Ratio of casein to whey is between 40:60 and
30:70 in human milk and 82:18 in cow’s milk
– some formulas provide more whey proteins than
others
Protein, cont.
– whey proteins of human and cow’s milk are
different and have different amino acid profiles.
• Major whey proteins of human milk at a
lactalbumin (high levels of essential aa) ,
immunoglobulins, and lactoferrin( enhances
iron transportation)
• Cow’s milk has low levels of these proteins and
high levels of b lactoglobulin
– Infants appear to thrive equally well with either
whey or casein predominant formulas.
Cow’s Milk Based Formula: Fat & CHO
• Fat: butterfat of cow’s milk is replaced with
vegetable fat sources to make the fatty acid
profile of cow’s milk formulas more like those
of human milk and to increase the proportion
of essential fatty acids
• Cho: Lactose is the major carbohydrate in
most cows’ milk based formulas.
Product
Human
Milk
Protein
g/100 ml
Source
~ 1.0
Human milk
Fat
g/100 ml Source
~3.9
Human
Milk
Enfamil
1.4
Reduced
mineral
whey,
Nonfat milk
3.6
Gerber
1.5
non fat milk
3.7
Good Start
1.6
Hydrolyzed
reduced
mineral
whey
3.5
Similac
(Improved)
1.4
3.7
Lactofree
1.5
Nonfat milk,
whey
protein
concentrate
Milk protein
isolate
3.6
Palm
olein, soy,
coconut,
high-oleic
sunflower
Palm
olein, soy,
coconut,
high-oleic
sunflower
Palm
olein, soy,
coconut,
high-oleic
sunflower
High oleic
safflower,
coconut
and soy oil
Palm
olein, soy,
coconut,
and high
oleic
sunflower
oils
Carbohydrate
g/100 ml
Source
~7.2
Human
Milk
Lactose
7.4
Lactose
7.3
Lactose
7.4
Lactose,
corn
maltodextri
ne
7.2
Lactose
6.9
Corn syrup
solids
Formulas with DHA & ARA
Ross
Mead Johnson
Full term
Similac
Advance
Enfamil Lipil
Preterm
Similac Special
Care, Similac
Natural Care,
NeoSure
Advance
Enfamil
Premature
Lipil,
Enfacare
Lipil
Soy Formulas
• Protein: soy protein isolate with added
methionine
• Fat: vegetables oils
• Cho: usually corn based products
American Academy of Pediatrics Committee on
Nutrition. Soy Protein-based Formulas:
Recommendations for Use in Infant Feeding.
Pediatrics 1998;101:148-153.
• Soy formulas given to 25% of infants but
needed by very few
• Offers no advantage over cow milk protein
based formula as a supplement for breastfed
infants
• Provides appropriate nutrition for normal
growth and development
• Indicated primarily in the case of vegetarian
families and for the very small number of
infants with galactosemia and hereditary
lactase deficiency
Possible Concerns about Soy
Formulas: AAP
• 60% of infants with cowmilk protein induced
enterocolitis will also be sensitive to soy protein damaged mucosa allows increased uptake of
antigen.
• Contains phytates and fiber oligosacharides so will
inhibit absorption of minerals (additional Ca is added)
• Higher levels of osteopenia in preterm infants given
soy formulas
• Phytoestrogens at levels that demonstrate
physiologic activity in rodent models
• Higher aluminum levels
Contraindications to Soy
Formula: AAP
– preterm infants due to increased risk of
inadequate bone mineralization
– infants with cow milk protein-induced
enteropathy or enterocolitis
– most previously well infants with acute
gastroenteritis
– prevention of colic or allergy.
Health Consequences of Early Soy
Consumption. Badger et al. J Nutr. 2002
• US soy formulas made with soy protein isolate (SPI+)
• SPI+ has several phytochemicals, including
isoflavones
• Isoflavones are referred to as phytoestrogens
• Phytoestrogens bind to estrogen receptors & act as
estrogen agonists, antagonists, or selective estrogen
receptor modulators depending on tissue, cell type,
hormonal status, age, etc.
Figure 1. Hypothetical serum concentrations profile of isoflavones from
conception through weaning in typical Asians and Americans. The values
represent the range of isoflavonoids reported by Adlercreutz et al. (6 ) for
Japanese (dotted lines) or reported by Setchell et al. (3 ) for Americans fed
soy infant formula (dashed line).
Should we be Concerned? Badger et al.
