29th January 2014Dr Nikoletta Lofitou

Introduction Nutritional requirementsDepartment of Health’s recommendationsBreast feeding/bottle feedingClinical conditionsClinical scenario

Infant NutritionGood nutrition is essential for: SurvivalPhysical growthMental developmentProductivityHealth and well being

A short term issue?

A short term issue?

Differences in nutritional experiences during sensitive periods in early life, both before and after birth, can program a person's future development, metabolism, and health (EARNEST, 2011)

StatisticsPrevalence of

breastfeeding 81% at birth(76% in

2005)69% at one week55% at six weeks34% at six months

(25% in 2005)

Prevalence of exclusively breastfeeding69% at birth46% at one week23% at six weeks1% at six months

More Statistics31% breastfed babies had received additional

feeds while in hospital

73% had given their baby milk other than breast milk by the age of six weeks and 88% by six months

High correlation between intentions and actual initial feeding behaviour

And more...Highest incidences of breastfeeding among

mothers >30 years old, from minor ethnic groups, left education aged over 18, in managerial and professional occupations, living in the least deprived areas

Relationship between how mothers were fed themselves as infants and and how their peers fed their babies with how long they breastfed their own babies

Nutritional requirementsAge dependent (the younger the child the

higher their energy needs per kilogram body weight)

0-3 months: Fluid 100-150 mls/kg Calories 100 kCals/kg Protein 2.1 g/kg Na 1.5 mmol/kg K 3 mmol/kg

Nutritional needs in Preterm babies (1)Adequate nutrition should ensure that a pre-term infant

achieves a post natal growth that reinstates them on their inter-uterine growth curve for length, weight and head circumference.

Premature babies may have increased needs as :-    May have dropped down >2 centiles on neonatal unit-    May have CLD and need O2-    May have been IUGR-    May have GOR and be unable to tolerate large feed volumes

Nutritional needs in Preterm babies (2)Fluid: 150-200ml/kg/day

Energy requirements: 110-135kcals/kg/day

Protein: according to weight

What are the Department of health’s recommendations on feeding infants?Breast milk is the best form of nutrition for

infantsExclusive breastfeeding is recommended for

the first six months of an infant’s lifeSix months is the recommended age for the

introduction of solid foods for infantsBreastfeeding (and/or breastmilk substitutes,

if used) should continue beyond the first six months, along with appropriate types and amounts of solid foods

ColostrumFor 2-4 days post delivery.Contains more sodiumHigh in Vit A and Vit K5x more protein than mature milkmore IgAless fat and carbohydrate

Mature breast milk is established by 4th week

Composition of breast milk vs formula milkWater: Equal amounts

Calories: Approx 67kcal/100ml

Protein: Human milk 1-1.5% protein(70% whey protein), Cows milk 3.3% protein due to greater content of casein

Composition of breast milk vs cows milk Carbohydrate: Human milk 7% (10% glycoproteins)

Cows milk 4.5% lactose

Fat: Approx 3.5% both principally triglycerides (olein, palmitin and stearin). Olein is more easily absorbed and there is

twice as much in breast milk.

Minerals: Cows milk contains more of all the minerals (esp sodium, calcium and phosphate) except iron and copper.

There is more iron in breast milk and it is more easily absorbed

Vitamins: Cow’s milk is low in vitamin C and D

What are the health benefits of breast feeding?Breastmilk provides all the nutrients a baby

needs for healthy growth and development for the first six months of life.

Contains growth factors and hormones to assist development

Anti infective properties: Macrophages, lymphocytes and polymorphs, Secretory IgA, Lyzozyme, Lactoferrin (inhibits growth of E.coli.), anti-viral agents.

Long term benefits to infantsReduced risk of respiratory, gastrointestinal and urinary

tract infections

Reduced risk of atopy

Reduced risk of juvenile diabetes in susceptible infants

Better dental health

Reduced incidence of later obesity

Improved neurological development

Maternal benefitsReduced risk of premenopausal cancer

Promotes weight loss after pregnancy

Lactational amenorrhoea

Cheaper and more convenient

Down side of breast feedingVitamin K deficiency

Hypernatraemia at end of first week in babies with inadequate intake

Inhibits modern control culture

Factors affecting prevalence of breast feeding in the UKFavourSocial class 1Mother educated

>18yearsMother >30 years first babybreast fed previous

baby

Againstsocial class Vmaternal smoking

Contraindications to breast feedingGalactosaemia

Maternal HIV infection in the UK

Anti-neoplastic drugs

Tetracyclines

Lithium

Types of milkInfant formulas are suitable from birth and are usually

based on cows milk

Whey based milks are usually first choice if not breast feeding

Casein based milks are suggested for hungrier babies

Soya infant milks

Follow on formulas: Higher iron content than cows milk

Specialised formulas for those who are preterm or have medical conditions (lactose free, phenylalanine free)

Soya Infant FormulaSimilar to cows milk but protein derived from

soya with lactose replaced with other carbohydrates (glucose syrups)

Recommended for use on medical advice but should not be the first choice for the management of CMP intolerance

Soya milks contain phytoestrogens which have been shown to have an immunosuppressive effect in rodents

Bottle feedingDay 1: 60ml/kg/day Day 3: 120ml/kg/day Day 2: 90ml/kg/day Day 4: 150ml/kg/day

3-4 hourly

Must be made up correctly (risk of hypernatraemia)

Has caused high mortality in developing world due to poor hygiene of equipment leading to gastroenteritis

Cow’s milk allergyA reproducible reaction to one or more cow’s

milk proteins mediated by one or more immune mechanisms

Affects about 1 in 50 infants

Most affected infants present by 6 months of age - rarely presents after 12 months

