Normal Infant Nutrition PDF

Normal Infant Nutrition Dr Wesam Alyahya PhD, MSc, BSc Clinical nutrition Nutrition during lifecycle course The importance of proper feeding in early life Describe what is in kids' menu in restaurants or in birthdays !!  Adequate Growth in Infancy In g...

Normal Infant Nutrition Dr Wesam Alyahya PhD, MSc, BSc Clinical nutrition Nutrition during lifecycle course The importance of proper feeding in early life Describe what is in kids' menu in restaurants or in birthdays !!  Adequate Growth in Infancy In general, if a mother is well nourished and is exclusively breast-feeding, her milk will provide adequate nutrition for her infant to grow at an appropriate rate. Human milk has unique nutritional characteristics: 1. Type of protein: high ratio of whey to casein. 2. high proportion of nonprotein nitrogen, and fatty acids essential for brain and retinal development. 3. Immunological and antimicrobial protection 4. Passage of breast milk hormones and growth factors. 5. Provision of digestive enzymes 6. Facilitation of mother-infant bonding Physiologic development: Estimation of gestational age Gestational age and size 1- Antenatally: Last menstrual period Uterus size Quickening (first move by the baby) Fetal heart tone 2- Postnatally: clinical assessment A- Neurologic signs mainly posture and tone. B- Physical maturity Physiological development Birth weight classification Gestational age GA Birth weight Classification 42 - 37 Full term Less 2500 gm Low birth weight Less 37 Premature (LBW) More than 42 Postterm Less than 1500 gm Very low birth weight (VLBW) Less than 1000 gm Extremely low birth weight (ELBW)  Physiologic development cont.. infant size for GA Small for gestational age (SGA) :BWT 90th %tile Intrauterine growth retardation (IUGR) : 1- Asymmetrical IUGR SGA, Poor weight gain, but linear and head growth 10-90th %tile 2- Symmetrical IUGR SGA length and head growth < 10th %tile on intrauterine growth chart. What are centiles? https://www.cdc.gov/growthcharts/data/set1clinical/cj41l017.pdf What are centiles? CDC growth chart calculator BMI Percentile Calculator for Child and Teen: This calculator provides body mass index (BMI) and the corresponding BMI-for-age percentile based on CDC growth charts for children and teens ages 2 through 19 years. Because of possible rounding errors in age, weight, and height, the results from this calculator may differ slightly from BMI-for-age percentiles calculated by other programs. https://www.cdc.gov/healthyweight/bmi/calculator.html  Development of Growth Charts The nutritional status of children is assessed by plotting height and weight on growth charts. The national survey data used in growth charts represent the combined size and growth patterns of breast-fed and formula-fed infants in the U.S. general population These data do not reflect differences in racial or ethnic groups that could affect growth and include all infants and children in the United States regardless of race and ethnicity. Current growth charts do not accurately reflect the growth patterns of breast-fed infants.  Growth charts Growth rates differ for breast-fed and formula-fed infants: -Formula-fed infants typically weigh 600 to 650 g more at 12 months than breast-fed infants. - Average weight of breast-fed infants is noticeably lower than formula-fed infants from 9 to 12 months, whereas length is not significantly different. Thus, breast-fed infants appear leaner.  Physiological factors influencing nutrition during infancy -Growth and body composition - Doubles birth weight by 4 months, triples by 12 months - e.g. normal size baby 3.5 kg, gains 3.5 kg in first 4 month and a further 3.5 kg in next 8 months - Increase of 50% in length by 12 months - Growth velocity (i.e. rate of increase in weight and length) is very rapid particularly in the early months and this imposes extra nutrient demand - 42% of weight gain in the first 4 months is fat and 19% in the next 18 months  Early Feeding: Colic Infantile colic is characterized by continuous uncontrolled crying or fussing in an otherwise healthy and well-nourished infant. And described by: 1- It starts at 3 weeks of age, there is more than 3 hours of crying a day for at least 3 days a week. 2- It lasts for more than 3 weeks. Causes: - It might be related to psychogenic causes from tension in the maternal- infant bond and to maternal smoking or alcohol consumption. - possible allergens in breast milk or infant formula as the causative agent. - Cow's milk protein Colic resolves spontaneously without any further intervention.  