Infant feeding and nutrition

Dr Janet Anderson

Infant Nutrition

Good nutrition is essential for

• Survival

• Physical growth

• Mental development

• Productivity

• Health and well being

-----across the whole life span

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?

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.

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 wasn’t until the 20th century that artificial milks were developed and after considerable research became nutritionally acceptable

19th and 20th Century feeding bottles

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

Breast Feeding

• It is the baby’s demand that regulates the supply of breast milk not necessarily lactation supply

• The let down reflex can be delayed in some mother’s 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

Colostrum

• Contains more sodium

• High in Vit A and Vit K

• Contains 5x more protein than mature milk

• Contains more IgA

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 infection—

particularly 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

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

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

Breast feeding and ObesityEpidemiological 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

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

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

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

1950’s Royal Formula

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

Pre-term formulas

• Developed in 1980s

• Contain more electrolytes

calories

minerals

• Long-chain polyunsaturated fatty acids plus pre-biotics added 2000s

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

Cow’s milk allergy

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

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 cow’s milk protein from

diet and watch• Do not confuse with lactose intolerance

Lactose intolerance

• Primary lactose intolerance rare• Usually secondary to gastrointestinal

infection especially rotavirus ,or neonatal gut surgery

• Explosive fermentative diarrhoea• Stool Clinitest > 0.5% / sugar

chromatography of stool• Usually transient but may need to remove

lactose from milk for 6+ weeks

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.

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

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.

Weaning

If breast feeding continued exclusively for too long i.e.> 4/5 months, this is associated with

1.Iron deficiency with its associated adverse developmental outcomes

2.Calcium/ Vit D deficiency

3.Other possible effects –allergy , coeliac disease and obesity?

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

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?

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

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.

Non-organic failure to thrive

• Maternal depression/psychiatric disorder

• Disturbed maternal-infant attachment

• Eating difficulties

• Neglect

Nutritional assessment

• Take a careful history

• Assess intake

• Consider requirements

• Weigh

• Children with chronic illness should have a detailed assessment

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 baby’s growth

Consequences of poor weight gain in infancy

• 5-20 points in IQ

• Increased cardiovascular risks, hypertension, hypercholesterolaemia and Type 2 diabetes

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 individual’s response to a high calorie

diet is subject to strong genetic influence

A world of difference

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