Cow’s milk allergy1. IgE-mediated phenotype: symptoms are

stereotypical of allergy skin (eczema, urticaria) gut (colic, vomiting, diarrhoea, FTT, blood in

the stools) respiratory (rhinitis, stridor, cough and wheeze)

2. Non IgE-mediated phenotype: delayed onset allergy symptoms

Do NOT confuse with lactose intolerance

Diagnosis and management of CMP allergy1. IgE-mediated: clinical symptoms + skin prick test2. Non IgE-mediated: clinical symptoms that improve

or resolve with exclusion of milk and reappear with reintroduction of cow’s milk

A food challenge may be necessary to confirm the diagnosis

diet free from cows’ milk for at least 1 year Choice of milk is usually one of casein or whey

extensive hydrolysed formula, or amino acid formula

(Lactose free and partially hydrolysed comfort formula milks and goats milk are not suitable for cows’ milk allergy)

Lactose intolerancerare in infants- more commonly in adolescence

typically with a more subtle and progressive onset over many years

Usually secondary to gastrointestinal infection especially rotavirus ,or neonatal gut surgery

Usually transient but may need to remove lactose from milk for 6+ weeks

Normal GrowthAll babies tend to lose 5-10% of birthweight over

first few days and regain it by about 10th day

Feeding requirement is 150ml/Kg/day

Normal weight gain 25-30g/day for first 6 months (preterm 10-15g/kg/day)

Most babies double their birthweight by 4-5 months and treble by one year

Weaning DOH recommend introduction of solid foods

at around 6 months of ageTrend towards mothers introducing solid

foods later (51% by 4 months in 2005, 30% in 2010)

75% introduced solid foods by 5 months of age; not following the guidelines

Solid foods tended to be introduced to younger babies among younger mothers and mothers from lower socio-economic groups

Why introduce solid foods at six months?Infants need more iron and other nutrients than milkAt 6 months infants can spoon-feed (upper lip moving

down, chew, use the tongue to move the food from front to back)

Development of eye-hand co-ordination (finger foods)

Introducing solids early before sufficient development of the neuro-muscular co-ordination or before the gut and kidneys have maturedrisk of infections and development of allergies (eczema, asthma)

Weaning Babies need to be exposed rapidly to a variety of

tastes and textures between 6-8 monthsApproximately 1 pt of milk should be given plus

clear fluids with mealsIs waiting to introduce solids until six months

likely to produce “fussy eaters”: NO (RCTs)Encouragement of finger food- promotes chewing

practice and independenceChewing encourages development of speech

musclesFeeding should always be supervised.

VitaminsAll children from six months to five years old

should be given a vitamin supplement containing vitamins A, C and D, unless they are receiving more than 500 ml of infant formula per day

If mothers did not take vit. D during pregnancy and if breast fed, start Vit D at 1 month

Iron supplemented milk is recommended until at least the age of 1 year in all infants Iron deficiency anaemia is a common problem in toddlers

worldwide- associated with developmental delay and increased susceptibility to infection

Faltering growthSignificant interruption in the expected rate of

growth compared with other children of similar age and sex during early childhood

affect around 5% of children under the age of two at some point

A single plot on a chart is of limited value

Need to consider parental height

Faltering growth

Causes of faltering growth1. Organic causes

Inability to feed (cleft palate, CP) Increased losses (diarrhoea/vomiting, GORD) Malabsorption (CF, post infective/allergic

enteropathy) Increased energy requirements (CF,

malignancy) Metabolic (hypothyroidism, CAH) Syndromes

Causes of faltering growth2. Non-organic causes

Insufficient breast milk or poor technique Maternal stress/ Maternal

depression/psychiatric disorder Disturbed maternal-infant attachment Low socio-economic class

Neglect

Approach and management to faltering growthRecheck weight-plot weight against centile chartCheck type and amount of feedObserve feeding techniqueAssess stoolExamine for underlying illness- appropriate

investigationsConsider admission to observe response to

feedingDietician involvementInform GP/health visitor/community nurse

Clinical scenarioA 4/52 baby presented to CED with vomiting. Birth weight 3.5kg. Current weight 4.3kg. The baby is bottle feeding and taking 150ml 4

hourly.

Clinical scenarioA 4/52 baby presented to CED with vomiting. Birth weight 3.5kg. Current weight 4.3kg. The baby is bottle feeding and taking 150ml 4

hourly.

Differential diagnosis?

Clinical scenarioDifferential diagnosis1.Symptoms suggesting infection (UTI,

meningitis, gastrointestinal infection)2.Pyloric stenosis (projectile vomiting, age)3.GORD4.Intestinal obstruction (bilious vomit,

abdominal distension)5.CMP allergy6.Overfeeding

Clinical scenarioAdequate weight gain? 30 x 28 = 840g 3.5 + 0.84 = 4.3 kgHow much does the baby require? 150 x 4.3 = 645mlHow much is the daily intake? 150 x 6 = 900 ml

Clinical scenarioAdequate weight gain? 30 x 28 = 840g 3.5 + 0.84 = 4.3 kgHow much does the baby require? 150 x 4.3 = 645mlHow much is the daily intake? 150 x 6 = 900 ml

Vomiting likely 2o to overfeeding

THANK YOU

References Infant Feeding Survey 2010, National Statistics Infant Feeding Recommendation, Department of HealthBreast-feeding: A Commentary by the ESPGHAN

Committee on Nutrition, Journal of Pediatric Gastroenterology and Nutrition 2009

www.pediatricsconsultant360.comBMJ 13/3/99, Archives Feb 99