Infant nutrient needs

1
Infantnutrient needs

• Basis/Approach
• Public health vs individual
• recommendations, guidelines, education
• Specific nutrients
• water
• energy
• protein
• fatty acids
• vitamin K
• Vitamin D
• Iron
• Fluoride

2
Basis of recommendations

• Growth and development
• Physiology
• GI
• Renal
• Programming
• Public health vs individual

• Optimize growth and development
• Prevent deficiencies
• Safety
• Prevention of chronic illness and optimize health
  through life cycle

3
Approaches to Estimating Nutrient Requirements

• Direct experimental evidence (ie protein and
  amino acids)
• Extrapolation from experimental evidence relating
  to human subjects of other age groups or animal
  models
• ie thiamin--related to energy intake .3-.5
  mg/1000 kcal
• Breast milk as gold standard (average X usual
  intake)
• Metabolic balance studies (ie protein, minerals)
• Clinical Observation (eg manufacturing errors
  B6, Cl)
• Factorial approach
• Population studies

4
Challenges

• Strength of Evidence
• Individual vs population
• Public health approach
• Individual genetics
• Maternal-infant dyad
• In utero endowment
• Beliefs, values, choices
• Relationship/nurture
• Environmental factors

5
Public health vs individual

• Prevalence of nutrient deficiencies
• Balance incidence, burden, and treatment
• Eg Vitamin K and hemorrhagic disease of newborn
• Prevalence and evidence of chronic conditions
  associated with dietary practices
• Etiology of nutrient deficiencies and/or chronic
  conditions
• Eg allergy, obesity, anemia, dental caries,

6
Individual Requirements

• Genetics
• Adaptation
• Environment
• Behavior/activity
• Choices, access, resources
• other

7
1940s

• Rickets (D)
• Pellagra (Niacin)
• Scurvy (C)
• Beriberi (Thiamin)
• Xeropthalmia (A)
• Goiter (Iodine)

8
United Nations 5th report on World Nutrition
March 2004
Prevalence () 1990 2005
underweight 35.2 26.5
Iodine deficiency 35.2
9
United Nations 5th report on World Nutrition
March 2004

• Vitamin A deficiency
• 140 million preschoolers
• 7 million pregnant women
• Iron Deficiency
• One of most prevalent
• 4-5 billion affected

10

• Reports in US of PEM, Rickets, Zinc deficiencies

11
Causes

• Nutrition ?-? Disease
• Access
• Food
• Health Care
• Environment
• Economics
• Education

12
Programming by Early Diet

• Nutrient composition in early diet may have long
  term effects on GI function metabolism and health
• Animal models show that glucose and amino acid
  transport activities are programmed by
  composition of early diet
• Animals weaned onto high CHO diet have higher
  rates of glucose absorption as adults compared to
  those weaned on high protein diet
• Barker Hypothesis
• Association between BMI and chronic disease HTN
  and cardiovascular, SGA/IUGR
• Other examples early diet associations with
  allergy, obesity, diabetes

13
Allergies Prevention by Avoidance (Zeigler,
Pediatr Allergy Immunol. 1994)

• High risk infants from atopic families,
  intervention group n103, control n185
• Restricted diet in pregnancy, lactation,
  Nutramagen when weaned, delayed solids for 6
  months, avoided highly allergenic foods
• Results reduced age of onset of allergies

14
Allergies Prevention by Avoidance (Zeigler,
Pediatr Allergy Immunol. 1994)
15
Allergies Early Introduction of
Foods(Fergussson et al, Pediatrics, 1990)

• 10 year prospective study of 1265 children in NZ
• Outcome chronic eczema
• Controlled for family hx, HM, SES, ethnicity,
  birth order
• Rate of eczema with exposure to early solids was
  10 Vs 5 without exposure
• Early exposure to antigens may lead to
  inappropriate antibody formation in susceptible
  children.

16
Early Introduction of Foods(Fergussson et al,
Pediatrics, 1990)
17
Allergies Prevention by Avoidance (Marini, 1996)

• 359 infants with high atopic risk
• 279 in intervention group
• Intervention breastfeeding strongly encouraged,
  no cows milk before one year, no solids before
  5/6 months, highly allergenic foods avoided in
  infant and lactating mother

18
Allergies Prevention by Avoidance (Marini, 1996)
19
Cochrane Review

• Osborn et al Formulas containing hydrolysed
  protein for prevention of allergy and food
  intolerance in infants 200618
• Concluded that use of hydrolysed formula in non
  breastfed infants at risk for allergy (atopic
  dermatitis) for at least 4 months reduces the
  incidence of allergy.

