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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