Introduction Nutritional requirementsDepartment of Health’s recommendationsBreast feeding/bottle feedingClinical conditionsClinical scenario
Infant NutritionGood nutrition is essential for: SurvivalPhysical growthMental developmentProductivityHealth and well being
A short term issue?
Differences in nutritional experiences during sensitive periods in early life, both before and after birth, can program a person's future development, metabolism, and health (EARNEST, 2011)
StatisticsPrevalence of
breastfeeding 81% at birth(76% in
2005)69% at one week55% at six weeks34% at six months
(25% in 2005)
Prevalence of exclusively breastfeeding69% at birth46% at one week23% at six weeks1% at six months
More Statistics31% breastfed babies had received additional
feeds while in hospital
73% had given their baby milk other than breast milk by the age of six weeks and 88% by six months
High correlation between intentions and actual initial feeding behaviour
And more...Highest incidences of breastfeeding among
mothers >30 years old, from minor ethnic groups, left education aged over 18, in managerial and professional occupations, living in the least deprived areas
Relationship between how mothers were fed themselves as infants and and how their peers fed their babies with how long they breastfed their own babies
Nutritional requirementsAge dependent (the younger the child the
higher their energy needs per kilogram body weight)
0-3 months: Fluid 100-150 mls/kg Calories 100 kCals/kg Protein 2.1 g/kg Na 1.5 mmol/kg K 3 mmol/kg
Nutritional needs in Preterm babies (1)Adequate nutrition should ensure that a pre-term infant
achieves a post natal growth that reinstates them on their inter-uterine growth curve for length, weight and head circumference.
Premature babies may have increased needs as :- May have dropped down >2 centiles on neonatal unit- May have CLD and need O2- May have been IUGR- May have GOR and be unable to tolerate large feed volumes
Nutritional needs in Preterm babies (2)Fluid: 150-200ml/kg/day
Energy requirements: 110-135kcals/kg/day
Protein: according to weight
What are the Department of health’s recommendations on feeding infants?Breast milk is the best form of nutrition for
infantsExclusive breastfeeding is recommended for
the first six months of an infant’s lifeSix months is the recommended age for the
introduction of solid foods for infantsBreastfeeding (and/or breastmilk substitutes,
if used) should continue beyond the first six months, along with appropriate types and amounts of solid foods
ColostrumFor 2-4 days post delivery.Contains more sodiumHigh in Vit A and Vit K5x more protein than mature milkmore IgAless fat and carbohydrate
Mature breast milk is established by 4th week
Composition of breast milk vs formula milkWater: Equal amounts
Calories: Approx 67kcal/100ml
Protein: Human milk 1-1.5% protein(70% whey protein), Cows milk 3.3% protein due to greater content of casein
Composition of breast milk vs cows milk Carbohydrate: Human milk 7% (10% glycoproteins)
Cows milk 4.5% lactose
Fat: Approx 3.5% both principally triglycerides (olein, palmitin and stearin). Olein is more easily absorbed and there is
twice as much in breast milk.
Minerals: Cows milk contains more of all the minerals (esp sodium, calcium and phosphate) except iron and copper.
There is more iron in breast milk and it is more easily absorbed
Vitamins: Cow’s milk is low in vitamin C and D
What are the health benefits of breast feeding?Breastmilk provides all the nutrients a baby
needs for healthy growth and development for the first six months of life.
Contains growth factors and hormones to assist development
Anti infective properties: Macrophages, lymphocytes and polymorphs, Secretory IgA, Lyzozyme, Lactoferrin (inhibits growth of E.coli.), anti-viral agents.
Long term benefits to infantsReduced risk of respiratory, gastrointestinal and urinary
tract infections
Reduced risk of atopy
Reduced risk of juvenile diabetes in susceptible infants
Better dental health
Reduced incidence of later obesity
Improved neurological development
Maternal benefitsReduced risk of premenopausal cancer
Promotes weight loss after pregnancy
Lactational amenorrhoea
Cheaper and more convenient
Down side of breast feedingVitamin K deficiency
Hypernatraemia at end of first week in babies with inadequate intake
Inhibits modern control culture
Factors affecting prevalence of breast feeding in the UKFavourSocial class 1Mother educated
>18yearsMother >30 years first babybreast fed previous
baby
Againstsocial class Vmaternal smoking
Contraindications to breast feedingGalactosaemia
Maternal HIV infection in the UK
Anti-neoplastic drugs
Tetracyclines
Lithium
Types of milkInfant formulas are suitable from birth and are usually
based on cows milk
Whey based milks are usually first choice if not breast feeding
Casein based milks are suggested for hungrier babies
Soya infant milks
Follow on formulas: Higher iron content than cows milk
Specialised formulas for those who are preterm or have medical conditions (lactose free, phenylalanine free)
Soya Infant FormulaSimilar to cows milk but protein derived from
soya with lactose replaced with other carbohydrates (glucose syrups)
Recommended for use on medical advice but should not be the first choice for the management of CMP intolerance
Soya milks contain phytoestrogens which have been shown to have an immunosuppressive effect in rodents
Bottle feedingDay 1: 60ml/kg/day Day 3: 120ml/kg/day Day 2: 90ml/kg/day Day 4: 150ml/kg/day
3-4 hourly
Must be made up correctly (risk of hypernatraemia)
