Department of Nutrition & Dietetics A.M.N.C.H.

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Presentation transcript:

Department of Nutrition & Dietetics A.M.N.C.H. INFANT NUTRITION Sinéad Feehan Department of Nutrition & Dietetics A.M.N.C.H. August 2009

Overview Assessing growth Requirements Breastfeeding Formula Feeding Introducing Solid Foods Iron & Vitamin D

Normal Growth: Weight Normal birth weight 3.5kg Regain birth weight by 2 weeks Expected gain 200g per week for 1st 3 months 150g per week for 2nd 3 months 100g per week for 3rd 3 months 50-75g per week for 4th 3 months NB standardisation of measurements Using metric 7lbs 11oz Slows after 1st year eg 2.5kg in 2nd year; 2kg per year thereafter til puberty depending on centile EN approved scales green M, self zeroing electronic sclales, accurate to 10g, 10g divisions Nude weight (no nappy no vest) (or dry nappy and weigh nappy) Hospital setting alt days pre first feed Same time, same scales, same place Older children age + 4 x 2

Normal Growth : Length Normal birth length 50cm Expected growth 1st year 25cm 2nd year 12cm 3rd year onwards 10-6cm per year until puberty Supine length until age 2 2 people required Can be useful to also use stadiometer when walking to accustom.. Sick infants once per month V difficult

Normal Growth: OFC Normal head circ at birth 35cm >0.5cm per week (48cm by 1 yr) Reflects brain growth Above eyes, upright, looking straight ahead Occipital frontal circumference

Centile Charts Various charts available Calculate age in weeks <37/40: correct until 2 years Weight at 4-8 weeks predictive View growth in relation to normal population

Reference Nutrient Intakes Age (months) Weight (kg) Fluid (mls) Energy (kcals/kg) Protein (g/kg) 0 - 3 4.4 150 115 – 110 2.8 4 - 6 7.2 130 95 1.8 7 - 9 9.0 120 1.5 10 – 12 10.0 110

WHO RECOMMENDATION Exclusively Breastfeed for 6 months Continue to breastfeed after that, in combination with appropriate complementary foods, until the age of 2 years or beyond WHO guidelines have been accepted and endorsed by the DOHC

Breastfeeding Benefits Immunological: Breastfed babies are at lower risk of infection. Nutritional: Easy to digest, optimal blend of nutrients, low risk of contamination. Psycho/social: Bonding, pain relief, maternal confidence & empowerment. Financial: Milk is always available: shorter hospital stay.

Benefits Optimal nutrition for human infant Immunological advantages Correct nutrient composition – macro/micronutrients Nutritionally complete until 6 mths Immunological advantages Macrophages: lysozymes and lactoferrin Lymphocytes: interferon and IgA Bifidus factor Antibodies Anti-trypsin factor Long list of benefits – nutritional, immunological, highly digestable and bioavailable, psychological and economical benenfits Several recent metanalysis: Ip et al 2007 Breastfeeding ans Maternal and Infant Health Outcomes in Developed Countries WHO 2007 Evidence on the longterm effects of breastfeeding Difficulty is that all data is observational not RCTs so v difficult to rule out self selection or other factors Otitis media comparing exclusively BF to bottle fed Atopic derm with fhx reduction if exclusively BF for >3 months Asthma if no fhx 27% redced risk, 42 if fhx Long term Small but significant effects on BP Significant at public health level because even reduction of mean BP by 2mmHg could lower incidence of hypertension by 17%, coronary events by 6% and stroke by 15% Effect less than other public health interventions targeted at adults such as dietary advice, physical activity, salt restriction ? Mechanism – salt intake, LCPs, obesity Adult chol 3.2% less than median if BF Effect similar to that of dietary advice in adulthood ?mechanism chol content of BF may downregulate synthesis This is why effect on reducing obesity most compelling ?diff in protein intake or hormanal influences but def protective Reduction v sig compared with ineffectiveness of dietary education and exercise

