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Pediatric Nutrition I Nutrition of Neonates and Infants

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Title: Pediatric Nutrition I Nutrition of Neonates and Infants


1
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

2
Neonatal Growth and Nutrition
  • 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)

3
Infancy Nutritional Goals
  • 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

4
Growth
Curves
for
Infants
GIRLS Birth to 36 mo
5
Growth
Curves
for
Infants
BOYS Birth to 36 mo
6
Infancy Energy Requirements
  • 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)

7
Infancy Energy Requirements
  • (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

8
Partitioning of the Energy Requirements During
Infancy
Basal Metabolism
Gross Energy Intake
Metabolizable Energy Intake
Thermic Effect of Feeding
Activity
Energy Stored growth
Tissue Synthesis
Energy Excretion
9
Infancy Energy Requirements in Disease
  • 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

10
Infancy Protein Requirements
  • 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

11
Rates of Whole Body Protein Synthesis During
Growth
  • Preterm infants 15 g/kg/d
  • Toddlers 6 g/kg/d
  • Adolescents 4 g/kg/d

12
Infancy Minerals, Trace Elements
  • Nutrient Term Preterm 5-12
    Month
  • Neonate Neonate Infant
  • Na (mEq/kg/d) 2 - 3 4 - 7 1 - 2
  • K (mEq/kg/d) 1 - 2 2 - 4
    1 - 2
  • Ca (mEq/kg/d) 60 150
    40
  • Iron (mEq/kg/d) 1 2 - 4 0.7
  • Zinc (mEq/kg/d) 0.2 - 0.5 0.4
    0.3

13
Infancy Vitamins
  • 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)

14
Infancy Fat-Soluble Vitamins
  • 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

15
Infancy Fat-Soluble Vitamins
  • (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

16
Infancy Limitations to Nutrient Accretion
  • Rapid transit time
  • Immature digestive capabilities
  • Reduced nutrient retention

17
Infancy Immature Digestion of CHO
  • 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)

18
Infancy Immature Digestion of CHO
  • Intestinal lactase concentrations are low at
    birth and are not inducible
  • Amylase, necessary for breaking down starches,
    are not adequate until gt 4 months

19
Weeks of Gestation
Sucrase, Maltase, Isomaltase Glucose Uptake
10 Wks
Salivary Amylase Zymogen Granules in Pancreas
20 Wks
Pancreatic Amylase
22 Wks
24 Wks
Lactose
24 - 28 Wks
Gluco-amylase
20
Infancy Proten Digestion
  • 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

21
Infancy Percent of Dietary Fat Absorbed
  • Adult 95
  • Term infant 85-95
  • Preterm infant 50 - 90 (dependent on source of
    fat)

22
Infancy Etiology of Fat Malabsorption
  • Low levels of intestinal lipases
  • Small bile salt pool

23
Infancy Breast Milk As a Food Source
  • Committee on Nutrition of the AAP strongly
    recommends breastfeeding for infants
  • The rates of breastfeeding have risen recently,
    but the attrition rate is high

24
Infancy Breast Milk As a Food Source
(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
  • Physicians role is to support, counsel and
    trouble-shoot

25
Advantages of Human Milk
  • Health
  • Nutritional
  • Immunologic
  • Neurodevelopmental
  • Economic
  • Environmental

26
Advantages Health
  • Studies in developed countries
  • Reduced prevalence of
  • Diarrhea
  • Otitis media
  • Lower respiratory infection
  • UTI
  • NEC (in preterms)
  • SIDS

27
Advantages Health
  • 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)

28
Advantages Health
  • Protection of mother from
  • Pregnancy
  • Postpartum hemorrhage
  • Bone demineralization
  • Ovarian cancer

29
Advantages Nutritional
  • 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

30
Advantages Nutritional
  • Amino acid spectrum matches infant need lower
    protein and solute load
  • Faster gastric emptying ? less reflux

31
Advantages Neurodevelopment
  • 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

32
Advantages Protection from Obesity
  • 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 lt 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)

33
Advantages Personal Economics
  • Reduced cost of feeding
  • No formula cost (-855/year)
  • Increased maternal consumption (lt400)
  • Net savings of gt400/child
  • Reduced health care costs due to
  • Lower incidence of childhood illness
  • Reduced income loss due to
  • Less days lost to cover childhood illness

34
Contraindications
  • 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?

35
Infancy Infant Formula
  • 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

36
Infancy Infant Formula
  • (Continued)
  • Cows 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
    cow- milk protein

37
Summary
  • 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
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