Colic prevalence o In both breast-fed and formula-fed infants. o Breastfeeding is not protective against colic. o Reported that but only 16% of breastfed infants demonstrated these symptoms. By 6 weeks distressed behavior was seen in 31% of breast-fed infants but only in 12% of formula fed infants. o St. James-Robert (1998) study Formula fed Breast fed At 2 weeks age 43% showed colic symptoms 16% showed colic symptoms At 6 weeks age 31% showed distressed 12% showed distressed behavior behavior  Treatment of colic Modify the infant's diet. Removal of Cow's milk protein may alleviate the symptoms. Use of a hypoallergenic formula for non-breast-fed infants may be recommended. Switching to a low lactose formula or a formula with fiber was not found to be helpful in reducing colic symptoms. Modify maternal diet A hypoallergenic maternal diet for breast-feeding mothers: - removal of all cow's milk from the mother's diet - Removal of other allergens such as protein from peanuts, eggs, soy, wheat, tree nuts, and strawberries. - Some studies suggest avoidance of some vegetables like cruciferous vegetables ,cabbage family, cabbage, cauliflower, broccoli, onion, and chocolate. But dose-response relationship is not clear according to the studies.  Food safety Safe Handling of Infant Formula Infant formula should be prepared with careful attention to manufacturer's instructions for use and storage. Bottle-feeding increases the risk of bacterial growth in the formula if the bottle is left for several hours at room temperature Freshly expressed breast milk, contains live white cells that destroy pathogens and can remain at room temperature for up to 8 hours before feeding. Powdered infant formula products are not sterile and can be a source of potentially devastating illness and infection in infants. At greatest risk are: Neonates in the first 28 days of life. Premature infants. Low birth weight infants. Immunocompromised infants. Nutritional requirements o The energy cost of growth is important in early infancy. At 3 months of age 22% of energy requirements are utilized for growth. This drops dramatically to 6% at 6 months and even further to 2% to 3% in late infancy. o To ensure that children receive sufficient calories, foods must be prepared with an adequate energy density and served an appropriate number of times per day. Nutritional requirements Energy It is difficult to estimate energy requirements for infants and young children. In general , Satisfactory growth is an indicator that energy needs are being met. 1. Estimating energy needs from energy intake Some organizations recommend normal intake of infants reflect desirable intake.  Disadvantages: The observed energy intake of infants and toddlers may not be optimal. It reflects outside influences such as type of feedings and caregiver behaviors.  Nutritional requirements cont, 2. Energy requirements for infants and toddlers based on actual energy expenditure: more accurately reflect true energy needs. Studies showed in the first 2 years of life total energy expenditure are characterized by: Greater in older infants than in younger infants. Greater for males than for females. Greater for formula-fed infants than for breast-fed infants.  improper introduction of complementary foods Providing excess energy in the form of complementary foods can reduce the intake of breast milk. Although it appears that the timing of breast-feeding in relation to complementary foods (e.g., offering complementary foods before or after breast-feeding) does not seem to affect overall breast milk intake. Protein o Exclusively breast-fed infants receive adequate protein for at least the first 6 months of life. o Adequate intake (AI) of protein for infants from birth to 6 months is 1.5 g/kg/day and reflects the observed mean intake of infants who are fed mostly human milk.  Protein cont, o Protein content in breast milk varies greatly during the course of lactation, providing from less than 2.0 g/kg/day in the first weeks life to approximately 1.15 g/kg/day at 4 months, less than the AI recommendations. o Protein intake of breast-fed infants decreases from 2.0 g/kg/day at 1 month to 1.0 g/kg/day : 6 months as protein concentration in milk decreases id average breast milk intake increases slightly. o 6-month-old breast-fed infant is 8.0 to 8.4 g/ day, lower than the calculated AI of 9.1 g/day. Protein intake of breast-fed infants 2.5 2 1.5 protein intake 1 0.5 0 1 week 4 month 6 month Protein cont, o Protein content of infant formula is greater than ' human milk, but no study has shown that the amount of protein in human milk has deleterious effects. o Multiple studies have shown that infants fed human milk have improved immune function and fewer illnesses than formula-fed infants. o The casein and whey in infant formula are different from those present in human milk; therefore, the digestibility, absorption, and functionality of these proteins differ. o Protein requirements for formula-fed infants may be greater due to less efficient utilization and retention of protein than breast-fed infants.  