29 th January 2014 Dr Nikoletta Lofitou

Introduction Nutritional requirements Department of Health’s recommendations Breast feeding/bottle feeding Clinical conditions Clinical scenario

Infant Nutrition Good nutrition is essential for: Survival Physical growth Mental development Productivity Health and well being

A short term issue?

Differences in nutritional experiences during sensitive periods in early life, both before and after birth, can program a person's future development, metabolism, and health (EARNEST, 2011)

Statistics Prevalence of breastfeeding 81% at birth(76% in 2005) 69% at one week 55% at six weeks 34% at six months (25% in 2005) Prevalence of exclusively breastfeeding 69% at birth 46% at one week 23% at six weeks 1% at six months

More Statistics 31% breastfed babies had received additional feeds while in hospital 73% had given their baby milk other than breast milk by the age of six weeks and 88% by six months High correlation between intentions and actual initial feeding behaviour

And more... Highest incidences of breastfeeding among mothers >30 years old, from minor ethnic groups, left education aged over 18, in managerial and professional occupations, living in the least deprived areas Relationship between how mothers were fed themselves as infants and and how their peers fed their babies with how long they breastfed their own babies

Nutritional requirements Age dependent (the younger the child the higher their energy needs per kilogram body weight) 0-3 months: Fluid mls/kg Calories 100 kCals/kg Protein 2.1 g/kg Na 1.5 mmol/kg K 3 mmol/kg

Nutritional needs in Preterm babies (1) Adequate nutrition should ensure that a pre-term infant achieves a post natal growth that reinstates them on their inter-uterine growth curve for length, weight and head circumference. Premature babies may have increased needs as : - May have dropped down >2 centiles on neonatal unit - May have CLD and need O2 - May have been IUGR - May have GOR and be unable to tolerate large feed volumes

Nutritional needs in Preterm babies (2) Fluid: ml/kg/day Energy requirements: kcals/kg/day Protein: according to weight

What are the Department of health’s recommendations on feeding infants? Breast milk is the best form of nutrition for infants Exclusive breastfeeding is recommended for the first six months of an infant’s life Six months is the recommended age for the introduction of solid foods for infants Breastfeeding (and/or breastmilk substitutes, if used) should continue beyond the first six months, along with appropriate types and amounts of solid foods

Colostrum For 2-4 days post delivery. Contains more sodium High in Vit A and Vit K 5x more protein than mature milk more IgA less fat and carbohydrate Mature breast milk is established by 4 th week

Composition of breast milk vs formula milk Water: Equal amounts Calories:Approx 67kcal/100ml Protein: Human milk 1-1.5% protein(70% whey protein), Cows milk 3.3% protein due to greater content of casein

Composition of breast milk vs cows milk Carbohydrate: Human milk 7% (10% glycoproteins) Cows milk 4.5% lactose Fat: Approx 3.5% both principally triglycerides (olein, palmitin and stearin). Olein is more easily absorbed and there is twice as much in breast milk. Minerals: Cows milk contains more of all the minerals (esp sodium, calcium and phosphate) except iron and copper. There is more iron in breast milk and it is more easily absorbed Vitamins: Cow’s milk is low in vitamin C and D

What are the health benefits of breast feeding? Breastmilk provides all the nutrients a baby needs for healthy growth and development for the first six months of life. Contains growth factors and hormones to assist development Anti infective properties: Macrophages, lymphocytes and polymorphs, Secretory IgA, Lyzozyme, Lactoferrin (inhibits growth of E.coli.), anti-viral agents.

Long term benefits to infants Reduced risk of respiratory, gastrointestinal and urinary tract infections Reduced risk of atopy Reduced risk of juvenile diabetes in susceptible infants Better dental health Reduced incidence of later obesity Improved neurological development

Maternal benefits Reduced risk of premenopausal cancer Promotes weight loss after pregnancy Lactational amenorrhoea Cheaper and more convenient

Down side of breast feeding Vitamin K deficiency Hypernatraemia at end of first week in babies with inadequate intake Inhibits modern control culture

Factors affecting prevalence of breast feeding in the UK Favour Social class 1 Mother educated >18years Mother >30 years first baby breast fed previous baby Against social class V maternal smoking

Contraindications to breast feeding Galactosaemia Maternal HIV infection in the UK Anti-neoplastic drugs Tetracyclines Lithium

Types of milk Infant formulas are suitable from birth and are usually based on cows milk Whey based milks are usually first choice if not breast feeding Casein based milks are suggested for hungrier babies Soya infant milks Follow on formulas: Higher iron content than cows milk Specialised formulas for those who are preterm or have medical conditions (lactose free, phenylalanine free)

Soya Infant Formula Similar to cows milk but protein derived from soya with lactose replaced with other carbohydrates (glucose syrups) Recommended for use on medical advice but should not be the first choice for the management of CMP intolerance Soya milks contain phytoestrogens which have been shown to have an immunosuppressive effect in rodents

Bottle feeding Day 1: 60ml/kg/day Day 3: 120ml/kg/day Day 2: 90ml/kg/day Day 4: 150ml/kg/day 3-4 hourly Must be made up correctly (risk of hypernatraemia) Has caused high mortality in developing world due to poor hygiene of equipment leading to gastroenteritis

Cow’s milk allergy A reproducible reaction to one or more cow’s milk proteins mediated by one or more immune mechanisms Affects about 1 in 50 infants Most affected infants present by 6 months of age - rarely presents after 12 months

