Download Nutrient Needs: Part 1

Nutrient Needs: Part 1
Basis
Water
Energy
CHO, Fat, Protein
Objectives
• Basis for nutritional recommendations
– Public health approach
– Indvidual needs
• Influence on growth, development, and health
throughout the life course
• Specific Nutrients
Feeding Guidelines and
Recommendations
• Population health and policy
• Individual health
• Optimal growth and development
• Prevention of Chronic Illness
• Safety
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,…
1940’s
•
•
•
•
•
•
Rickets (D)
Pellagra (Niacin)
Scurvy (C)
Beriberi (Thiamin)
Xeropthalmia (A)
Goiter (Iodine)
United Nations 5th report on World
Nutrition: March 2004
Prevalence
(%)
1990
2005
underweight 35.2
26.5
Iodine
deficiency
35.2
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
• Reports in the U.S. of PEM, Ricketts, Zinc
deficiency
• Reports in US of PEM, Rickets, Zinc
deficiencies
Causes
Nutrition - Disease
Access
Food
Health Care
Environment
Economics
Education
Nutrient Needs in Infancy
Influences
– Genetics
– Adaptation
– Environment
– Behavior/activity
– Choices, access,
resources
– other
Influences
– Rates of growth
– Activity
– Basal needs
– Nutrient interactions
– Physiological and
developmental
progressions
Nutrition: Growth, development and
health throughout life course
• Maternal-fetal
interactions
• Critical Periods
• Genetics
• Environment
Lifecourse theory
• Complex interplay of biological,
behavioral, psychological, social and
environmental factors contribute to health
outcomes across the course of a person’s
life.
• Early Programming model
• Cummulative pathway model
• Critical Periods
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
Recommendations/guidelines
• DRI: Dietary Reference Intakes
– AI
– UL
– EER
• AAP
• Bright Futures
• Start Healthy feeding guidelines
Guidelines/Recommendations
•
•
•
•
•
•
USDA Guidelines for WIV and CSF Programs
http://www.nal.usda.gov/infants/infant-feeding
Public health vs individualized approach
Rationale
Compare to current AAP recommendations
Guidelines for feeding, choices, transitions,
preparation, safety with recognition of
developmental readinesss
• 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
Guidelines
Examples
• Transition
• Supplements to breast
milk
• Safety
• Allergy prevention
• Dental health
• other
• AAP
• Bright Futures
• Start Healthy Feeding
Guidelines
• USDA/WIC
• Considerations:
–
–
–
–
Public health approach
Anticipatory Guidance
Individual approach
Dx/tx
Nutrient Needs: Part 1
• Water
• Energy
• CHO, Fat, Protein
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
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.
Water
• Water balance
– RSL in diet
– Water in
– Water out
– Renal concentrating
ability
Water Needs
Age
Amount of Water (ml/kg/day)
3 days
80-100
10 days
125-150
3 mo.
140-160
6 mo.
130-155
9 mo.
125-145
1 yr.
120-135
2 yr.
115-125
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
• Water vs fluid
• Concentrating formula decreases free water
and increases RSL
• What is the % water in 20 kcal/oz infant
formula? 0ther food?
– 90%
– To achieve 100 ml/kg/d needs to consume at least
110 cc/kg/d
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
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
Energy Partition in Infancy (kcal/kg/d)
Birth-6 months
6-12 months
Losses
5
5
Activity
10
25
Thermic effect
of food
Growth
10
10
40
12
Resting
metabolic rate
Total
50
55
115
107
Energy Intakes by Breastfed and Formula Fed
Boys (kcal/kg)
Age in Mos.