Nutritional requirements Lipids Adequate fat intake is very essential for infant health. Linoleic acid is essential for growth and dermal integrity Significantly lower fat intakes may result in an inadequate total energy intake Fat content of Human milk: contains a generous amount of the essential fatty acids: - linoleic acid - a-linolenic acid - arachidonic acid (ARA) - docosahexaenoic acid (DHA) Infant formulas are supplemented with essential fatty acids: linoleic acid and a-linolenic acid,from which ARA and DHA are derived. linoleic acid should provide 3% of the infant's total energy intake Lipids o DHA can be formed by desaturation of linolenic acid. o The concentration of DHA in human milk varies, depending on the amount of DHA in the mother's diet. o DHA is important for visual and psychomotor development, especially in premature infants. Carbohydrate o30 – 60% of the energy intake during infancy should come from carbohydrate. o Human milk contains 40-50% of the energy as carbohydrate. oType of carbohydrate is lactose. Botulism o Is the ingestion of Clostridium botulinum spores, which germinate and produce toxin in the bowel lumen. o The carbohydrates honey and corn syrup, have been identified as the only food sources of these spores in infants' diets. o The spores are extremely resistant to heat treatment and are not destroyed by current methods of processing. o Honey should not be given to infants younger than 1 year of age. Water The water requirement for infants is determined by the amount lost from the skin and lungs and in the feces and urine, in addition to a small amount needed for growth. The recommended total water intake for infants, based on the DRIs, is 0.7-0.8 L for infants Note that total water includes all water contained in food, beverages, and drinking water.  water Because the renal concentrating capacity of young infants may be less than that of older children and adults, they may be vulnerable to developing a water imbalance. Under ordinary conditions, human milk and formula that is properly prepared supply adequate amounts of water. Boiled formula is inappropriate for infants? In very hot, humid environments, infants may require additional water: in case of hot ,humid weather, also in case of diarrhea and vomiting. Water deficits result in hypernatremic dehydration and its associated neurologic consequences (e.g., seizures, vascular damage). Hypernatremic dehydration has been reported in breast-fed infants who lose greater than 10% of their birth weight in the first few days of life. (more studies needed) Because of the potential for hypernatremic dehydration, careful monitoring of volume of intake, daily weights, and hydration status (e.g., number of wet diapers) in all newborns is warranted. Water intoxication results in hyponatremia. This condition may occur when water is provided in replacement for milk, the formula is excessively diluted. It appear with the symptoms: restlessness, nausea, vomiting, diarrhea, and polyuria or oliguria; seizures can also result.  Minerals Calcium Breast-fed infants retain approximately two thirds of their calcium intake. The AI(adequate intake) for infants 0 to 6 months of age is 200 -260 mg/day for formulas are enhanced accordingly. Fluoride o The importance of fluoride in preventing dental caries has been well documented. o Excessive fluoride may cause dental fluorosis, ranging from fine white lines to entirely chalky teeth. o To prevent fluorosis, the tolerable upper intake level for fluoride has been at 0.7 -0.9 mg/day for infants Sources of fluoride :Human milk is very low in fluoride. Commercially prepared infant cereals, wet pack cereals, and fruit juice produced with fluoridated water are significant sources of fluoride in infancy. minerals Iron o Full-term infants are considered to have adequate stores of iron for growth up to a doubling of their birth weight at approximately 4 months of age in full-term infants and much earlier in prematurely born infants. o Recommended intakes of iron increase according to age, growth rate, and iron stores. At 4 to 6 months of age iron store may starts to deplete. o Iron in human milk is highly bioavailable; however, breastfed infants should receive an additional source of iron by 4 to 6 months of. Food sources o Iron-fortified cereals and infant formula are common food sources. o Cow's milk is a poor source of iron and should not be given before 12 months of age. Monitoring iron status is important because of long term cognitive effect of iron deficiency anemia. like motor development and behavioral issues.  