Infant Nutrition : Proposals for the Mediterranean Area Eleftheria Roma Greece

Concerns about infant feeding……. Normal growth Prevention of: Malnutrition Obesity Allergy Epigenetics Establishment of taste for different foods Emotional support

Metabolic Programming in the Immediate Postnatal Life

Early influences of nutrition on postnatal growth. Rapid weight gain in infancy and the first 2 years was shown to predict increased obesity risk in childhood and adulthood. Breastfeeding leads to lesser high weight gain in infancy and reduces obesity risk in later life due to the lower protein the 'Early Protein Hypothesis' Cows' milk as a drink provides high protein intake and should be avoided in infancy. Koletzko B et al ; European Childhood Obesity Trial Study Group. Nestle Nutr Inst Workshop Ser. 2013;71:11-27

ALLERGY PREVENTION

Infant feeding and allergy prevention….. Most studies have focused on 4 main areas of infant feeding: A. Breast feeding (duration and exclusivity) B. Cow’s milk hydrolysate infant formulas C. Introduction of solids D. Pre and/or probiotics

Nutrition in early life, immune-programming and allergies: the role of epigenetics The associated parallel rise in metabolic diseases interplay between modern dietary patterns and increasing abnormalities of both immune and metabolic health These changes have been associated with changes in the gut microbiome, metabolic responses and immune function - all of which may contribute to the rising propensity for chronic low-grade inflammation In children, Immunoglobulin E (IgE) levels are linearly related to body mass index (BMI) and c-reactive protein (CRP), and childhood obesity is an independent risk factor for food allergy. Asian Pac J Allergy Immunol 2013;31:175-82

Food or environmental antigen Maternal Milk: Antigen Free Complexed to IgA Complexed to IgG Tolerogenic immune mediators TGF-β, IL10, Vit A, ... Microbiota modulating factors Prebiotics (oligosaccharides, glycoproteins) Antimicrobial (lysosyme, lactoferrine, IgA, ...) Gut growth factors (EGF, TGF-β, ...) Antigen handling by maternal digestive system Antigen transferred across gut barrier Possible maternal influence on neonatal tolerance induction through breast-feeding. Mucosal Immunology | VOL 3 NUMBER 4 : 2010 Oral tolerance

American Academy of Allergy, Asthma & Immunology Avoidance diets during pregnancy and lactation are not recommended at this time, but more research is necessary for peanut Exclusive breast-feeding for at least 4 and up to 6 months is endorsed For high-risk infants who cannot be exclusively breast-fed, hydrolyzed formula appears to offer advantages to prevent allergic disease and cow’s milk allergy Complementary foods can be introduced between 4 and 6 months of age The Complementary should be delayed, however, until the infant is able to sit with support and has sufficient head and neck control. J Allergy Clin Immunol: In Practice 2013;1:29-36)

Prevalence of childhood celiac disease and changes in infant feeding. Although there is little evidence that complementary feeding before the age of 6 months is harmful, some studies have shown that there is a higher risk of iron-deficiency anaemia. In addition, there is a higher risk of coeliac disease in those who have not been weaned until 6 months of age. There is evidence that the infant feeding recommendation to gradually introduce gluten-containing foods from 4 months of age, preferably during ongoing breast-feeding, reduces the prevalence of coeliac disease.   Ivarsson et al . Pediatrics. 2013 Mar;131(3):687

UNICEF's position on infant feeding: "Babies should be exclusively breastfed . Breastfeeding should be sustained until the baby is at least two years old, but beginning at about six months breast milk should be complemented with appropriate solid foods.“ There are three signals for a possible need for early complementation after four and prior to six months: -shows interest in semisolid foods -appears hungry after breastfeeds - is not gaining weight adequately

Breast-feeding: A Commentary by the ESPGHAN Committee on Nutrition Exclusive breast-feeding for around 6 months is a desirable goal Partial breast-feeding as well as breast-feeding for shorter periods of time are also valuable Continuation of breastfeeding after the introduction of complementary feeding is encouraged as long as mutually desired by mother and child JPGN 49:112–125, 2009.

Initiation of breastfeeding within the first hour of life To enable mothers to establish and sustain exclusive breast feeding for 6 months, WHO and UNICEF recommend: Initiation of breastfeeding within the first hour of life Exclusive breastfeeding – that is the infant only receives breast milk without any additional food or drink, not even water Breastfeeding on demand – that is as often as the child wants, day and night No use of bottles, teats or pacifiers Follow the ten steps

Weaning Age: 4-6 months? Or after 6 months? Quality of supplementary foods Which food ? First : fruits?, cereals? Meat, Gluten introduction : when? Fresh milk? Yoghourt, cheese? Quantity small amounts gradually? Protein? Opinion of different societies……..

Complementary feeding WHO recommends introducing complementary food at the age of 6 months. The recommendation further specifies that appropriate complementary feeding is: Timely: when the need for energy and nutrients exceed what can be provided through exclusive breast-feeding; Adequate: sufficient energy, protein and micronutrients Safe: hygienically stored and prepared Properly fed: consistent with a child’s signals and abilities for solids

Europe: Introducing solids/weaning A recent Cochrane review : no apparent risks in recommending, as a general policy, exclusive breast-feeding for the first 6 months of life in both developing and developed country settings. Cochrane Database Syst Rev. 2012 Aug 15;8 The EFSA's panel on dietetic products, nutrition, and allergies has concluded that for infants across the EU, complementary foods may be introduced safely between 4 to 6 months, and 6 months of exclusive breast-feeding may not always provide sufficient nutrition for optimal growth and development. European Food Safety Authority, 2009

Evidence related to the timing of introduction of complementary foods Solid introduction before 4 months and the number of foods introduced was associated with increased eczema No study found any benefit on allergic outcome by delaying the introduction of solids Two studies found association between delayed introduction of milk and egg Expose to cereal grains before 6 months opposed to after 6 are protected from the development of wheat-specific IgE Allergy 2009, 94:140 Complementary feeding should not be introduced before 17 wk and not later than26 wk. Early diet and the risk of allergy: what can we learn from the prospective birth cohort studies GINIplus and LISAplus Am J Clin Nutr 2011;94(suppl):2012S–7S.

