Infant nutrient needs

1
Infantnutrient needs

• Basis
• Approach
• Specific nutrients
• water
• energy
• protein
• fatty acids
• vitamin K
• Vitamin D
• Iron
• Fluoride

2
Basis of recommendations

• Growth and development
• Preventing deficiencies
• Meeting nutrient requirements
• Physiology
• GI
• Renal
• Programming
• Preventing chronic conditions
• Optimizing health through lifecycle

3
Goals and Objectives

• Optimal growth and development
• Safety
• Individual health
• Population Health
• Prevention and Chronic Illness

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
1940s

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

6
United Nations 5th report on World Nutrition
March 2004
Prevalence () 1990 2005
underweight 35.2 26.5
Iodine deficiency 35.2
7
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

8

• Reports in US of PEM, Rickets, Zinc deficiencies

9
Causes

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

10
Physiology - GI Maturation
11
In utero

• Fetal GI tract is exposed to constant passage of
  fluid that contains a range of physiologically
  active factors
• growth factors
• hormones
• enzymes
• immunoglobulins
• These play a role in mucosal differentiation and
  GI development as well as development of
  swallowing and intestinal motility

12
At Birth

• Gut of the newborn is faced with the formidable
  task of passing, digesting, and absorbing large
  quantities of intermittent boluses of milk
• Comparable feeds per body weight for adults would
  be 15 to 20 L

13
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.

14
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

15
Programming by Early Diet

• Nutrient composition in early diet may have long
  term effects on GI function and metabolism
• 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

16
Nutrients

• Guidelines
• Recommendations
• Education

17
Individual Requirements

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

18
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

19
Recommendations/guidelines

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

20

• 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

21
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

22
Water
23
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

24
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.

25
Water Needs
26
Water

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

27
Water

• Water balance
• RSL in diet
• Water in
• Water out
• Renal concentrating ability

28
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

29

• 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

30
Energy
31
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

32
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

33
Energy Partition in Infancy (kcal/kg/d)
34
Energy Intakes by Breastfed and Formula Fed Boys
(kcal/kg)
35
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)

36
2002 Energy DRI
37
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

38
2002 Protein DRI
39
2002 Carbohydrate DRI
40
2002 Fat DRI
41
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43
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.

44
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.

45
LCPUFA

• DHA and ARA

46
LCPUFA Background
47
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

48
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

49
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.

50
Bayley Scales at 12 months
51
MacArthur Communicative Development Inventories
at 14 Months of Age
52
Conclusion

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

53
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

54
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.

55
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.

56
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

57
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

58
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.

59
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

60
Vitamins and Minerals

• Need for minerals and vitamins increased per kg
  compared to adults
• growth rates
• mineralization of bone increases in bone length
• Increased blood volume
• energy, protein, and fat intakes

61
Vitamins and Minerals

• Focus on nutrients with controversies and/or
  recent research
• Vitamin K
• Vitamin D
• Iron
• Fluoride

62
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

63
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

64
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

65
Controversies Concerning Vitamin K and the
Newborn AAP Policy Statement, 2003
66
Vitamin K Deficiency- definitions AAP, 2003
Term Age of onset Symptoms
Early vitamin K deficiency bleeding (VKDB) First week of life Unexpected bleeding in previously healthy-appearing neonates
Late VKDB 2-12 weeks unexpected bleeding attributable to severe vitamin K deficiency
Formerly known as classic hemorrhagic disease
of the newborn
67
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

68
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).

69
Cochran

• Vitamin K is necessary for the synthesis of
  coagulation factors II (prothrombin), VII, IX and
  X in the liver.
• In the absence of vitamin K the liver will
  synthesize inactive precursor proteins, known as
  PIVKAs (proteins induced by the absence of
  vitamin K).
• HDN is caused by low plasma levels of the vitamin
  K-dependent clotting factors. In the newborn the
  plasma concentrations of these factors are
  normally 30-60 of those of adults. They
  gradually reach adult values by six weeks of age

70
Cochran

• HDN is divided into three categories early,
  classic and late HDN. Early HDN occurs within 24
  hours post partum and falls outside the scope of
  this review.
• Classic HDN occurs on days 1-7. Common bleeding
  sites are gastrointestinal, cutaneous, nasal and
  from a circumcision. Late HDN occurs from week
  2-12.
• The most common bleeding sites in this latter
  condition are intracranial, cutaneous, and
  gastrointestinal (Hathaway 1987 and von Kries
  1993).

71
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

72
Cochran

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

73
The problem

• Oral vitamin K has effect similar to IM in
  preventing early VKDB, but not in preventing late
  VKDB

74
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

75
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 .

76
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.

77
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

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79
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.

80
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.

