2Infant Nutrition Good nutrition is essential for Survival Physical growthMental developmentProductivityHealth and well being-----across the whole life span
3What we knowGood 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?
4Early ProgrammmingBabies 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.
5Infant feedingUntil the latter part of the 19th century infant survival was dependent on breast feedingWet 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
9Nutritional requirements Age dependentThe younger the child the higher their energy needs per kilogram body weight0-3 months Fluid mls/kgCalories 100kCals/kgProtein g/kgNa mmol/lK mmol/l
10Breast FeedingIt is the baby’s demand that regulates the supply of breast milk not necessarily lactation supplyThe 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 termAd libitum breast feeding is associated with improved outcomes
11Colostrum Contains more sodium High in Vit A and Vit K Contains 5x more protein than mature milkContains more IgA
12Advantages of breast feeding Appropriate bonding and psycho social developmentReduced morbidity (-- NEC less in preterm breast fed babies)Better nutritive balance– minerals are more easily absorbedIgA, lactoferrin and lysozyme reduce infection—particularly gut and earsHuman milk contains a growth factor for Lactobacillus bifidus which increases acidity in the gut to inhibit growth of pathogensImmune response to Hib vaccine higherReduces the risk of obesity
13Down sides of breast feeding Vitamin K deficiencyHypernatraemia at end of first week in babies with inadequate intake.Inhibits modern control culture!No good evidence that reduces colicBreast feeding alone beyond 6 months may lead to anaemia and Vit D deficiency therefore wean and add vitamin supplements
16Breast feeding and obesity prevention Artificially fed babies consume 30,000 more calories than breastfed infantsby 8 months of age Riordan et al. 1999
17Breast 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 lifeBreast 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 9-14sLeptin, an anorexiogenic hormone, in breast milk may also play a part
18Long term benefits of breast feeding Compelling evidence that reducesCardiovascular diseaseObesityImproves cognitive developmentReduces atopy but not in allMore controversialReduces IDDM,--(recent trials to determine whether BF is protective), neoplastic disease, osteoporosis and inflammatory bowel disease
19Contraindications to breast feeding Maternal drugs includinganti-metabolites, opiates, amiodarone, phenindione ----others but mostly relative not absoluteMaternal HIV in the developed world; still controversial in resource poor countriesNote:---Babies of mothers with TB can be immunised at birth with BCG and treated with Isoniazid for 6 weeks and still be breast fed
20Artificial feeds Introduced in 1907 by Rotch in U.S. Nutritionally completeContain more Vit. K ,Iron ( but less available) and Calcium and Vit. D than breast milkWhey based or casein basedSoya 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 gastroenteritisMust be made up correctly
22Types of artificial formula Whey basedCasein basedLactose free/partially lactose free (Omneocomfort)ARFollow on milksOrganic milksLow allergenic milksSpecialist milks i.e. phenylalanine freeSoya milkGoats milk
23Pre-term formulas Developed in 1980s Contain more electrolytes caloriesmineralsLong-chain polyunsaturated fatty acids plus pre-biotics added 2000s
24Questions? How many calories in 100ml of breast milk? A kCals (depends whether fore or hind milk)How many calories in ordinary formula?A. 70kCals/100mlHow many calories does a baby need to grow normally in the first 3 months?A. 100kCals/kg
25Cow’s milk allergy Clinical features include Gastrointestinal---colic vomitingdiarrhoeacolitisRashes including eczema and urticariaRespiratory—rhinitisstridorcough and wheezeIrritabilityFailure to thrive etc
26Diagnosis of CMP allergy Formal allergy tests may not help.Rast test may be negativeSkin testing is betterColonoscopy may be necessary in colitisBest is to remove cow’s milk protein from diet and watchDo not confuse with lactose intolerance
27Lactose intolerance Primary lactose intolerance rare Usually secondary to gastrointestinal infection especially rotavirus ,or neonatal gut surgeryExplosive fermentative diarrhoeaStool Clinitest > 0.5% / sugar chromatography of stoolUsually transient but may need to remove lactose from milk for 6+ weeks
28Weaning Latest government recommendations suggest 6 months. Some controversy about this a hard and fast rule- not before 17 wks and not later than 26wksBabies 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 limitedVegetables and fruits are ideal weaning foodsEncourage finger feeding because they can pick up food and are unlikely to choke.
29WeaningBreast fed babies run low on iron and calcium if not weaned at 6 months and this may occur before this timeThey are often perceived to be signaling hunger before 6monthsOnly 1-2% of a cohort of British breast feeding mothers delayed weaning until 6 monthsESPGAN suggest weaning weeks –no earler, no later
30Baby-led feeding Allows babies to feed themselves No spoon feeding and no pureesOnly the baby feeds themselves.Starts at 6 months when baby can sit upright, able to pick up pieces of food and chew themExpect a mess.Keep it enjoyable-sits with family to eat.
31WeaningIf breast feeding continued exclusively for too long i.e.> 4/5 months, this is associated withIron deficiency with its associated adverse developmental outcomesCalcium/ Vit D deficiencyOther possible effects –allergy , coeliac disease and obesity?
32VitaminsAll 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
33Allergy 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 allergyCritical window of exposure?2008 review suggested increased risk if solids introduced before 3 /4 monthsGluten exposure best between 3 and 6 months along side breast feeding?
34Failure to thrive Definition: growth or weight faltering - Weight and/or height below 2nd centile;Crossing down 2 centile channels for height and weightMost due to non organic failure to thriveOrganic causes related to feeding difficulties because of anatomical defects or chronic illness eg heartdiseaseFood intolerance including coeliac diseaseNeurological problems
36Factors in the historyConsider factors that interfere with sucking and intakeConditions that interfere with absorption e.g. intestinal resection, coeliac diseaseConditions that increase losses e.g. diarrhoea, vomitingIncreased needs e.g. fever, sepsis, tissue injury, heart failureConditions that restrict intake e.g.food intolerance, renal disease, heart diseaseOther gastrointestinal pathology.
37Non-organic failure to thrive Maternal depression/psychiatric disorderDisturbed maternal-infant attachmentEating difficultiesNeglect
38Nutritional assessment Take a careful historyAssess intakeConsider requirementsWeighChildren with chronic illness should have a detailed assessment
39Clinical pointers in failure to thrive Differentiate from the normal baby who is crossing the centilesIdentify any symptoms and signs that suggest an organic conditionOnly perform investigations if there are clinical leadsIdentify psychosocial problems that might be affecting the baby’s growth
40Consequences of poor weight gain in infancy 5-20 points in IQIncreased cardiovascular risks, hypertension, hypercholesterolaemia and Type 2 diabetes
41Obesity Increasing morbidity Prevention is required Increased risk of early Type 2 diabetes, fatty liver, sleep apnoea, poor school performance, SUFE, etc25% children at riskNote –an individual’s response to a high calorie diet is subject to strong genetic influence
44Constipation in the first year of life Common causesOver diagnosed in breast fed babiesIncorrect making up of formula feedsChanging from whey based to casein based feedsWeaningOver dependence on milk as nutrition in older babiesPotty training