infant nutrition richard l. mones md
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INFANT NUTRITION RICHARD L. MONES MD. HARLEM HOSPITAL. HOW DID WE GET HERE?. MUST DEVELOP EXPERTISE TIME HISTORY. EVOLUTION. BM – BEST FOR HUMAN BABIES ? IDEAL CHANGES IN DIET/HYGEINE AFFECTED VIT.K, D, Fe. NO BREAST MILK MEANT CERTAIN DEATH. WET NURSE—AN ALTERNATIVE. - PowerPoint PPT PresentationTRANSCRIPT
INFANT NUTRITION
RICHARD L. MONES MD
HARLEM HOSPITAL
HOW DID WE GET HERE?
MUST DEVELOP EXPERTISE TIME HISTORY
EVOLUTION
BM – BEST FOR HUMAN BABIES
? IDEAL CHANGES IN DIET/HYGEINE AFFECTED VIT.K, D, Fe
NO BREAST MILK MEANT CERTAIN DEATH
WET NURSE—AN ALTERNATIVE
4th century B.C. 13th century…highly
organized State controlled practice Transmit traits
LOUIS XIV AND WET NURSE
VESSELS TO FEED MILK
BOVINE HORNS ANIMAL HIDE 1800 GLASS FEEDING
BOTTLE
MIDDLE AGES
INFANTS TO SUCKLE FROM ANIMALS
GOAT SHEEP
AGE OF WEANING
HAS DECREASED FROM AGE 3 YEARS TO THE PRESENT 12 MONTHS.
NEVER WEANED IN JULY,AUGUST,SEPTEMBER
ANIMAL MILK
REPLACED WET NURSES IN 18 CENTURY
COW, ASS, GOAT 50-100% MORTALITY RATE
IN EARLY 19 CENTURY
WHY?
POOR SANITATION ADULTERATION NO ICE BOX
IMPORTANT EVENTS
GERM THEORY DISCOVERED KNOWLEDGE OF MILK
COMPOSITION BORDEN-CONDENSED MILK
IMPORTANT EVENTS
PASTUERIZATION RUBBER NIPPLES-CLEAN 1910 ICE BOXES DEVELOPMENT OF
FORMULAS
TODAY
BREAST FEEDING FORMULA BOTH MUCH IS TAKEN FOR
GRANTED
OBJECTIVE
PROVIDE NUTRIENTS TO SUPPORT OPTIMUM GROWTH
DEVELOP OROMOTOR SKILLS APPROPRIATE EATING
BEHAVIORS
HOW MUCH ENERGY IS NEEDED?
ENERGY BALANCE E(INTAKE)=E(EXCRETED)+E(EXPENDED)+E(STORED)
POSITIVE IN INFANTS AND CHILDREN
EXPENDITURE- BASAL FUNCTIONS + ACTIVITY
EXCRETION- STOOL FAT STORED- IN MOLECULES OF FAT AND
PROTEIN ENERGY COST OF GROWTH
COST OF DEPOSITING FAT 10.8KCAL/GM.
COST OF DEPOSITING PROTEIN13.4 KCAL/GM.
HOW MUCH DOES IT TAKE?
DOUBLE BW IN 4 MONTHS TRIPLE BW IN LESS THAN
12 MONTHS
FACTORS INFLUENCING FOOD INTAKE
DENSITY DIGESTIBILITY TASTE PREFERENCES PARENTAL ATTITUDES BREAST VS. BOTTLE
NEEDS
0-2MOS……90-120 KCAL/KG/DAY 3-5 MOS……80-100 KCAL/KG/DAY 6-8 MOS…….80-100 KCAL/KG/DAY 9-11 MOS……90-100 KCAL/KG/DAY
HOW DO YOU KNOW?
GROWTH NAKED WEIGHT LENGTH BOARD PLOT WT./HT. SHOW GC TO PARENTS
EXPECTATIONS
GROWTH CURVES DIFFICULT DURING FIRST 1-2 MONTHS LOW RESOLUTION
REFLECT INTRA-UTERINE NUTRITION
WHAT ELSE CAN YOU DO?
