1. Infant Feeding and Nutrition Dr.Renu Jainer

2. Few things engender more anxiety than symptoms associated with feeding. Early difficulties can influence a mothers relationship with her baby for months or even years

3. A Short Term Issue? Suggested that nutritional state in infancy exerts a long term effect on health and development through metabolic programming (Lucas 1994) Suggested that nutritional state in infancy exerts a long term effect on health and development through metabolic programming (Lucas 1994)

4. Statistics By 4 weeks of age 30% of mothers bottle feed their babies solely. By 4-10weeks 58% were solely bottle fed with up to 75% having some formula. By 4 weeks of age 30% of mothers bottle feed their babies solely. By 4-10weeks 58% were solely bottle fed with up to 75% having some formula. By 8 months 8% were giving cows milk as the main milk drink. By 8 months 8% were giving cows milk as the main milk drink.

5. More Statistics 69% of women started breast feeding in UK. 69% of women started breast feeding in UK. At 6 weeks 43% were breast fed. At 6 weeks 43% were breast fed. At 4 months only 28% breast fed and at 6 months only 21%. At 4 months only 28% breast fed and at 6 months only 21%. Exclusive breast feeding is recommended for the first 6 months of life. Exclusive breast feeding is recommended for the first 6 months of life. Department of Health Feeding Survey 2000 Department of Health Feeding Survey 2000

6. Breast is best? Breast is best? Contains all the nutrients an infant needs in the right amounts and in an easily absorbable form. Its composition changes as the baby grows. Contains all the nutrients an infant needs in the right amounts and in an easily absorbable form. Its composition changes as the baby grows. Contains growth factors and hormones to assist development 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. Anti infective properties: Macrophages, lymphocytes and polymorphs, Secretory IgA, Lyzozyme, Lactoferrin (inhibits growth of E.coli.), anti-viral agents.

7. Long term benefits to infant Reduced risk of atopy Reduced risk of atopy Better dental health Better dental health Reduced incidence of later obesity. Reduced incidence of later obesity. Improved neurological development Improved neurological development Reduced risk of SIDS Reduced risk of SIDS

8. Maternal benefits Reduced risk of premenopausal cancer. Reduced risk of premenopausal cancer. Promotes weight loss after pregnancy Promotes weight loss after pregnancy Lactational amenorrhoea Lactational amenorrhoea Cheaper, easier more convenient and portable. Cheaper, easier more convenient and portable. No other equipment to prepare. No other equipment to prepare.

9. Breast milk Varies greatly according to: Varies greatly according to: Hindmilk vs foremilk Hindmilk vs foremilk Duration of lactation (reducing protein concentration) Duration of lactation (reducing protein concentration) Gestational age of baby Gestational age of baby Maternal diet. Maternal diet.

10. Composition of breast milk vs formula milk Colostrum: For 2-4 days post delivery. Has high protein and mineral content but less carbohydrate and fat. Mature breast milk established by 4th week. Colostrum: For 2-4 days post delivery. Has high protein and mineral content but less carbohydrate and fat. Mature breast milk established by 4th week. Water: Equal amounts Water: Equal amounts Calories:Approx 67kcal/100ml. Calories:Approx 67kcal/100ml. Protein: Protein: Human milk 1-1.5% protein(70% whey protein) Cows milk 3.3% protein due to greater content of casein

11. Composition of breast milk vs cows milk Carbohydrate:Human milk 7% (10% glycoproteins) Cows milk 4.5% lactose Carbohydrate:Human milk 7% (10% glycoproteins) Cows milk 4.5% lactose FatApprox 3.5% both principally triglycerides Olein is more easily absorbed and there is twice as much in breast milk. FatApprox 3.5% both principally triglycerides Olein is more easily absorbed and there is twice as much in breast milk. MineralsCows 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. MineralsCows 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. VitaminsCows milk is low in vitamin C and D but more thiamine and riboflavin. VitaminsCows milk is low in vitamin C and D but more thiamine and riboflavin.