• No human data support toxicity of
soyfoods
• Soyfoods have a long history in Asia
• Millions of American infants have been
fed soy formula over the past 3 decades
• Rat studies indicate a potential
protective effect of soy in infancy for
cancer
Hydrolysate Formulas
• Whey Hydrolysate Formula: Cow’s milk based
formula in which the protein is provided as whey
proteins that have been hydrolyzed to smaller protein
fractions, primarily peptides. This formula may
provoke an allergic response in infants with cow’s
milk protein allergy.
• Casein Hydrolysate Formula: Infant formula based
on hydrolyzed casein protein, produced by partially
breaking down the casein into smaller peptide
fragments and amino acids. `
AAP Policy Statement Re:
Hypoallergenic Infant Formulas
(August, 2000)
• Currently available, partially hydrolyzed
formulas are not hypoallergenic.
AAP Policy Statement Re:
Hypoallergenic Infant Formulas
(August, 2000)
• Carefully conducted randomized controlled
studies in infants from families with a history
of allergy must be performed to support a
formula claim for allergy prevention. Allergic
responses must be established prospectively,
evaluated with validated scoring systems,
and confirmed by double-blind,placebocontrolled challenge. These studies should
continue for at least 18 months and
preferably for 60 to 72 months or longer
where possible
AAP Policy Statement Re:
Hypoallergenic Infant Formulas
(August, 2000)
Recommendations
• 1.Breast milk is an optimal source of nutrition
for infants through the first year of life or
longer. Those breastfeeding infants who
develop symptoms of food allergy may
benefit from:
– a.maternal restriction of cow's milk, egg, fish,
peanuts and tree nuts and if this is unsuccessful,
– b.use of a hypoallergenic (extensively hydrolyzed
or if allergic symptoms persist, a free amino acidbased formula) as an alternative to breastfeeding.
• Those infants with IgE-associated symptoms
of allergy may benefit from a soy formula,
either as the initial treatment or instituted after
6 months of age after the use of a
hypoallergenic formula. The prevalence of
concomitant is not as great between soy and
cow's milk in these infants compared with
those with non–IgE-associated syndromes
such as enterocolitis, proctocolitis,
malabsorption syndrome, or esophagitis.
Benefits should be seen within 2 to 4 weeks
and the formula continued until the infant is 1
year of age or older.
2.Formula-fed infants with confirmed
cow's milk allergy may benefit from the
use of a hypoallergenic or soy formula
as described for the breastfed infant.
3.Infants at high risk for developing allergy,
identified by a strong (biparental; parent, and
sibling) family history of allergy may benefit
from exclusive breastfeeding or a
hypoallergenic formula or possibly a partial
hydrolysate formula. Conclusive studies are
not yet available to permit definitive
recommendations. However, the following
recommendations seem reasonable at this
time:
a.Breastfeeding mothers should continue
breastfeeding for the first year of life or
longer. During this time, for infants at risk,
hypoallergenic formulas can be used to
supplement breastfeeding. Mothers should
eliminate peanuts and tree nuts (eg,
almonds, walnuts, etc) and consider
eliminating eggs, cow's milk, fish, and
perhaps other foods from their diets while
nursing. Solid foods should not be introduced
into the diet of high-risk infants until 6 months
of age, with dairy products delayed until 1
year, eggs until 2 years, and peanuts, nuts,
and fish until 3 years of age.
b.No maternal dietary restrictions during
pregnancy are necessary with the possible
exception of excluding peanuts;
4. Breastfeeding mothers on a restricted
diet should consider the use of
supplemental minerals (calcium) and
vitamins.
