Understanding Infant Nutrition

1. Understanding Infant Nutrition By James A. Yost, MD, MS, MBA Emory Family Medicine

2. Calculating Infant Nutrition Objectives: Formula Breast feeding Calculating ounces per day Calculating calories per day Ensure continuation of growth by giving enough calories Expiration of breast milk and formula

3. Infant Nutrition Body water composition Neonates are born with an excess of TBW This is primarily ECF They normally lose this excess ECF in the first postnatal week. Term neonate bodies are 75% water 40% ECF and 35% ICF Term neonates usually lose 5-10% of their weight in the first week of life, almost all of which is water loss.

4. Infant Nutrition • Energy expenditure of an infant • Resting energy use 40 kcal/kg/d • Minimal activity 2-4 kcal/kg/d • Occasional cold stress 10 kcal/kg/d • Fecal loss of energy 10 kcal/kg/d • Growth 40 kcal/kg/d • Total 100-105 kcal/kg/d

5. Infant Nutrition • Distribution of Energy Sources • Glucose 16.3gm = 55 kcal/kg/d…. 50% • Protein 3.1gm =10 kcal/kg/d…12% • Fat 4gm = 40 kcal/kg/d…38% • Total 105 kcal/kg/d

6. Infant Nutrition • Formula: • Term Formulas • modeled after breast milk and contains 20 kcal per ounce • carbohydrate source is lactose • contain cow's-milk protein • no evidence to recommend one brand over another • May choose WIC formula for Medicaid - currently Similac till Sept 2009

7. Infant Nutrition • Formula Continued • Arachidonic acid (AA) and docosahexaenoic acid (DHA) • These fatty acids are found in breast milk • important in the development of membrane constituents in the central nervous system • promote eye and brain development • most well-conducted randomized trials show no benefit

8. Infant Nutrition • Formula Continued • How to initiate feeds (<36wks gest.) • Calculate 80ml/kg/day = total daily intake • Then divide by 8 (for 8feedings in a day) • Then divide by 30 (for 30ml in one ounce) • This will equal the number of ounces per feed • Increase by 20ml/kg/day to a max of 150ml/kg/day • The formula needs 22 - 24 kcal/oz

9. Infant Nutrition • Examples: • A new born weighs 7lbs (3.2Kg) • 80ml x 3.2Kg = 265ml total daily intake • 265ml /8 = 32ml/feed • 32ml/30ml/oz = approx 1 oz per feeding • Total daily caloric intake should be 160 kcal

10. Infant Nutrition • Formula Continued • How to initiate feeds (>36wks gest.) • Calculate 150ml/kg/day = total daily intake • Then divide by 8 (for 8feedings in a day) • Then divide by 30 (for 30ml in one ounce) • This will equal the number of ounces per feed • The formula has 20 kcal/oz

11. Infant Nutrition • Examples: • A new born weighs 7lbs (3.2Kg) • 150ml x 3.2Kg = 480ml total daily intake • 480ml /8 = 60ml/feed • 60ml/30ml/oz = approx 2 oz per feeding • Total daily caloric intake should be 320 kcal

12. Infant Nutrition • Soy Formula • Use should be limited to infants with galactosemia or congenital lactase deficiency • may also be used by strict vegan families • accounts for almost 25 percent of formula sales • made with corn-based carbohydrate and soy protein • free of lactose and cow's-milk protein • parents believe that this improves digestibility

13. Infant Nutrition • Soy Formula Continued • The evidence regarding soy formula and peanut allergy is mixed • has been shown to reduce the duration of diarrhea in acute gastroenteritis • soy formula should never be used for preterm infants • FPs should direct parents toward breastfeeding and cow's-milk-based formulas in most cases

14. Infant Nutrition • Lactose-free Formulas • alternative to soy formula • indicated for galactosemia and congenital and primary lactase deficiency • Lactose intolerance is overdiagnosed in infancy • most proven cases develop after 12 months

15. Infant Nutrition • Hypoallergenic and Nonallergenic Formulas • Only a small minority of infants have true immunoglobulin E (IgE)-mediated milk protein allergy • Milk protein allergy can present with any combination of cutaneous, respiratory, and gastrointestinal complaints • blood in the stool is a classic symptom • usually diagnosed in the setting of a strong family history

16. Infant Nutrition • Hypoallergenic and Nonallergenic Formulas Continued • Milk protein intolerance can manifest as enteropathy and enterocolitis • These infants are equally sensitive to soy protein – so hypoallergenic is preferred • Infants on hypoallergic formulas have slightly greater weight gain during the first year • infants show improvement in atopic symptoms • Only a few infants continue to have symptoms despite switching

17. Infant Nutrition • Antireflux Formulas • Gastroesophageal reflux is common in infants • decreased resting tone of the lower esophageal sphincter • Should be considered physiologic • does not require treatment unless it is accompanied by poor weight gain or significant infant discomfort • have been shown to decrease daily episodes of regurgitation and emesis • parents should be reassured that GERD is normal and will resolve with time • antireflux formulas appear safe and nutritionally adequate for severe or persistent cases

18. Infant Nutrition • Infant Formula and Colic • Parents often change formulas in response to infant colic • Soy and lactose-free formulas • Most colic improves spontaneously between four and six months of age • no evidence to support lactose-free or soy formula for colic • Two systematic reviews have found some benefit with hypoallergenic formula • So a 1-2 week trial is reasonable

19. Infant Nutrition

20. Infant Nutrition

22. Infant Nutrition • Breast Feeding: • should initiate as soon as possible after giving birth • Early breast-feeding is associated with fewer nighttime feeding problems and better mother-infant communication

23. Infant Nutrition • Breast Feeding • Benefits, helps prevent the following: • bacterial meningitis • bacteremia • 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 Please

24. Infant Nutrition • Breast Feeding • Contraindications to breastfeeding • infants with classic galactosemia (galactose 1-phosphate uridyltransferase deficiency) • In the US, mothers who are infected with HIV • NOT contraindicated • Mothers who are Hep B surface antigen-positive or have Hep C infection • mothers who are febrile • mothers who smoke tobacco or occasionally drink

25. Infant Nutrition • Breast Feeding • 20kcal/oz and contains lactose • breast milk alone does not provide infants with an adequate intake of vitamin D • Recommended for infants who are strictly breast fed to supplement with an infant vitamin dropper

26. Infant Nutrition • Breast Feeding • What’s in this stuff!!!! • Proteins • Whey and casein • Lactoferrin • inhibits the growth of iron-dependent bacteria • Immunoglobulin • Lysozyme • protects the infant against E. Coli and Salmonella • Bifidus factor • supports the growth of lactobacillus

27. Infant Nutrition • Breast Feeding • What’s in this stuff!!!! • Fats • Vitamins • Fat-soluble vitamins, including vitamins A, D, E, and K • Water-soluble vitamins such as vitamin C, riboflavin, niacin, and panthothenic acid • Carbohydrates • Lactose is the primary carbohydrate • 40% of the total calories provided by breast milk • improves the absorption of calcium, phosphorus, and magnesium

28. Infant Nutrition • Breast Feeding • Colostrum • Produced in sufficient amounts during the last trimester and at delivery • high in protein and immunoglobulin • Present for 5-7 days or until the milk comes in • Schedule • Need to feed every 2-3 hrs for about 15 minutes on each breast

29. Infant Nutrition • How long can I leave this stuff out anyway? • Breast Milk • Rule of 5s • Room temp for 5 hrs • Frig. For 5 days • Freezer for 5 months • Formula • Rule of 1s • Room temp for 1 hr. • Frig for 1 day • Never frozen

30. Thank You