1. Infant nutrient needs Basis Approach Specific nutrients water energy protein fatty acids vitamin K Vitamin D Iron Fluoride

2. Basis of recommendations Growth and development –Preventing deficiencies –Meeting nutrient requirements Physiology –GI –Renal Programming –Preventing chronic conditions –Optimizing health through lifecycle

3. Goals and Objectives Optimal growth and development Safety Individual health Population Health Prevention and Chronic Illness

4. Challenges Strength of Evidence Individual vs population –Public health approach –Individual genetics –Maternal-infant dyad In utero endowment Beliefs, values, choices Relationship/nurture –Environmental factors

5. 1940’s Rickets (D) Pellagra (Niacin) Scurvy (C) Beriberi (Thiamin) Xeropthalmia (A) Goiter (Iodine)

6. United Nations 5 th report on World Nutrition: March 2004 Prevalence (%)19902005 underweight35.226.5 Iodine deficiency35.2

7. Vitamin A deficiency –140 million preschoolers –7 million pregnant women Iron Deficiency –One of most prevalent –4-5 billion affected United Nations 5 th report on World Nutrition: March 2004

8. Reports in US of PEM, Rickets, Zinc deficiencies

9. Causes Nutrition  -  Disease Access Food Health Care Environment Economics Education

10. Physiology - GI Maturation

11. In utero Fetal GI tract is exposed to constant passage of fluid that contains a range of physiologically active factors: –growth factors –hormones –enzymes –immunoglobulins These play a role in mucosal differentiation and GI development as well as development of swallowing and intestinal motility

12. At Birth Gut of the newborn is faced with the formidable task of passing, digesting, and absorbing large quantities of intermittent boluses of milk Comparable feeds per body weight for adults would be 15 to 20 L

13. Renal Limited ability to concentrate urine in first year due to immaturities of nephron and pituitary Potential Renal solute load determined by nitrogenous end products of protein metabolism, sodium, potassium, phosphorus, and chloride.

14. Urine Concentrations Most normal adults are able to achieve urine concentrations of 1300 to 1400 mOsm/l Healthy newborns may be able to concentrate to 900-1100 mOsm/l, but isotonic urine of 280-310 mOsm/l is the goal In most cases this is not a concern, but may become one if infant has fever, high environmental temperatures, or diarrhea

15. Programming by Early Diet Nutrient composition in early diet may have long term effects on GI function and metabolism Animal models show that glucose and amino acid transport activities are programmed by composition of early diet Animals weaned onto high CHO diet have higher rates of glucose absorption as adults compared to those weaned on high protein diet Barker Hypothesis: –Association between BMI and chronic disease: HTN and cardiovascular, SGA/IUGR

16. Nutrients Guidelines Recommendations Education

17. –Genetics –Adaptation –Environment –Behavior/activity –Choices, access, resources –other Individual Requirements

18. Approaches to Estimating Nutrient Requirements Direct experimental evidence (ie protein and amino acids) Extrapolation from experimental evidence relating to human subjects of other age groups or animal models –ie thiamin--related to energy intake.3-.5 mg/1000 kcal Breast milk as gold standard (average [] X usual intake) Metabolic balance studies (ie protein, minerals) Clinical Observation (eg: manufacturing errors B6, Cl) Factorial approach Population studies

19. Recommendations/guidelines DRI: Dietary Reference Intakes –AI –UL –EER AAP Bright Futures Start Healthy feeding guidelines

20. DRI: Dietary Reference Intakes – periodically revised recommendations (or guidelines) of the National Academy of Sciences –quantitative estimates of nutrient intakes for planning and assessing diets for healthy people AI: Adequate Intake UL: Tolerable Upper Intake Level EER: Estimated Energy Requirement

21. DRI’s for infants Macronutrients based on average intake of breast milk –Protein less than earlier RDA AAP Recommendations –Vitamin D: 200 IU supplement for breastfed infants and infants taking <500 cc infant formula –Iron: Iron fortified formula (4-12 mg/L), Breastfed Infants supplemented 1mg/kg/d by 4-6 months

22. Water

23. Water requirement is determined by: –water loss evaporation through the skin and respiratory tract (insensible water loss) perspiration when the environmental temperature is elevated elimination in urine and feces. –water required for growth –solutes derived from the diet

24. Water Water lost by evaporation in infancy and early childhood accounts for more than 60% of that needed to maintain homeostasis, as compared to 40% to 50% later in life NAS recommends 1.5 ml water per kcal in infancy.

