470 likes | 883 Views
Growth rates are most rapid in the first six months of human lifeNutrient requirements on a weight basis are highest during the first six monthsRapid organ growth and development occurs during the last trimester and first six monthsThe detrimental effects of nutritional insufficiencies are mag
E N D
1. Pediatric Nutrition I Nutrition of Neonates and Infants
Prior to 1 year of age
Growth Rates and Nutritional Goals
Nutrient Requirements
Energy, Protein, Minerals, Vitamins
Absorptive/Digestive Immaturity
Human Milk
Infant Formulas
2. Growth rates are most rapid in the first six months of human life
Nutrient requirements on a weight basis are highest during the first six months
Rapid organ growth and development occurs during the last trimester and first six months
The detrimental effects of nutritional insufficiencies are magnified during periods of rapid organ growth (I.e., vulnerable periods for brain growth)
3. Provide sufficient macro- and micronutrient delivery to promote normal growth rate and body composition, as assessed by curves which are generated from the population
Curves exist for:
Standard anthropometrics: weight, length, OFC
Special anthropometrics: arm circumference, skinfold thickness
Body proportionality: weight/length, mid-arm circumference: head circumference ratio
Body composition measurements (e.g. DEXA, PeaPod) are not standardized yet
6. Term infants require 85-90 Kcal/kg/d if breast-fed, 100-105 Kcal//kg/d if formula
Differences are due to increased digestibility and absorbability of breast milk
Presence of compensatory enzymes (lipases)
7. (Continued)
Energy requirements are 20% higher in premature infants due to:
Higher basal metabolic rate
Lower coefficient of absorption for fat and carbohydrates
Energy requirements decrease to 75 Kcal/kg/d between 5-12 months
9. Diseases of infancy that increase BMR (cardiac, neurologic, respiratory) affect energy requirements
Diseases that increase nutrient losses (malabsorption due to cystic fibrosis, celiac disease, short bowel syndrome) increase the need for energy delivery, although the BMR is normal
10. Late gestation and infancy is the time of highest protein accretion in human life
Protein requirements range from 1.5 g/kg/d (healthy breast-fed infant) to 3.5 g/kg/d (septic, preterm infant)
Amino acid synthesis is incomplete in the premature; taurine and cysteine are additional essential amino acids because of immaturity of enzyme systems
11. Preterm infants: 15 g/kg/d
Toddlers: 6 g/kg/d
Adolescents: 4 g/kg/d
12. Nutrient Term Preterm 5-12 Month
Neonate Neonate Infant
Na (mEq/kg/d) 2 - 3 4 - 7 1 - 2
K (mEq/kg/d) 1 - 2 2 - 4 1 - 2
Ca (mEq/kg/d) 60 150 40
Iron (mEq/kg/d) 1 2 - 4 0.7
Zinc (mEq/kg/d) 0.2 - 0.5 0.4 0.3
13. Water-soluble vitamins (B, C, folate, etc.) are rarely a problem in newborns and infants; babies are born with adequate stores and/or all food sources have adequate amounts
Fat-soluble vitamins (A,E,D,K) may present significant problems because of relatively poor fat absorption by newborn infants (especially premature infants)
14. K: Needs to be given at birth to prevent hemorrhagic disease of newborn; adequate thereafter due to synthesis by intestinal bacteria
D: Low amounts in breast milk; infants born in winter in north and infants who are clothed at all times (minimal sun exposure) have been identified with rickets
AAP now recommends 400 IU/d for all infants
15. (Continued)
A: Essential for normal structural collagen synthesis and retinal development deficiency in premature infants contribute to fibrotic chronic lung disease
E: Antioxidant that protects against peroxidation of lipid membranes; preterms have poor antioxidant defense and are subjected to large amounts of oxidant stress; vitamin E deficiency causes severe hemolytic anemia
16. Rapid transit time
+
Immature digestive capabilities
=
Reduced nutrient retention
17. Primary sources of CHO in newborn and infant diet are disaccharides (esp. lactose)
Disaccharides must be broken into component monosaccharides to be absorbed
Lactose = glucose + galactose (lactase)
Sucrose = glucose + fructose (sucrase)
Maltose = glucose + glucose (maltase)
18.
