Understanding Infant Nutrition

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Understanding Infant Nutrition

• By
• James A. Yost, MD, MS, MBA
• Emory Family Medicine

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Calculating Infant Nutrition

• Objectives
• Formula
• Breast feeding
• Calculating ounces per day
• Calculating calories per day
• Ensure continuation of growth by giving enough
  calories
• Expiration of breast milk and formula

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Infant Nutrition

• Body water composition
• Neonates are born with an excess of TBW
• This is primarily ECF
• They normally lose this excess ECF in the first
  postnatal week.
• Term neonate bodies are 75 water
• 40 ECF and 35 ICF
• Term neonates usually lose 5-10 of their weight
  in the first week of life, almost all of which is
  water loss.

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Infant Nutrition

• Energy expenditure of an infant
• Resting energy use 40 kcal/kg/d
• Minimal activity 2-4 kcal/kg/d
• Occasional cold stress 10 kcal/kg/d
• Fecal loss of energy 10 kcal/kg/d
• Growth 40 kcal/kg/d
• Total 100-105
  kcal/kg/d

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Infant Nutrition

• Distribution of Energy Sources
• Glucose 16.3gm 55 kcal/kg/d. 50
• Protein 3.1gm 10 kcal/kg/d12
• Fat 4gm 40 kcal/kg/d38
• Total 105 kcal/kg/d

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Infant Nutrition

• Formula
• Term Formulas
• modeled after breast milk and contains 20 kcal
  per ounce
• carbohydrate source is lactose
• contain cow's-milk protein
• no evidence to recommend one brand over another
• May choose WIC formula for Medicaid - currently
  Similac till Sept 2009

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Infant Nutrition

• Formula Continued
• Arachidonic acid (AA) and docosahexaenoic acid
  (DHA)
• These fatty acids are found in breast milk
• important in the development of membrane
  constituents in the central nervous system
• promote eye and brain development
• most well-conducted randomized trials show no
  benefit

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Infant Nutrition

• Formula Continued
• How to initiate feeds (lt36wks gest.)
• Calculate 80ml/kg/day total daily intake
• Then divide by 8 (for 8feedings in a day)
• Then divide by 30 (for 30ml in one ounce)
• This will equal the number of ounces per feed
• Increase by 20ml/kg/day to a max of 150ml/kg/day
• The formula needs 22 - 24 kcal/oz

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Infant Nutrition

• Examples
• A new born weighs 7lbs (3.2Kg)
• 80ml x 3.2Kg 265ml total daily intake
• 265ml /8 32ml/feed
• 32ml/30ml/oz approx 1 oz per feeding
• Total daily caloric intake should be 160 kcal

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Infant Nutrition

• Formula Continued
• How to initiate feeds (gt36wks gest.)
• Calculate 150ml/kg/day total daily intake
• Then divide by 8 (for 8feedings in a day)
• Then divide by 30 (for 30ml in one ounce)
• This will equal the number of ounces per feed
• The formula has 20 kcal/oz

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Infant Nutrition

• Examples
• A new born weighs 7lbs (3.2Kg)
• 150ml x 3.2Kg 480ml total daily intake
• 480ml /8 60ml/feed
• 60ml/30ml/oz approx 2 oz per feeding
• Total daily caloric intake should be 320 kcal

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Infant Nutrition

• Soy Formula
• Use should be limited to infants with
  galactosemia or congenital lactase deficiency
• may also be used by strict vegan families
• accounts for almost 25 percent of formula sales
• made with corn-based carbohydrate and soy protein
• free of lactose and cow's-milk protein
• parents believe that this improves digestibility

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Infant Nutrition

• Soy Formula Continued
• The evidence regarding soy formula and peanut
  allergy is mixed
• has been shown to reduce the duration of diarrhea
  in acute gastroenteritis
• soy formula should never be used for preterm
  infants
• FPs should direct parents toward breastfeeding
  and cow's-milk-based formulas in most cases

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Infant Nutrition

• Lactose-free Formulas
• alternative to soy formula
• indicated for galactosemia and congenital and
  primary lactase deficiency
• Lactose intolerance is overdiagnosed in infancy
• most proven cases develop after 12 months

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Infant Nutrition

• Hypoallergenic and Nonallergenic Formulas
• Only a small minority of infants have true
  immunoglobulin E (IgE)-mediated milk protein
  allergy
• Milk protein allergy can present with any
  combination of cutaneous, respiratory, and
  gastrointestinal complaints
• blood in the stool is a classic symptom
• usually diagnosed in the setting of a strong
  family history

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Infant Nutrition

• Hypoallergenic and Nonallergenic Formulas
  Continued
• Milk protein intolerance can manifest as
  enteropathy and enterocolitis
• These infants are equally sensitive to soy
  protein so hypoallergenic is preferred
• Infants on hypoallergic formulas have slightly
  greater weight gain during the first year
• infants show improvement in atopic symptoms
• Only a few infants continue to have symptoms
  despite switching

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Infant Nutrition

• Antireflux Formulas
• Gastroesophageal reflux is common in infants
• decreased resting tone of the lower esophageal
  sphincter
• Should be considered physiologic
• does not require treatment unless it is
  accompanied by poor weight gain or significant
  infant discomfort
• have been shown to decrease daily episodes of
  regurgitation and emesis
• parents should be reassured that GERD is normal
  and will resolve with time
• antireflux formulas appear safe and nutritionally
  adequate for severe or persistent cases

