Infant feeding and nutrition

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Infant feeding and nutrition

• Dr Janet Anderson

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Infant Nutrition

• Good nutrition is essential for
• Survival
• Physical growth
• Mental development
• Productivity
• Health and well being
• -----across the whole life span

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What we know

• Good early nutrition has profound effects on long
  term health, by programming aspects of subsequent
  cognitive function, obesity, cardiovascular risk,
  cancer and atopy.
• But what is optimal early nutrition?

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Early Programmming

• Babies who are small for gestational age at birth
  or who are light for height at one year are more
  likely to have cardiovascular disease,
  hypertension, type 2 diabetes and/or
  hypercholesterolemia particularly if they are
  forced to gain weight after this time.

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Infant feeding

• Until the latter part of the 19th century infant
  survival was dependent on breast feeding
• Wet nurses were frequently used if mother could
  not produce enough milk.
• Although infant feeding bottles were found in the
  artifacts of Pharaohs it wasnt until the 20th
  century that artificial milks were developed and
  after considerable research became nutritionally
  acceptable

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19th and 20th Century feeding bottles
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Nutritional requirements

• Age dependent
• The younger the child the higher their energy
  needs per kilogram body weight
• 0-3 months Fluid100-150mls/kg
• Calories 100kCals/kg
• Protein 2.1g/kg
• Na 1.5mmol/l
• K 3mmol/l

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Breast Feeding

• It is the babys demand that regulates the supply
  of breast milk not necessarily lactation supply
• The let down reflex can be delayed in some
  mothers leading to frustration .
• Any practice that limits milk output in the first
  week of life may limit milk output in the long
  term
• Ad libitum breast feeding is associated with
  improved outcomes

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Colostrum

• Contains more sodium
• High in Vit A and Vit K
• Contains 5x more protein than mature milk
• Contains more IgA

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Advantages of breast feeding

• Appropriate bonding and psycho social development
• Reduced morbidity (-- NEC less in preterm breast
  fed babies)
• Better nutritive balance minerals are more
  easily absorbed
• IgA, lactoferrin and lysozyme reduce
  infectionparticularly gut and ears
• Human milk contains a growth factor for
  Lactobacillus bifidus which increases acidity in
  the gut to inhibit growth of pathogens
• Immune response to Hib vaccine higher
• Reduces the risk of obesity

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Down sides of breast feeding

• Vitamin K deficiency
• Hypernatraemia at end of first week in babies
  with inadequate intake.
• Inhibits modern control culture!
• No good evidence that reduces colic
• Breast feeding alone beyond 6 months may lead to
  anaemia and Vit D deficiency therefore wean and
  add vitamin supplements

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Breast feeding and obesity prevention
Artificially fed babies consume 30,000 more
calories than breastfed infants by 8 months of
age Riordan et
al. 1999
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Breast feeding and Obesity

• Epidemiological evidence suggests that breast
  feeding represents an ideal opportunity for
  obesity prevention.
• Breast milk could influence the development of
  taste receptor profile which fosters a preference
  for lower energy diets later on in life
• Breast fed learn to regulate their appetites by
  stopping when they are full. Fore milk satiates
  thirst, hind milk hunger.
• Breastfed babies have lower levels of insulin, a
  hormone that promotes the storage of fat.
• The link between breast feeding and obesity
  appears to be greatest after infancy- in the
  9-14s
• Leptin, an anorexiogenic hormone, in breast milk
  may also play a part

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Long term benefits of breast feeding

• Compelling evidence that reduces
• Cardiovascular disease
• Obesity
• Improves cognitive development
• Reduces atopy but not in all
• More controversial
• Reduces IDDM,--(recent trials to determine
  whether BF is protective), neoplastic disease,
  osteoporosis and inflammatory bowel
  disease

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Contraindications to breast feeding

• Maternal drugs including
• anti-metabolites, opiates, amiodarone,
  phenindione ----others but mostly relative not
  absolute
• Maternal HIV in the developed world still
  controversial in resource poor countries
• Note---Babies of mothers with TB can be
  immunised at birth with BCG and treated with
  Isoniazid for 6 weeks and still be breast fed

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Artificial feeds

• Introduced in 1907 by Rotch in U.S.
• Nutritionally complete
• Contain more Vit. K ,Iron ( but less available)
  and Calcium and Vit. D than breast milk
• Whey based or casein based
• Soya milk no longer recommended for under 6
  months (probably better after one year)
• Has caused high mortality in developing world due
  to poor hygiene of equipment leading to
  gastroenteritis
• Must be made up correctly

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1950s Royal Formula
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Types of artificial formula

• Whey based
• Casein based
• Lactose free/partially lactose free
  (Omneocomfort)
• AR
• Follow on milks
• Organic milks
• Low allergenic milks
• Specialist milks i.e. phenylalanine free
• Soya milk
• Goats milk

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Pre-term formulas

• Developed in 1980s
• Contain more electrolytes
• calories
• minerals
• Long-chain polyunsaturated fatty acids plus
  pre-biotics added 2000s

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Questions?