20
DRI

• Nutrition Recommendations from the Institute of
  Medicine (IOM) of the U.Sgt National Academy of
  Sciences for general public and health
  professionals.
• Hx WWII, to investigate issues that might
  affect national defense
• Population/institutional guidelines
• Application to individuals.

21
DRI

• Estimated Average Requirement (EAR) expected to
  satisfy the needs of 50 of the people in that
  age group based on review of scientific
  literature.
• Recommended Dietary Allowance (RDA) Daily
  dietary intake level considered sufficient by the
  FNB to meet the requirement of nearly all
  (97-98) healthy individuals. Calculated from EAR
  and is usually 20 higher
• Adequate intake (AI) where no RDA has been
  established.
• Tolerable upper limit (UL) Caution against
  excess

22
DRIs for infants

• Macronutrients based on average intake of breast
  milk
• Protein less than earlier RDA
• Energy EER

23
DRIs for infants

• Macronutrients based on average intake of breast
  milk
• Protein less than earlier RDA
• AAP Recommendations
• Vitamin D 200 IU supplement for breastfed
  infants and infants taking lt500 cc infant formula
• Iron Iron fortified formula (4-12 mg/L),
  Breastfed Infants supplemented 1mg/kg/d by 4-6
  months

24
Feeding Guidelines and Recommendations

• Public health policy
• Health promotion
• Prevention

25
Recommendations/guidelines

• DRI Dietary Reference Intakes
• AI
• UL
• EER
• AAP
• Bright Futures
• Start Healthy feeding guidelines

26
Comparison of individual intake data to a
reference or estimate of nutrient needs

• DRI Dietary Reference Intakes
• periodically revised recommendations (or
  guidelines) of the National Academy of Sciences
• quantitative estimates of nutrient intakes for
  planning and assessing diets for healthy people

• AI Adequate Intake
• UL Tolerable Upper Intake Level
• EER Estimated Energy Requirement

27
DRIs for infants

• Macronutrients based on average intake of breast
  milk
• Protein less than earlier RDA
• Factors to consider fetal endowment, individual
  variability, impact of diet on bioavailability
  and need

28
The Start Healthy Feeding Guidelines for Infants
and Toddlers (JADA, 2004)
29
Bright Futures

• AAP/HRSA/MCHB
• http//www.brightfutures.org
• Bright Futures is a practical development
  approach to providing health supervision for
  children of all ages from birth through
  adolescence.

30
Examples

• Transition
• Supplements to breastmilk
• Safety
• Allergy prevention
• Dental health
• other

31
Water
32
Water

• Water requirement is determined by
• water loss
• evaporation through the skin and respiratory
  tract (insensible water loss)
• perspiration when the environmental temperature
  is elevated
• elimination in urine and feces.
• water required for growth
• solutes derived from the diet

33
Water

• Water lost by evaporation in infancy and early
  childhood accounts for more than 60 of that
  needed to maintain homeostasis, as compared to
  40 to 50 later in life
• NAS recommends 1.5 ml water per kcal in infancy.

34
Renal

• Limited ability to concentrate urine in first
  year due to immaturities of nephron and pituitary
• Potential Renal solute load determined by
  nitrogenous end products of protein metabolism,
  sodium, potassium, phosphorus, and chloride.

35
Urine Concentrations

• Most normal adults are able to achieve urine
  concentrations of 1300 to 1400 mOsm/l
• Healthy newborns may be able to concentrate to
  900-1100 mOsm/l, but isotonic urine of 280-310
  mOsm/l is the goal
• In most cases this is not a concern, but may
  become one if infant has fever, high
  environmental temperatures, or diarrhea

36
Renal solute load

• Samuel Foman J Pediatrics Jan 1999 134 1
  (11-14)
• RSL is important consideration in maintaining
  water balance
• In acute febrile illness
• Feeding energy dense formulas
• Altered renal concentrating ability
• Limited fluid intake

37
Water Needs
38
Water

• Individual needs
• Renal concentrating ability
• Solute in diet
• Health
• environment

39

• Water vs fluid
• Concentrating formula decreases free water and
  increases RSL
• What is the water in 20 kcal/oz infant formula?
• 90
• To achieve 100 ml/kg/d needs to consume at least
  110 cc/kg/d

40
Energy Requirements

• Higher than at any other time per unit of body
  weight
• Highest in first month and then declines
• High variability - SD in first months is about 15
  kcal/kg/d
• Breastfed infants many have slighly lower energy
  needs
• RDA represents average for each half of first
  year