GUIDE TO WEIGHT GAIN FIRST TWO MONTHS
50th %ile= 30 GMS./DAY 95th %ile=45 GMS./DAY 5th %ile=15 GMS./day LESS THAN 15 GM./DAY
IS INADEQUATE
POSSIBLE EXCEPTIONS
CATCH UP GROWTH
CATCH DOWN GROWTH
BREAST MILK
MILK COMPOSITION VARIES AND IS DYNAMIC
WOMAN TO WOMAN
OVER TIME- DAY TO DAY, MONTH TO MONTH
DURING A FEED FOREMILK VS. HINDMILK
BREAT MILK
WELL NOURISHED WOMAN WILL MEET ALL NUTRITIONAL NEEDS FOR FIRST 6 MOS. OF LIFE
EVENTUALLY, EXCLUSIVE BF WILL NOT MATCH NEED OF THE INFANT
SUBOPTIMAL GROWTH
BREAST MILK
INFANT WITH GROWTH RATE AT 95%ILE BUT
MOTHER’S MILK PRODUCTION IS ON THE 5%ILE
WEIGHT GAIN <5%ILE = RED FLAG FOR UNDERNUTTION
MISMATCH IN MACRO AND MICRO NUTRIENTS
BREAST MILK
ADVANTAGES OTHER THAN NUTRITIONAL CLEAN MILK PROTECT AGAINST INFECTION
MACROPHAGES LYMPHOCYTES LACTOFERRIN LYSOZYMES IgA
CASE 34 YO G1P0 MOM BRINGS HER BABY IN WITH A
CC: IRRITABITLIY, POOR SLEEPING, XS CRYING. SURGICAL RESIDENT, LIVES ACROSS FROM
HOSPITAL. XLUIVELY Breast Feeding MOM IS QUITE FATIGUED 3 WEEKS OF AGE (21DAYS) BW=7-4 (3290), D/C 7-0 (3180)
CAN TOLERATE UP TO 15% WEIGHT LOSS IN FIRST 24-72 HOURS. (DIURESIS)
TODAY= 7-8(3410)
BREAST MILK
WHAT WOULD YOU DO?
BREAST MILK
GAIN ABOUT 11 GMS./DAY NORMAL OR NOT? ?LABS-----HYPERNATREMIA REMIAFORMULA FEED? LIFESTYLE CHANGES?
INSUFFICIENT BREAST MILK SYNDROME
STRESS STRESS STRESS STRESS
CHICKENS LAY FEWER EGGS COWS PRODUCE LESS MILK SO DO HUMANS
BREAST VS. FORMULA * G/100ML
CAL/30ML PRO FAT CHO OSM
BREAST 20 0.9 3.9 6.7 260-300FORMLA 20 1.45 3.6 7.3 300
BREAST VS. FORMULA
CHO FAT PROHUMAN LACTOSE HUMAN MILK
FATHUMAN W:C=60:40
FRMLA LACTOSE VEGETABLE OILS
COW W:C=40:60
FORMULA
CONVENIENCE NECESSITY CULTURAL SUPPLEMENTAL
convenience
NUMEROUS FORMULAS
SOY COLIC REFLUX ALLERGY GI ABNORMALITES (SHORT GUT,
post-infectious gastroenteritis) INBORN ERRORS OF METABOLISM
HOW DO YOU CHOOSE ?
FIRST DECIDE WHAT YOUR GOAL IS !!!! IS THERE EVIDENCE TO SUPPORT THAT
GOAL? SET REALISTIC EXPECTATIONS FOR THE
PARENTS CONSIDER COST AND AVAILABILITY KNOW ONE FORMULA IN EACH CATEGORY
SOY FORMULAS
20 CAL/OZ. SOY PROTEIN FAT- MIXTURE OF VEGETABLE
OILS ( PALM,SOY,COCNUT,SFFLOWER,SUNFLOWER)
CHO- SUCROSE AND CORN SYRUP
SOY FORMULA
VEGETARIAN WILL SUPPORT NORMAL GROWTH COLIC? MILK PROTEIN ALLERGY
40% CROSS REACTIVITY NOT IgE
PROTEIN HYDROLYSATE
ALIMENTUM NUTRAMIGEN PREGESTIMIL
HYDROLYSTE
HYDROLIZED CASEIN CHO-CORN SYRUP SOLIDS AND MALDEXTRINS FAT-VEGETABLE OIL SOME WITH MCT ( PREGESTIMIL)
HYDROLYSATE
COW MILK PROTEIN ALLERGY STILL POSSIBLE
“SEMI-ELEMENTAL” FORMULAS POST INFECTIOUS GASTROENTERITIS COLIC CHOLESTASIS SHORT GUT
ELEMENTAL FORMULA
MACRONUTRIENTS IN MOST BASIC FORM
PROTEIN = FREE AMINO ACIDS CHO=POLYCOSE AND GLUCOSE FAT= MIXTURE OF MCT AND LCT HIGH OSMOLARITY
ELEMENTAL FORMULAE
NEOCATE ELECARE NUTRAMIGEN AA
ELEMENTAL FORMULAE
SHORT GUT SYNDROME COW PROTEIN/SOY PROTEIN
ALLERGY COLIC PATIENT DEMAND EXTREMELY EXPENSIVE NOT COVERED BY INSURANCE
FOLLOW THE MONEY
PRESSURE BY COMPANY REPS SPONSORSHIP OF
MEETINGS,LUNCHES ETC. MILLIONS IN COSTS FOR
ADVERTISING ENFAMIL AR
KEY POINTS ABOUT FORMULAE
COMMUNICATE REALISTIC EXPECTATIONS TO PARENTS
MOST OFTEN SYMPTOMS ARE NOT RELATED TO FORMULA
THEREFORE YOU WILL FAIL !