81
AAP Recommendations

• 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.

82
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

83
Cochran

• HDN is divided into three categories early,
  classic and late HDN. Early HDN occurs within 24
  hours post partum and falls outside the scope of
  this review.
• Classic HDN occurs on days 1-7. Common bleeding
  sites are gastrointestinal, cutaneous, nasal and
  from a circumcision. Late HDN occurs from week
  2-12.
• The most common bleeding sites in this latter
  condition are intracranial, cutaneous, and
  gastrointestinal (Hathaway 1987 and von Kries
  1993).

84
Vitamin D
85
Vitamin D

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

86
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

87
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

88
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

89
Prevalence

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

90
Prevention of Rickets and Vitamin D Deficiency
New Guidelines for Vitamin D Intake

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

91
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

92
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

93
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

94
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

95
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.

96
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

97
Iron
98
Iron

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

99
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

100
Iron

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

101
Iron in Formula

• Infant formulas have been classified as low-iron
  or iron-fortified based on whether they contain
  less or more than 6.7 mg/L of iron.
• Current mean content of low iron formula is 1.1
  to 1.5 mg/L of iron and high iron is 10 to 12
  mg/L.
• One company recently increased to 4.5 for low
  iron.
• European formulas are 4-7 mg/l
• Foman found same levels of iron deficiency at 8
  and 12 mg/l

102
Iron Absorption In Infancy
103
Iron deficiency

• Anemia
• Inadequate iron in diet
• Loss
• GI bleeding, cows milk proteins, infectious
  agents
• Other causes
• Genetics
• Lead
• Other nutrients

104
Iron Fortification of Infant FormulasPediatrics,
July 1999 v104 i1 p119

• During the first 4 postnatal months, excess fetal
  red blood cells break down and the infant retains
  the iron. This iron is used, along with dietary
  iron, to support the expansion of the red blood
  cell mass as the infant grows. The estimated iron
  requirement of the term infant to meet this
  demand and maintain adequate stores is 1 mg/kg
  per day.
• Infants born prematurely and those born to poorly
  controlled diabetic mothers are at higher risk of
  iron deficiency

105
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.

106
Iron Fortified Formula Iron Deficiency

• 9-30 of current US sales are low-iron formulas
• Iron deficiency leads to reduction of
  iron-containing cellular protein before it can be
  detected as iron deficiency anemia by hct or hgb
• Permanent effects of Fe deficiency on cognitive
  function are of special concern.

107
Iron Deficiency Prevalence at 9 Months
108
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.

109
GI Effects Attributable to Iron

• Double blind RTC have not found effects.
• Most providers know that, but parents often want
  to change to low iron..
• yet it may remain temptingly easier to prescribe
  a low-iron formula, achieve a placebo effect, and
  ignore the more insidious long-term consequences
  of iron deficiency.

110
AAP Iron Recommendations

• 1. In the absence of underlying medical factors
  (which are rare), human milk is the preferred
  feeding for all infants.
• 2. Infants who are not breastfed or are partially
  breastfed should receive an iron-fortified
  formula (containing between 4.0-12 mg/L of iron)
  from birth to 12 months. Ideally, iron
  fortification of formulas should be standardized
  based on long-term studies that better define
  iron needs in this range

111
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.

112
AAP Iron Recommendations

• 1. In the absence of underlying medical factors
  (which are rare), human milk is the preferred
  feeding for all infants.
• 2. Infants who are not breastfed or are partially
  breastfed should receive an iron-fortified
  formula (containing between 4.0-12 mg/L of iron)
  from birth to 12 months. Ideally, iron
  fortification of formulas should be standardized
  based on long-term studies that better define
  iron needs in this range

113
AAP Iron Recommendations

• 3. The manufacture of formulas with iron
  concentrations less than 4.0 mg/L should be
  discontinued. If these formulas continue to be
  made, low-iron formulas should be prominently
  labeled as potentially nutritionally inadequate
  with a warning specifying the risk of iron
  deficiency. These formulas should not be used to
  treat colic, constipation, cramps, or
  gastroesophageal reflux.

114
AAP Iron Recommendations

• 4. If low-iron formula continues to be
  manufactured, iron-fortified formulas should have
  the term "with iron" removed from the front
  label. Iron content information should be
  included in a manner similar to all other
  nutrients on the package label.

115
AAP Iron Recommendations

• Parents and health care clinicians should be
  educated about the role of iron in infant growth
  and cognitive development, as well as the lack of
  data about negative side effects of iron and
  current fortification levels.

116
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.

117
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

118
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

119
Fluoride

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

120
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

121
Fluoride

• Concerns
• Excess
• Fluorosis
• Cancer
• other

122
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.

123
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.