25. Water Needs

26. Water Individual needs Renal concentrating ability Solute in diet Health environment

27. Water Water balance –RSL in diet –Water in –Water out –Renal concentrating ability

28. Renal solute load Samuel Foman J Pediatrics Jan 1999 134 # 1 (11-14) RSL is important consideration in maintaining water balance: In acute febrile illness Feeding energy dense formulas Altered renal concentrating ability Limited fluid intake

29. Water vs fluid Concentrating formula decreases free water and increases RSL What is the % water in 20 kcal/oz infant formula? –90% –To achieve 100 ml/kg/d needs to consume at least 110 cc/kg/d

30. Energy

31. Energy Requirements Higher than at any other time per unit of body weight Highest in first month and then declines High variability - SD in first months is about 15 kcal/kg/d Breastfed infants many have slighly lower energy needs RDA represents average for each half of first year

32. Energy Requirements, cont. RDA represents additional 5% over actual needs and is likely to be above what most infants need. Energy expended for growth declines from approximately 32.8% of intake during the first 4 months to 7.4% of intake from 4 to 12 months

33. Energy Partition in Infancy (kcal/kg/d)

34. Energy Intakes by Breastfed and Formula Fed Boys (kcal/kg)

35. EER 0-3 months (89 x wt -100) + 175 4-6 months (89 x wt -100) + 56 7-12 months (89 x wt -100) + 22 13-35 months (89 x wt -100) + 20 Equations for older children factor in weight, height and physical activity level (PAL)

36. 2002 Energy DRI

37. Protein Increases in body protein are estimated to average about 3.5 g/day for the first 4 months, and 3.1 g/day for the next 8 months. The body content of protein increases from about 11.0% to 15.0% over the first year

38. 2002 Protein DRI

39. 2002 Carbohydrate DRI

40. 2002 Fat DRI

43. Essential Fatty Acids The American Academy of Pediatrics and the Food and Drug Administration specify that infant formula should contain at least 300 mg of linoleate per 100 kilocalories or 2.7% of total kilocalories as linoleate.

44. Essential Fatty Acids The American Academy of Pediatrics and the Food and Drug Administration specify that infant formula should contain at least 300 mg of linoleate per 100 kilocalories or 2.7% of total kilocalories as linoleate.

45. LCPUFA DHA and ARA

46. LCPUFA: Background

47. Ability to synthesize 20 C FA from 18 C FA is limited. n-3 and n-6 fatty acids compete for enzymes required for elongation and desaturation Human milk reflects maternal diet, provides AA, EPA and DHA n-3 important for neurodevelopment, high levels of DHA in neurological tissues n-6 associated with growth & skin integrity

48. Formula supplementation with long-chain polyunsaturated fatty acids: are there developmental benefits? Scott et al. Pediatrics, Nov. 1998. RCT, 274 healthy full term infants Three groups: –standard formula –standard formula with DHA (from fish oil) –formula with DHA and AA (from egg) Comparison group of BF

49. Outcomes at 12 and 14 months No significant differences in Bayley, Mental or Psychomotor Development Index Differences in vocabulary comprehension across all categories and between formula groups for vocabulary production.

50. Bayley Scales at 12 months

51. MacArthur Communicative Development Inventories at 14 Months of Age

52. Conclusion “We believe that additional research should be undertaken before the introduction of these supplements into standard infant formulas.”