Product
Prosobee
Protein
g/100 ml Source
2.0
Soy protein
isolate, Lmethionine
Isomil
1.7
Soy protein
isolate, Lmethionine
Nutramigen
1.9
Pregestimil
1.9
Alimentum
1.9
Casein
hydrolysate,
L-cystine, Ltyrosine, Ltryptophan,
taurine
Casein
hydrolysate,
L-cystine, Ltyrosine, Ltryptophan,
taurine
Casein
hydrolysate,
L-cystine, Ltyrosine, Ltryptophan
Fat
g/100 ml Source
3.6
Palm
olein, soy,
coconut,
high oleic
sunflower
oils
3.7
High oleic
safflower,
coconut
and soy
oils
2.7
3.8
3.8
Carbohydrate
g/100 ml
Source
6.8
Corn syrup
solids
7.0
Corn
syrup,
sucrose,
modified
corn
starch
Corn syrup
solids,
modified
corn
starch
Palm
olein, soy,
coconut,
high oleic
sunflower
oils
55% MCT,
corn, soy,
high oleic
safflower
oils
9.1
6.9
Corn syrup
solids,
dextrose,
corn
starch
50% MCT,
Safflower
and soy
oils
6.9
Sucrose,
modified
tapioca
starch
Specialty Formulas
• Elemental - Neocate
• Premature Follow Up - Neosure, Enfamil 22
• Other highly specialized for metabolic conditions
Formula Safety Issues - 2002
• Enterobacter Sakazakii in Intensive care units
• Powered formula is not sterile so should not
be used with high risk infants
• FDA recommends mixing with boiling water
but this may affect availability of vitamins &
proteins and also cause clumping
• Irradiation proposed
Milk Feedings
Cautionary Tales
• Cooper et al. Pediatrics 1995. Increased
incidence of severe breastfeeding
malnutrition and hypernatremia in a
metropolitan area.
• Keating et al. AJDC 1991. Oral water
intoxication in infants.
• Lucas et al. Arch Dis Child. 1992.
Randomized trial of ready to fed compared
with powdered formula.
Cooper, cont.
• 5 breastfed infants admitted to Children’s
hospital in Cincinnati over 5 months period for
breastfeeding malnutrition and dehydration
– age at readmission was 5 to 14 days
– mothers were between the ages of 28 and 38, had prepared
for breastfeeding
– 3 had inverted nipples and reported latch-on problems
before discharge
– 3 families had contact with health care providers before
readmission including calls to PCP and home visit by PHN
Cooper, cont.
• at time of readmit none of presenting
complaints related to s&s of dehydration, only
one infant presented with feeding complaint
• wt. Loss at admission: 23%, range 14-32%
• Serum Na - mean 186 mmol/l, range 161-214
(136-143 is wnl)
• 3 infants had severe complications: multiple
cerebral infarctions, left leg amputation
secondary to iliac artery thrombus
Keating
• 24 cases of oral water intoxication in 3 years
at Children’s Hospital and St. Louis
• Most were from very low income families and
were offered water at home when formula ran
out
• Authors suggest: provision of adequate
formula and anticipatory guidance
Lucas
• 43 infants randomized to RTF or powdered formula
• Infants given powdered formula had increased body
wt. And skinfold thickness at 3 and 6 mos..
Compared to RTF and breastfed
• Powdered formula - 6 of 19 were above the 90th
percentile wt/ht, but only 1 of 19 RTF infants
• Authors suggest errors in reconstitution of formula
Formula Preparation Microwave
Protocol (Sigman-Grant, 1992)
• Heat only 4 oz or more refrigerated
formula with bottle top uncovered
• 4 oz bottles < 30 seconds
• 8 oz bottles < 45 seconds
• Invert 10 times before use
• Should be cool to the touch
• Always test drops of formula on tongue
or top of hand
AAP: Timing of Introduction of
Non-milk Feedings
• Based on individual development, growth,
activity level as well as consideration of
social, cultural, psychological and economic
considerations
• Most infants ready at 4-6 months
• Introduction of solids after 6 months may
delay developmental milestones.
• By 8-10 months most infants accept finely
chopped foods.
Solids: Foman, 1993
• “For the infant fed an iron-fortified
formula, consumption of beikost is
important in the transition from a liquid
to a nonliquid diet, but not of major
importance in providing essential
nutrients.”
• Breastfed infants: nutritional role of
beikost is to supplement intakes of
energy, protein, perhaps Ca and P
Solids: Borrensen - (J Hum
Lact. 1995)
• Some studies find exclusive
breastfeeding for 9 months supports
adequate growth.
• Iron needs have individual variation.
• Drop in breastmilk production and
consequent inadequate intake may be
due to management errors
Solids: Weight Gain
• Weight gain: Forsyth (BMJ 1993) found
early solids associated with higher
weights at 8-26 weeks but not thereafter
Solids: Respiratory
Symptoms
• Forsyth (BMJ 1993) found increased
incidence of persistent cough in infants
fed solids between 14-26 weeks.
• Orenstein (J Pediatr 1992) reported
cough in infants given cereal as
treatment for GER.
Solids
Too Early
• allergic disease
• diarrheal disease
• decreased breastmilk production
• developmental
concerns
Too Late
• potential growth
failure
• iron deficiency
• developmental
concerns
AAP: Specific Recommendations
for Infant Foods
• Start with introduction of single ingredient
foods at weekly intervals.
