1. Infant Nutrition : Proposals for the Mediterranean Area
Eleftheria Roma
Greece

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

3. Metabolic Programming in the Immediate Postnatal Life

4. 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

5. ALLERGY PREVENTION

6. 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

7. 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

8. 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

9. 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)

10. 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 Mar;131(3):687

11. 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

12. 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.

13. 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

14. 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……..

15. 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

16. 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 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

17. 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.

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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 ?

28. Thank you