53. PUFA Status and Neurodevelopment: A summary and critical analysis of the literature (Carlson and Neuringer, Lipids, 1999) In animal studies use deficient diets through generations - effects on newborn development may be through mothering abilities. Behaviors of n-3 fatty acid deficient monkeys: higher frequency of stereotyped behavior, locomotor activity and behavioral reactivity

54. Efficacy and safety of docosahexaenoic acid and arachidonic acid addition to infant formulas: can one buy better vision and intelligence? (Koo. J Am Coll Nutr. 2003 Apr;22(2):101-7) “Functional benefits in particular visual or neural development from IF containing LCPUFA remains controversial.” “Potential for excessive and/or imbalanced intake of n-6 and n-3 fatty acids exists with increasing fortification of LCPUFA to infant foods other than IF.”

55. Formula Supplemented with DHA & ARA: A Critical Review of the Research (Wright et al, 2006) 10 RCTs from 1997-2003 of variable quality Considered the strength of each study by looking at indices of research quality.

56. Wright et al, cont. Growth (7 studies) –no differences in weight, length, OFC FA in blood (7 studies) –DHA & ARA higher with supplementation –those supplemented with only DHA had lower levels of ARA than those on standard formula –Supplementation with LCPUFA for only 17 weeks lead to higher EFA levels at 1 year of age

57. Wright et al, cont. Vision (6 trials) –2 found better visual function with LCPUFA, 4 did not Neurodevelopment –1 of 4 found positive results on Bayley Scales of Infant Development II –2 of 5 found positive information processing/IQ/cognitive effects

58. Wright et al, cont Conclusions –No detrimental effects found –Possibly a small improvement in visual acuity, but significance of this small effect in global development is questionable –“thoughtful consideration is advised before recommending more expensive formula for term infants.”

59. Longchain polyunsaturated fatty acid supplementation in infants born at term (Cochrane, 2001). At present there is little evidence from randomised trials of LCPUFA supplementation to support the hypothesis that LCPUFA supplementation confers a benefit for visual or general development of term infants. A beneficial effect on information processing is possible but larger studies over longer periods are required to conclude that LCPUFA supplementation provides a benefit when compared with standard formula. Data from randomised trials do not suggest that LCPUFA supplements influence the growth of term infants

60. Vitamins and Minerals Need for minerals and vitamins increased per kg compared to adults: –growth rates –mineralization of bone & increases in bone length –Increased blood volume –energy, protein, and fat intakes

61. Vitamins and Minerals Focus on nutrients with controversies and/or recent research: –Vitamin K –Vitamin D –Iron –Fluoride

62. Vitamin K Lack of specific information regarding an infant’s requirement Vitamin K concentration of breastmilk is low and for the breastfeeding infant a deficiency state has been described No “gold standard” available

63. Vitamin K DRI for infants 2-2.5 ug/day Formula provides 7-9 ug/kg/d BM contains < 10 ug/L Hemorrhagic disease of the Newborn…Vitamin K deficiency Prophylaxis: 1 mg Vitamin K IM for all newborn infants

64. Vitamin K Controversy Adequacy of BM Maternal Diet and Vitamin A content of BM ? Significance/prevalence of hemorrhagic disease of newborn IM injections of all newborns

65. Controversies Concerning Vitamin K and the Newborn: AAP Policy Statement, 2003

66. Vitamin K Deficiency- definitions – AAP, 2003 TermAge of onset Symptoms Early vitamin K deficiency bleeding (VKDB)* First week of life Unexpected bleeding in previously healthy- appearing neonates Late VKDB2-12 weeksunexpected bleeding attributable to severe vitamin K deficiency * Formerly known as classic hemorrhagic disease of the newborn

67. Incidence of VKDB Early: 0.25%–1.7% incidence Late: –No vitamin K prophylaxis: 4.4 to 7.2 per 100,000 births –Single oral vitamin K prophylaxis:1.4 to 6.4 per 100 000 births –IM vitamin K prophylaxis: 0

68. Cochran Prophylactic Vitamin K for preventing haemorrhagic disease in newborn infants Vitamin K deficiency can cause bleeding in an infant in the first weeks of life. This is known as Haemorrhagic Disease of the Newborn (HDN) or Vitamin K Deficiency Bleeding (VKDB).