Has caused high mortality in developing world due to poor hygiene of equipment leading to gastroenteritis
Cow’s milk allergyA reproducible reaction to one or more cow’s
milk proteins mediated by one or more immune mechanisms
Affects about 1 in 50 infants
Most affected infants present by 6 months of age - rarely presents after 12 months
Cow’s milk allergy1. IgE-mediated phenotype: symptoms are
stereotypical of allergy skin (eczema, urticaria) gut (colic, vomiting, diarrhoea, FTT, blood in
the stools) respiratory (rhinitis, stridor, cough and wheeze)
2. Non IgE-mediated phenotype: delayed onset allergy symptoms
Do NOT confuse with lactose intolerance
Diagnosis and management of CMP allergy1. IgE-mediated: clinical symptoms + skin prick test2. Non IgE-mediated: clinical symptoms that improve
or resolve with exclusion of milk and reappear with reintroduction of cow’s milk
A food challenge may be necessary to confirm the diagnosis
diet free from cows’ milk for at least 1 year Choice of milk is usually one of casein or whey
extensive hydrolysed formula, or amino acid formula
(Lactose free and partially hydrolysed comfort formula milks and goats milk are not suitable for cows’ milk allergy)
Lactose intolerancerare in infants- more commonly in adolescence
typically with a more subtle and progressive onset over many years
Usually secondary to gastrointestinal infection especially rotavirus ,or neonatal gut surgery
Usually transient but may need to remove lactose from milk for 6+ weeks
Normal GrowthAll babies tend to lose 5-10% of birthweight over
first few days and regain it by about 10th day
Feeding requirement is 150ml/Kg/day
Normal weight gain 25-30g/day for first 6 months (preterm 10-15g/kg/day)
Most babies double their birthweight by 4-5 months and treble by one year
Weaning DOH recommend introduction of solid foods
at around 6 months of ageTrend towards mothers introducing solid
foods later (51% by 4 months in 2005, 30% in 2010)
75% introduced solid foods by 5 months of age; not following the guidelines
Solid foods tended to be introduced to younger babies among younger mothers and mothers from lower socio-economic groups
Why introduce solid foods at six months?Infants need more iron and other nutrients than milkAt 6 months infants can spoon-feed (upper lip moving
down, chew, use the tongue to move the food from front to back)
Development of eye-hand co-ordination (finger foods)
Introducing solids early before sufficient development of the neuro-muscular co-ordination or before the gut and kidneys have maturedrisk of infections and development of allergies (eczema, asthma)
Weaning Babies need to be exposed rapidly to a variety of
tastes and textures between 6-8 monthsApproximately 1 pt of milk should be given plus
clear fluids with mealsIs waiting to introduce solids until six months
likely to produce “fussy eaters”: NO (RCTs)Encouragement of finger food- promotes chewing
practice and independenceChewing encourages development of speech
musclesFeeding should always be supervised.
VitaminsAll children from six months to five years old
should be given a vitamin supplement containing vitamins A, C and D, unless they are receiving more than 500 ml of infant formula per day
If mothers did not take vit. D during pregnancy and if breast fed, start Vit D at 1 month
Iron supplemented milk is recommended until at least the age of 1 year in all infants Iron deficiency anaemia is a common problem in toddlers
worldwide- associated with developmental delay and increased susceptibility to infection
Faltering growthSignificant interruption in the expected rate of
growth compared with other children of similar age and sex during early childhood
affect around 5% of children under the age of two at some point
A single plot on a chart is of limited value
Need to consider parental height
Causes of faltering growth1. Organic causes
Inability to feed (cleft palate, CP) Increased losses (diarrhoea/vomiting, GORD) Malabsorption (CF, post infective/allergic
enteropathy) Increased energy requirements (CF,
malignancy) Metabolic (hypothyroidism, CAH) Syndromes
Causes of faltering growth2. Non-organic causes
Insufficient breast milk or poor technique Maternal stress/ Maternal
depression/psychiatric disorder Disturbed maternal-infant attachment Low socio-economic class
Neglect
Approach and management to faltering growthRecheck weight-plot weight against centile chartCheck type and amount of feedObserve feeding techniqueAssess stoolExamine for underlying illness- appropriate
investigationsConsider admission to observe response to
feedingDietician involvementInform GP/health visitor/community nurse
Clinical scenarioA 4/52 baby presented to CED with vomiting. Birth weight 3.5kg. Current weight 4.3kg. The baby is bottle feeding and taking 150ml 4
hourly.
Clinical scenarioA 4/52 baby presented to CED with vomiting. Birth weight 3.5kg. Current weight 4.3kg. The baby is bottle feeding and taking 150ml 4
hourly.
Differential diagnosis?
Clinical scenarioDifferential diagnosis1.Symptoms suggesting infection (UTI,
meningitis, gastrointestinal infection)2.Pyloric stenosis (projectile vomiting, age)3.GORD4.Intestinal obstruction (bilious vomit,
abdominal distension)5.CMP allergy6.Overfeeding
Clinical scenarioAdequate weight gain? 30 x 28 = 840g 3.5 + 0.84 = 4.3 kgHow much does the baby require? 150 x 4.3 = 645mlHow much is the daily intake? 150 x 6 = 900 ml
Clinical scenarioAdequate weight gain? 30 x 28 = 840g 3.5 + 0.84 = 4.3 kgHow much does the baby require? 150 x 4.3 = 645mlHow much is the daily intake? 150 x 6 = 900 ml
Vomiting likely 2o to overfeeding