41
Energy Requirements, cont.

• RDA represents additional 5 over actual needs
  and is likely to be above what most infants need.
• Energy expended for growth declines from
  approximately 32.8 of intake during the first 4
  months to 7.4 of intake from 4 to 12 months

42
Energy Partition in Infancy (kcal/kg/d)
43
Energy Intakes by Breastfed and Formula Fed Boys
(kcal/kg)
44
2002 Energy DRI
45
EER

• 0-3 months (89 x wt -100) 175
• 4-6 months (89 x wt -100) 56
• 7-12 months (89 x wt -100) 22
• 13-35 months (89 x wt -100) 20
• Equations for older children factor in weight,
  height and physical activity level (PAL)

46
Examples of EER by age and weight
47
Energy

• Correlate individual intake with growth

48
2002 Carbohydrate DRI
49
Protein

• Increases in body protein are estimated to
  average about 3.5 g/day for the first 4 months,
  and 3.1 g/day for the next 8 months.
• The body content of protein increases from about
  11.0 to 15.0 over the first year

50
2002 Protein DRI
51
2002 Fat DRI
52
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53
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54
Essential Fatty Acids

• The American Academy of Pediatrics and the Food
  and Drug Administration specify that infant
  formula should contain at least 300 mg of
  linoleate per 100 kilocalories or 2.7 of total
  kilocalories as linoleate.

55
LCPUFA

• DHA and ARA

56
LCPUFA Background
57
LCPUFA Background

• Ability to synthesize 20 C FA from 18 C FA is
  limited.
• n-3 and n-6 fatty acids compete for enzymes
  required for elongation and desaturation
• Human milk reflects maternal diet, provides AA,
  EPA and DHA
• n-3 important for neurodevelopment, high levels
  of DHA in neurological tissues
• n-6 associated with growth skin integrity

58

• DHA represents 10 of total FA in brain grey
  matter, and 35 in rod and cone membranes of
  retina
• Synthetic ability to convert linolenic acid to
  DHA present when diet sufficient in w-3 FA (alpha
  linolenic)
• Alterations in visual and neurodevelopmental fx
  associate with insufficient DHA

59
Formula supplementation with long-chain
polyunsaturated fatty acids are there
developmental benefits? Scott et al.
Pediatrics, Nov. 1998.

• RCT, 274 healthy full term infants
• Three groups
• standard formula
• standard formula with DHA (from fish oil)
• formula with DHA and AA (from egg)
• Comparison group of BF

60
Outcomes at 12 and 14 months

• No significant differences in Bayley, Mental or
  Psychomotor Development Index
• Differences in vocabulary comprehension across
  all categories and between formula groups for
  vocabulary production.

61
Conclusion

• We believe that additional research should be
  undertaken before the introduction of these
  supplements into standard infant formulas.

62
PUFA Status and Neurodevelopment A summary and
critical analysis of the literature (Carlson and
Neuringer, Lipids, 1999)

• In animal studies use deficient diets through
  generations - effects on newborn development may
  be through mothering abilities.
• Behaviors of n-3 fatty acid deficient monkeys
  higher frequency of stereotyped behavior,
  locomotor activity and behavioral reactivity

63
Efficacy and safety of docosahexaenoic acid and
arachidonic acid addition to infant formulas can
one buy better vision and intelligence?(Koo. J
Am Coll Nutr. 2003 Apr22(2)101-7)

• Functional benefits in particular visual or
  neural development from IF containing LCPUFA
  remains controversial.
• Potential for excessive and/or imbalanced intake
  of n-6 and n-3 fatty acids exists with increasing
  fortification of LCPUFA to infant foods other
  than IF.

64
Formula Supplemented with DHA ARA A Critical
Review of the Research (Wright et al, 2006)

• 10 RCTs from 1997-2003 of variable quality
• Considered the strength of each study by looking
  at indices of research quality.

65
Wright et al, cont.

• Growth (7 studies)
• no differences in weight, length, OFC
• FA in blood (7 studies)
• DHA ARA higher with supplementation
• those supplemented with only DHA had lower levels
  of ARA than those on standard formula
• Supplementation with LCPUFA for only 17 weeks
  lead to higher EFA levels at 1 year of age

66
Wright et al, cont.

• Vision (6 trials)
• 2 found better visual function with LCPUFA , 4
  did not
• Neurodevelopment
• 1 of 4 found positive results on Bayley Scales of
  Infant Development II
• 2 of 5 found positive information
  processing/IQ/cognitive effects

67
Wright et al, cont

• Conclusions
• No detrimental effects found
• Possibly a small improvement in visual acuity,
  but significance of this small effect in global
  development is questionable
• thoughtful consideration is advised before
  recommending more expensive formula for term
  infants.