69. Cochran Vitamin K is necessary for the synthesis of coagulation factors II (prothrombin), VII, IX and X in the liver. In the absence of vitamin K the liver will synthesize inactive precursor proteins, known as PIVKA’s (proteins induced by the absence of vitamin K). HDN is caused by low plasma levels of the vitamin K- dependent clotting factors. In the newborn the plasma concentrations of these factors are normally 30-60% of those of adults. They gradually reach adult values by six weeks of age

70. Cochran HDN is divided into three categories: early, classic and late HDN. Early HDN occurs within 24 hours post partum and falls outside the scope of this review. Classic HDN occurs on days 1-7. Common bleeding sites are gastrointestinal, cutaneous, nasal and from a circumcision. Late HDN occurs from week 2-12. The most common bleeding sites in this latter condition are intracranial, cutaneous, and gastrointestinal (Hathaway 1987 and von Kries 1993).

71. Cochran The risk of developing vitamin K deficiency is higher for the breastfed infant because breast milk contains lower amounts of vitamin K than formula milk or cow's milk

72. Cochran In different parts of the world, different methods of vitamin K prophylaxis are practiced.

73. The problem: Oral vitamin K has effect similar to IM in preventing early VKDB, but not in preventing late VKDB

74. Cochran Oral Doses: The main disadvantages are that the absorption is not certain and can be adversely affected by vomiting or regurgitation. If multiple doses are prescribed the compliance can be a problem

75. Cochran I.M. prophylaxis is more invasive than oral prophylaxis and can cause a muscular haematoma. Since Golding et al reported an increased risk of developing childhood cancer after parenteral vitamin K prophylaxis (Golding 1990 and 1992) this has been a reason for concern.

76. Cochrane Conclusions, 2000 A single dose (1.0 mg) of intramuscular vitamin K after birth is effective in the prevention of classic HDN. Either intramuscular or oral (1.0 mg) vitamin K prophylaxis improves biochemical indices of coagulation status at 1-7 days. Neither intramuscular nor oral vitamin K has been tested in randomized trials with respect to effect on late HDN. Oral vitamin K, either single or multiple dose, has not been tested in randomized trials for its effect on either classic or late HDN.

77. Brousson and Klien, Controversies surrounding the administration of vitamin K to newborns; a review. CMAJ. 154(3):307-315, February 1, 1996. Study selection: Six controlled trials met the selection criteria: a minimum 4-week follow-up period, a minimum of 60 subjects and a comparison of oral and intramuscular administration or of regimens of single and multiple doses taken orally. All retrospective case reviews were evaluated. Because of its thoroughness, the authors selected a meta-analysis of almost all cases involving patients more than 7 days old published from 1967 to 1992. Only five studies that concerned safety were found, and all of these were reviewed

79. Brousson and Klien, Controversies surrounding the administration of vitamin K to newborns; a review. CMAJ. 154(3):307-315, February 1, 1996. Data synthesis: Vitamin K (1 mg, administered intramuscularly) is currently the most effective method of preventing HDNB. The previously reported relation between intramuscular administration of vitamin K and childhood cancer has not been substantiated. An oral regimen (three doses of 1 to 2 mg, the first given at the first feeding, the second at 2 to 4 weeks and the third at 8 weeks) may be an acceptable alternative but needs further testing in largeclinical trials.

80. Brousson and Klien, Controversies surrounding the administration of vitamin K to newborns; a review. CMAJ. 154(3):307-315, February 1, 1996 Conclusion: There is no compelling evidence to alter the current practice of administering vitamin K intramuscularly to newborns.

81. AAP Recommendations 1. Vitamin K1 should be given to all newborns as a single, intramuscular dose of 0.5 to 1 mg. 2. Further research on the efficacy, safety, and bioavailability of oral formulations of vitamin K is warranted.

82. AAP Recommendations 3. Health care professionals should promote awareness among families of the risks of late VKDB associated with inadequate vitamin K prophylaxis from current oral dosage regimens, particularly for newborns who are breastfed exclusively

83. Cochran HDN is divided into three categories: early, classic and late HDN. Early HDN occurs within 24 hours post partum and falls outside the scope of this review. Classic HDN occurs on days 1-7. Common bleeding sites are gastrointestinal, cutaneous, nasal and from a circumcision. Late HDN occurs from week 2-12. The most common bleeding sites in this latter condition are intracranial, cutaneous, and gastrointestinal (Hathaway 1987 and von Kries 1993).