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Infant Nutrition

• Infant Formula and Colic
• Parents often change formulas in response to
  infant colic
• Soy and lactose-free formulas
• Most colic improves spontaneously between four
  and six months of age
• no evidence to support lactose-free or soy
  formula for colic
• Two systematic reviews have found some benefit
  with hypoallergenic formula
• So a 1-2 week trial is reasonable

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Infant Nutrition
Table 1. Comparison of Breast Milk and Available Infant Formulas Table 1. Comparison of Breast Milk and Available Infant Formulas Table 1. Comparison of Breast Milk and Available Infant Formulas Table 1. Comparison of Breast Milk and Available Infant Formulas Table 1. Comparison of Breast Milk and Available Infant Formulas Table 1. Comparison of Breast Milk and Available Infant Formulas Table 1. Comparison of Breast Milk and Available Infant Formulas Table 1. Comparison of Breast Milk and Available Infant Formulas Table 1. Comparison of Breast Milk and Available Infant Formulas
Class Brand names Calories(kcal per oz) Carbohydrate source Protein source Indications Cost per ounce Cost per ounce
Class Brand names Calories(kcal per oz) Carbohydrate source Protein source Indications Powdered formula Ready-to-feed
Breast milk - 20 Lactose Human milk Preferred for all infants - -
Term formula Carnation Good Start Enfamil with Iron Similac with Iron 20 Lactose Cow's milk Appropriate for most infants 0.14 0.27
Term formula with DHA and AA Enfamil Lipil Good Start DHA ARA Similac Advance 20 Lactose Cow's milk Marketed to promote eye and brain development 0.16 0.30
Enriched formula Enfacare Similac Neosure 22 Lactose Cow's milk 34 to 36 weeks' gestation Weight 1,800 g (3 lb, 15 oz) or greater 0.19 0.32
Soy formula Enfamil Prosobee Good Start Soy Similac Isomil 20 Corn-based Soy Congenital lactase deficiency, galactosemia 0.16 0.30
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Infant Nutrition
Class Brand names Calories(kcal per oz) Carbohydrate source Protein source Indications Cost per ounce Cost per ounce
Class Brand names Calories(kcal per oz) Carbohydrate source Protein source Indications Powdered formula Ready-to-feed
Lactose-free formula Enfamil Lactose free Similac Sensitive 20 Corn-based Cow's milk Congenital lactase deficiency, primary lactase deficiency, galactosemia, gastroenteritis in at-risk infants 0.16 0.30
Hypoallergenic formula Similac Alimentum Enfamil Nutramigen Enfamil Pregestimil 20 Corn or sucrose Extensively hydrolyzed Milk protein allergy 0.25 0.37
Nonallergenic formula Elecare Neocate Nutramigen AA 20 Corn or sucrose Amino acids Milk protein allergy 0.35 -
Antireflux formula Enfamil AR Similac Sensitive RS 20 Lactose, thickened with rice starch Cow's milk Gastroesophageal reflux 0.18 0.31
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Infant Nutrition

• Breast Feeding
• should initiate as soon as possible after giving
  birth
• Early breast-feeding is associated with fewer
  nighttime feeding problems and better
  mother-infant communication

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Infant Nutrition

• Breast Feeding
• Benefits, helps prevent the following
• bacterial meningitis
• bacteremia
• diarrhea
• respiratory tract infection
• necrotizing enterocolitis
• otitis media
• urinary tract infection
• late-onset sepsis in preterm infants
• type 1 and type 2 diabetes
• lymphoma, leukemia, and Hodgkins disease
• childhood overweight and obesity

Please
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Infant Nutrition

• Breast Feeding
• Contraindications to breastfeeding
• infants with classic galactosemia (galactose
  1-phosphate uridyltransferase deficiency)
• In the US, mothers who are infected with HIV
• NOT contraindicated
• Mothers who are Hep B surface antigen-positive
  or have Hep C infection
• mothers who are febrile
• mothers who smoke tobacco or occasionally drink

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Infant Nutrition

• Breast Feeding
• 20kcal/oz and contains lactose
• breast milk alone does not provide infants with
  an adequate intake of vitamin D
• Recommended for infants who are strictly breast
  fed to supplement with an infant vitamin dropper

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Infant Nutrition

• Breast Feeding
• Whats in this stuff!!!!
• Proteins
• Whey and casein
• Lactoferrin
• inhibits the growth of iron-dependent bacteria
• Immunoglobulin
• Lysozyme
• protects the infant against E. Coli and
  Salmonella
• Bifidus factor
• supports the growth of lactobacillus

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Infant Nutrition

• Breast Feeding
• Whats in this stuff!!!!
• Fats
• Vitamins
• Fat-soluble vitamins, including vitamins A, D, E,
  and K
• Water-soluble vitamins such as vitamin C,
  riboflavin, niacin, and panthothenic acid
• Carbohydrates
• Lactose is the primary carbohydrate
• 40 of the total calories provided by breast milk
• improves the absorption of calcium, phosphorus,
  and magnesium

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Infant Nutrition

• Breast Feeding
• Colostrum
• Produced in sufficient amounts during the last
  trimester and at delivery
• high in protein and immunoglobulin
• Present for 5-7 days or until the milk comes in
• Schedule
• Need to feed every 2-3 hrs for about 15 minutes
  on each breast

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Infant Nutrition

• How long can I leave this stuff out anyway?
• Breast Milk
• Rule of 5s
• Room temp for 5 hrs
• Frig. For 5 days
• Freezer for 5 months
• Formula
• Rule of 1s
• Room temp for 1 hr.
• Frig for 1 day
• Never frozen

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Thank You