Possible Contra-indications Medications IV Drug Abuse HIV Galactosaemia, Alactasia Note: Very low birth weight/premature, can be fed expressed breast milk Nucleotides – nitrogenous group (purine or pyrimidine) and sugar (pentose deoxyribose or ribose) and one or more phospates Monomers of nucleic acids Structural untis of DNA RNA and other cofactors and have role in metabolism and signaling

Colostrum Protein rich – Arginine & Tryptophan Essential fatty acids Vitamins (A, D & B12) and minerals Frequent suckling – increases hormone production (Prolactin & Oxytocin) which increases milk production

Mature Breast Milk Fore milk & hind milk Less protein, more fat and energy Antibodies & anti-infective agents Digestive enzymes – lipase and amylase Vitamins, minerals and trace elements High bioavailability of nutrients 67 -70 kcals/100mls

Formula Feeding Approved formulae – nutritionally complete No immunological/enzymic properties Cows milk based, modified to mimic the nutrient profile of mature breast milk Provide 65-69 Kcals / 100mls Demand feed: 150 – 200mls/kg/day

Standard Products Whey based/ first milks Cow & Gate First Infant Milk Farley’s First Milk Milupa Aptamil First Infant Milk SMA First Infant Milk Caesin based/ “milk for hungrier babies” Cow & Gate Second Infant Milk Farley’s Second Milk Milupa Aptamil Extra Hungry SMA Extra Hungry Good to know colours! Caesin slower gastric emptying Quote calorie and protein contents.. Cow and Gate – prebiotics, nucleotides, LCPs Farleys made by Heinz LCPs and nucleotides Milupa prebiotics nucleotides and LCPs SMA alphalactalbumin more similar protein to BM

Follow-on Formulae Follow-on milks Marketed for babies > 6 months Cow & Gate Follow-on Milk Farley’s Follow-on Milk Milupa Aptamil Follow-on Milk SMA Follow-on Milk Marketed for babies > 6 months Higher Energy, Iron & Vitamin D than term formulae Higher protein and some vits and minerals most notably iron Higher iron, caesin based World Health Assembly adpted a resolution in 1986 stating FOF not necessary. EU regulations do permit their use after 4 months. Marketing of infant formula is prohibited by irish law but FOF can be marketed for babies > 6 months

Specialised Formula (Non-Px) Anti-regurgitation Formula Enfamil AR SMA Staydown Not effective with ant-acid medications Lactose-free Formula Enfamil 0-Lac SMA LF Glucose syrup instead of lactose Lactose intolerance usually transient - avoid prolonged use “Thickening agents..should not be used indiscriminantly in healthy, thriving infants who spit up. …used only in selected infants with failure to thrive caused by excessive nutrient losses associated with regurgitation….with appropriate medical treatment and supervision” Aggett et al, J Ped Gastr Nutr 2002 May;34(5):496-498 Normal stool frequency 12 per day to 1-2 per week symptomatic 2 positive reducing subs – v fresh samples Acidic stools

Special Formula (Non-Px) Soya milks Farley’s Soya Formula SMA Wysoy Lower biological value Limited clinical indications – Galactosaemia Not indicated in colic, lactose intolerance, CMPI Contra-indicated under 6 months (BDA) Soya studies 2001 and 2002 prolonged and painful menstruation in woman, changes in leydig cells of testes and testosterone suppression Not recommended in infants under 6 mo – no clinical indications Prob related to phytoeostrogens After 6 months dose per kg less cos of weaning. Also vulnerable organ tissue will have matured Kindergen, Caprilon

Prescribable Specialised Formulae Nutrient dense SMA High Energy, Infatrini Hydrolysed Pepti-Junior, Pepdite, Nutramigen 1 and 2, Pregestimil, Nutrilon Pepti, Prejomin, MCT Pepdite Elemental Neocate LBW/ Premature Nutriprem 1 and 2, SMA Gold Prem, BM Fortifier Disease specific Caprilon, Kindergen, Galactomin 17 and 19, Monogen, Locasol

Volumes Feed on demand Initially small frequent feeds Volumes increase, frequency decreases Example 4 week old infant weighing 4.3kg Fluid requirement 150mls/kg = 645mls/day 80mls 3 hourly x 8 or 95mls 3.5 hourly x 7 or 110mls 4 hourly x 6 All suitable, baby dictates, don’t restrict hungry baby Newborn offer 3-4oz bottle 7-8oz bottles by 6 months