84. Vitamin D

85. Role Source –Dietary –sunlight Deficiency –Rickets

86. Role Enhances intestinal absorption of Ca Increase tubular resorption of Ph Mediation of recycling of Ca and Ph for bone growth and remodeling Sterol hormone –Deficiency: Rickets

87. Prevalence Thought to be disease of past (prior to 1960’s) –Disappeared secondary to recognition of role of sunlight, fortification of milk, use of multivitamins, AAPCON recommendation for 400 IU supplementation of infants

88. Prevalence Increased incidence and case reports 1970’2 No national data in US –Georgia 1997-99: 9 per million hospitalized children –National Hospital Discharge Survey: 9 per million –Pediatric Research in Office Setting (AAP):23-32 hospitalized cases reported 1999-2000

89. Prevalence Literature Review –13 articles published between 1996-2001 –122 case reports

90. Prevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D Intake PEDIATRICS Vol. 111 No. 4 April 2003, pp. 908-910

91. Vitamin D and Sunlight Vitamin D requirements are dependent on the amount of exposure to sunlight. Dermatologists recommend caution with sun exposure. –Sunscreens markedly decrease vitamin D production in the skin –Decreased sunlight exposure occurs during the winter and other seasons and when sunlight is attenuated by clouds, air pollution, or the environment –AAP recommends against exposing infants < 6 months to direct sun

92. Breastfeeding and Vitamin D Breastmilk has < 25 IU/L Recommended adequate intake can not be met with breastmilk alone Formerly stated that needs could be met with sun exposure, but now, due to cancer concerns recommend against this

93. Vitamin D Recommendations Before 2003 AAP recommended 10  g (400 IU) per day for breastfeed infants 2003: American Academy of Pediatrics recommends supplements of 5  g (200 IU) per day for all infants as recommended in DRIs. 10/14/2008: AAP updates guidelines vor vitamin D intake for infants, children, and teens to be published in Nov 5 th ed Pediatrics –400 IU per day intake of vitamin D beginning in first few days of life

94. Formulas if an infant is ingesting at least 500 mL per day of formula (vitamin D concentration of 400 IU/L), he or she will receive the recommended vitamin D intake of 200 IU per day. If intake is less than 500 ml recommend additional supplement of vitamin D

95. Summary of AAP Recommendations, 2003 All breastfed infants unless they are weaned to at least 500 mL per day of vitamin D-fortified formula or milk. All nonbreastfed infants who are ingesting less than 500 mL per day of vitamin D-fortified formula or milk. Children and adolescents who do not get regular sunlight exposure, do not ingest at least 500 mL per day of vitamin D-fortified milk, or do not take a daily multivitamin supplement containing at least 200 IU of vitamin D.

96. AAP Recommendations for Vitamin D 2008 –Intake of 400 IU beginning in first few days of life Supplement breastfed, partially breastfed, infants and children consuming less than 1 liter formula or vitamin D fortified whole milk

97. Iron

98. Function Source –Formula, breast milk, other foods –Bioavailability: Breast milk Soy formula Deficiency –Anemia

99. Iron Biological function –Oxygen transport primarily in hemoglobin –Component of other proteins including cytochrome a, b, c, and cytochrome oxidase essential for electron transport and cellular energetics

100. Iron Iron absorption from soy formulas is less Greater bioavailabilty of iron in breastmilk

101. Iron in Formula Infant formulas have been classified as low-iron or iron-fortified based on whether they contain less or more than 6.7 mg/L of iron. –Current mean content of low iron formula is 1.1 to 1.5 mg/L of iron and high iron is 10 to 12 mg/L. –One company recently increased to 4.5 for low iron. –European formulas are 4-7 mg/l –Foman found same levels of iron deficiency at 8 and 12 mg/l

102. Iron Absorption In Infancy

103. Iron deficiency Anemia –Inadequate iron in diet –Loss –GI bleeding, cows milk proteins, infectious agents –Other causes Genetics Lead Other nutrients