Intestinal lactase concentrations are low at birth and are not inducible
Amylase, necessary for breaking down starches, are not adequate until > 4 months
20. 85 % of ingested protein is absorbed in spite of functional immaturities:
Reduces stomach acidity
Low pancreatic peptides levels (chymotrypsin caroboxypeptidases)
Compensation is by trypsin and brush border peptidases
21. Adult: 95%
Term infant: 85-95%
Preterm infant: 50 - 90% (dependent on source of fat)
22. Low levels of intestinal lipases
Small bile salt pool
23. Committee on Nutrition of the AAP strongly recommends breastfeeding for infants
The rates of breastfeeding have risen recently, but the attrition rate is high
24. The goal of the AAP and NIH Health People 2010 is to have 75% women breastfeed, with a continuation rate of 50% at 6 months
It is necessary to breastfeed for at least 12 weeks to achieve the immunologic and disease preventative benefits of breast milk
Physician’s role is to support, counsel and trouble-shoot
25. Health
Nutritional
Immunologic
Neurodevelopmental
Economic
Environmental
26. Studies in developed countries
Reduced prevalence of:
Diarrhea
Otitis media
Lower respiratory infection
UTI
NEC (in preterms)
SIDS
27. Protection of infant from chronic diseases:
Insulin dependent diabetes mellitus
(OR 0.61)
Inflammatory bowel disease
Allergic disease
Childhood lymphoma (OR 0.91)
Obesity (OR 0.75-0.87)
28. Protection of mother from:
Pregnancy
Postpartum hemorrhage
Bone demineralization
Ovarian cancer
29. Complete human nutrition for 6 months
Iron at 4 months
Vitamin D in northern climates, covered infants and mothers, vegetarians (vegans)
Energy is more accessible than from formula
Compensatory lipases ? better fat retention
But, BF babies grow slower too
30. Amino acid spectrum matches infant need; lower protein and solute load
Faster gastric emptying ? less reflux
31. Better visual acuity (early)
Role of DHA?
Higher IQ (debatable)
Independent of nursing
Components in human milk which may potentiate the effect:
DHA
Growth factors
32. 25% reduced risk of obesity if BF
Adjusted OR: 0.75-0.89
Dose response (Koletzko et al)
Rate of Adolescent Obesity
12% if BF < 1month
2% if BF 12 months
“Small” effect compared to OR if parents are obese (4.2), low physical activity (3.5) or TV (1.5)
33. Reduced cost of feeding
No formula cost (-$855/year)
Increased maternal consumption (<+$400)
Net savings of >$400/child
Reduced health care costs due to:
Lower incidence of childhood illness
Reduced income loss due to:
Less days lost to cover childhood illness
34. Galactosemia in infant
Illicit drug use by mother
Certain maternal infectious diseases
Active TB
HIV (US only)
Not CMV
Certain maternal medications
Anti-neoplastics, isotopes, etc
How about SSRI's?
35. Promotes adequate growth, but not brain and immunologic development compared to human milk
New formulas contain LC-PUFAs
Soon to be added: prebiotics; probiotics
Most are cow-milk based, although soy-protein based and fully elemental formulas are available
36. (Continued)
Cow’s milk (not formula) is contraindicated in the first year of life
High solute load can lead to azotemia
Inadequate vitamin D and A
Milk fat poorly tolerated
Low in calcium; can lead to neonatal seizures
Gastrointestinal blood loss/sensitization to cow- milk protein
37. Feed humans human milk
It is species specific
If not human milk, CMF or Soy formulas with iron are indicated
Hypoallergenic formulas are highly specialized, expensive and overused