Dominique TurckJeanne de Flandre Children’s Hospital,

and University of Lille, Lille, France.dominique.turck@chru-lille.fr

•Infant feeding- Goat’s milk proteins and IF-FOF- Rice protein hydrolysates- Prebiotics/Probiotics- Health claims

•Complementary feeding- Definitions - When? Timing

- What? Content of the diet - How? Feeding practices

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Symptom Number

AD 54

Urticaria 32

Asthma 26

Gastro-intestinal 24

Shock 16

Angioedema 11

Rhinitis 9

Conjunctivitis 2

Laryngospasm 1

The Italian CMA study group. Children allergic to cow s milk tolerate a rice hydrolysate formula.

Clin Exp Allergy 2006; 36:311-6

Challenge +

CM 78/91

Rice none

HRF none

The Italian CMA study group. Children allergic to cow s milk tolerate a rice hydrolysate formula.

Clin Exp Allergy 2006; 36:311-6

Z-score W/A

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Z-score H/A

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Prebiotics(= oligosaccharides)

Probiotics= live and safe bacteria

Stimulationof the endogenous flora

(Bifidobacteria)

Exogenous flora

Journal of Pediatric Gastroenterology and Nutrition 2011; 52: 238-50

• No safety concern

• « No recommendation for the routine use of prebiotics or

probiotics in infant formula »

NUTRITION CLAIM HEALTH CLAIM

« Any message or representation including pictorial, graphic or symbolic representation, in any form, that states, suggests or implies that a food has particular characteristics »

• Claims: should not be false, ambiguous or misleading

• Nutrition claims: permitted if in conformity with a list

• Health claims: authorised for use only after a scientific assessment

Saavedra et al. Lancet 1994;344: 1046-9

BREAST MILK

COMPLEMENTARY FOODS

Infant formulaSolid foods

MILK

SOLID FOODS

Breast milk or infant formula

WHO Pragmatic

Exclusive breastfeeding during the first 6 months (WHO, 2002)

Complementary feeding >6 months

1 - Renal and GI function are sufficiently mature to metabolise nutrients from complementary foods by the age of 4 months

2 - Neurodevelopment• “Extrusion” of solid foods up to 3-4 months

• Tongue flexibility around 6-7 months allowing chewing and swallowing more solid lumpier foods

Early solid feeding and recurrent childhood eczema: a 10 yearlongitudinal study. Fergusson et al. Pediatrics 1990; 86: 541-6

Not before 4 months and not after 6 months”

Not too early but also not too late…

A prospective study on 1560 children enfants at risk followed for a mean of 4.7 years. DAISY Study. Denver, Colorado, EU

Norris et al. JAMA 2005; 293: 2343-51

1307 children followed from birth:- 996 for cord blood HLA-DR3- 311 for FH of IDDM

Interviews with telephone questionnaireat age 3, 6, 9, 12, 15 months

Blood drawn for celiac serology (TG2)at 9, 15, 24 m and then annually

Same dietary information collected retrospectively

Blood drawn for celiac serology (TG2)at enrollment and then annually

253 children enrolled at age 2-3 for FH of IDDM

51 developed + TG260% with symptoms, mostly GI

Norris et al. JAMA 2005; 293: 2343-51

HR IC 95% : 7.28 (2.02-26.25)

HR IC 95% : 1.68 (0.84-3.36)

A prospective study in 1560 children at risk

Induction de toléranceDelayed introduction

of allergens

?Induction of tolerance

Alm et al. Arch Dis Child 2009; 94: 11-5

• Prospective cohort of 4053 Swedish infants• Questionaires @ 6 & 12 months• Prevalence of eczema @ 6 mo. (13.9%) & @ 12 mo. (20.9%)

Introduction of fish <9 months: OR = 0,76 [IC 95%: 0.62-0.94]

Du Toit et al. J Allergy Clin Immunol 2008; 122: 984-91

• 1st questionaire : prevalence of peanut allergy (PA) in Jewishschoolchildren (UK: n=5171; Israel: n=5615)

• 2nd questionaire: peanut consumption and weaning in Jewish infants (UK: n=77; Israel: n=99)

Prevalence of PA: Israel = 0.17%; UK = 1.85% (p < 0.0001)

Consumption of peanut in 8-14 months old infants:Israel = 7.1 g/month; UK = 0 g/month (p < 0.0001)

Median number of times peanut is eaten per month: Israel : 8/month ; RU = 0 (p < 0.0001)

EAT study (RCT of early introduction of 6 allergenic foodsvs current recommendations)

http://www.eatstudy.co.uk/index.html

LEAP study – RCT of early vsdelayed exposure to peanut in at-risk infants

http://www.leapstudy.co.uk/

… the introduction of CF into the diet of healthy term infants in the EU between the age of 4 and 6 months is safe and does not pose a risk for adverse health effects

…. EBF provides adequate nutrition up to 6 months of age for the majority of infants, while some infants may need CF before 6 months (but not before 4 months)….

EFSA Journal 2009;7:1423

• High requirements during the first year

• Fat content of diet should not be <25% of W

• More if poor appetite, infrequent meals,recurrent infections

• Poor source of iron

• Very high protein content

• Generally recommended not to be used < 12 mo.

• Associated with poor iron status and increased risk of anemia (> 400 mL/d)

Hopkins D et al. Arch Dis Child 2007; 92: 850Thorsdottir et al. Eur J Clin Nutr 2003; 57: 505-13

• Would reduce energy density of diet

• May be appropriate for some infants

• Foods with high bio-available iron-red meat

• Fortified foods - cereals

• Better developmental outcome at 12 monthsKrebs et al. JPGN 2006; 42: 207

• Smaller decrease in Hb in late infancyEngelmann et al. JPGN 1998; 26: 26

• Greater weight gain, improved psychomotor development

Morgan, et al. JPGN 2004; 39: 493

• Breast milk: Low protein content

• Increases rapidly with CF but depends on what milk is fed

• Could this be harmful for later obesity / CVD risk?

• Higher infant salt intake associated with higher infant blood pressure

• One study - Effect persisted to adolescenceAdjusted systolic blood pressure: 3.6 mm Hg lower (95% CI, -6.6 to -0.5)

• Recommendation – No addition of salt

Geleijnse et al. Hypertension 1997; 29: 913

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•

• Infants show innate preference for sweet or salty foods, dislike for bitter foods, rejection of new foods

• Can be modified by early experience

• Repeated exposure to a variety of foods is important

• Exposure to home-cooked fruit or vegetablesand intake of F&V at 7 yrs

Coulthard H et al. Public Health Nutri 2010; 13: 2044

• Adherence to recommendations on CF and morehealthy eating patterns at 3 yrs

Golley RK et al. J Nutr 2012; 142: 901

• Earlier introduction of lumpy foods and diversityof intake at age 7 yrs

Coulthard H et al. Matern Child Nutr 2009; 5: 75

‘Traditional’ ‘Baby-led’

How Feasible Is Baby-Led Weaning as an Approach to Infant Feeding? A Review of the Evidence Cameron SL et al. Nutrients 2012, 4, 1575-1609

RCT requiredCan infants obtain adequate nutritional intakes using this method?

• Beware of health claims

• They may be wrong

• When? - Not before 17 weeks, but by 26 weeks- Gluten alongside breastfeeding

• What? - Adequate source of energy, protein, iron, zinc- Consider main source of milk

• How? - Depends on mother and infant!- Repeated exposure to facilitate acceptance