104. Iron Fortification of Infant Formulas Pediatrics, July 1999 v104 i1 p119 During the first 4 postnatal months, excess fetal red blood cells break down and the infant retains the iron. This iron is used, along with dietary iron, to support the expansion of the red blood cell mass as the infant grows. The estimated iron requirement of the term infant to meet this demand and maintain adequate stores is 1 mg/kg per day. Infants born prematurely and those born to poorly controlled diabetic mothers are at higher risk of iron deficiency

105. Iron Fortification of Formula “The increased use of iron-fortified infant formulas from the early 1970s to the late 1980s has been a major public health policy success. During the early 1970s, formulas were fortified with 10 mg/L to 12 mg/L of iron in contrast with nonfortified formulas that contained less than 2 mg/L of iron. The rate of iron-deficiency anemia dropped dramatically during that time from more than 20% to less than 3%.”

106. Iron Fortified Formula: Iron Deficiency 9-30% of current US sales are low-iron formulas Iron deficiency leads to reduction of iron-containing cellular protein before it can be detected as iron deficiency anemia by hct or hgb Permanent effects of Fe deficiency on cognitive function are of special concern.

107. Iron Deficiency Prevalence at 9 Months

108. Iron Deficiency in Breastfeeding At 4 to 5 months prevalence of low iron stores in exclusively breastfed infants is 6 - 20%. A higher rate (20%-30%) of iron deficiency has been reported in breastfed infants who were not exclusively breastfed The effect of iron obtained from formula or beikost supplementation on the iron status of the breastfed infant remains largely unknown and needs further study.

109. GI Effects Attributable to Iron Double blind RTC have not found effects. Most providers know that, but parents often want to change to low iron….. “yet it may remain temptingly easier to prescribe a low-iron formula, achieve a placebo effect, and ignore the more insidious long-term consequences of iron deficiency.”

110. AAP Iron Recommendations 1. In the absence of underlying medical factors (which are rare), human milk is the preferred feeding for all infants. 2. Infants who are not breastfed or are partially breastfed should receive an iron-fortified formula (containing between 4.0-12 mg/L of iron) from birth to 12 months. Ideally, iron fortification of formulas should be standardized based on long-term studies that better define iron needs in this range

111. Foman on Iron - 1998 Proposes that breastfed infants should have supplemental iron (7 mg elemental) starting at 2 weeks. Rational: –some exclusively breastfed infants will have low iron stores or iron deficiency anemia –Iron content of breastmilk falls over time –animal models indicate that deficits due to Fe deficiency in infants may not be recovered when deficiency is corrected.

112. AAP Iron Recommendations 1. In the absence of underlying medical factors (which are rare), human milk is the preferred feeding for all infants. 2. Infants who are not breastfed or are partially breastfed should receive an iron-fortified formula (containing between 4.0-12 mg/L of iron) from birth to 12 months. Ideally, iron fortification of formulas should be standardized based on long-term studies that better define iron needs in this range

113. AAP Iron Recommendations 3. The manufacture of formulas with iron concentrations less than 4.0 mg/L should be discontinued. If these formulas continue to be made, low-iron formulas should be prominently labeled as potentially nutritionally inadequate with a warning specifying the risk of iron deficiency. These formulas should not be used to treat colic, constipation, cramps, or gastroesophageal reflux.

114. AAP Iron Recommendations 4. If low-iron formula continues to be manufactured, iron-fortified formulas should have the term "with iron" removed from the front label. Iron content information should be included in a manner similar to all other nutrients on the package label.

115. AAP Iron Recommendations Parents and health care clinicians should be educated about the role of iron in infant growth and cognitive development, as well as the lack of data about negative side effects of iron and current fortification levels.

116. Foman on Iron - 1998 Proposes that breastfed infants should have supplemental iron (7 mg elemental) starting at 2 weeks. Rational: –some exclusively breastfed infants will have low iron stores or iron deficiency anemia –Iron content of breastmilk falls over time –animal models indicate that deficits due to Fe deficiency in infants may not be recovered when deficiency is corrected.

