Infancy 2002

1
Infancy2002
2

• Growth in infancy
• Physiology of infancy
• GI
• Renal
• Development of feeding skills
• Nutrient requirements
• Infant formulas
• Non milk feedings/solids
• Oral health

3
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.

4
Weight Gain in Grams per Day in One Month
Increments - Girls
Guo et al., J Peds. 1991
5
Weight Gain in Grams per Day in One Month
Increments - Boys
Guo et al., J Peds. 1991
6
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

7
Body increment gained, g/day Energy Used for
Growth
8
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

9
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

10
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

11
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

12
Assessment of Growth

• Growth Charts
• http//www.cdc.gov/growthcharts/
• Growth Velocity

13
New Growth Charts

• Data from old charts came from private study of
  primarily Caucasian, formula-fed, 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

14
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

15
(No Transcript)
16
(No Transcript)
17
Physiology - GI Maturation
18
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

19
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

20
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

21
Human Milk

• complements Immaturities of these systems as well
  as their maturation
• Epithelial growth factors and hormones
• Digestive enzymes - lipases and amylase

22
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

23
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

24
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

25
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

26
Common GI Symptoms
27
Common GI Symptoms Infant Stools
28
Effect of infant formula on stool characteristics
of young infants. Pediatrics 1995 Jan95(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.

29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
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

34
Possible Roles for Gut Hormones in Early Infancy
35
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)

36
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

37
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 monthsLipase levels do not approach adult
  efficiency until about 6 months

38
Protein Digestion
39
Fat Digestion
40
Carbohydrate Digestion
41
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
  monthsRetention 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.

42
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.

43
Potential Renal Solute Load
44
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

45
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

46
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.

47
Water Needs
48
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

49
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

50
Feeding behavior of infants Gessell A, Ilg FL
51
Feeding Interactions
52
Feeding Interactions, cont.
53
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

54
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

55
Mean Daily Energy and Protein Intakes
56
Mean Daily Energy and Protein Intakes
57
Energy Intakes by Breastfed and Formula Fed Boys
(kcal/kg)
58
1989 RDA Energy and Protein
59
2002 Energy DRI
60
2002 Protein DRI
61
2002 Carbohydrate DRI
62
2002 Fat DRI
63
Distribution of Kcals
64
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

65
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.

66
(No Transcript)
67
(No Transcript)
68
LCPUFA Background
69
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

70
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

71
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.

72
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.

73
Bayley Scales at 12 months
74
MacArthur Communicative Development Inventories
at 14 Months of Age
75
Conclusion

• We believe that additional research should be
  undertaken before the introduction of these
  supplements into standard infant formulas.

76
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

77
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

78
Vitamins and Minerals

• Focus on nutrients with controversies and/or
  recent research
• Vitamin K
• Vitamin D
• Iron
• Fluoride

79
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

80
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

81
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.

82
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.

83
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.

84
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).

85
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).

86
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
  PIVKAs (proteins induced by the absence of
  vitamin K).
• HDN is caused by low plasma levels of the vitamin
  K-dependent 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

87
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

88
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.

89
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

90
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 .

91
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

92
(No Transcript)
93
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.

94
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.

95
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.

96
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.

97
Iron Fortification of Infant FormulasPediatrics,
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

98
(No Transcript)
99
Iron

• Iron absorption from soy formulas is less
• Also consider gastrointestinal bleeding
  associated with exposure to cow milk protein or
  infectious agents

100
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.

101
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.

102
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

103
Iron Deficiency Prevalence at 9 Months
104
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.

105
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.

106
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

107
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.

108
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.

109
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.

110
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.

111
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.

112
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.

113
(No Transcript)
114
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 visit at 2 to 4 days of age, assessment at 5 to 7
  days, and be seen at one month.

115
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.)

116
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.

117
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.

118
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.

119
Infant Formulas AAP

• Cows milk based formula is recommended for the
  first 12 months if breastmilk is not available

120
AAP Cows Milk in Infancy

• Objections include
• Cows 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

121
Infant Formulas - History

• Cows 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

122
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
• Cows milk feedings started in middle of first
  year between 1950-1970s. In 1970 almost 70 of
  infants were receiving cows milk.

123
Soy Formulas

• First developed in 1930s with soy flour
• Early formulas produced diarrhea and excessive
  gas
• Now use soy protein isolate with added methionine

124
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

125
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.

126
Cows 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

127
Protein

• Predominant protein of human milk is whey
  predominant protein in cows 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 4060 and
  3070 in human milk and 8218 in cows milk
• some formulas provide more whey proteins than
  others

128
Protein, cont.

• whey proteins of human and cows 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)
• Cows 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.