124
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125
Feeding Guidelines and Recommendations

• Public health policy
• Health promotion
• Prevention

126
The Start Healthy Feeding Guidelines for Infants
and Toddlers (JADA, 2004)
127
Examples

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

128
Some Issues Foman, 1993

• For the infant fed an iron-fortified formula,
  consumption of beikost is important in the
  transition from a liquid to a nonliquid diet, but
  not of major importance in providing essential
  nutrients.
• Breastfed infants nutritional role of beikost
  is to supplement intakes of energy, protein,
  perhaps Ca and P.
• Nutrient content of breastmilk is a compromise
  between maternal and infant needs. Most human
  societies supplement breastmilk early in life.

129
C-P-F Recommendations

• No strong evidence for benefits from fat
  restriction early in life
• AAP recommends
• high carbohydrate infant foods may be appropriate
  for formula fed infants
• no fat restriction in first year
• a varied diet after the first year
• after 2nd year, avoid extremes, total fat intake
  of 30-40 of kcal suggested

130
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.

131
Early Introduction of Foods(Fergussson et al,
Pediatrics, 1990)
132
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

133
Allergies Prevention by Avoidance (Marini, 1996)
134
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

135
Allergies Prevention by Avoidance (Zeigler,
Pediatr Allergy Immunol. 1994)
136
Early Childhood Caries

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

137
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

138
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

139
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

140
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

141
Early Childhood Caries Cost

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

142
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

143
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

144
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.

145
Newborn Visit Breastfeeding

• Infant Guidance
• how to hold the baby and get him to latch on
  properly
• feeding on cue 8-12 times a day for the first
  four to six weeks
• feeding until the infant seems content.
• Newborn breastfed babies should have six to eight
  wet diapers per day, as well as several
  "mustardy" stools per day.
• Give the breastfeeding infant 400 I.U.'s of
  vitamin D daily if he is deeply pigmented or does
  not receive enough sunlight.

146
Newborn Visit Breastfeeding

• Maternal care
• rest
• fluids
• relieving breast engorgement
• caring for nipples
• eating properly
• Follow-up support from the health professional by
  telephone, home visit, nurse visit, or early
  office visit.

147
Newborn Visit Bottle-feeding

• type of formula, preparation
• feeding techniques, and equipment.
• Hold baby in semi-sitting position to feed.
• Do not use a microwave oven to heat formula. To
  avoid developing a habit that will harm your
  infant's teeth, do not put him to bed with a
  bottle or prop it in his mouth.

148
First Week

• Do not give the infant honey until after her
  first birthday to prevent infant botulism.
• To avoid developing a habit that will harm your
  infant's teeth, do not put her to bed with a
  bottle or prop it in her mouth.

149
One Month

• Delay the introduction of solid foods until the
  infant is four to six months of age. Do not put
  cereal in a bottle.

150
Four Months

• Continue to breastfeed or to use iron-fortified
  formula for the first year of the infant's life.
  This milk will continue to be his major source of
  nutrition.
• Begin introducing solid foods with a spoon when
  the infant is four to six months of age.
• Use a spoon to give him an iron-fortified,
  single-grain cereal such as rice.

151
Four Months, cont.

• If there are no adverse reactions, add a new
  pureed food to the infant's diet each week,
  beginning with fruits and vegetables.
• Always supervise the infant while he is eating.
• Give exclusively breastfeeding infants iron
  supplements.
• Continue to give the breastfeeding infant 400
  I.U.'s of vitamin D daily if he is deeply
  pigmented or does not receive enough sunlight.
• Do not give the infant honey until after his
  first birthday to prevent infant botulism. .

152
Six Months

• Continue to breastfeed or use iron-fortified
  formula for the first year of the infant's life.
  This milk will continue to be her major source of
  nutrition.
• Avoid giving the infant foods that may be
  aspirated or cause choking (e.g., peanuts,
  popcorn, hot dogs or sausages, carrot sticks,
  celery sticks, whole grapes, raisins, corn, whole
  beans, hard candy, large pieces of raw vegetables
  or fruit, tough meat).
• Learn emergency procedures for choking.

153
Six Months, cont.

• Let the infant indicate when and how much she
  wants to eat.
• Serve solid food two or three times per day.
• Begin to offer a cup for water or juice.
• Limit juice to four to six ounces per day.
• Give iron supplements to infants who are
  exclusively breastfeeding.

154
Nine Months

• Start giving the infant table foods in order to
  increase the texture and variety of foods in his
  diet.
• Encourage finger foods and mashed foods as
  appropriate.
• Closely supervise the infant while he is eating.
• Continue teaching the infant how to drink from a
  cup.
• Continue to breastfeed or use iron-fortified
  formula for the first year of the infant's life.