1
2
3
5
6
Breastfed
115
104
95
89
86
Formula
120
106
95
95
92
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)
Examples of EER by age and weight
Age
Weight (kg) Total
Per kg
0-3 months
2
3
4
253
342
431
126
114
108
4-6 months
6
7
8
490
579
668
81
82
83
7-12
months
9
10
11
723
812
901
80
81
81
13-35
months
12
14
988
1166
82
83
Carbohydrates
• Sources
–
–
–
–
–
Dextrins
Maltoses
corn syrup solids
sucrose
lactose
• Density
– 40-50% of kcal as CHO
2002 Carbohydrate DRI
Fats and Fatty Acids
• Sources
– Palm olein, soy, coconut,
and high oleic sunflower
oils (primary source)
– Mortierella alpina,
Crypthecodinium cohnii
oils (source of DHA and
ARA)
• Density
– Human milk
• ~ 50% of kcals as fat
• 5% as EFA (mostly
linoleic)
– AAP
• ~3.3 gm fat/100 kcals
(30% of kcals)
• 300 mg linoleic acid/100
kcals (2.7% of total kcals)
– Max 6 gm fat/100 kcals
(54%)
2002 Fat DRI
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.
LCPUFA
DHA and ARA
• 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
LCPUFA: Background
n-6
n-3
18:2
Linoleic
18:3
Linolenic
18:3
 linolenic
20:5
EPA
20:4
Arachidonic
22:6
DHA
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
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.
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
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
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.”
Omega-3 FA and Neural Development to 2 years of Age: Do we Know
enough for Dietary Recommendations: Innis JPGN 48:S16-24:2009
• 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
Omega-3 FA and Neural Development to 2 years of Age: Do we Know enough
for Dietary Recommendations: Innis JPGN 48:S16-24:2009
• “ 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”
Protein
• Protein is needed for
– Tissue replacement
– Deposition of lean body mass
– growth
• Protein needs during rapid growth
of infants higher than adults or
older children
• Recommendations based on
composition of human milk with
assumption of 100% efficiency of
utilization
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
Protein: Amino Acids
• Require higher percentage of total amino
acids as essential amino acids
• Conditional essential amino acids
– Histidine (infant vs adult needs)
– Tyrosine, cystine, and taurine (premature infants)
2002 Protein DRI
Protein content of milks
•
•
•
•
•
Food
Pro (gm/oz)
Human milk
0.3
Infant formulas
0.5
Infant soy formulas
0.5
Homogenized milk
1.0
Distribution: Protein/CHO/Fat
Age
g/d Protein/CHO
AMDR protein/CHO/Fat
Infant
9.1-11/60-95
1-3
13/130
5-20/45-65/30-40
4-8
19/130
10-30/45-65/25-35
Comparison of breastmilk and infant formula
©2001 Brooks/Cole, a division of Thomson Learning, Inc. Thomson Learning ™ is a trademark used herein under license.
Percentages of energy yielding nutrients in breastmilk and formula
Nutrient Needs: Part 2
• Vitamin K
• Vitamin D
• Calcium and
Phosphorus
• Iron
• Zinc
• B-12
• Flouride
Vitamin K
• 2 forms: K1 or phylloquinone (plant form) and
K2 (synthesized by bacteria)
• Function: cofactor in metabolic conversion of
precursors of Vitamin K dependent proteins to
active form ( eg: prothrombins, osteocalcin)
Vitamin K
• Lack of specific information regarding an
infant’s requirement
• Vitamin K concentration of breastmilk is low
and for the breastfeeding infant a deficiency
state has been described
• No “gold standard” available
Vitamin K
•
•
•
•
DRI for infants 2-2.5 ug/day
Formula provides 7-9 ug/kg/d
BM contains < 10 ug/L
Hemorrhagic disease of the
Newborn…Vitamin K deficiency
• Prophylaxis: 1 mg Vitamin K IM for all
newborn infants
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).