68
Longchain polyunsaturated fatty acid
supplementation in infants born at term
(Cochrane, 2001).

• At present there is little evidence from
  randomised trials of LCPUFA supplementation to
  support the hypothesis that LCPUFA
  supplementation confers a benefit for visual or
  general development of term infants.
• A beneficial effect on information processing is
  possible but larger studies over longer periods
  are required to conclude that LCPUFA
  supplementation provides a benefit when compared
  with standard formula.
• Data from randomised trials do not suggest that
  LCPUFA supplements influence the growth of term
  infants

69
Omega-3 FA and Neural Development to 2 years of
Age Do we Know enough for Dietary
Recommendations Innis JPGN 48S16-242009

• Estimated requirement and variability among
  individuals necessary to set DRI
• Dietary recommendations affect food supply and
  supplements and are used in labeling
• When scientific information is incomplete,
  consideration must be given to implications of
  recommendations

70
Omega-3 FA and Neural Development to 2 years of
Age Do we Know enough for Dietary
Recommendations Innis JPGN 48S16-242009

• While there is no doubt that DHA is critical
  for the developing brain, western diets poor in
  w-3 FA and rich in w-6 FA are becoming
  increasingly implicated in contributing to risk
  of poor neurodevelopment and function..The w-3
  FAs are clearly essential nutrients, suggesting
  that dietary recommendations, such as AI, to
  minimize risk of poor CNS development can be
  justified, and are consistent with a philosophy
  of dietary advice that promotes optimal child
  development and health. However, because dietary
  recommendations often promulgate changes in the
  food supply and supplement use..premature
  recommendations based on incomplete science that
  focus on individual nutrients rather than dietary
  practices such as breastfeeding and foods such as
  fish rich in DHA are not necessarily in the best
  public interest

71
Vitamin K
72
Vitamin K

• 2 forms K1 or phylloquinone (plant form) and K2
  (synthesized by bacteria)
• Function cofactor inmetabolic conversion of
  precursors of Vitamin K dependent proteins to
  active form ( eg prothrombins, osteocalcin)

73
Vitamin K

• Lack of specific information regarding an
  infants requirement
• Vitamin K concentration of breastmilk is low and
  for the breastfeeding infant a deficiency state
  has been described
• No gold standard available

74
Vitamin K

• DRI for infants 2-2.5 ug/day
• Formula provides 7-9 ug/kg/d
• BM contains lt 10 ug/L
• Hemorrhagic disease of the NewbornVitamin K
  deficiency
• Prophylaxis 1 mg Vitamin K IM for all newborn
  infants

75
Vitamin K Controversy

• Adequacy of BM
• Maternal Diet and Vitamin A content of BM
• ? Significance/prevalence of hemorrhagic disease
  of newborn
• IM injections of all newborns

76
Controversies Concerning Vitamin K and the
Newborn AAP Policy Statement, 2003
77
Vitamin K Deficiency- definitions AAP, 2003
Term Age and Incidence Symptoms
Early vitamin K deficiency bleeding (VKDB) First week of life Unexpected bleeding in previously healthy-appearing neonates
Late VKDB 2-12 weeks of age unexpected bleeding attributable to severe vitamin K deficiency
Formerly known as classic hemorrhagic disease
of the newborn
78
Incidence of VKDB

• Early 0.251.7 incidence
• Late
• No vitamin K prophylaxis 4.4 to 7.2 per 100,000
  births
• Single oral vitamin K prophylaxis1.4 to 6.4 per
  100 000 births
• IM vitamin K prophylaxis 0
• Oral vitamin K has effect similar to IM in
  preventing early VKDB, but not in preventing late
  VKDB

79
Danielson et al Arch Dis Child 2004 89F546-550

• Late onset vitamin K deficient bleeding in
  infants who did not receive prophylactic vitamin
  K at birth in Hanoi province
• Incidence 116 per 100,000 births
• Higher in rural areas
• 9 mortality
• 42 impaired neurodevelopmental status at
  discharge in survivors

80
Incidence

• Netherlands 2005 3.2 per 100,000 births
• Canada 2004 0.45 per 100,000 births
• Conclude low incidence associated with current
  practice of prophylactic Vitamin K at birth

81
Closing the LoopholeMidwives and the
Administration of Vitamin K in the Neonate

• Adame and Carpenter J Pediatr 2009 154769-771
• Case Report of a previously healthy, exclusively
  breastfed 6 week old infant delivered by a
  midwife on the south Texas border. Did not
  receive Vitamin K at birth. Admitted with severe
  intracranial hemorrhage, cooagulopathy, and
  seizures, unresponsive, pupils fixed and dialated

82
Cochran Prophylactic Vitamin K for preventing
haemorrhagic disease in newborn infants

• Vitamin K deficiency can cause bleeding in an
  infant in the first weeks of life. This is known
  as Haemorrhagic Disease of the Newborn (HDN) or
  Vitamin K Deficiency Bleeding (VKDB).