Formulae : Possible Problems Over-concentration Hypernatraemia and dehydration Inappropriate calorie density Over-dilution Excess volume Vomiting and hyponatraemia FTT and malnutrition Hygiene Safefood: “How to prepare your babys bottle feed”

Weaning Solid food should be introduced at 6 mths ? Not before 4 months: -milk meets all nutrient requirements -immature GIT & limited renal capacity -Poor neuromuscular co-ordination ? by 6 months: -increasing energy & nutrient needs -decreased body stores : Fe & Zn -aids chewing & speech development -food refusal less likely

Weaning cont’d First foods (6mths): - puree fruit, veg, rice/ gluten-free cereals - puree meat/chicken/fish - offer variety of tastes & textures Next foods: -introduce wheat, gluten, eggs*,citrus fruit -don’t add salt or sugar -more lumpier/mashed consistency -introduce finger foods - include iron-rich foods

Weaning cont’d Cow’s milk not as drink before 1 year Potential allergens No evidence to delay introduction Eggs – well cooked after 6 months Nuts – avoid whole until 5 years; fhx avoid for 3 years Gluten Currently > 6 months Literature 4 – 7 months, gradual intro while BF Vegetarian Ensure 500mls of BM/ formula Vegan Not recommended

Suitable Drinks Breast milk / formula & water only Unmodified cows, goats, sheeps milk unsuitable Juice – not required but not before 6 mths and not in quantities > 120-180mls per day. Offer diluted. Tea, aerated drinks, mineral waters, coffee : unsuitable No additions to bottles Encourage cup from 6 months Discourage bottle from 1 year NB dental care When teeth appear clean with soft cloth or guaze No toothpaste til 2 years No scientific evidence re reduced allergenicity

Current Practices: Tarrant et al 2006 23% of infants weaned to solids <12 weeks 9% <10 weeks 10% at 6 months crisps/choc/biscuits >4/week 6% add solids to bottles 31% add gravy to weaning foods 16% add sugar to weaning foods 5% add salt to weaning foods

Current Practices: Tarrant et al 2006 (contd.) 4% have tea/lemonade/cola at 6 months 2% have these drinks regularly 6% have >180ml juice per day at 6 months 4% have sugar water as a drink at 6 months 20% mothers avoid meat in weaning diets

By 1 year…. Eat family meals Wide range of textures and tastes Approx 1 pint cow’s milk per day Drinking from cup not bottle Low fat milk not before2, skimmed not before 5

Common feeding problems FALTERING GROWTH IRON DEFICIENCY ANAEMIA VITAMIN D DEFICIENCY & RICKETTS

Faltering Growth Downward deviation in weight across 2 or more centiles from the max centile achieved at 4-8 weeks for a period of a month or more Possible Causes: -inadequate dietary intake -malabsorption/excessive losses -increased nutrient requirements -inability to utilise nutrients, e.g. metabolic conditions -psychological problems, e.g. poor parenting skills

Faltering Growth : Management Increase feed volume, if inadequate Consider Nasogastric feeding Supplement feeds to increase energy density Aim For: 130 - 150 Kcals/Kg 3 - 4.5g protein/Kg

Iron Deficiency Anaemia Definition: Hb < 11g/dl, Ferritin < 10microg Symptoms include - apathy, poor appetite, poor growth, psychomotor delay Possible causes are prematurity and inadequate weaning diet Inhibitors of iron are tannins, phytic acid, phosphoproteins Prevention = Breast milk/Fe fortified formula Weaning foods rich in haem iron Adequate vitamin C

Vitamin D Re-emergance of rickets Low vitamin D levels in normal population Risk factors Latitude, lack of sunlight exposure Pigmented skin Poor maternal status Prolonged breastfeeding, poor weaning diets FSAI recommend 5μg daily for all infants Await policy…….

Infant Nutrition Breast/Formula feed up to One year old Introduce solids from 6 months Include iron-rich foods in weaning diet Offer variety of tastes & textures Encourage drinking from a cup from 6-8 months