infant nutrition.docx

Fetal Period Critical period Time of rapid fetal growth  Weight triples in last trimester  Weight doubles between 23-28/40 Brain is developing Most nutrient stores established Requirements per kg greater than at any other time in life Neonatal Period Birth  Lost up to 10% BW  Regain BW by 7-10 d...

Fetal Period Critical period Time of rapid fetal growth  Weight triples in last trimester  Weight doubles between 23-28/40 Brain is developing Most nutrient stores established Requirements per kg greater than at any other time in life Neonatal Period Birth  Lost up to 10% BW  Regain BW by 7-10 days Birth to 6 months  Length grows 1.5-2.5 cm/month  HC grows 2 cm/month for the first 3 months, than 1 cm/month for the next 3 months  Gain about 20-30 g/day  Double BW by about 5 months 6 to 12 months  Length grows about 1 cm/month  HC grows 0.5 cm/month  Gain 12-20 g/day  Triple BW by about 1 year of age Long-Term Effect of Early Nutrition Differences in nutritional experience during sensitive periods of early life, both before and after birth, can programme a person’s future development, metabolism and health. ‘Developmental Origins of Wellbeing’ Barker DJB, The developmental origins of wellbeing, Phil Trans R Soc Lond B 2004 Long-term programming effect may persist into future generations Neu J et al, Postnatal nutrition and adult health programming, Sem Fetal Neo Med 2007 Barker Hypothesis Neurodevelopment Poor nutrition and growth associated with poorer neonatal outcomes Benefits of breastfeeding below: Anti-proteases Bifidus factor Cytokines Enzymes – digestive, anti-inflammatory Epidermal Growth Factor Glycoproteins Hormones Immunoglobulins Lactoferrin Lactoperoxidase Leukocytes LCPUFAs Lymphocytes Lysozyme Nucleotides Oligosacharides Peroxidase Polyamines Secretory IgA Benefits of Breast Feeding (Infant) Protects Infant Against: Bacteremia Bacterial Meningitis Diarrhea Respiratory tract infection Necrotizing enterocolitis Otitis media Urinary tract infection Late-onset sepsis in preterm infants Type 1 and type 2 diabetes Lymphoma, leukemia, and hodgkins disease Childhood overweight and obesity AAP Policy: Breast Feeding and Use of Human Milk Benefits of Breast Feeding (Infant) Each additional month of exclusive breastfeeding May reduce hospital admissions secondary to infection (by as must as 30% in the first year of life) Paricio Talayero JM, Lizán-García M, Otero Puime A, et al. Full breastfeeding and hospitalization as a result of infections in the first year of life. Pediatrics 2006;118(1):e92-9. Linked to  A decrease in Sudden Infant Death Syndrome (SIDS)  Although sleeping position and smoking were two risk factors that were difficult to control for these studies Venneman MM, Bajanowski T, Brinkmann B, et al. Does breastfeeding reduce the risk of sudden infant death syndrome? Pediatrics 2009;123(3):e406-10.  Associated with enhanced performance on neurocognitive testing Mortensen EL, Michaelsen KF, Sanders SA, Reinisch JM. The association between duration of breastfeeding and adult intelligence. JAMA 2002;287(18):2365-71. Breast Milk & Neurodevelopment Source of LCPUFAs  For developing brain and retina Improved intelligence scores and teaching ratings Significant positive effect on long-term neurodevelopment in preterm infants AAP, Breastfeeding and the use of human milk (policy statement), Pediatrics 2012 Benefits of Breast Feeding (Maternal) Maternal-infant bonding Decreased postpartum bleeding and more rapid uterine involution Decreased menstrual blood loss and increased child spacing (lactational amenorrhea) Earlier return to pre-pregnancy weight Decreased risk of breast and ovarian cancers AAP Policy: Breast Feeding and Use of Human Milk Benefits of Breast Feeding (Environment & Society) Breastfeeding families are sick less often and the parents miss less work It does not require the use of energy for manufacturing or create waste or air pollution There is no risk of contamination Always at the right temperature Ready to feed AAP Policy: Breast Feeding and Use of Human Milk Breast Milk – Feed of Choice Given the documented short and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice” “Published research and systematic reviews have reinforced the conclusion that breastfeeding and human milk are the reference normative standards for infant feeding and nutrition” AAP, Breastfeeding and the use of human milk (policy statement), Pediatrics 2012 Breast Feeding Concerns that this recommendation could result in  Iron deficiency, other micronutrient deficiencies and growth faltering in susceptible infants − Poor maternal nutrition − Infants had high rates of iron, zinc and vitamin A deficiency However, an 8% global increase in exclusive breastfeeding to six months is estimated to have  Reduced