129
Cows Milk Based Formula Fat CHO

• Fat butterfat of cows milk is replaced with
  vegetable fat sources to make the fatty acid
  profile of cows 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.

130
(No Transcript)
131
Formulas with DHA ARA
132
Soy Formulas

• Protein soy protein isolate with added
  methionine
• Fat vegetables oils
• Cho usually corn based products

133
American Academy of Pediatrics Committee on
Nutrition. Soy Protein-based Formulas
Recommendations for Use in Infant Feeding.
Pediatrics 1998101148-153.

• 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

134
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

135
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.

136
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.

137
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).
138
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

139
Hydrolysate Formulas

• Whey Hydrolysate Formula Cows 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 cows 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.

140
AAP Policy Statement Re Hypoallergenic Infant
Formulas (August, 2000)

• Currently available, partially hydrolyzed
  formulas are not hypoallergenic.

141
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,placebo-controlled challenge. These
  studies should continue for at least 18 months
  and preferably for 60 to 72 months or longer
  where possible

142
AAP Policy Statement Re Hypoallergenic Infant
Formulas (August, 2000)

• Recommendations

143

• 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
  acid-based formula) as an alternative to
  breastfeeding.

144

• 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 nonIgE-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.

145

• 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.

146

• 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

147

• 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.

148

• 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.

149
(No Transcript)
150
Specialty Formulas

• Elemental - Neocate
• Premature Follow Up - Neosure, Enfamil 22
• Other highly specialized for metabolic conditions

151
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

152
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.

153
Cooper, cont.

• 5 breastfed infants admitted to Childrens
  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

154
Cooper, cont.

• at time of readmit none of presenting complaints
  related to ss 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

155
Keating

• 24 cases of oral water intoxication in 3 years at
  Childrens 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

156
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

157
Formula Preparation Microwave Protocol
(Sigman-Grant, 1992)

• Heat only 4 oz or more refrigerated formula with
  bottle top uncovered
• 4 oz bottles
• 8 oz bottles
• Invert 10 times before use
• Should be cool to the touch
• Always test drops of formula on tongue or top of
  hand

158
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.

159
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

160
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

161
Solids Weight Gain

• Weight gain Forsyth (BMJ 1993) found early
  solids associated with higher weights at 8-26
  weeks but not thereafter

162
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.

163
Solids

• Too Early
• allergic disease
• diarrheal disease
• decreased breast-milk production
• developmental concerns

• Too Late
• potential growth failure
• iron deficiency
• developmental concerns

164
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.

165
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

166
Foman S. Feeding Normal Infants Rationale for
Recommendations. JADA 1011102

• 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)

167
The Use and Misuse of Fruit Juice in Pediatrics -
AAP, May 2001

• Conclusions
• Recommendations

168
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.
169
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.
170
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.

171
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.)

172
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

173
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

174
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

175
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

176
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.

177
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

178
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.

179
Early Introduction of Foods(Fergussson et al,
Pediatrics, 1990)
180
Allergies Prevention by Avoidance (Marini, 1996)

• 359 infants with high atopic risk
• 279 in intervention group
• Intervention breastfeeding strongly encouraged,
  no cows milk before one year, no solids before
  5/6 months, highly allergenic foods avoided in
  infant and lactating mother

181
Allergies Prevention by Avoidance (Marini, 1996)
182
Allergies Prevention by Avoidance (Zeigler,
Pediatr Allergy Immunol. 1994)

• High risk infants from atopic families,
  intervention group n103, control n185
• Restricted diet in pregnancy, lactation,
  Nutramagen when weaned, delayed solids for 6
  months, avoided highly allergenic foods
• Results reduced age of onset of allergies

183
Allergies Prevention by Avoidance (Zeigler,
Pediatr Allergy Immunol. 1994)
184
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

185
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.

186
Early Childhood Caries

• AKA Baby Bottle Tooth Decay
• Rampant infant caries that develop between one
  and three years of age

187
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

188
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

189
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

190
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

191
Early Childhood Caries Cost

• 1,000 - 3,000 for repair
• Increased risk of developing new lesions in
  primary and permanent teeth

192
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

193
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

194
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.

195
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.

196
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.

197
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.

198
Newborn Visit Bottle-feeding

• 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.

199
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.

200
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.

201
Four Months

• Continue to breastfeed or to use iron-fortified
  formula for the first year of the infant's life.
  This milk will continue