83
Cochran

• The risk of developing vitamin K deficiency is
  higher for the breastfed infant because breast
  milk contains lower amounts of vitamin K than
  formula milk or cow's milk

84
Cochran

• In different parts of the world, different
  methods of vitamin K prophylaxis are practiced.

85
Cochran

• Oral Doses
• The main disadvantages are that the absorption is
  not certain and can be adversely affected by
  vomiting or regurgitation. If multiple doses are
  prescribed the compliance can be a problem

86
Cochran

• I.M. prophylaxis is more invasive than oral
  prophylaxis and can cause a muscular haematoma.
  Since Golding et al reported an increased risk of
  developing childhood cancer after parenteral
  vitamin K prophylaxis (Golding 1990 and 1992)
  this has been a reason for concern .

87
Cochrane Conclusions, 2000

• A single dose (1.0 mg) of intramuscular vitamin K
  after birth is effective in the prevention of
  classic HDN.
• Either intramuscular or oral (1.0 mg) vitamin K
  prophylaxis improves biochemical indices of
  coagulation status at 1-7 days.
• Neither intramuscular nor oral vitamin K has been
  tested in randomized trials with respect to
  effect on late HDN.
• Oral vitamin K, either single or multiple dose,
  has not been tested in randomized trials for its
  effect on either classic or late HDN.

88
Brousson and Klien, Controversies surrounding the
administration of vitamin K to newborns a
review. CMAJ. 154(3)307-315, February 1,
1996.

• Study selection Six controlled trials met the
  selection criteria a minimum 4-week follow-up
  period, a minimum of 60 subjects and a comparison
  of oral and intramuscular administration or of
  regimens of single and multiple doses taken
  orally. All retrospective case reviews were
  evaluated. Because of its thoroughness, the
  authors selected a meta-analysis of almost all
  cases involving patients more than 7 days old
  published from 1967 to 1992. Only five studies
  that concerned safety were found, and all of
  these were reviewed

89
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Brousson and Klien, Controversies surrounding the
administration of vitamin K to newborns a
review. CMAJ. 154(3)307-315, February 1,
1996.

• Data synthesis Vitamin K (1 mg, administered
  intramuscularly) is currently the most effective
  method of preventing HDNB. The previously
  reported relation between intramuscular
  administration of vitamin K and childhood cancer
  has not been substantiated. An oral regimen
  (three doses of 1 to 2 mg, the first given at the
  first feeding, the second at 2 to 4 weeks and the
  third at 8 weeks) may be an acceptable
  alternative but needs further testing in
  largeclinical trials.

91
Brousson and Klien, Controversies surrounding the
administration of vitamin K to newborns a
review. CMAJ. 154(3)307-315, February 1, 1996

• Conclusion There is no compelling evidence to
  alter the current practice of administering
  vitamin K intramuscularly to newborns.

92
AAP Recommendations PediatricsVol1121 July 2003

• 1. Vitamin K1 should be given to all newborns as
  a single, intramuscular dose of 0.5 to 1 mg.
• 2. Further research on the efficacy, safety, and
  bioavailability of oral formulations of vitamin K
  is warranted.

93
AAP Recommendations

• 3. Health care professionals should promote
  awareness among families of the risks of late
  VKDB associated with inadequate vitamin K
  prophylaxis from current oral dosage regimens,
  particularly for newborns who are breastfed
  exclusively
• 4. Earlier concern regarding a possible causal
  association between IM vitamin K and childhood
  cancer has not been substantiated

94

• Note put recent articles on re-emergence of HDNB
  texas, ? Japan

95
Vitamin D
96
Vitamin D

• Role
• Source
• Dietary
• sunlight
• Deficiency
• Rickets

97
Role

• Enhances intestinal absorption of Ca
• Increase tubular resorption of Ph
• Mediation of recycling of Ca and Ph for bone
  growth and remodeling
• Sterol hormone
• Deficiency Rickets

98
Role

• Extraskeletal effects of Vitamin D
• Modulates B and T Lymphocyte fx and deficiency
  may be associated with autoimmune diseases
  (diabetes, MS associations)
• Regulation of cell growth (assoc with breast,
  prostrate, and colon cancer)

