INFANT NUTRITION RICHARD L. MONES MD

1. INFANT NUTRITIONRICHARD L. MONES MD HARLEM HOSPITAL

2. HOW DID WE GET HERE? • MUST DEVELOP EXPERTISE • TIME • HISTORY

3. EVOLUTION • BM – BEST FOR HUMAN BABIES • ? IDEAL • CHANGES IN DIET/HYGEINE • AFFECTED VIT.K, D, Fe

4. NO BREAST MILK MEANT CERTAIN DEATH

5. WET NURSE—AN ALTERNATIVE • 4th century B.C. • 13th century…highly organized • State controlled practice • Transmit traits

6. LOUIS XIV AND WET NURSE

7. VESSELS TO FEED MILK • BOVINE HORNS • ANIMAL HIDE • 1800 GLASS FEEDING BOTTLE

11. MIDDLE AGES • INFANTS TO SUCKLE FROM ANIMALS • GOAT • SHEEP

12. AGE OF WEANING • HAS DECREASED FROM AGE 3 YEARS TO THE PRESENT 12 MONTHS. • NEVER WEANED IN JULY,AUGUST,SEPTEMBER

13. ANIMAL MILK • REPLACED WET NURSES IN 18 CENTURY • COW, ASS, GOAT • 50-100% MORTALITY RATE IN EARLY 19 CENTURY

14. WHY? • POOR SANITATION • ADULTERATION • NO ICE BOX

15. IMPORTANT EVENTS • GERM THEORY DISCOVERED • KNOWLEDGE OF MILK COMPOSITION • BORDEN-CONDENSED MILK

16. IMPORTANT EVENTS • PASTUERIZATION • RUBBER NIPPLES-CLEAN • 1910 ICE BOXES • DEVELOPMENT OF FORMULAS

17. TODAY • BREAST FEEDING • FORMULA • BOTH • MUCH IS TAKEN FOR GRANTED

18. OBJECTIVE • PROVIDE NUTRIENTS TO SUPPORT OPTIMUM GROWTH • DEVELOP OROMOTOR SKILLS • APPROPRIATE EATING BEHAVIORS

19. HOW MUCH ENERGY IS NEEDED? • ENERGY BALANCE • E(INTAKE)=E(EXCRETED)+E(EXPENDED)+E(STORED) • POSITIVE IN INFANTS AND CHILDREN • EXPENDITURE- BASAL FUNCTIONS + ACTIVITY • EXCRETION- STOOL FAT • STORED- IN MOLECULES OF FAT AND PROTEIN • ENERGY COST OF GROWTH

20. COST OF DEPOSITING FAT • 10.8KCAL/GM. COST OF DEPOSITING PROTEIN 13.4 KCAL/GM.

21. HOW MUCH DOES IT TAKE? • DOUBLE BW IN 4 MONTHS • TRIPLE BW IN LESS THAN 12 MONTHS

22. FACTORS INFLUENCING FOOD INTAKE • DENSITY • DIGESTIBILITY • TASTE PREFERENCES • PARENTAL ATTITUDES • BREAST VS. BOTTLE

23. NEEDS • 0-2MOS……90-120 KCAL/KG/DAY • 3-5 MOS……80-100 KCAL/KG/DAY • 6-8 MOS…….80-100 KCAL/KG/DAY • 9-11 MOS……90-100 KCAL/KG/DAY

24. HOW DO YOU KNOW? • GROWTH • NAKED WEIGHT • LENGTH BOARD • PLOT WT./HT. • SHOW GC TO PARENTS

25. EXPECTATIONS • GROWTH CURVES DIFFICULT DURING FIRST 1-2 MONTHS • LOW RESOLUTION • REFLECT INTRA-UTERINE NUTRITION • WHAT ELSE CAN YOU DO?

26. GUIDE TO WEIGHT GAIN FIRST TWO MONTHS • 50th %ile= 30 GMS./DAY • 95th %ile=45 GMS./DAY • 5th %ile=15 GMS./day • LESS THAN 15 GM./DAY IS INADEQUATE

27. POSSIBLE EXCEPTIONS • CATCH UP GROWTH • CATCH DOWN GROWTH

28. BREAST MILK • MILK COMPOSITION VARIES AND IS DYNAMIC • WOMAN TO WOMAN • OVER TIME- DAY TO DAY, MONTH TO MONTH • DURING A FEED • FOREMILK VS. HINDMILK

29. BREAT MILK • WELL NOURISHED WOMAN WILL MEET ALL NUTRITIONAL NEEDS FOR FIRST 6 MOS. OF LIFE • EVENTUALLY, EXCLUSIVE BF WILL NOT MATCH NEED OF THE INFANT • SUBOPTIMAL GROWTH