Vitamin K deficiency: Haemorrhagic
disease of newborn
• First used in 1894 to describe bleeding in the
newborn not due to trauma or haemophilia
• Current Terminology:
– VKDB: vitamin K deficiency bleeding
• EVKDB: early
• LVKDB: late
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
Incidence of VKDB
• Early: 0.25%–1.7% incidence
• Late:
– No vitamin K prophylaxis: 4.4 to 7.2 per 100,000 births
– Single oral vitamin K prophylaxis:1.4 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
Controversies Concerning Vitamin K and the Newborn:
AAP Policy Statement, 2003
Vitamin K Controversy
• Adequacy of BM
• Maternal Diet and Vitamin K content of BM
• ? Significance/prevalence of hemorrhagic
disease of newborn
• IM injections of all newborns
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
Danielson et al Arch Dis Child 2004 89:F546-550
• 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
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
Closing the Loophole:Midwives and the Administration
of Vitamin K in the Neonate
• Adame and Carpenter J Pediatr 2009 154:769-771
• 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
Controversies
• Prophylactic Treatment at birth
– Safety
– pain
– Effectiveness: Oral vs IM
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 .
Cochran
• In different parts of the world, different
methods of vitamin K prophylaxis are
practiced.
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 metaanalysis 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
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.
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
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.
Oral Supplementation with Vitamin K
• Increase in reports of late VKDB
• Single oral dose does not provide sustained elevations
in serum Vitamin K to prevent late bleeding
• Multidose regimen (1-2 mg given 3X over first 3
months) has been used in some countries
– Some studies report efficacy
– Also, reports of treatment failure (eg Germany, Australia,
Sweden)
– Disadvantages: reliance on compliance, increased cost,
unreliable infant intake/feeding
– AAP recommends contininuation of IM prophylaxis
AAP Recommendations:
Pediatrics:Vol112#1 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.
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
Vitamin D
• Role
• Source
– Dietary
– sunlight
• Deficiency
– Rickets
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
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)
Prevalence
• Thought to be disease of past (prior to 1960’s)
– Disappeared secondary to recognition of role of
sunlight, fortification of milk, use of multivitamins,
AAPCON recommendation for 400 IU
supplementation of infants
Prevalence
• Increased incidence and case reports 1970’2
• 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
Prevalence
• Literature Review
– 13 articles published between 1996-2001
– 122 case reports
Prevention of Rickets and Vitamin D
Deficiency: New Guidelines for Vitamin
D Intake
PEDIATRICS Vol. 111 No. 4 April 2003,
pp. 908-910
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 < 6 months to
direct sun
Breastfeeding and Vitamin D
• Breastmilk has < 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
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 for 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
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 200 IU per day.
• ? Supplement formula feed newborn taking <
1 liter of formula
Summary of AAP Recommendations
•
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 addequate amounts of vitamin Dfortified milk or foods that are a good source of vitamin D
require a supplement to meet new recommendations of
600 IU/day.
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 2008;122;1142-1152
Basis of recommendations
• Previous RDA of 400-800 mg/d of Ca was
based on formula feeding with 25-30%
retention
• Breastfed infants retain 2/3 of their Ca intake
from breastmilk
Calcium
Age
DRI mg/d
Birth-6 months
210
7-12 months
270
1-3 years
500
4-8 years
800
Hot off the Presses!
• FNB IOM recommends Calcium intake
– B-6 months:
– 7-12 months:
– 1-3 years of age:
– 4-8 years of age:
200 mg/d
260 mg/d
700 mg/d
1000 mg/d
Calcium/Phosphorus content of typical
Infant feedings: (mg/dl)
• Breastmilk:
– 28/14
• Standard Infant Formula
– 49/38
Iron
• Function
• Source
– Formula, breast milk, other foods
– Bioavailability:
• Breast milk
• Soy formula
• Deficiency
– Anemia
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
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
Iron deficiency (ID and IDA)
• Anemia: Hgb <11 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
• Association between ID and IDA and
neurobehavioral development
– Lozoff
– McCann and Ames
– Cochrane review
– Carter
– Recent sleep studies
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 48:S8-S15
– Lozoff et al: Dose-Response Relationships between Iron deficiency
with or without anemia and Infant Social-emotional Behavior J Pediatr
2008 152:696-702
Peirano
• Slower neurotransmission in auditory and
visual systems
• Different motor activity patterning sleepwaking and sleep state organization
• Alterations in behavioral and cognitive
function
Lozoff
• N=77
• “Infant social-emotional behavior appears to
be adversely affected by iron deficiency with
or without anemia”
– Shyness, orientation engagement, soothability
Carter et al: Iron Deficiency Anemia and Cognitive Function in
Infancy: Pediatrics 2010 126;2427-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))
Carter et al: Iron Deficiency Anemia and Cognitive Function in
Infancy: Pediatrics 2010 126;2427-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/orientation, described as “shyer”
Iron Deficiency
• Among children in developing world, iron is
the most common single nutrient deficiency
• No national statistics for prevalence of ID or
IDA < 12 months
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.