Vitamins Vitamin B12 Lactating mother who restrict their intake of B12 have less vitamin in their milk. Vitamin D Breast milk provides all the needed vitamins except vitamin D. Vitamin D content in breast milk is low as 20 International unit per liter. Therefore, AAP recommends all breast-fed infants and formula fed infants who receive less than 1000 ml per day of formula need supplementation of 400 IU of vitamin D. The supplementation is higher for premature infants, dark skinned infants and children. vitamin D supplementation should be given carefully by parents because it is fat soluble vitamins that can be stored in the body and cause complications. Vitamins Vitamin K The vitamin K requirements of the neonate need special attention. Deficiency may result in bleeding or hemorrhagic diseases of the newborn. This condition is more common in breast-fed infants than in other infants because human milk contains only 2.5 mcg/L of vitamin K, whereas cow's milk-based formulas contain approximately 20 times this amount Most hospitals require that infants receive an injection of vitamin K as a prophylactic measure shortly after birth. Supplementation  Milk Human milk is unquestionably the food of choice for the infant. Its composition is designed to provide the necessary energy and nutrients in appropriate amounts. Benefits of human milk 1. It contains specific and nonspecific immune factors that support the immature immune system and protect the body against infections. 2. decreases infant morbidity, prevent diarrhea and otitis media. 3. the closeness of the mother and infant during breast-feeding facilitates attachment and bonding. 4. provides nutritional benefits (e.g., optimal nourishment in an easily digestible and bioavailable form). 5. provides maternal health benefits (e.g., maternal weight loss, some cancer protection). 6. economic and environmental benefits.  Milk Colostrums :is a yellow, transparent fluid that meets the infant's needs during the first week of life. It contains less fat and carbohydrate but more protein and greater concentrations of sodium, potassium, and chloride than mature milk. It is also an excellent source of immunologic substances. Contraindications to breast feeding : Mothers infected with human immunodeficiency virus can transmit the infection to the infant. Mother using psychotropic drugs or other pharmacologic drugs may pass the medication to the infant through her breast. The American Dietetic Association (ADA) and the AAP support exclusive breast feeding for the first 6 months of life and then breast feeding supplemented by complementary foods until at least 12 months.  Anti-infective factors of human milk o The human milk contains secretory immunoglobulin A (sIgA) plays a major role in protecting the immature function of the infant gut. At least 3 months of breast feeding is needed to get this benefit. o Lactoferrin : is iron binding protein, its function is to deprive the bacteria form iron thus slows their growth. o Lysozymes: bacteriolytic enzymes ,destroys cell membranes of the bacteria. o Lactobacillus bifidus: probiotic o It produces acidic environment that inhibit bacterial growth. o Human milk is important for normal flora distribution. Composition of human and cow milk The composition of human milk is different from that of cow's milk; for this reason, unmodified cow's milk is not recommended for infants until at least 1 year of age. Both provide 20 kcal/oz; however, the nutrient sources of the energy are different. Protein provides 6% to 7% of the energy in human milk and 20% of the energy in cow's milk. Human milk is 60% whey proteins (mainly lactalbumins) and 40% casein; by contrast, cow's milk is 20% whey proteins and 80% casein. Casein forms a tough, hard-to-digest curd in the infant's stomach, whereas lactalbumin in human milk forms soft, flocculent, easy-to-digest curds. Feeding behavior Simple feeding schedule Satiety behaviors of infants