12. Factors Affecting Prevalence Of Breast Feeding in the UK Favourable: Favourable: -Social class 1 -Social class 1 -Mother educated -Mother educated -Mother >25 years -Mother >25 years -Live in London/SE -Live in London/SE -first baby -first baby -breast fed previous baby -breast fed previous baby Against : Against : -social class V -social class V -maternal smoking -maternal smoking

13. Dangers of Unmodified Cows Milk High renal solute load: Hypernatraemia Hypernatraemia High blood urea and acidaemia High blood urea and acidaemia Hyperosmolality Hyperosmolality Hypocalcaemia Hypocalcaemia

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

15. Baby Milks Infant formulas are suitable from birth and are usually based on cows milk. Composition controlled by EC and UK legislation. Infant formulas are suitable from birth and are usually based on cows milk. Composition controlled by EC and UK legislation. Whey based milks are usually first choice if not breast feeding. Whey based milks are usually first choice if not breast feeding. Casein based milks are suggested for hungrier babies Casein based milks are suggested for hungrier babies Soya infant milks Soya infant milks Follow on formulas: Higher iron content than cows milk. Composition less controlled Follow on formulas: Higher iron content than cows milk. Composition less controlled Specialised formulas for those who are preterm or have medical conditions Specialised formulas for those who are preterm or have medical conditions

16. Soya Infant Formula Recommended for use on medical advice but should not be the first choice for the management of CMP intolerance. Recommended for use on medical advice but should not be the first choice for the management of CMP intolerance. Similar to cows milk but protein derived from soya with lactose replaced with other carbohydrates (glucose syrups). Similar to cows milk but protein derived from soya with lactose replaced with other carbohydrates (glucose syrups).

17. Preterm Requirements The aim of feeding premature babies is to achieve a rate of growth which is similar to intra-uterine growth at the same gestational age. Preferably the feed should be of constituents that do not load the metabolism and promote development of gastrointestinal function. The aim of feeding premature babies is to achieve a rate of growth which is similar to intra-uterine growth at the same gestational age. Preferably the feed should be of constituents that do not load the metabolism and promote development of gastrointestinal function. Special Needs Special Needs 1)Glycogen stores are small. Minimal fat stores. Reduced response to hypoglycaemia. 1)Glycogen stores are small. Minimal fat stores. Reduced response to hypoglycaemia. 2)Increased energy requirements (100-120 kcal/kg/day) 2)Increased energy requirements (100-120 kcal/kg/day) 3)Higher protein synthesis than term infants. 3)Higher protein synthesis than term infants. 3)Nervous system potentially at risk if inadequate nutrition provided.(LCPs) 3)Nervous system potentially at risk if inadequate nutrition provided.(LCPs)

18. Bottle feeding Start with small amounts 20-60ml/kg/day Start with small amounts 20-60ml/kg/day Increase to 150ml/kg/day by day 4-5. Usually given 3-4 hourly. Increase to 150ml/kg/day by day 4-5. Usually given 3-4 hourly. Follow instructions: risk of hypernatraemia Follow instructions: risk of hypernatraemia Hygiene issues. Hygiene issues.

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

20. Plotting growth on the centiles

21. Statistics again By 17 weeks, 49% of mothers had introduced solid food. By 17 weeks, 49% of mothers had introduced solid food. 49% had introduced solids between 17- 26 weeks. 49% had introduced solids between 17- 26 weeks. At 4-5 months 62% will use commercially prepared food. At 4-5 months 62% will use commercially prepared food. At 8-9 months only 52% using commercial food. At 8-9 months only 52% using commercial food.

22. Weaning For the first 6 months babies cannot properly digest solid food. For the first 6 months babies cannot properly digest solid food. Commence weaning at 6months old and increase so that by 12 months solids are the main part of the diet with milk to drink along side. Commence weaning at 6months old and increase so that by 12 months solids are the main part of the diet with milk to drink along side. Do not rush or force-feed. Do not rush or force-feed. Full fat cows milk can be used from 12 months. Full fat cows milk can be used from 12 months.

23. Foods to avoid in weaning Salt Salt Sugar Sugar Tea Tea Honey Honey Nuts: Do not give any type of whole nut to children under 5 yrs due to risk of choking. Nuts: Do not give any type of whole nut to children under 5 yrs due to risk of choking. Serious nut allergy affects less than 1% of the population. Those most at risk have FH of atopy. Avoid giving peanuts and peanut products until the child is 3 yrs old if FH of atopy. Serious nut allergy affects less than 1% of the population. Those most at risk have FH of atopy. Avoid giving peanuts and peanut products until the child is 3 yrs old if FH of atopy.

