Download Infant nutrition

Infant nutrition
Gábor Veres, MD, PhD
Ist Dept. of Pediatrics
Semmelweis University, Budapest
Lecture of Habilitation, 04.10.2011
What is the most important
question in infancy?
Weight gain?
Content
•
•
•
•
•
Breast feeding
Composition of breast milk
Eosinophilic enteropathy, Reflux (GOR)
Formulas, solids
Iron, vitamins
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. Followon formulas are recommended.
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
Silano M, Agostoni C, Guandalini S. Effect of the timing of gluten introduction on the
development of celiac disease. World J Gastroenterol. 2010 16:1939-42.
Demand feeding, BUT:
• Jaundice: sleepy infant, wake-up!
• Infantile colic: not every crying means
baby is hungry
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
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
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
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
• Atopic dermatitis, allergy ???
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
BUT:
Breast fed infants do have:
• Atopic dermatitis
• Allergic-eosinophilic esophagitis
• Allergic-eosinophilic colitis
Foreign proteins in breast milk
Eosinophilic esophagitis
•
•
•
•
Main problem: reflux
BUT: pH is normal, therapy resistant,
75% in males
Food allergy in 50%, eosinophilia 42%
• Dg: upper endoscopy
• WHEN ???
Eosinophilic esophagitis (upper endoscopy)
Granulation
(eosinophilic clusters)
Conc. rings and furrows
(reversible fibrosis)
Eosinophilic esophagitis (histology)
• Papilla
elongation
• min. 20
eosinophil /HPF
• Epithelial
eosinophil
„cluster”
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)
Lymphonodular hyperplasia
• Colonoscopy:
rectosigmoid
region
• Allergic colitis (cow’s milk
protein induced)
• Similar to M. Crohn
• Special aminoacid formula
(Neocate)
Troncone: Colon in food allergy. JPGN.
2009;48 Suppl 2:S89-91.
blood in feces disappeared
Percentage of breast fed infants in Sweden (%)
%
100
80
60
Adatsor1
40
20
0
1
1945
2
1970
19993
Percentage of breast feeding
(Hungarian data)
100%
96%
89%
83%
90%
75%
80%
68%
70%
61%
60%
60%
54%
50%
50%
42% 40%
40%
34% 34%
30%
20%
10%
months
0%
0
1
2
• 3 months: 75%
• 6 months: 60%
3
4
5
6
7
8
9
10
11
12
MGYT, 2009
Composition of breast milk
Newburg DS: Handbook of milk composition. Academic Press 1995;pp 273-349
• Lactose
55-60 g/l
• Proteins
10 g/l
• Lipids
40 g/l
• Nucleotids, Erythropoietin, IgA, TGF-beta
I. Lactose in BM (55-60 g/l)
galactose
•
•
•
•
glucose
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
II.
Proteins in BM
Age (month)
(10 g/l)
Protein
intake(g/kg/day)
1
Breast milk
consumtion
(g/day)
794
2
766
1,41-1,48
3
764
1,19-125
4
812
1,27-1,33
5
782
1,11-1,16
6
881
1,05-1,11
1,95-2,04
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
Whey/casein ratio
(BM=60:40)
Whey:
• Intestinal transport, motility
• More digestable
Casein:
• Viscosity , anti-reflux effect
Recommended protein
content of formulas
ESPGHAN
AAP
Räihä
g/100 kcal
1,8-2,8
1,8-4,5
1,6-1,8
g/l
12-19
12-30
11-12
At decreased protein content the serum urea
level will be similar to that found at exclusively
breast fed infants
Low protein intake in infancy
is beneficial for future life I.
• 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
Low protein intake in infancy
is beneficial for future life II.
•
•
•
•
Protein intake in infancy
DONALD study (203 children, mean age, 7 years)
BMI and BF (body fat)
If high protein intake in infancy
• BMI and BF were increased (at 7 years)
Günther, Am J Clin Nutr 2007
Which mammals has the
lowest protein in the BM ???
• Human breast milk
III. Lipids in BM (40 g/l)
Importance of lipids
• High energy content
• Beta-palmitate trygliceride is high in BM
(70%)
• Significance of poly-unsaturated fatty acids
(PUFA)
Structure of triglicerides
(α
α) CH3 - O - R1
|
(β
β) CH2 - O - R2
|
(α
α) CH3 - O - R3
Pancreas lipase split the palmitic acid
located in α position
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
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
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
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 ‰
Infant formulas
For healthy babies
formulas
1. Standard formula
2. Follow-on
3. Baby’s milk
Special
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
Why is not optimal to give cow’s
milk to infants under one year?
• It contains too
much
– protein
– sodium
• It contains too less
– linolic acid
– iron
– vitamins (C, D, E)
Cow’s milk feeding may
cause:
• Iron-deficiency
anaemia
• Blood in feces
• Atopic dermatitis
• Increased osmotic load
for kidneys
3. Baby’s milk
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•
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Recommended from 7-9 months
Until 1-3 years
More expensive than cow’s milk
Price: 1.5-2x than cow’s milk
Special
formulas
Anti-reflux
• seads of Saint John’s bread-tree
(KAREB/CARAT)
• Corn-starch (AR) or potato-starch
• HA and anti-reflux together (HA/AR)
Reflux, regurgitation
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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.)
Solids
• Foods besides breast milk and
formulas
• Introduction between 4-7 months
– fruits
– cereals
– vegetables
– meat
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
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%
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 69 months
source: red
blood cells
• Preterm baby: 2mg/kg after 2 months
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
Vitamin D
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•
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•
Low level in BM
Supplementation: 400U/day
After 2 weeks - 1-1.5 years
Formula contains vitamin D
Allergy, atopic dermatitis
Probability of atopy in
positive family history
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•
•
•
No atopy in the family
One parent / one sibling
Both of parents
Both p. with the same manifest.
