Pediatric Nutrition

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Pediatric Nutrition

• The first two years
• Joan Brennan
• Clinical Dietitian

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Early Recommendations

• Breastfeeding and Human Milk
• exclusive human milk feeding for first 4-6 months
  of life
• breastfeeding may continue until two years of age
  and beyond
• vitamin D supplementation of 400 IU to all human
  milk fed infants from birth until diet provides a
  source of vitamin D

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Human Milk Feeding

• either by breast or as expressed human milk using
  manual expression or pump and given by
  bottle/tube
• various pumps available
• manual vs. electric
• electric most efficient and effective best one
  is rental from pharmacy
• may take 7-10 days to establish breastfeeding
• frequent feedings will help establish milk supply
• number of wet diapers in a 24 hour period good
  indicator of whether baby is getting enough
• supplemental formula may obstruct establishment
  breastfeeding

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Infant Formulas

• when an informed mother chooses not to
  breastfeed, commercial infant formulas are the
  most acceptable alternative to human milk
• nutrient content of iron-fortified infant formula
  is designed to meet the nutritional needs of
  healthy term infants until 12 months of age
• composition, processing, packaging, labeling are
  regulated under the Canadian Food and Drug
  Regulations

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Infant Formula - Cows Milk Based

• designed for most preterm infants gt 2000g and
  healthy term infants with no family history of
  allergy
• designed to resemble human milk in nutrient
  composition and digestibility
• available low in iron or as iron-fortified
• iron-fortified recommended until 9-12 months of
  age and consuming a variety of foods
• Eg Enfamil A, Similac Advance

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Infant Formula - Follow-up

• designed for infants in the second six months of
  life who are eating solid foods
• more appropriate quantities and forms of
  nutrients compared to cows milk
• lower renal solute load
• iron-fortified
• not superior to starter formulas
• eg Next Step, Follow-up

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Infant Formula - Lactose-free, cows milk based

• suitable for infants with lactose intolerance
• primary lactose intolerance due to congenital
  lactase deficiency (rare)
• secondary due to acute gastroenteritis or chronic
  conditions
• glucose polymers from corn syrup are substituted
  for the lactose
• eg Enfalac Lactose-free

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Infant Formula - Soy

• soy protein and glucose and/or sucrose have been
  substituted for milk protein and lactose only
  available iron-fortified
• approximately 40 of infants allergic to milk
  will also be allergic to soy
• not suitable for use in children with a family
  history of allergy
• suitable for infants with galactosemia or vegan
  lifestyle

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Infant Formula - Protein Hydrolysate

• Two types available in Canada
• less extensively hydrolyzed
• eg Good Start
• for use in infants at risk for atopy
• extensively hydrolyzed (casein-based)
• eg Nutramigen
• for infants at high risk for allergy to cows
  milk or soy protein

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Infant Formula - Specialized

• designed for infants with disorders of digestion,
  absorption and/or metabolism of protein, fat or
  carbohydrate
• expensive, less palatable, for use under
  supervision of a health care practitioner
• eg Pregestimil, Neocate, Alimentum, Portagen

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Infant Formula - Distribution of Energy
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Transition to Cows Milk

• pasteurized whole cows milk may be introduced
  between 9-12 months of age and continued
  throughout the second year of life
• partly skimmed milk (1 and 2) is not routinely
  recommended in the first 2 years of life
• skim milk is inappropriate in the first 2 years
  of life

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Transition to Solid Foods

• infants between 4 and 6 months of age are
  physiologically and developmentally ready for new
  foods, textures and modes of feeding
• infants intestinal track is relatively permeable
  and may predispose the infant to absorb foreign
  proteins resulting in an allergic reaction
• introduction of single foods makes it easier to
  identify allergen

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Transition to Solid Foods

• single grains such as rice, barley and oat
  cereals offered first before mixed cereals
• little nutritional or developmental benefit
  associated with practice of adding infants
  cereals or other pureed foods to bottles
  containing formula
• introducing solids should support developmental
  readiness to progress from sucking to spoon
  feeding

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Transition to Solid Foods

• critical learning period where texture should be
  introduced (6-10 months) or it becomes more
  difficult with increasing age
• important to encourage transition from pureed
  foods to finger foods and table foods
• by 1 year, a variety of foods should be consumed
  with less dependency on milk as major source of
  nutrition

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Other Highlights

• iron-containing foods such as iron-fortified
  cereals are recommended as the first foods
• fruit juice intake should be limited to avoid
  interfering with the intake of nutrient
  containing foods and fluids
• soy (except soy formula), rice or other
  vegetarian beverages, whether or not they are
  fortified, are inappropriate alternatives to
  human milk, formula or pasteurized whole cows
  milk in the first two years

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Other Highlights

• dietary fat restriction during the first 2 years
  of life is not recommended as it may compromise
  the intake of energy and EFA and affect growth
  and development
• to prevent infant botulism, honey should not be
  used in infants under 1 year
• to prevent nursing bottle syndrome, infants
  should not be fed using a propped bottle

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Gastroenteritis

• mild to moderate dehydration may be managed with
  an oral electrolyte solution and early refeeding
• for infants who are breastfed, continue
  breastfeeding while supplementing fluid intake
  with an oral electrolyte solution
• there is no justification to recommend a lactose
  free formula for routine feeding after a bout of
  gastroenteritis

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Constipation

• parents should be educated about the wide
  variation in normal bowel function in infants and
  toddlers
• no evidence to support infants on iron-fortified
  formula are more constipated
• often seen with transition to whole cows milk
  when done too quickly
• transition with half formula/human milk feedings
  and half whole cows milk minimizes complications