117. Fluoride Fluoride and dental caries –At beginning of 20 th century dental caries was common with extraction only treatment available –Failure to meet minimum standards of 6 opposing teeth was common cause of rejection from military service in WWI and WWII

118. Fluoride 1901 Dr. Frederick S Mckay noted mottled teeth (fluorosis) in practice in Colo Springs Colo that were resistent to decay 1909 Dr. FC Robertson noted same mottling in his area of practice after a new well dug –Believed was due to something in the water

119. Fluoride 1945 study was conducted in 4 city pairs (Michigan, NY, Illinois, Ontario) Followed 13-15 years 50-60% reduction in dental caries

120. Fluoride Proposed mode of action –Promotes remineralization of areas of cariogenic lesions –Increases resistance to acid demineralization –Interferes with formation and function of plaque forming microorganisms –Improves tooth morphology

121. Fluoride Concerns –Excess –Fluorosis –Cancer –other

122. Fluoride Fluoride Recommendations were changed in 1994 due to concern about fluorosis. Breast milk has a very low fluoride content. Fluoride content of commercial formulas has been reduced to about 0.2 to 0.3 mg per liter to reflect concern about fluorosis. Formulas mixed with water will reflect the fluoride content of the water supply. Fluorosis is likely to develop with intakes of 0.1 mg/kg or more.

123. Fluoride, cont. Fluoride adequacy should be assessed when infants are 6 months old. Dietary fluoride supplements are recommended for those infants who have low fluoride intakes.

125. Feeding Guidelines and Recommendations Public health policy Health promotion Prevention

126. The Start Healthy Feeding Guidelines for Infants and Toddlers (JADA, 2004)

127. Examples Transition Supplements to breastmilk Safety Allergy prevention Dental health other

128. Some Issues: Foman, 1993 “For the infant fed an iron-fortified formula, consumption of beikost is important in the transition from a liquid to a nonliquid diet, but not of major importance in providing essential nutrients.” Breastfed infants: nutritional role of beikost is to supplement intakes of energy, protein, perhaps Ca and P. Nutrient content of breastmilk is a compromise between maternal and infant needs. Most human societies supplement breastmilk early in life.

129. C-P-F: Recommendations No strong evidence for benefits from fat restriction early in life AAP recommends: –high carbohydrate infant foods may be appropriate for formula fed infants –no fat restriction in first year –a varied diet after the first year –after 2nd year, avoid extremes, total fat intake of 30-40% of kcal suggested

130. Allergies: Early Introduction of Foods (Fergussson et al, Pediatrics, 1990) 10 year prospective study of 1265 children in NZ Outcome = chronic eczema Controlled for: family hx, HM, SES, ethnicity, birth order Rate of eczema with exposure to early solids was 10% Vs 5% without exposure Early exposure to antigens may lead to inappropriate antibody formation in susceptible children.

131. Early Introduction of Foods (Fergussson et al, Pediatrics, 1990)

132. Allergies: Prevention by Avoidance (Marini, 1996) 359 infants with high atopic risk 279 in intervention group Intervention: breastfeeding strongly encouraged, no cow’s milk before one year, no solids before 5/6 months, highly allergenic foods avoided in infant and lactating mother

133. Allergies: Prevention by Avoidance (Marini, 1996)

134. Allergies: Prevention by Avoidance (Zeigler, Pediatr Allergy Immunol. 1994) High risk infants from atopic families, intervention group n=103, control n=185 Restricted diet in pregnancy, lactation, Nutramagen when weaned, delayed solids for 6 months, avoided highly allergenic foods Results: reduced age of onset of allergies

135. Allergies: Prevention by Avoidance (Zeigler, Pediatr Allergy Immunol. 1994)

136. Early Childhood Caries AKA Baby Bottle Tooth Decay Rampant infant caries that develop between one and three years of age

137. Early Childhood Caries: Etiology Bacterial fermentation of cho in the mouth produces acids that demineralize tooth structure Infectious and transmissible disease that usually involves mutans streptococci MS is 50% of total flora in dental plaque of infants with caries, 1% in caries free infants

138. Early Childhood Caries: Etiology Sleeping with a bottle enhances colonization and proliferation of MS Mothers are primary source of infection Mothers with high MS usually need extensive dental treatment