BEIKOST
COMPLIMRNTARY OR WEANING FOODS
BEIKOST
INTRODUCED BETWEEN 4-6 MOS.
GRADUALLY SUPPLIES INCREASING FRACTION OF ENERGY
BY 12 MOS. MAY BE 50%
BEIKOST-WHEN?
MAY OVERLOOK INDIVIDUAL NEEDS IF ORTHODOX ABOUT AGE
DEVELOPMENTAL SKILLS MORE IMPORTANT INDIVIDUALIZE FEEDING
BABIES ABLE TO SIT, TRUNCAL
SUPPORT, GOOD HEAD CONTROL
BEIKOST
ABILITY TO PROPEL FOOD T0 THE POSTERIOR PHARYNX
EXTINCTION OF THE EXTRUSION REFLEX ABILITY TO INDICATE DESIRE FOR FOOD.
OPEN MOUTH LEAN FORWARD
SIGNS OF SATIETY
BEIKOST
MONES METHOD AT 4 MOS. INTODUCE CEREALS ONE KIND AT A TIME FOR 1 WEEK HAS VARIETY OF CEREALS IN ONE MONTH
BEIKOST
ADD ONE FOOD GROUP EACH MONTH FRUITS, VEGGIES,LEAN MEATS
INCREASE REPETOIRE OF FOODS AND MIX AND MATCH
INTRODUCE ONE FOOD EVERY 4 DAYS
PUREED FOODS THIN TO THICK
BEIKOST
ADVANCE TO THICKER PUREES AND SOFT MASHED FOODS
INCREMENTAL INCREASE IN TEXTURE HELPS AQUIRE NORMAL CHEWING AND SWALLOWING SKILLS
A MISMATCH IN TEXTURE AND READINESS IS A DISASTER
VITAMINS VITAMIN K GIVEN IN NB NURSERY TO AVOID
HEM. DIS.NB D: NEED SUPPLEMENT IN SOME BABIES
DEPENDING ON LATITUDE AND SKIN COLOR Fe: FORMULA FORTIFIED (12MG./L)
BREAST :ADEQUATE ABSORPTION FOODS (FORTIFIED CEREAL) WILL
ADD IRON 1 MG./KG/24H FT 2-3 MG./KG/24 PREMIE
VITAMINS
FLOURIDE: KNOW STATUS OF WATER IN COMMUNITY
IF USE READY TO FEED FORMULA, MUST SUPPLEMENT FLOURIDE
B12 RECCOMMENDED FOR BF BABIES OF STRICT VEGETARIAN MOTHERS
NIGHT TIME –NAP TIME BOTTLE SYNDROME
TIPS
FEED ON DEMAND !!
WHEN THE BABY SHOWS CUES OF HUNGER SUCK ON HAND MOVE LIPS FUSS/CRY NO “SCHEDULE”
TIPS
INTRODUCE SIPPY CUP AT 9 MOS. WCM, SMALL AMOUNTS, IN CUP GRADUALLY INCREASE WCM OVER
NEXT 3 MOS. WEAN FROM BOTTLE BY 12-15 MOS.
TIPS
STOP WHEN FULL TURN AWAY, CLOSE LIPS, SLOW DOWN SUCKING, SPIT OUT NIPPLE
QUESTIONS