99
Prevalence

• Thought to be disease of past (prior to 1960s)
• Disappeared secondary to recognition of role of
  sunlight, fortification of milk, use of
  multivitamins, AAPCON recommendation for 400 IU
  supplementation of infants

100
Prevalence

• Increased incidence and case reports 19702
• No national data in US
• Georgia 1997-99 9 per million hospitalized
  children
• National Hospital Discharge Survey 9 per million
• Pediatric Research in Office Setting (AAP)23-32
  hospitalized cases reported 1999-2000

101
Prevalence

• Literature Review
• 13 articles published between 1996-2001
• 122 case reports

102
Prevention of Rickets and Vitamin D Deficiency
New Guidelines for Vitamin D Intake

• PEDIATRICS Vol. 111 No. 4 April 2003, pp. 908-910

103
Vitamin D and Sunlight

• Vitamin D requirements are dependent on the
  amount of exposure to sunlight.
• Dermatologists recommend caution with sun
  exposure.
• Sunscreens markedly decrease vitamin D production
  in the skin
• Decreased sunlight exposure occurs during the
  winter and other seasons and when sunlight is
  attenuated by clouds, air pollution, or the
  environment
• AAP recommends against exposing infants lt 6
  months to direct sun

104
Breastfeeding and Vitamin D

• Breastmilk has lt 25 IU/L Recommended adequate
  intake can not be met with breastmilk alone
• Formerly stated that needs could be met with sun
  exposure, but now, due to cancer concerns
  recommend against this

105
Vitamin D Recommendations

• Before 2003 AAP recommended 10 mg (400 IU) per
  day for breastfeed infants
• 2003 American Academy of Pediatrics recommends
  supplements of 5 mg (200 IU) per day for all
  infants as recommended in DRIs.
• 10/14/2008 AAP updates guidelines vor vitamin D
  intake for infants, children, and teens to be
  published in Nov 5th ed Pediatrics
• 400 IU per day intake of vitamin D beginning in
  first few days of life

106
Formulas

• if an infant is ingesting at least 500 mL per day
  of formula (vitamin D concentration of 400 IU/L),
  he or she will receive the recommended vitamin D
  intake of 200 IU per day.
• If intake is less than 500 ml recommend
  additional supplement of vitamin D

107
Summary of AAP Recommendations, 2003

• All breastfed infants unless they are weaned to
  at least 500 mL per day of vitamin D-fortified
  formula or milk.
• All nonbreastfed infants who are ingesting less
  than 500 mL per day of vitamin D-fortified
  formula or milk.
• Children and adolescents who do not get regular
  sunlight exposure, do not ingest at least 500 mL
  per day of vitamin D-fortified milk, or do not
  take a daily multivitamin supplement containing
  at least 200 IU of vitamin D.

108
AAP Recommendations for Vitamin D

• 2008
• Intake of 400 IU beginning in first few days of
  life
• Supplement breastfed, partially breastfed,
  infants and children consuming less than 1 liter
  formula or vitamin D fortified whole milk
• Wagner et al Prevention of Rickets and Vitamin D
  Deficiency in Infants, Children, and Adolescents
  Pediatrics 20081221142-1152

109
Vitamin D

• DRI B-6 months 200 IU, 7-12 months 250 IU
• UL 1000 IU

110
Iron
111
Iron

• Function
• Source
• Formula, breast milk, other foods
• Bioavailability
• Breast milk
• Soy formula
• Deficiency
• Anemia

112
Anemia

• Anemia (low Hct, Hgb not specific for iron
  deficiency)
• Causes
• Inadequate iron in diet
• Loss
• GI bleeding, cows milk proteins, infectious
  agents
• Other
• Genetics
• Lead
• Other nutrients

113
Iron

• Biological function
• Oxygen transport primarily in hemoglobin
• Component of other proteins including cytochrome
  a, b, c, and cytochrome oxidase essential for
  electron transport and cellular energetics

114
Iron deficiency (ID and IDA)

• Anemia Hgb lt11 g/dl 12-36 months
• Iron deficiency Anemia (IDA) anemia due to iron
  deficiency
• Iron deficiency Insufficient iron to maintain
  normal physiologic functions leading to decrease
  in iron stores as measured by serum ferritin with
  or without IDA

115

• Association between ID an IDA and neurobehavioral
  development
• Lozoff
• McCann and Ames
• Cochrane review
• Carter
• Recent sleep studies

