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

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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
kcals/100mls

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

16. 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

17. 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

18. 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):
Normal stool frequency 12 per day to 1-2 per week
symptomatic
2 positive reducing subs – v fresh samples
Acidic stools

19. 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

20. 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

21. 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

22. 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”

23. 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

24. 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

25. 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

26. 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 > mls 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

27. 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

28. 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

29. 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

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

31. 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

32. Faltering Growth : Management
Increase feed volume, if inadequate
Consider Nasogastric feeding
Supplement feeds to increase energy density
Aim For: Kcals/Kg
g protein/Kg

33. 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

34. 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…….

35. 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