Cow’s milk allergy 1. IgE-mediated phenotype: symptoms are stereotypical of allergy skin (eczema, urticaria) gut (colic, vomiting, diarrhoea, FTT, blood in the stools) respiratory (rhinitis, stridor, cough and wheeze) 2. Non IgE-mediated phenotype: delayed onset allergy symptoms Do NOT confuse with lactose intolerance

Diagnosis and management of CMP allergy 1. IgE-mediated: clinical symptoms + skin prick test 2. Non IgE-mediated: clinical symptoms that improve or resolve with exclusion of milk and reappear with reintroduction of cow’s milk A food challenge may be necessary to confirm the diagnosis diet free from cows’ milk for at least 1 year Choice of milk is usually one of casein or whey extensive hydrolysed formula, or amino acid formula (Lactose free and partially hydrolysed comfort formula milks and goats milk are not suitable for cows’ milk allergy)

Lactose intolerance rare in infants- more commonly in adolescence typically with a more subtle and progressive onset over many years Usually secondary to gastrointestinal infection especially rotavirus,or neonatal gut surgery Usually transient but may need to remove lactose from milk for 6+ weeks

Normal Growth All babies tend to lose 5-10% of birthweight over first few days and regain it by about 10 th day Feeding requirement is 150ml/Kg/day Normal weight gain 25-30g/day for first 6 months (preterm 10-15g/kg/day) Most babies double their birthweight by 4-5 months and treble by one year

Weaning DOH recommend introduction of solid foods at around 6 months of age Trend towards mothers introducing solid foods later (51% by 4 months in 2005, 30% in 2010) 75% introduced solid foods by 5 months of age; not following the guidelines Solid foods tended to be introduced to younger babies among younger mothers and mothers from lower socio-economic groups

Why introduce solid foods at six months? Infants need more iron and other nutrients than milk At 6 months infants can spoon-feed (upper lip moving down, chew, use the tongue to move the food from front to back) Development of eye-hand co-ordination (finger foods) Introducing solids early before sufficient development of the neuro-muscular co-ordination or before the gut and kidneys have matured  risk of infections and development of allergies (eczema, asthma)

Weaning Babies need to be exposed rapidly to a variety of tastes and textures between 6-8 months Approximately 1 pt of milk should be given plus clear fluids with meals Is waiting to introduce solids until six months likely to produce “fussy eaters”: NO (RCTs) Encouragement of finger food- promotes chewing practice and independence Chewing encourages development of speech muscles Feeding should always be supervised.

Vitamins All children from six months to five years old should be given a vitamin supplement containing vitamins A, C and D, unless they are receiving more than 500 ml of infant formula per day If mothers did not take vit. D during pregnancy and if breast fed, start Vit D at 1 month Iron supplemented milk is recommended until at least the age of 1 year in all infants Iron deficiency anaemia is a common problem in toddlers worldwide- associated with developmental delay and increased susceptibility to infection

Faltering growth Significant interruption in the expected rate of growth compared with other children of similar age and sex during early childhood affect around 5% of children under the age of two at some point A single plot on a chart is of limited value Need to consider parental height

Faltering growth

Causes of faltering growth 1. Organic causes  Inability to feed (cleft palate, CP)  Increased losses (diarrhoea/vomiting, GORD)  Malabsorption (CF, post infective/allergic enteropathy)  Increased energy requirements (CF, malignancy)  Metabolic (hypothyroidism, CAH)  Syndromes

Causes of faltering growth 2. Non-organic causes  Insufficient breast milk or poor technique  Maternal stress/ Maternal depression/psychiatric disorder  Disturbed maternal-infant attachment  Low socio-economic class  Neglect

Approach and management to faltering growth Recheck weight-plot weight against centile chart Check type and amount of feed Observe feeding technique Assess stool Examine for underlying illness- appropriate investigations Consider admission to observe response to feeding Dietician involvement Inform GP/health visitor/community nurse

Clinical scenario A 4/52 baby presented to CED with vomiting. Birth weight 3.5kg. Current weight 4.3kg. The baby is bottle feeding and taking 150ml 4 hourly.

Clinical scenario A 4/52 baby presented to CED with vomiting. Birth weight 3.5kg. Current weight 4.3kg. The baby is bottle feeding and taking 150ml 4 hourly. Differential diagnosis?

Clinical scenario Differential diagnosis 1. Symptoms suggesting infection (UTI, meningitis, gastrointestinal infection) 2. Pyloric stenosis (projectile vomiting, age) 3. GORD 4. Intestinal obstruction (bilious vomit, abdominal distension) 5. CMP allergy 6. Overfeeding

Clinical scenario Adequate weight gain? 30 x 28 = 840g = 4.3 kg How much does the baby require? 150 x 4.3 = 645ml How much is the daily intake? 150 x 6 = 900 ml

Clinical scenario Adequate weight gain? 30 x 28 = 840g = 4.3 kg How much does the baby require? 150 x 4.3 = 645ml How much is the daily intake? 150 x 6 = 900 ml Vomiting likely 2 o to overfeeding

THANK YOU

References Infant Feeding Survey 2010, National Statistics Infant Feeding Recommendation, Department of Health Breast-feeding: A Commentary by the ESPGHAN Committee on Nutrition, Journal of Pediatric Gastroenterology and Nutrition BMJ 13/3/99, Archives Feb 99