116
Iron Deficiency Anemia

• Impact on social, neurobehavioral and sleep
• Peirano et al Sleep and Neurofunction Throughout
  Child development Lasting Effects of Early Iron
  Deficiency J Ped Gastroenterology and Nutr 2009
  48S8-S15
• Lozoff et al Dose-Response Relationships between
  Iron deficiency with or without anemia and Infant
  Social-emotional Behavior J Pediatr 2008
  152696-702

117
Peirano

• Slower neurotransmission in auditory and visual
  systems
• Different motor activity patterning sleep-waking
  and sleep state organization
• Alterations in behavioral and cognitive function

118
Lozoff

• N77
• Infant social-emotional behavior appears to be
  adversely affected by iron deficiency with or
  without anemia
• Shyness, orientation engagement, soothability

119
Carter et al Iron Deficiency Anemia and
Cognitive Function in Infancy Pediatrics 2010
1262427-e434

• N 87 (28 IDA, 49 no anemia)
• Methods at 9 and 12 months series of cognitive,
  intellegent and behavioral tests administered
  (Fagan test of infant intellegence (FTII),
  Emotionality, Activity and Sociability Temperment
  Survey, and Behavior Rating Scale (BRS))

120
Carter et al Iron Deficiency Anemia and
Cognitive Function in Infancy Pediatrics 2010
1262427-e434

• N 87 (28 IDA, 49 no anemia)
• Methods at 9 and 12 months series of cognitive,
  intellegent and behavioral tests administered
  (Fagan test of infant intellegence (FTII),
  Emotionality, Activity and Sociability Temperment
  Survey, and Behavior Rating Scale (BRS))

121
Carter et al Iron Deficiency Anemia and
Cognitive Function in Infancy Pediatrics 2010
1262427-e434

• Results
• Sociodemographic background similar between 2
  groups
• IDA infants less likely to exhibit object
  permanence, less novelty preference on the FTII,
  lower BRS scores, and decrease engagement/orientat
  ion, described as shyer

122
Iron Deficiency

• Among children in developing world, iron is the
  most common single nutrient deficiency
• No national statistics for prevalence of ID or
  IDA lt 12 months

123
Iron Fortification of Formula

• The increased use of iron-fortified infant
  formulas from the early 1970s to the late 1980s
  has been a major public health policy success.
  During the early 1970s, formulas were fortified
  with 10 mg/L to 12 mg/L of iron in contrast with
  nonfortified formulas that contained less than 2
  mg/L of iron. The rate of iron-deficiency anemia
  dropped dramatically during that time from more
  than 20 to less than 3.

124
ID and IDA 12-35 Months NHANES 2002
Population ID () IDA ()
General US 9.2 2.1
Above poverty 8.9 2.2
Below poverty 8.6 2.3
Enrolled in WIC 10.7 3.2
Mexican American 13.9 0.9
Other ethnicity 15.2 4.4
125
Iron

• Iron absorption from soy formulas is less
• Greater bioavailabilty of iron in breastmilk

126
Iron Absorption In Infancy
127
Iron Deficiency in Breastfeeding

• At 4 to 5 months prevalence of low iron stores in
  exclusively breastfed infants is 6 - 20.
• A higher rate (20-30) of iron deficiency has
  been reported in breastfed infants who were not
  exclusively breastfed
• The effect of iron obtained from formula or
  beikost supplementation on the iron status of the
  breastfed infant remains largely unknown and
  needs further study.

128
Foman on Iron - 1998

• Proposes that breastfed infants should have
  supplemental iron (7 mg elemental) starting at 2
  weeks.
• Rational
• some exclusively breastfed infants will have low
  iron stores or iron deficiency anemia
• Iron content of breastmilk falls over time
• animal models indicate that deficits due to Fe
  deficiency in infants may not be recovered when
  deficiency is corrected.

129
AAP recommendations for Dx and prevention of ID
and IDA2010Pediatrics 2010 126 5

• Birth-6 months 0.27 mg/d
• Assuming average content Breastmilk 0.35 mg/L and
  average intake 0.78 L/day
• Noted variability of iron content of breastmilk,
  high risk populations (IUGR, LGA associate with
  maternal IDM, maternal anemia, Preterm birth)

130
AAP recommendations for Dx and prevention of ID
and IDA2010Pediatrics 2010 126 5

• 7-12 months 11 mg/d
• Factorial approach iron loss, iron needed for
  increased blood volume, tissue mass, and stores
• Noted that there isnt a sudden increase in needs
  from 6 to 7 months.

