Presentation on theme: "Infant feeding and nutrition Dr Janet Anderson. Infant Nutrition Good nutrition is essential for Survival Physical growth Mental development Productivity."— Presentation transcript:
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 19 th 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 20 th century that artificial milks were developed and after considerable research became nutritionally acceptable
19th and 20 th Century feeding bottles
Nutritional requirements Age dependent The younger the child the higher their energy needs per kilogram body weight 0-3 months Fluid mls/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 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 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 kCals (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 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 2 nd 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.
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