infant mortality by 1,000,000  Decreased fertility by 600,000  Saved countries billions of dollar in unneeded breastmilk substitutes UNICEF. Facts and Figures. www.unicef.org/programme/breastfeeding/facts.htm Breast Feeding The Canadian Paediatric Society recommends  Exclusive breastfeeding for the first six months of life and health, term infants Breast milk is the optimal food for infants, and breastfeeding may continue for up to two years and beyond CPS Statement: Nutrition for Healthy Term Infants EtOH and Breast Feeding Ample evidence drinking alcohol during pregnancy poses a severe and avoidable risk to unborn babies Risks of drinking alcohol while breastfeeding, however, are not well defined. Alcohol consumed by a mother passes easily into her breast milk at concentrations similar to those found in her bloodstream  A nursing infant is actually exposed to only a fraction of the alcohol the mother ingests  but infants detoxify alcohol in their first weeks of life at only half the rate of adults. www.motherrisk.org EtOH and Breast Feeding Proven or potential adverse effects, even after exposure to only moderate levels:  impaired motor development  changes in sleep patterns  decrease in milk intake  risk of hypoglycemia  drinking large amounts of alcohol could affect lactating women's milk flow. Elimination follows zero-order kinetics, drinking water, resting, or 'pumping and dumping" breast milk will not accelerate elimination Unlike urine, which stores substances in the bladder, alcohol is not trapped in breast milk, but is constantly removed as it diffuses back into the bloodstream www.motherrisk.org History of Human Milk Banking 1st human milk bank  Vienna, Austria, in 1909 1st in North America  Boston, USA, in 1919 Continued until 1980s - most banks closed  fear of HIV transmission In Canada, only the Vancouver, milk bank remained open Milk banks are not able to meet the needs of all preterm neonates in Canada With current screening protocols and serological testing, the safety of human milk can again be assured When new milk banks open, there is significant support from the community, and donor milk has been well received in NICUs CPS Statement: Human Milk Banking Donor EBM Considerations Handled as a human body substance All donors undergo screening process similar to donating blood:  interview, serological screening and physician consent Serology  HBV, HCV, HIV, HTLV testing Collected, frozen, stored, pasteurized and cultured in accordance with food preparation guidelines as set out by the Canadian Food Inspection Agency Using all of the aforementioned safety controls  There has never been a reported case of disease transmission through the use of pasteurized donor breast milk  However, this can never be absolutely assured CPS Statement: Human Milk Banking Colostrum The initial milk produced around the time of deliver Contains immunological components  Lymphocytes, IgA, IgG, IgM, among many others Higher protein, lower fat Allowing high concentration of nutrient in a low volume Mild laxative effect promoting passing of meconium (and bilirubin) Cow Milk Formulas Often referred to as “standard” infant formulas  The most commonly used substitutes for human milk They are available as  Ready-to-use liquids − 20 kcal/oz or 67 kcal/100 mL  Powder or liquid concentrates − May be mixed with specific quantities of water to yield caloric densities 20-30 kcal/oz or 67-100 kca;/100 mL Martinez JA, Ballew MP. Infant Formulas, Pediatrics in Review 2012;32:5,179-189. Vitamin D Breast feeding  Need Vitamin D! Rickets – very little supplementation needed Prevention of childhood and adult onset dz Involved in the regulation of cell growth, immunity, cell metabolism Linked to osteoporosis, asthma, autoimmune disorders (rheumatoid arthritis, multiple sclerosis, inflammatory bowel disease, diabetes), disturbed muscle function, resistance to TB, and pathogenesis of specific types of cancer Health Canada Pregnancy & Lactation 200 IU daily → current PNV are 400 IU Evidence for much higher doses in pregnancy First year of life All exclusive breast fed, healthy term infants → 400 IU daily  If the mother has normal stores during pregnancy and lactation In Northern 1st Nations communities during the winter months → 800 IU daily Formulas are fortified to ~400 IU/L Vitamin B12 Deficiency is a rare but treatable cause of failure to thrive and developmental delays in infants May also develop vomiting, hypotonia, tremors, chorea, myoclonus at 2-12 months Attention to infants whose mom’s are: Vegan Have pernicious anemia Iron In 1959, iron fortification implemented in response to recognition of a high prevalence of iron deficiency anemia among formula-fed infants Iron from human milk is absorbed at a higher rate 20-50% in human milk