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Infant nutrition. Care of the healthy baby.

Infant nutrition. Care of the healthy baby. Gábor Veres, MD, PhD, Dsc Professor of Pediatrics Ist Dept. of Pediatrics Semmelweis University, Budapest. What is the most important question in infancy?. Weight gain !. Content. Breast feeding Composition of breast milk

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Infant nutrition. Care of the healthy baby.

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  1. Infant nutrition. Care of the healthy baby. Gábor Veres, MD, PhD, Dsc Professor of Pediatrics Ist Dept. of Pediatrics Semmelweis University, Budapest

  2. What is the most important question in infancy?

  3. Weight gain !

  4. Content • Breast feeding • Composition of breast milk • Eosinophilic enteropathy, Reflux (GOR) • Formulas, solids • Iron, vitamins

  5. Three basic principles of infants feeding • Until 6 months exclusive breast feeding. • Demand feeding. • Milk or diluted milk can not be given even between 6-12 months. Follow-on formulas are recommended.

  6. Introduction of gluten: 4-12 months (Celiac disease) Until 6 months exclusive breast feeding, BUT: • Introduction of gluten and solids • Between 4-7 months (+ breast feeding) • Decrease of celiac disease and food allergy Vriezinga, NEJM, 2014 Silano M, Agostoni C, Guandalini S. Effect of the timing of glutenintroduction on the development of celiac disease. World J Gastroenterol. 2010;16:1939-42.

  7. Demand feeding, BUT: • Jaundice: sleepy infant, wake-up! • Infantile colic: not every crying means baby is hungry

  8. Energy content of the breast milk (BM) • Exclusive breast feeding covers the energy needs of infants until 6 months • Energy needs: 90-120 kcal/kg/die • Energy of BM 60-70 kcal/100ml • 5000g baby: 500kcal BM pro day 750ml BM / day

  9. Advantages of breast feeding I. • Composition of breast feeding is optimal for the development of infants • PUFA content is necessary for the development of retina and brain • Breast milk is easier digestable than the different formulas

  10. Advantages of breast feeding II. • Breast milk, especially colostrum ensures immune defense • It contains antibacterial and antiviral antibodies, as well as T-cells and macrophages • Stool pH is lower, bacterial microflora bifidogen inhibiting enteral infections

  11. Advantages of breast feeding III. • Frequency of obesity, hypertonia, IBD and Type I. diabetes mellitus are rare • Favourable psychological relationship between the mother and child

  12. Immunoglobulins and cytokines in BM Tomicić et al. Pediatr Res. 2010;68:330-4. • IgA neutralizes pathogens, does not activate complement system (oral tolerance) • TGF-beta (transforming growth factor) inhibits immune activation less allergy in breast fed infants

  13. BUT: Breast fed infants do have: • Atopic dermatitis • Allergic-eosinophilic esophagitis • Allergic-eosinophilic colitis Foreign proteins in breast milk

  14. Eosinophilic esophagitis • Reflux, BUT: pH is normal, PPI therapy resistant • Dyspepsia • 75% in males • Food allergy in 50%, eosinophilia 42% • Dg: upper endoscopy • Histology: 15 eosinophils/HPF

  15. Eosinophilic esophagitis (upper endoscopy) Conc. rings and furrows (reversible fibrosis) Granulation (eosinophilic clusters)

  16. Eosinophilic esophagitis (histology) • Papilla elongation • min. 15 eosinophil /HPF • Epithelial eosinophil • „cluster”

  17. Hematochezia (fresh blood in feces) • 3 months old infant, breast feeding • No family history for polyposis • CRP, blood picture, coagulogram: normal • Feces: no bacteria • RDE: no fissures, no obstipation Dg: ALLERGIC COLITIS Mother’s elimination diet (cow’s milk)

  18. Lymphonodular hyperplasia • Colonoscopy: rectosigmoid region • Allergic colitis (cow’s milk protein induced) • Similar to M. Crohn • Special aminoacid formula (Neocate) • blood in feces disappeared Troncone: Colon in food allergy. JPGN. 2009;48 Suppl 2:S89-91.

  19. Percentage of breast fed infants in Sweden (%) % 1945 1970 1999

  20. Percentage of breast feeding (Hungarian data) months • 3 months: 75% • 6 months: 60% MGYT, 2009

  21. Composition of breast milk Newburg DS: Handbook of milk composition. Academic Press 1995;pp 273-349 • Lactose 55-60 g/l • Proteins10 g/l • Lipids40 g/l • Nucleotids, Erythropoietin, IgA, TGF-beta

  22. I. Lactose in BM (55-60 g/l) • Main sugar/energy source • Enzyme: lactase • After 34. weeks lactase activity matures • Lactase activity after the age of 3y. • Congenital absence of lactase: very rare galactose glucose

  23. II. Proteins in BM (10 g/l)

  24. Proteins (1%=1g/100ml) • Protein content of colostrum and early milk is higher • Mature breast milk contains less secretory IgA and lactoferrin • Ratio of whey and casein is also high (80/20) which is gradually decreasing to 60/40