Iron Deficiency Prevalence at 9
Months
1.1 mg iron per L plus
supplemental foods
12-15 mg iron per L
28-38%
0.6%
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%.”
ID and IDA 12-35 Months NHANES 2002
Population
General US
Above poverty
Below poverty
Enrolled in
WIC
Mexican
American
Other ethnicity
ID (%)
9.2
8.9
8.6
10.7
IDA (%)
2.1
2.2
2.3
3.2
13.9
0.9
15.2
4.4
Iron
• Iron absorption from soy formulas is less
• Greater bioavailabilty of iron in breastmilk
Iron Absorption In Infancy
Human Milk
Human Milk – in 5 to
7 month olds who
are also eating solid
foods.
Iron Fortified Cow’s
milk based Formula
Infant Cereals
Percent
Reported
Absorbed
48%
Study
Hallberg et al
21%
Abrams et al
6.7%
Hurrel et al
4 to 5%
Fomon et al
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.
AAP recommendations for Dx and prevention of ID and
IDA:2010
Pediatrics 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)
AAP recommendations for Dx and prevention of ID and
IDA:2010
Pediatrics 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 isn’t a sudden increase in needs
from 6 to 7 months.
AAP recommendations for Dx and prevention of ID and
IDA:2010
Pediatrics 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
AAP recommendations for Dx and prevention of ID and
IDA:2010
Pediatrics 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 shouldn’t be used < 12 months
• Breastfed: Exclusively breastfed infants are a increasing risk of
ID >4 months and should be supplemented with 1 mg/kg/d
oral Fe until appropriate complimentary food are introduced
AAP recommendations for Dx and prevention of ID and
IDA:2010
Pediatrics 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
AAP recommendations for Dx and prevention of ID and
IDA:2010
Pediatrics 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
Iron: DRI
Age
Iron mg/d
Birth-6 months
0.27
7-12 months
11
1-3 years
7
4-8 years
10
Food sources of Iron
Food
Measure
Iron (mg)
Iron fortified formula
8 oz
2.9
Infant Cereal (rice)
1TB
1.7
Strained meats with vegetable
2 Tb
0.1
Strained beef
2 TB
0.2
meats
2 TB
1.2
egg
1
0.7
Peanut butter
1 TB
0.3
Bread white
1 slice
0.2
Enriched macaroni cooked
¼ cup
0.5
vegetables
¼ cup
0.2
fruits
¼ cup
0.1
cheerios
½ cup
1.2
Rice Chex
½ cup
1
Other Causes of Anemia
• Jones et al Hidden Threats: Lead Poisoning
From Unusual Sources Pediatrics 1999
104(1223-1225)
• Jones et al Trends in Blood Lead Levels and
Blood Lead Testing Among US Children Aged
1-5 years Pediatrics 2009 123 (e376-e385)
Iron-Lead Interactions
• IDA increases intestinal lead absorbtion
• Epidemiologic association between IDA and
increased lead concentrations
• Primary prevention of IDA may contribute to
prevention of lead poisoning
• IDA also decreases the efficiency of chelation
therapy for lead poisoning.