: 10%
: 30%
: 50%
: 70%
Allergy prevention of infants
• (Diet of mother during pregnacy: NO
effect!!!)
• Longer breast feeding
• Avoid food with high allergenicity (also
during breast feeding)
• Hypoallergen formulas
• Probiotics (Kalliomaki, Lancet, 2001)
Probiotics („Good” bacteria)
• 1-1.5kg bacteria in the
intestinal tract
• 400 bacterium species
• 10 times more
bacteria than cells in
the body
• „Good” bacteria:
Bifidobacteria,
Lactobacillus species
Probiotics and atopy
• Kalliomaki, Lancet, 2001
• Lactobacillus GG was given to mother
before delivery and to children for 6
months
Frequency of atopy at 1 year %
50
46 %
40
30
23 %
20
10
0
probiotikum
Probiotics
kontroll
Controls
Feeding of preterms
• Carnitin, taurin
• LC-PUFA, MCT
• Phosphate
crosses
placenta in the last 3
months
• Iodine, selenium
Rachitis
(rickets) and
preterms
Swelling of metaphyses at wrists
If you think, the
preterm baby has
rickets, first check
serum
phosphorus
before giving more
vitamin D
Rachitic rosary
Somatic development of
breast fed infants II.
• After 3 years no difference can be
detected in length of breast fed and
formula fed children
• The weight of formula fed babies is
always higher, among them the
frequency of obesity is high
Contraindications of breast
feeding
• From the mother’s part
– Severe acut or chronic infections (typhus,
erysipelas, tuberculosis, AIDS)
– Sepsis
– Postpartum psychosis
• From the infant’s part
– Some types of inborn error of metabolism
(galactosaemia, some forms of glycogenosis)
Difficulties of breast feeding
• Mother’s side
– Mamilla rhagad
– Papilla plana
– Papilla plana inverta
• Infant’s side
– Cleft palate
– Missing sucking reflex (prematurity,
cerebral impairment)
– Severe rhinitis
Fruits
• First apple and peach
• other recommended fruits seasonal
fruits
– sour cherry
– cherry
– pealed plum
– pear
– orange, lemon, banana
• Fruit juices and mashed form
Vegetables
• First is the potato
• Following with carrots, beetroot,
lettuce, pumpkin, Brussels sprout,
spinach, bean, green peas,
asparagus
• Savoy, cauliflower only after 8
months
• Spinach, sorrel have high oxalate
content therefore only once a week
Meats and egg
• Fish is advantageous because of its
fatty acid composition, but it may
cause allergic reactions.
• Chicken liver once a week
• Egg yolk after 8 moths
• Egg white after 1 year
Zug-Frauenfeld Study (ZUFF)
Exl, EJN, 2000
Zug:
564 infants, allergy prevention group (HA)
Frauenfeld:
566 infants, controls
60
%
49
50
37
40
33
27
HA
30
Kontroll
20
10
0
3 hónap
3 month
6 hónap
6 months
Ten Steps to Successful
Breastfeeding(WHO/UNICEF)
1. Have a written breastfeeding policy
that is routinely communicated to all
health care staff
2. Train all health care staff in skills
necessary to implement this policy
3. Inform all pregnant women about the
benefits and management of
breastfeeding
Ten Steps to Successful
Breastfeeding(WHO/UNICEF)
4. Help mothers initiate breastfeeding within a
half-hour of birth
5. Show mothers how to breastfeed, and how to
maintain lactation even if they should be
separated from their infants
6. Give newborn infants no food or drink other
than breastmilk, unless medically indicated
7. Practice rooming-in: allow mothers and
infants to remain together 24 hours a day
Ten Steps to Successful
Breastfeeding(WHO/UNICEF)
8. Encourage breastfeeding on demand
9. Give no arteficial teats or pacifiers
(also called dummies or soothers) to
breastfeeding infants.
10. Foster the establishment of
breastfeeding support groups and
refer mothers to them on discharge
from the hospital or clinic
Utilization of breast milk’s
proteins
• Total protein content 11 g/l, from which
only 9 g/l is utilized for nutrition.
• Secretory IgA, lactoferrin and lizozym
are not used for nutrition
• Only 13 % of urea can be used for
aminoacid synthesis
How to decrease allergenity?
• Heating, home-canning is good:
apple, celery, fish
BUT not good: cow’s milk, eggs
• Gene technology (rice, wheat)
• Enzymatic hydrolysis
Special formulas: hypoallergen (HA)
Why should not be given formula instead of
breast milk after birth?
• Frequency of cow’s milk allergy
in breast fed infants
0.4%
• But: every child was given formula in the hospital!
Host, Acta Paed Scand, 1988
40 ml cow’s milk contains:
β-lactoglobulin (main allergen in cow’s milk)
1 litre of breast milk/day for 21 years !!!
Role of nucleotides I.
• Although they can be synthetised, in infants
nucleotides are semiessencial compounds as
the rate of their endogen synthesis is not
sufficient to the normal functions
• Breast milk contains nucleotides in higher
concentration than the cow’s milk and
formulas
Role of nucleotides II.
• Nucleotids help the development of intestinal
mucosa and improve the absorption of
different nutritients
• They promote the growth of Bifidobacteria
• Increase the cellular and humoral immune
response
Erythropoietin (Epo)
• Breast milk (BM): Epo
(Kling, Pediatr Res,
1998)
• Per os
Epo can be absorbed
BM protects
Protease activity
Intestinal permeability
What is the role of EPO in BM?
• No effect on erythropoesis
• Epo: trophic factor in the intestine (Juul, Gut,
2001)
intestine
Epo receptor
EPO