• How many calories in 100ml of breast milk?
• A. 65-70kCals (depends whether fore or hind
  milk)
• How many calories in ordinary formula?
• A. 70kCals/100ml
• How many calories does a baby need to grow
  normally in the first 3 months?
• A. 100kCals/kg

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Cows milk allergy

• Clinical features include
• Gastrointestinal---colic
• vomiting
• diarrhoea
• colitis
• Rashes including eczema and urticaria
• Respiratoryrhinitis
• stridor
• cough and wheeze
• Irritability
• Failure to thrive etc

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Diagnosis of CMP allergy

• Formal allergy tests may not help.
• Rast test may be negative
• Skin testing is better
• Colonoscopy may be necessary in colitis
• Best is to remove cows milk protein from diet
  and watch
• Do not confuse with lactose intolerance

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Lactose intolerance

• Primary lactose intolerance rare
• Usually secondary to gastrointestinal infection
  especially rotavirus ,or neonatal gut surgery
• Explosive fermentative diarrhoea
• Stool Clinitest gt 0.5 / sugar chromatography of
  stool
• Usually transient but may need to remove lactose
  from milk for 6 weeks

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Weaning

• Latest government recommendations suggest 6
  months.
• Some controversy about this a hard and fast rule
• - not before 17 wks and not later than 26wks
• Babies need to be exposed rapidly to a variety of
  tastes and textures between 6-8 months if weaning
  is delayed otherwise taste preferences will be
  limited
• Vegetables and fruits are ideal weaning foods
• Encourage finger feeding because they can pick up
  food and are unlikely to choke.

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Weaning

• Breast fed babies run low on iron and calcium if
  not weaned at 6 months and this may occur before
  this time
• They are often perceived to be signaling hunger
  before 6months
• Only 1-2 of a cohort of British breast feeding
  mothers delayed weaning until 6 months
• ESPGAN suggest weaning 17-26 weeks no earler, no
  later

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Baby-led feeding

• Allows babies to feed themselves
• No spoon feeding and no purees
• Only the baby feeds themselves.
• Starts at 6 months when baby can sit upright,
  able to pick up pieces of food and chew them
• Expect a mess.
• Keep it enjoyable-sits with family to eat.

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Weaning

• If breast feeding continued exclusively for too
  long i.e.gt 4/5 months, this is associated with
• Iron deficiency with its associated adverse
  developmental outcomes
• Calcium/ Vit D deficiency
• Other possible effects allergy , coeliac disease
  and obesity?

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Vitamins

• All children from 6 months onwards should be
  given supplements that contain vitamins A,C and D
  such as Healthy Start vitamins unless they are
  drinking more than 500mls of formula.
• If mothers did not take vit. D during pregnancy
  and if breast fed, start Vit. D at 1 month

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Allergy and Coeliac Disease

• Rising rates of allergy despite increasing advice
  to delay exposure to potentially allergenic
  foods.
• Where peanuts are used as weaning foods, lower
  incidence of peanut allergy
• Critical window of exposure?
• 2008 review suggested increased risk if solids
  introduced before 3 /4 months
• Gluten exposure best between 3 and 6 months along
  side breast feeding?

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Failure to thrive

• Definition growth or weight faltering
• - Weight and/or height below 2nd centile
• Crossing down 2 centile channels for
  height and weight
• Most due to non organic failure to thrive
• Organic causes related to feeding difficulties
  because of anatomical defects or chronic illness
  eg heart
• disease
• Food intolerance including coeliac disease
• Neurological problems

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Factors in the history

• Consider factors that interfere with sucking and
  intake
• Conditions that interfere with absorption e.g.
  intestinal resection, coeliac disease
• Conditions that increase losses e.g. diarrhoea,
  vomiting
• Increased needs e.g. fever, sepsis, tissue
  injury, heart failure
• Conditions that restrict intake e.g.food
  intolerance, renal disease, heart disease
• Other gastrointestinal pathology.

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Non-organic failure to thrive

• Maternal depression/psychiatric disorder
• Disturbed maternal-infant attachment
• Eating difficulties
• Neglect

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Nutritional assessment

• Take a careful history
• Assess intake
• Consider requirements
• Weigh
• Children with chronic illness should have a
  detailed assessment

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Clinical pointers in failure to thrive

• Differentiate from the normal baby who is
  crossing the centiles
• Identify any symptoms and signs that suggest an
  organic condition
• Only perform investigations if there are clinical
  leads
• Identify psychosocial problems that might be
  affecting the babys growth

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Consequences of poor weight gain in infancy

• 5-20 points in IQ
• Increased cardiovascular risks, hypertension,
  hypercholesterolaemia and Type 2 diabetes

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Obesity

• Increasing morbidity
• Prevention is required
• Increased risk of early Type 2 diabetes, fatty
  liver, sleep apnoea, poor school performance,
  SUFE, etc
• 25 children at risk
• Note an individuals response to a high calorie
  diet is subject to strong genetic influence

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A world of difference
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Constipation in the first year of life

• Common causes
• Over diagnosed in breast fed babies
• Incorrect making up of formula feeds
• Changing from whey based to casein based feeds
• Weaning
• Over dependence on milk as nutrition in older
  babies
• Potty training