30. BREAST MILK • INFANT WITH GROWTH RATE AT 95%ILE BUT • MOTHER’S MILK PRODUCTION IS ON THE 5%ILE • WEIGHT GAIN <5%ILE = RED FLAG FOR UNDERNUTTION • MISMATCH IN MACRO AND MICRO NUTRIENTS

31. BREAST MILK • ADVANTAGES OTHER THAN NUTRITIONAL • CLEAN MILK • PROTECT AGAINST INFECTION • MACROPHAGES • LYMPHOCYTES • LACTOFERRIN • LYSOZYMES • IgA

32. CASE • 34 YO G1P0 MOM BRINGS HER BABY IN WITH A CC: IRRITABITLIY, POOR SLEEPING, XS CRYING. • SURGICAL RESIDENT, LIVES ACROSS FROM HOSPITAL. XLUIVELY Breast Feeding • MOM IS QUITE FATIGUED • 3 WEEKS OF AGE (21DAYS) • BW=7-4 (3290), D/C 7-0 (3180) CAN TOLERATE UP TO 15% WEIGHT LOSS IN FIRST 24-72 HOURS. (DIURESIS) TODAY= 7-8(3410)

33. BREAST MILK • WHAT WOULD YOU DO?

34. BREAST MILK • GAIN ABOUT 11 GMS./DAY • NORMAL OR NOT? • ?LABS-----HYPERNATREMIA • REMIAFORMULA FEED? • LIFESTYLE CHANGES?

35. INSUFFICIENT BREAST MILK SYNDROME • STRESS STRESS STRESS STRESS • CHICKENS LAY FEWER EGGS • COWS PRODUCE LESS MILK • SO DO HUMANS

36. BREAST VS. FORMULA * G/100ML

37. BREAST VS. FORMULA

38. FORMULA • CONVENIENCE • NECESSITY • CULTURAL • SUPPLEMENTAL

39. convenience

40. NUMEROUS FORMULAS • SOY • COLIC • REFLUX • ALLERGY • GI ABNORMALITES (SHORT GUT, post-infectious gastroenteritis) • INBORN ERRORS OF METABOLISM

41. HOW DO YOU CHOOSE ? • FIRST DECIDE WHAT YOUR GOAL IS !!!! • IS THERE EVIDENCE TO SUPPORT THAT GOAL? • SET REALISTIC EXPECTATIONS FOR THE PARENTS • CONSIDER COST AND AVAILABILITY • KNOW ONE FORMULA IN EACH CATEGORY

42. SOY FORMULAS • 20 CAL/OZ. • SOY PROTEIN • FAT- MIXTURE OF VEGETABLE OILS ( PALM,SOY,COCNUT,SFFLOWER,SUNFLOWER) • CHO- SUCROSE AND CORN SYRUP

43. SOY FORMULA • VEGETARIAN • WILL SUPPORT NORMAL GROWTH • COLIC? • MILK PROTEIN ALLERGY • 40% CROSS REACTIVITY • NOT IgE

44. PROTEIN HYDROLYSATE • ALIMENTUM • NUTRAMIGEN • PREGESTIMIL

45. HYDROLYSTE • HYDROLIZED CASEIN • CHO-CORN SYRUP SOLIDS AND MALDEXTRINS • FAT-VEGETABLE OIL • SOME WITH MCT ( PREGESTIMIL)

46. HYDROLYSATE • COW MILK PROTEIN ALLERGY • STILL POSSIBLE • “SEMI-ELEMENTAL” FORMULAS • POST INFECTIOUS GASTROENTERITIS • COLIC • CHOLESTASIS • SHORT GUT

47. ELEMENTAL FORMULA • MACRONUTRIENTS IN MOST BASIC FORM • PROTEIN = FREE AMINO ACIDS • CHO=POLYCOSE AND GLUCOSE • FAT= MIXTURE OF MCT AND LCT • HIGH OSMOLARITY

48. ELEMENTAL FORMULAE • NEOCATE • ELECARE • NUTRAMIGEN AA

49. ELEMENTAL FORMULAE • SHORT GUT SYNDROME • COW PROTEIN/SOY PROTEIN ALLERGY • COLIC • PATIENT DEMAND • EXTREMELY EXPENSIVE • NOT COVERED BY INSURANCE

50. FOLLOW THE MONEY • PRESSURE BY COMPANY REPS • SPONSORSHIP OF MEETINGS,LUNCHES ETC. • MILLIONS IN COSTS FOR ADVERTISING • ENFAMIL AR