• Sequence of foods is not critical, iron fortified
infant cereals are a good choice.
• Home prepared foods are nutritionally
equivalent to commercial products.
• Water should be offered, especially with foods
of high protein or electrolyte content.
AAP: Specific
Recommendations
• Home prepared spinach, beets, turnips,
carrots, collard greens not
recommended due to high nitrate levels
• Canned foods with high salt levels and
added sugar are unsuitable for
preparation of infant foods
• Honey not recommended for infants
younger than 12 months
Foman S. Feeding Normal Infants:
Rationale for Recommendations.
JADA 101:1102
• “It is desirable to introduce soft-cooked
red meats by age 5 to 6 months. “
• Iron used to fortify dry infant cereals in
US are of low bioavailablity. (use wet
pack or ferrous fumarate)
The Use and Misuse of Fruit Juice in
Pediatrics - AAP, May 2001
• Conclusions
• Recommendations
1.Fruit juice offers no nutritional benefit for infants younger than 6 months.
2.Fruit juice offers no nutritional benefits over whole fruit for infants older
than 6 months and children.
3.One hundred percent fruit juice or reconstituted juice can be a healthy part
of the diet when consumed as part of a well-balanced diet. Fruit drinks,
however,
are not nutritionally equivalent to fruit juice.
4.Juice is not appropriate in the treatment of dehydration or management of
diarrhea.
5.Excessive juice consumption may be associated with malnutrition
(overnutrition and undernutrition).
6.Excessive juice consumption may be associated with diarrhea, flatulence,
abdominal distention, and tooth decay.
7.Unpasteurized juice may contain pathogens that can cause serious illnesses.
8.A variety of fruit juices, provided in appropriate amounts for a child's age,
are not likely to cause any significant clinical symptoms.
9.Calcium-fortified juices provide a bioavailable source of calcium but lack
other nutrients present in breast milk, formula, or cow's milk.
1. Juice should not be introduced into the diet of infants before 6 months of age.
2. Infants should not be given juice from bottles or easily transportable covered cups
that allow them to consume juice easily throughout the day. Infants should not be given
juice at bedtime.
3. Intake of fruit juice should be limited to 4 to 6 oz/d for children 1 to 6 years old. For
children 7 to 18 years old, juice intake should be limited to 8 to 12 oz or 2 servings per
day.
4. Children should be encouraged to eat whole fruits to meet their recommended daily
fruit intake.
5. Infants, children, and adolescents should not consume unpasteurized juice.
6. In the evaluation of children with malnutrition (overnutrition and undernutrition), the
health care provider should determine the amount of juice being consumed.
7. In the evaluation of children with chronic diarrhea, excessive flatulence, abdominal
pain, and bloating, the health care provider should determine the amount of juice being
consumed.
8. In the evaluation of dental caries, the amount and means of juice consumption should
be determined.
9. Pediatricians should routinely discuss the use of fruit juice and fruit drinks and
should educate parents about differences between the two.
C-P-F: Possible Concerns
Michaelsen et al. Eur J Clin Nutr. 1995
• Dietary Fat is ~ 50% of Kcals with exclusive
breastmilk or formula intake.
• Dietary fat contribution can drop to 20-30%
with introduction of high carbohydrate infant
foods.
• Infants receiving low fat milks are at risk of
insufficient energy intake.
• Fat intake often increases with addition of
high fat family foods.
C-P-F: Low Energy Density
• Low fat diet often means diet has low
energy density
• Increased risk of poor growth
• Reduction in physical activity
• Energy density of 0.67 kcal/g
recommended for first year of life
(Michaelson et al.)
C-P-F: Low fat Diets in Infancy
• No strong evidence linking fat intake in
infancy and adult atherosclerosis
• Low weight at 12 months linked to increased
risk of mortality from CVD
• Very low fat diet may be low in dairy and
meats and nutrients from those foods
• Very high fat diet may have lower
micronutrient content
C-P-F: Recommendations
• No strong evidence for benefits from fat
restriction early in life
• AAP recommends:
– high carbohydrate infant foods may be
appropriate for formula fed infants
– no fat restriction in first year
– a varied diet after the first year
– after 2nd year, avoid extremes, total fat
intake of 30-40% of kcal suggested
Allergies: Areas of Recent
Interest
• Early introduction of dietary allergens
and atopic response
– atopy is allergic reaction/especially
associated with IgE antibody
– examples: atopic dermatitis (eczema),
recurrent wheezing, food allergy, urticaria
(hives) , rhinitis
• Prevention of adverse reactions in high
risk children
Allergies: Infancy
• Increased risk of sensitization as
antigens penetrate mucosa, react with
antibodies or cells, provoking cellular
response and release of mediators
• Immaturities that increase risk:
– gastric acid, enzymes
– microvillus membranes
– lysosomal functions of mucosal cells
– immune system, less sIgA in lumen
Allergies: Breastmilk
• May be protective due to sIgA and
mucosal growth factors
• Maternal avoidance diets in lactation
remain speculative. May be useful for
some highly motivated families with
attention to maternal nutrient adequacy.