• Effect of iron supplementation on iron replete
children with lead poisoning is not know
Zinc
• Function: metalloenzymes associated with CHO and
energy metabolism, protein catabolism and
synthesis, nucleic acid synthesis, and heme
biosynthesis. Other zinc dependent enzymes include
erythrocyte carbonic anhydrase, alkaline
phosphatase, DNA and RNA polymerases. Through
its role in superoxide dismutase enzyme systems,
Zinc acts in stabilzing cell membranes and protecting
them from lipid peroxidation. Zinc is also involved in
protein and collagen synthesis
Zinc
• Concentration in colostrum is high, but
concentration rapidly declines over 1st year.
• Reports of subclinical zinc deficiency in
growing preterm infant fed human milk
– * continued post-discharge
Zinc
• Globally, zinc deficiency is widespread in
infants and young children in developing
countries, being a major cause of morbidity
and mortality, and of impaired growth.
– Diarrhea, pneumonia associated morbidities
– Due to zinc dependent host defense mechanisms
(T and B cell functions)
Zinc, Folate, Vitamin E
Age
Zinc mg/d
Folate mcg/d
Vitamin E mg/d
Birth-6 months
2
65
4
7-12 months
3
80
5
1-3 years
3
150
6
4-8 years
5
200
7
B-12
• B-12 concentration in breastmilk may be
influenced by maternal diet.
• Milk from lactating mothers following a strict
vegan diet may provide inadequate vitamin B12 to their infants.
• B-12 deficiency has been reported in infants
breast-fed by mothers with pernicious
anemia.
Vitamin B12
• No reports of overt toxicity
• Overt deficiency
documented among infants
and children who are fed no
animal foods & are not
supplemented
• DRI: (mcg.d)
–
–
–
–
B-6 months: 0.4
7-12 months: 0.5
1-3 years: 0.9
4-8 years: 1.2
•
•
•
•
•
15 mo old infant
Breastmilk only, 10 x/day
Appeared well-nourished
Refused solids
Demonstrated
developmental delay
• < blood B12, folate, Fe
Vitamin B12
• Mother, appeared wellnourished
• taking extra Vit A,
100ug B12, 3-4000mg
Vit C/day
• Reluctant to D/C
breastfeeding
• Worried re: intro of
solids, allergies
• Infant
– supplemented
• folic acid, iron
– 1000 ugB12 IM
– PolyViFlor
Clinical presentation and metabolic consequences in 40
breastfed infants with nutritional Vitamin B-12 deficiency
• Eur J Paed Neurol Nov 2010 14(16) 488-95
• 40 Breast fed infants with B-12 deficiency (17
severe, 23 mild
• Maternal B-12 satus major contributing factor
• Symptoms: FTT (48%), DD (38%),
microcephaly (23%), anemia (63%)
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
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
Fluoride
• 1945 study was conducted in 4 city pairs
(Michigan, NY, Illinois, Ontario)
• Followed 13-15 years
• 50-60% reduction in dental caries
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
Fluoride
• Concerns
– Excess
– Fluorosis
– Cancer
– other
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.
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.
Fluoride Supplementation Schedule
Age
Fluoride Concentration in Local
Water Supply, ppm
< 0.3
0.3-0.6
>0.6
6 mo. to 3 y
0.25
0.00
0.00
3-6 y
0.50
0.25
0.00
6 y to at
1.00
0.50
0.00
least 16 y
American Dental Association, American Academy of
Pediatrics, American Academy of Pediatric Dentistry, 1994.
Fluoride
• To prevent fluorosis, tolerable upper limit (UL)
has been set at 0.7 mg/d B-6 months, and 0.9
mg/d 7-12 months
• AAP
– Not recommended < 6 months
– 0.25 mg/d after 6 months if water contains < 0.3 ppm)
– After tooth eruption: fluoridated water several
times/day (BF) or prepare formula with water with
fluoridated water (<0.3 mg/L)
–
Early Childhood Caries
• AKA Baby Bottle Tooth
Decay
• Rampant infant caries
that develop between
one and three years of
age
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
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
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
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
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
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