  25. Whey/casein ratio (BM=60:40) Whey: • Intestinal transport, motility • More digestable Casein: • Viscosity , anti-reflux effect

  26. Recommended protein content of formulas g/100 kcal g/l ESPGHAN 1,8-2,8 12-19 AAP 1,8-4,5 12-30 Räihä 1,6-1,8 11-12 At decreased protein content the serum urea level will be similar to that found at exclusively breast fed infants

  27. Low protein intake in infancy is beneficial for future life • Danish survey, 631 intants • At birth, 3 months, 18 months (US, blood) Higher protein intake (formula fed infants): • Increased size of kidney • Higher urea in blood Schmidt, Pediatr Nephrol, 2004;19: 1137-44

  28. Which mammals has the lowest protein in the BM ??? • Human breast milk

  29. III. Lipids in BM (40 g/l)

  30. Importance of lipids • High energy content • Beta-palmitate trygliceride is high in BM (70%) • Significance of poly-unsaturated fatty acids (PUFA)

  31. Structure of triglicerides () CH3 - O - R1 | () CH2 - O - R2 | () CH3 - O - R3 Pancreas lipase split the palmitic acid located in  position

  32. The advantage of tryglicerides containing beta-palmitate • In this position the lipase does not split the palmitic residue • Can be absorbed !!! • Free palmitic acid forms with calcium unsoluble calcium soap which is not able to absorbe • Therefore it decreases energy and calcium supply

  33. Significance of LC-PUFA in infant nutrition • Linolic and linolenic acid is not synthesized in the human body (essential fatty acids) • Docosahexaenoic acid is indispensable to the normal function of cell membrane

  34. Somatic development of breast fed infants • After two months the length and weight of breast fed infants are slightly less than those of formula fed • At the preparation of reference curves a preponderance of formula fed babies occured • Not the maximal but optimal development is advantageous

  35. Infant mortality (1000 newborns ? at 1 year) • Prehistoric man, chimpanzee infant mortality: 250 ‰ • End of XIX. is the same for men • One of the reasons: NO infant formula 1903 (Derby) infant mortality: - arteficial feeding: 230 ‰ - breast fed: 70 ‰

  36. Infant formulas For healthy babiesSpecial formulas 1. Standard formula 2. Follow-on 3. Baby’s milk

  37. 1. Standard formulas • Strict criteria • Range of energy: E:60-75 kcal/100ml Trend toward less protein • Whey/casein = 60 : 40 • Taurin: development of retina and CNS • Carnitin: lipid metabolism

  38. It contains too much protein sodium It contains too less linolic acid iron vitamins (C, D, E) Why is not optimal to give cow’s milk to infants under one year?

  39. Cow’s milk feeding may cause: • Iron-deficiency anaemia • Blood in feces • Atopic dermatitis • Increased osmotic load for kidneys

  40. 3. Baby’s milk • Recommended from 7-9 months • Until 1-3 years • More expensive than cow’s milk • Price: 1.5-2x than cow’s milk

  41. Special formulasAnti-reflux (AR) • Seads of Saint John’s bread-tree (Nutriton) • Corn-starch (AR) or potato-starch • Nestle HA+AR: HA: Hypoallergenic: only for prevention and anti-reflux together

  42. Reflux, regurgitation • Size of stomach: 30 ml • Adults: 1500 ml • 5kg infant: 200 ml BM • 70kg adult: 2.8 litre !!! • Growing well? • Exclude other causes (pyloric stenosis, intest. stenosis, CAH, infections, metabolic etc.)

  43. Solids • Foods besides breast milk and formulas • Introduction between 4-7 months • fruits • cereals • vegetables • meat

  44. Iron deficiency • 1 billion people affected • Developed country: 12%, developing: 51% • Hungary: 8-36 months: 30% 4-6 years: 51% iron deficiency ! • Iron psychomotorial and cognitive function • In iron deficiency: lead absorption

  45. Bioavailablity of iron Iron content% of absorption breast milk 0.5-1 mg/l 50% cow’s milk 0.5-1 mg/l 10% meat 2.5 mg/100g 30% iron fortif. formula 12 mg/l 7%

  46. Iron and everyday practice • First: measure iron level • Bacteria needs iron for growing • Do NOT give iron in bacterial infection! • Term baby: no supplementation in 6-9 months source: red blood cells • Preterm baby: 2mg/kg after 2 months

  47. Vitamin K • Vitamin K dependent coagulatory proteins (prothrombin, VII, IX, X) • BM contains low level, supplementation • At birth, 1 week, once/months per os, 2mg • Formula contains vitamin K • Intestinal bacteria produce vitamin K • Liver, soybean, spinach, tomatoes, kale

  48. Vitamin D • Low level in BM • Supplementation: 400U/day • After 2 weeks - 1-1.5 years or more! • Formula contains vitamin D

  49. Allergy, atopic dermatitis

  50. Probability of atopy in positive family history • No atopy in the family : 10% • One parent / one sibling : 30% • Both of parents : 50% • Both p. with the same manifest. : 70%

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