131
AAP recommendations for Dx and prevention of ID
and IDA2010Pediatrics 2010 126 5

• Diagnosis
• Iron status is a continuum with IDA at one end of
  the spectrum
• No single measurement is currently available to
  characterize iron status
• HgB limitations include specificity and
  sensitivity. Identifies anemia but not
  necessarily ID or IDA

132
AAP recommendations for Dx and prevention of ID
and IDA2010Pediatrics 2010 126 5

• Term, healthy infants have sufficient Fe to 4
  months.
• Formula fed Fe needs met by standard infant
  formula with 12 mg/dl and introduction of
  complementary foods after 4-6 months. Whole milk
  shouldnt be used lt 12 months
• Breastfed Exclusively breastfed infants are a
  increasing risk of ID gt4 months and should be
  supplemented with 1 mg/kg/d oral Fe until
  appropriate complimentary food are introduced

133
AAP recommendations for Dx and prevention of ID
and IDA2010Pediatrics 2010 126 5

• 6-12 months
• 11 mg/d
• Use complimentary foods with higher iron content.
  Liquid supplement may be needed to augment
  complimentary foods

134
AAP recommendations for Dx and prevention of ID
and IDA2010Pediatrics 2010 126 5

• Univeral screening should be done at 12 months
  with Hgb and risk determination
• Additional screening can be preformed at any time
  if there is a risk of ID/IDA including inadequate
  intake

135
Lead and Anemia
136
Fluoride

• Fluoride and dental caries
• At beginning of 20th century dental caries was
  common with extraction only treatment available
• Failure to meet minimum standards of 6 opposing
  teeth was common cause of rejection from military
  service in WWI and WWII

137
Fluoride

• 1901 Dr. Frederick S Mckay noted mottled teeth
  (fluorosis) in practice in Colo Springs Colo that
  were resistent to decay
• 1909 Dr. FC Robertson noted same mottling in his
  area of practice after a new well dug
• Believed was due to something in the water

138
Fluoride

• 1945 study was conducted in 4 city pairs
  (Michigan, NY, Illinois, Ontario)
• Followed 13-15 years
• 50-60 reduction in dental caries

139
Fluoride

• Proposed mode of action
• Promotes remineralization of areas of cariogenic
  lesions
• Increases resistance to acid demineralization
• Interferes with formation and function of plaque
  forming microorganisms
• Improves tooth morphology

140
Fluoride

• Concerns
• Excess
• Fluorosis
• Cancer
• other

141
Fluoride

• Fluoride Recommendations were changed in 1994 due
  to concern about fluorosis.
• Breast milk has a very low fluoride content.
• Fluoride content of commercial formulas has been
  reduced to about 0.2 to 0.3 mg per liter to
  reflect concern about fluorosis.
• Formulas mixed with water will reflect the
  fluoride content of the water supply. Fluorosis
  is likely to develop with intakes of 0.1 mg/kg or
  more.

142
Fluoride, cont.

• Fluoride adequacy should be assessed when infants
  are 6 months old.
• Dietary fluoride supplements are recommended for
  those infants who have low fluoride intakes.

143
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144
Early Childhood Caries

• AKA Baby Bottle Tooth Decay
• Rampant infant caries that develop between one
  and three years of age

145
Early Childhood Caries Etiology

• Bacterial fermentation of cho in the mouth
  produces acids that demineralize tooth structure
• Infectious and transmissible disease that usually
  involves mutans streptococci
• MS is 50 of total flora in dental plaque of
  infants with caries, 1 in caries free infants

146
Early Childhood Caries Etiology

• Sleeping with a bottle enhances colonization and
  proliferation of MS
• Mothers are primary source of infection
• Mothers with high MS usually need extensive
  dental treatment

147
Early Childhood Caries Pathogenesis

• Rapid progression
• Primary maxillary incisors develop white spot
  lesions
• Decalcified lesions advance to frank caries
  within 6 - 12 months because enamel layer on new
  teeth is thin
• May progress to upper primary molars

148
Early Childhood Caries Prevalence

• US overall - 5
• 53 American Indian/Alaska Native children
• 30 of Mexican American farmworkers children in
  Washington State
• Water fluoridation is protective
• Associated with sleep problems later weaning

149
Early Childhood Caries Cost

• 1,000 - 3,000 for repair
• Increased risk of developing new lesions in
  primary and permanent teeth

150
Early Childhood Caries Prevention

• Anticipatory Guidance
• importance of primary teeth
• early use of cup
• bottles in bed
• use of pacifiers and soft toys as sleep aides

151
Early Childhood Caries Prevention

• Chemotheraputic agents fluoride varnishes and
  supplements, chlorhexidene mouthwashes for
  mothers with high MS counts
• Community education training health providers
  and the public for early detection

152
Infant Feeding

• Implications
• Translation into practice
• Recommendations