139. Early Childhood Caries: Pathogenesis Rapid progression Primary maxillary incisors develop white spot lesions Decalcified lesions advance to frank caries within 6 - 12 months because enamel layer on new teeth is thin May progress to upper primary molars

140. Early Childhood Caries: Prevalence US overall - 5% 53% American Indian/Alaska Native children 30% of Mexican American farmworkers children in Washington State Water fluoridation is protective Associated with sleep problems & later weaning

141. Early Childhood Caries: Cost $1,000 - $3,000 for repair Increased risk of developing new lesions in primary and permanent teeth

142. Early Childhood Caries: Prevention Anticipatory Guidance: –importance of primary teeth –early use of cup –bottles in bed –use of pacifiers and soft toys as sleep aides

143. Early Childhood Caries: Prevention Chemotheraputic agents: fluoride varnishes and supplements, chlorhexidene mouthwashes for mothers with high MS counts Community education: training health providers and the public for early detection

144. Bright Futures AAP/HRSA/MCHB http://www.brightfutures.org “Bright Futures is a practical development approach to providing health supervision for children of all ages from birth through adolescence.”

145. Newborn Visit: Breastfeeding Infant Guidance –how to hold the baby and get him to latch on properly; –feeding on cue 8-12 times a day for the first four to six weeks; –feeding until the infant seems content. –Newborn breastfed babies should have six to eight wet diapers per day, as well as several "mustardy" stools per day. –Give the breastfeeding infant 400 I.U.'s of vitamin D daily if he is deeply pigmented or does not receive enough sunlight.

146. Newborn Visit: Breastfeeding Maternal care –rest –fluids –relieving breast engorgement –caring for nipples –eating properly Follow-up support from the health professional by telephone, home visit, nurse visit, or early office visit.

147. Newborn Visit: Bottle- feeding type of formula, preparation feeding techniques, and equipment. Hold baby in semi-sitting position to feed. Do not use a microwave oven to heat formula. To avoid developing a habit that will harm your infant's teeth, do not put him to bed with a bottle or prop it in his mouth.

148. First Week Do not give the infant honey until after her first birthday to prevent infant botulism. To avoid developing a habit that will harm your infant's teeth, do not put her to bed with a bottle or prop it in her mouth.

149. One Month Delay the introduction of solid foods until the infant is four to six months of age. Do not put cereal in a bottle.

150. Four Months –Continue to breastfeed or to use iron- fortified formula for the first year of the infant's life. This milk will continue to be his major source of nutrition. –Begin introducing solid foods with a spoon when the infant is four to six months of age. –Use a spoon to give him an iron-fortified, single-grain cereal such as rice.

151. Four Months, cont. –If there are no adverse reactions, add a new pureed food to the infant's diet each week, beginning with fruits and vegetables. –Always supervise the infant while he is eating. –Give exclusively breastfeeding infants iron supplements. –Continue to give the breastfeeding infant 400 I.U.'s of vitamin D daily if he is deeply pigmented or does not receive enough sunlight. –Do not give the infant honey until after his first birthday to prevent infant botulism..

152. Six Months Continue to breastfeed or use iron-fortified formula for the first year of the infant's life. This milk will continue to be her major source of nutrition. Avoid giving the infant foods that may be aspirated or cause choking (e.g., peanuts, popcorn, hot dogs or sausages, carrot sticks, celery sticks, whole grapes, raisins, corn, whole beans, hard candy, large pieces of raw vegetables or fruit, tough meat). Learn emergency procedures for choking.

153. Six Months, cont. Let the infant indicate when and how much she wants to eat. Serve solid food two or three times per day. Begin to offer a cup for water or juice. Limit juice to four to six ounces per day. Give iron supplements to infants who are exclusively breastfeeding.

154. Nine Months Start giving the infant table foods in order to increase the texture and variety of foods in his diet. Encourage finger foods and mashed foods as appropriate. Closely supervise the infant while he is eating. Continue teaching the infant how to drink from a cup. Continue to breastfeed or use iron-fortified formula for the first year of the infant's life.