compared with 4-7% in cow milk To compensate for lower bioavailability All fortified formulas contain more iron than human milk It is strongly recommended that all formula-fed infants receive iron-fortified formulas to prevent anemia Iron stored in BF infants are depleted by ~6 months of life Martinez JA, Ballew MP. Infant Formulas, Pediatrics in Review 2012;32:5,179-189. Early Iron Deficiency Iron deficiency during the first 6-12 months of life likely to experience persistent effects of the deficiency that alter functioning in adulthood may significantly delay the development of the central nervous system as a result of alterations in morphology, neurochemistry, and bioenergetics depending on the stage of development at the time of iron deficiency, there may be an opportunity to reverse adverse effects, but the success of repletion efforts appear to be time dependent Solid Food At ~6 months, most babies are ready for other foods Can breastfeed when baby is 2 years and beyond. Solid Food Ready to start other foods when the baby: Seems hungry earlier than usual. Can sit up without support (good control of neck muscles) Holds food in his mouth without pushing it out with tongue Shows interest in food when others are eating Opens mouth when sees food coming his way Demonstrates doesn’t want food by leaning back or turning head away Remember that all babies are different  Some babies may be ready a few weeks before or just after 6 months  However, waiting too long after 6 months to introduce other foods increases risk of iron deficiency How to Introduce Solid Food to Your Baby? Introduction of Solids 1st foods usually vary from culture to culture and from family to family Start with foods that contain iron Meat, poultry, cooked egg yolk and well-cooked legumes (beans, lentils, chick peas) Store-bought iron-fortified infant cereals such as rice or barley are also common There is no special order to introduce new foods to your baby Healthy foods that the whole family is eating are best Ensure they are plain, with no added salt, sugar or spices Commercial baby foods: read the label to ensure there is no added salt or sugar. Food Allergies The CPS does NOT recommended delaying any food (such as peanuts, fish or eggs) beyond 6 months of age as a way to prevent children from developing allergies Applies even for high risk children (a child is considered high risk if a parent or sibling has an allergic condition) When introducing foods that are common food allergens, try offering no more than one per day Wait two days before you introduce another → easier to identify a food that may have caused a reaction Once introduced continue to offer these regularly Avoidance of Foods Babies shouldn’t be offered sugary drinks or foods such as juice, candies, soda/pop or energy drinks Monitor for choking hazards Don’t give honey to babies under 1 year old risk of infant botulism (food poisoning) Other Milk If transitioning to cow milk as your child’s main milk source, wait until baby is 9-12 months Start with homogenized cow milk (3.25% M.F.) Do not offer skim or partly skimmed milk (1% or 2% M.F.) before 2 years of age If fortified soy beverage is the child’s main milk source, wait until they are 2 years of age Rice or nut beverages should not be used as a child’s main milk source Probiotics Microbial cell preparations or components of microbial cells with a beneficial effect on health and well being of the host ESPGHAN, Probiotic Bacteria in Dietetic Products for Infants: A Commentary by the ESPGHAN Committee on Nutrition, JPGN 2004 Probiotics: Non-digestible food components that benefit the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon, and thereby improve host health ESPGHAN, Prebiotic Oligosaccharides in Dietetic Products for infants: A commentary by the ESPGHAN Committee on Nutrition, JPGN 2004 Probiotics?  Some evidence for safety  Well-tolerated, adequate growth Saavedra et al. 2013 Am J Clin Nutr  Lack of evidence body to support:  Favourable changes in microbiome  Improvements in short- & long-term health outcomes  More research is needed  Probiotics and single bacterial strains are not a panacea... How (else) can we Improve Dysbiosis? 1. Support exclusive breastfeeding  The easy choice is not always easy!  NB - Breastfeeding ~ breast milk feeding − Breast milk from bottle associated with increased incidence of cough/wheeze, diarrhea, AOM o Negative pressure during bottle sucking may transmit bacteria into middle ear during feeding o Bioactive/protective components may be altered during freezing/preparation To(o) clean or not to(o) clean… 2. Reduce antibiotic use Judicious prescribing Be aware of heavy use in agricultural industry 3. Avoid over-sanitization “Let Them Eat Dirt!” Brett Finlay & Marie-Claire Arrieta Questions?