Allergies: Breastmilk
(Saarinen, 1995)
• 235 Helsinki infants born in 1995
• Categorized by duration of
breastfeeding, > 6 months, 1-6 months,
no or short breastfeeding
• Incidence of food and respiratory allergy
was greatest in short or no
breastfeeding group
• Differences persisted at 17 years of age
Allergies: Early Introduction of
Foods
(Fergussson et al, Pediatrics, 1990)
• 10 year prospective study of 1265 children in
NZ
• Outcome = chronic eczema
• Controlled for: family hx, HM, SES, ethnicity,
birth order
• Rate of eczema with exposure to early solids
was 10% Vs 5% without exposure
• Early exposure to antigens may lead to
inappropriate antibody formation in
susceptible children.
Early Introduction of Foods
(Fergussson et al, Pediatrics, 1990)
Proportional Hazard Coefficient (p<0.01)
For Risk of Chronic Eczema
No solid Food before 1.00
4 months
1-3 types of food
before 4 months
1.69
4+ types of foods
before 4 months
2.87
Allergies: Prevention by
Avoidance (Marini, 1996)
• 359 infants with high atopic risk
• 279 in intervention group
• Intervention: breastfeeding strongly
encouraged, no cow’s milk before one
year, no solids before 5/6 months,
highly allergenic foods avoided in infant
and lactating mother
Allergies: Prevention by
Avoidance (Marini, 1996)
% of Children With Any Allergic
Manifestations (cummulative incidence)
80
60
non-intervention
intervention
40
20
0
1 yr
2 yrs
3 yrs
Allergies: Prevention by
Avoidance (Zeigler, Pediatr Allergy Immunol.
1994)
• High risk infants from atopic families,
intervention group n=103, control n=185
• Restricted diet in pregnancy, lactation,
Nutramagen when weaned, delayed
solids for 6 months, avoided highly
allergenic foods
• Results: reduced age of onset of
allergies
Allergies: Prevention by
Avoidance (Zeigler, Pediatr Allergy Immunol. 1994)
Definite or Probable Food Allergy
Age
Intervention Control
p
12 mo
5%
16%
0.007
24 mo
7%
20%
0.005
48 mo
4%
6%
ns
Allergies: Predicting Risk
(Odelram, 1994)
• Methods of screening newborns for risk
of atopy were compared
• Screening tools included many blood
tests as well as skin hypersensitivity
• Combination of family history of atopy
and dry skin in newborn was informative
• Sensitivity of 80%, specificity of 85%
Allergies: IDDM
• Theory: sensitization and development
of immune memory to food allergens
may contribute to pathogenesis of IDDM
in genetically susceptible individuals.
• Milk, wheat, soy have been implicated.
• Studies are not conclusive.
• Breastfeeding and delay in non-milk
feedings may be beneficial.
Early Childhood Caries
• AKA Baby Bottle Tooth Decay
• Rampant infant caries that develop
between one and three years of age
Early Childhood Caries: Etiology
• Bacterial fermentation of cho in the
mouth produces acids that demineralize
tooth structure
• Infectious and transmissible disease
that usually involves mutans
streptococci
• MS is 50% of total flora in dental plaque
of infants with caries, 1% in caries free
infants
Early Childhood Caries: Etiology
• Sleeping with a bottle enhances
colonization and proliferation of MS
• Mothers are primary source of infection
• Mothers with high MS usually need
extensive dental treatment
Early Childhood Caries:
Pathogenesis
• Rapid progression
• Primary maxillary incisors develop white
spot lesions
• Decalcified lesions advance to frank
caries within 6 - 12 months because
enamel layer on new teeth is thin
• May progress to upper primary molars
Early Childhood Caries:
Prevalence
• US overall - 5%
• 53% American Indian/Alaska Native
children
• 30% of Mexican American farmworkers
children in Washington State
• Water fluoridation is protective
• Associated with sleep problems & later
weaning
Early Childhood Caries: Cost
• $1,000 - $3,000 for repair
• Increased risk of developing new
lesions in primary and permanent teeth
Early Childhood Caries:
Prevention
• Anticipatory Guidance:
–
–
–
–
importance of primary teeth
early use of cup
bottles in bed
use of pacifiers and soft toys as sleep aides
Early Childhood Caries:
Prevention
• Chemotheraputic agents: fluoride
varnishes and supplements,
chlorhexidene mouthwashes for
mothers with high MS counts
• Community education: training health
providers and the public for early
detection
Summary
• Breastfeeding should be encouraged
• Non milk feedings appropriate by 6 months.