Medical Position Paper Complementary Feeding: A Commentary by the ESPGHAN Committee on Nutrition Complementary feeding (ie, solid foods and liquids other than breast milk or infant formula and follow-on formula)should not be introduced before 17 weeks and not later than 26 weeks. Cow’s milk is a poor source of iron and should not be used as the main drink before 12 months, although small volumes may be added to complementary foods. It is prudent to avoid both early (<4 months) and late (≥ 7 months) introduction of gluten, and to introduce gluten gradually while the infant is still breast fed JPGN 46:99–110, 2008.

Current international recommendations for infant feeding and allergy prevention Breast feeding exclusive ESPACI and ESPGHAN : 4-6 WHO : 6 months Cow’s milk based formulas ESPACI and ESPGHAN: formula of reduced allergenicity if not breast fed Introduction of complementary foods AAP, ESPGHAN: no before 4 m and no after 6m WHO/UNICEF : after 6 months

Infant Feeding Guidelines Australian Dietary Guidelines Introducing solids at around the age of 6 months Delaying the introduction of solid foods beyond this age may increase the risk of developing allergic syndromes By 12 months of age, a variety of nutritious foods from the five food groups is recommended Commonwealth of Australia 2012

Recommendation of Canadian Paediatric Society Breastfeeding is the normal method of feeding infants Recommend exclusive breast feeding for the first 6 months Supplemental vitamin D (400 IU) is recommended for breastfed infants First complementary foods should be iron-rich Recommend meat, meat alternatives and iron-fortified cereal as an infant’s first complementary foods Complementary foods should also be led by the infant’s signs of readiness and may be a few weeks before or just after the sixth month Use the WHO Growth Charts for Canada for optimal monitoring of infant growth Paediatr Child Health Vol 18 No 4 April 2013

SCIENTIFIC OPINION Scientific Opinion on the appropriate age for introduction of complementary feeding of infants EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA) The Panel agrees with WHO and other authoritative national and international bodies that breast-milk is the preferred food for infants Introduction of complementary food into the diet of healthy term infants in the EU between the age of 4 and 6 months is safe and does not pose a risk for adverse health effects Presently available data on the risk of celiac disease and type 1 diabetes mellitus support also the timing of the introduction of gluten containing food (preferably while still breast-feeding) not later than 6 months of age Exclusive breast-feeding provides adequate nutrition up to 6 months of age EFSA Journal (2009) 7(12): 1423

Breast-Feeding and Weaning Practices in the DONALD Study: Age and Time Trends Infants born between 2008 and 2012 were 3.3-fold less fully breast-fed for 4 months than those born before 2004 With the constantly high consumption of commercial Complementary Food at all ages: Nutritional adequacy of both homemade and commercial CF needs to be investigated closer, as their long-term influence on health and dietary habits, e.g. fruit and vegetable intake JPGN 2014;58: 361–367 No Effect of Sequencing of Complementary Feeding in relation to Breast-Feeding on Total Intake in Infants JPGN 2014;58: 339–343

Iron intake and iron status in breastfed infants during the first year of life. Healthy infants, fully breastfed at 4 months of age, demonstrated ID in about 21% and IDA in up to 6% during the second half of infancy while fed according to the paediatric dietary guidelines This finding supports the recommendation that supplementation with bioavailable iron via complementary foods should be started early (4-6 months of age) in order to prevent iron deficiency during infancy Clin Nutr. 2010 Dec;29(6):773

Percentage of Iron Absorbed Iron and vitamin D Supplement of 400 IU per day of vitamin D is recommended for all breastfed infants Pediatrics November 2008 Iron deficiency at risk: preterm infants The vitamin C and high lactose levels in breast milk aid in iron absorption. Iron Source Percentage of Iron Absorbed Breast milk ~50 – 70% iron-fortified cow milk formula ~3 – 12% iron-fortified soy formula less than 1% – 7% iron-fortified cereals 4 – 10% cow’s milk ~10% The introduction of iron supplements and iron-fortified foods, particularly during the first six months, reduces the efficiency of baby’s iron absorption

Does timing matter? And we do not yet have all the answers Confused? So are we. And so are our patients. Practically, it seems that the timing of introduction of certain foods might matter It is unclear why earlier publications showed delay in introduction of solid food to be preventive. The food, dose, frequency, age of introduction, and heritable background of the child might all play important roles And we do not yet have all the answers Can Fam Physician 2013;59:721-2

Proposal for the Mediterranean area Exclusive breast feeding up to 6 months Vitamin D 400 IU in exclusively breast fed infants Continuation of breast feeding up to 12 months is desirable Supplementary foods about 6 months : Adequate foods providing sufficient energy, protein and micronutrients to meet a growing child’s nutritional needs Adding new food, according to tradition in each country, every 5-7 days Introduction of all allergenic foods before 12 months No fresh milk as the main drink during the first year of life Infant formula up to 12 months Breast milk ideal for prevention of obesity, allergy and cardiovascular disorders Hydrolyzed formulas may prevent allergy in high risk infants ?

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