Family Medicine Study: Infant Nutrition

1. Family Medicine Study: Infant Nutrition Sarah A. Bailey D.O. and Master Nicholas edward bailey iii Emory Family Medicine October 11, 2007

2. Family Medicine Study • Infant Nutrition: Supplementation • Prevention and Treatment of Iron Deficiency • Prevention of Rickets and Vitamin D Deficiency • Infant Oral Health and Fluoride Supplementation.

3. Iron Deficiency Anemia (IDA) • High prevalance 1930’s and became standard to screen all infants 9 to 12 months. • Mid-1980’s decline IDA b/c increase breastfeeding, iron fortified formulas and cereals, and WIC in the 1970’s. • Led to decreased screening for IDA. • Prevalence IDA in 1 to 3 year old children increasing recent years.

4. Mental, Motor, and Behavioral Effects • Mental, motor and behavioral effects develop when iron deficiency severe enough to cause anemia. • By 1990’s established association between IDA and lower developmental test scores (ex. Gross and fine motor, and affect). • Tx with iron to resolve anemia does not correct all mental, motor, and behavioral effects.

5. Prevention • Screening in infants and toddlers is important. (Ex. NHANES III) • One to 3 year olds have the lowest daily iron intake of any age group across lifespan. • Related to discontinued use of iron fortified formula and breastfeeding. • Introduction cow’s milk, noniron-fortified cereals, and juices.

6. Primary Prevention of IDA • Strict avoidance of cow’s milk first 12 months of life. (low iron, low absorption) • Breast milk more bioavailability but exclusive breastfeeding(BF) after 4 to 6 months increase risk of IDA. • Recommend BF term infants to obtain iron supplementation 1mg/kg/day starting at 4 to 6 months. (via drops, cereal.) • BF pre-term or LBW infants require 2mg/kg/day oral iron supplement at 2 to 4 weeks of age. (<1500g then 3mg/kg/day, <1000g then 4mg/kg/day).

7. Primary Prevention • Term and preterm infants (>1000g) on iron fortified formula do not need additional supplementation. • Do not use low iron formula (<6.7mg/liter) as no benefit vs. standard iron formula. • Cow’s milk consumption less than 24 oz per day in 2nd year of life. • Avoid excessive juice. • Toddlers’ diets rich in iron and vitamin C.

8. Risk Factors

9. Secondary Prevention: Screening • Infants with one or more RF for IDA should be screened (cow’s milk, lower SES). • 9 and 12 month screening for term infants • 6 months of age for pre-term or LBW infants • 15 months, 18 months, and 24 months for toddlers at risk (ex. h/o IDA, >24oz cow’s milk/day, low iron/Vit C diet, or recent immigrant)

10. Secondary Prevention: Screening • Ideal test be able to identify iron deficiency in the absence of anemia. (not just Hgb levels) • Example serum ferritin level, transferrin saturation, erythrocyte protoporhyrin level, or red cell distribution width for diagnosis of iron deficiency. • If erythrocyte protoporhyrin level elevated or Hgb is low then therapeutic trial of oral iron is the gold standard to establish dx of iron deficiency. • Recommended to delay testing in infant or toddler who has had infection within the previous two weeks.

12. Therapeutic Trial

13. Treatment • Initiate course of iron therapy, after positive screening test for iron deficiency and confirmation by therapeutic trial of iron. • 3mg/kg/day orally (ferrous sulfate) once daily before breakfast. Increased absorption if taken with Vitamin C. • Total length of treatment is 3 months, including one month of therapeutic trial of iron.

14. Nicky and Blue Bear

15. Prevention Rickets and Vitamin D Deficiency • Guidelines from American Academy of Pediatrics recommends all infants, including exclusively breastfed, receive 200 IU per day of Vitamin D to prevent deficiency. • A potential source of vitamin D is synthesis in the skin from UVB sunlight. • American Academy of Pediatrics guidelines advises children < 6 months of age out of direct sunlight, and protective clothing as well as sunscreens should be used. Sunscreens markedly decrease vit D production in skin.

16. Vitamin D pathway

17. Rickets • Table 2 • Skeletal and Radiographic Findings Associated with Rickets • Bowing or widening of physis • Costochondral beading (rachitic rosary) • Craniotabes • Delayed closure of anterior fontanel • Dental abnormalities • Flaring of ribs at diaphragm level (Harrison's groove) • Flaring of wrists • Fractures • Fraying and cupping of metaphysis • Frontal bossing of skull • Genuvalgum or varum • Lordosis/kyphosis/scoliosis • Osteopenia

18. Cupping, fraying, splaying

19. Rachictic Changes

20. Vitamin D supplementation • Human milk typically contains Vitamin D concentration < 25 IU/ liter or less. • Recommend all breastfed infants be given supplemental Vitamin D • If an infant is ingesting at least 500mL / day of formula they will receive atleast 200 IU / day. • If child drinking < 500 mL / day of Vitamin D fortified milk, then will need supplement with MVI containing 200 IU of vitamin D.

22. Recommendations

23. Summary • Vitamin D supplementation of 200 IU / day recommended for following: • All BF infants unless weaned to atleast 500 mL per day vitamin D-fortified formula. • All non BF infants ingesting < 500 mL per day of vitamin D-fortified formula • All children and adolescents who do not get regular sunlight exposure, ingest < 500mL / day of vitamin D fortified milk, or do not take MVI containing at least 200 IU of vitamin D.

24. Infant Oral Health • Dental caries in children < 6 yoa is most common chronic disease of childhood. (5x more prevalant than asthma). • Most children no dental care until 3 yoa. (> 30% have caries) • Caries may develop as soon as teeth erupt and visible by 10 months of age. (white lines on maxillary incisors) • Bacteria predominately mutans streptococci, metabolize simple sugars to produce acid that demineralizes teeth and causes cavities.

25. Etiology • Mutans streptococci typicaly originate from the mother and are transmitted via saliva. • Exposure to environmental tobacco smoke increases the likelihood of streptococci colonization in children. • Practices that allow frequent sugar consumption in presence of mutans steptococci may result in caries formation. (propped bottles and frequent “sippy” cups of sweetened liquids, and frequent snacking)

26. Childhood Caries

27. Erupting Teeth

28. White lines on enamel

29. Yellow cavitations

30. Oral Health Promotion • Periodontal disease linked to preterm labor. • Prenatal visits should include evaluation for cavities, poor oral hygiene, inflamed gingiva, loose teeth, and frequency of sugar consumption. • Monitor oral health after delivery as well to decrease infant colonization. • Chewing xylitol chewing gum 4x/day may decrease caries in their children.

32. Supplement Schedule

33. Recommendations

34. REFERENCES Douglass JM, Douglass AB, Silk HJ. A Practical Guide to Infant Oral Health. American Family Physician 2004; 70(11): 221-31. Gartner LM, Greer FR. Prevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D intake. Pediatrics 2003; 111(4): 908-10. Kazal LA. Prevention of Iron Deficiency in Infants and Toddlers. American Family Physician 2002; 66(7): 213-15. Nield LS, Mahajan P, Joshi A. Rickets: Not a Disease of the Past. American Family Physician 2006; 74(6): 619-22.