• Recommended food choices include fruits,
vegetables, legumes, protein sources for
breast fed infants, and variety of fat sources.
• Individual variations in feeding patterns may
be beneficial for infants at risk of allergies,
failure to thrive, and nutrition related disease
conditions.
Bright Futures
• AAP/HRSA/MCHB
• http://www.brightfutures.org
• “Bright Futures is a practical
development approach to providing
health supervision for children of all
ages from birth through adolescence.”
Newborn Visit:
Breastfeeding
• Infant Guidance
– how to hold the baby and get him to latch on properly;
– feeding on cue 8-12 times a day for the first four to six
weeks;
– feeding until the infant seems content.
– Newborn breastfed babies should have six to eight wet
diapers per day, as well as several "mustardy" stools per
day.
– Give the breastfeeding infant 400 I.U.'s of vitamin D daily if
he is deeply pigmented or does not receive enough sunlight.
Newborn Visit:
Breastfeeding
• Maternal care
– rest
– fluids
– relieving breast engorgement
– caring for nipples
– eating properly
• Follow-up support from the health
professional by telephone, home visit,
nurse visit, or early office visit.
Newborn Visit: Bottlefeeding
•
•
•
•
type of formula, preparation
feeding techniques, and equipment.
Hold baby in semi-sitting position to feed.
Do not use a microwave oven to heat
formula.
To avoid developing a habit that will harm
your infant's teeth, do not put him to bed with
a bottle or prop it in his mouth.
First Week
• Do not give the infant honey until after her
first birthday to prevent infant botulism.
• To avoid developing a habit that will harm
your infant's teeth, do not put her to bed with
a bottle or prop it in her mouth.
One Month
• Delay the introduction of solid foods until the
infant is four to six months of age. Do not put
cereal in a bottle.
Four Months
– Continue to breastfeed or to use ironfortified formula for the first year of the
infant's life. This milk will continue to be his
major source of nutrition.
– Begin introducing solid foods with a spoon
when the infant is four to six months of
age.
– Use a spoon to give him an iron-fortified,
single-grain cereal such as rice.
Four Months, cont.
– If there are no adverse reactions, add a new
pureed food to the infant's diet each week,
beginning with fruits and vegetables.
– Always supervise the infant while he is eating.
– Give exclusively breastfeeding infants iron
supplements.
– Continue to give the breastfeeding infant 400 I.U.'s
of vitamin D daily if he is deeply pigmented or
does not receive enough sunlight.
– Do not give the infant honey until after his first
birthday to prevent infant botulism. .
Six Months
• Continue to breastfeed or use iron-fortified
formula for the first year of the infant's life.
This milk will continue to be her major source
of nutrition.
• Avoid giving the infant foods that may be
aspirated or cause choking (e.g., peanuts,
popcorn, hot dogs or sausages, carrot sticks,
celery sticks, whole grapes, raisins, corn,
whole beans, hard candy, large pieces of raw
vegetables or fruit, tough meat).
• Learn emergency procedures for choking.
Six Months, cont.
• Let the infant indicate when and how much
she wants to eat.
• Serve solid food two or three times per day.
• Begin to offer a cup for water or juice.
• Limit juice to four to six ounces per day.
• Give iron supplements to infants who are
exclusively breastfeeding.
Nine Months
• Start giving the infant table foods in order to
increase the texture and variety of foods in
his diet.
• Encourage finger foods and mashed foods as
appropriate.
• Closely supervise the infant while he is
eating.
• Continue teaching the infant how to drink
from a cup.
• Continue to breastfeed or use iron-fortified
formula for the first year of the infant's life.