24. Weaning Finger foods promote chewing practice and independence. Finger foods promote chewing practice and independence. Soft lumps are often manageable from 6 months. Chewing encourages development of speech muscles. Soft lumps are often manageable from 6 months. Chewing encourages development of speech muscles. Feeding should always be supervised. Feeding should always be supervised. Approx 1 pt of milk should be given plus clear fluids with meals. The bottle should be phased out by 1 yr of age. Avoid fruit juice until >6months. Approx 1 pt of milk should be given plus clear fluids with meals. The bottle should be phased out by 1 yr of age. Avoid fruit juice until >6months.

25. Vitamins Vitamin K deficiency results in HDN Vitamin K deficiency results in HDN If still breast feeding > 6months of age use Vitamin A,C and D drops. Not required if taking > 1pt of formula/day. If still breast feeding > 6months of age use Vitamin A,C and D drops. Not required if taking > 1pt of formula/day. Give vitamin drops to all children of 1-5 years. Give vitamin drops to all children of 1-5 years. Half an hour playing outside is sufficient to meet daily Vit D requirements. Half an hour playing outside is sufficient to meet daily Vit D requirements.

26. Vitamins continued Iron deficiency anaemia is a common problem in toddlers worldwide, particularly in urban populations(10-30%) in the UK. It has been shown to be associated with developmental delay and increased susceptibility to infection. Iron supplemented milk is recommended until at least the age of 1 year in all infants. BMJ 13/3/99, Archives Feb 99. Iron deficiency anaemia is a common problem in toddlers worldwide, particularly in urban populations(10-30%) in the UK. It has been shown to be associated with developmental delay and increased susceptibility to infection. Iron supplemented milk is recommended until at least the age of 1 year in all infants. BMJ 13/3/99, Archives Feb 99.

27. Failure To Thrive Occurs when child’s growth fails to meet expected potential for age. Occurs when child’s growth fails to meet expected potential for age. A single plot on a chart is of limited value A single plot on a chart is of limited value Need to consider parental height Need to consider parental height Not a diagnosis but a term which describes the end result of a number of different conditions which may be organic (gastrointestinal or non gastro), nonorganic (psychosocial) or mixed. Not a diagnosis but a term which describes the end result of a number of different conditions which may be organic (gastrointestinal or non gastro), nonorganic (psychosocial) or mixed.

28. Failure to thrive Four basic reasons Four basic reasons -Inadequate intake -Abnormal losses from vomiting/diarrhoea -Underlying illness eg CF -Abnormal baby (dysmorphic)

29. Approach to FTT Check weight against centile chart. Check weight against centile chart. Check type, amount and making up of feed. Dietary assessment. Check type, amount and making up of feed. Dietary assessment. Observe a feed and infant response Observe a feed and infant response Assess stool Assess stool Examine for underlying illness. Examine for underlying illness. Consider admission to observe response to feeding Consider admission to observe response to feeding

30. Task! You are asked to see a 4 week old baby because mum says the baby will not settle. Birth weight was 3.5kg. The baby is bottle feeding every 4 hours and taking 3- 4oz (90-120ml) each feed. You are asked to see a 4 week old baby because mum says the baby will not settle. Birth weight was 3.5kg. The baby is bottle feeding every 4 hours and taking 3- 4oz (90-120ml) each feed. How much is the daily intake? How much is the daily intake? How much does the baby require? How much does the baby require?

31. Task part two The baby weighs 4.2kg The baby weighs 4.2kg Is this adequate weight gain? Is this adequate weight gain? What is the milk requirement? What is the milk requirement?

32. Further Reading Birth To Five, Department Of Health Birth To Five, Department Of Health Allergy UK, www.allergyfoundation.com Allergy UK, www.allergyfoundation.comwww.allergyfoundation.com Infant Feeding 2000, Department of Health Feeding survey. Infant Feeding 2000, Department of Health Feeding survey.

33. Any questions?