Infant Feeding and Infant Feeding and NutritionNutrition

Dr.Renu JainerDr.Renu Jainer

Few things engender more Few things engender more anxiety than symptoms anxiety than symptoms associated with feeding. associated with feeding. Early difficulties can Early difficulties can influence a mothers influence a mothers relationship with her baby for relationship with her baby for months or even yearsmonths or even years

A Short Term Issue?A Short Term Issue?

• Suggested that nutritional state in Suggested that nutritional state in infancy exerts a long term effect on infancy exerts a long term effect on health and development through health and development through metabolic programming metabolic programming (Lucas 1994)(Lucas 1994)

StatisticsStatistics

• By 4 weeks of age 30% of mothers By 4 weeks of age 30% of mothers bottle feed their babies solely. By 4-bottle feed their babies solely. By 4-10weeks 58% were solely bottle fed 10weeks 58% were solely bottle fed with up to 75% having some formula. with up to 75% having some formula.

• By 8 months 8% were giving cows By 8 months 8% were giving cows milk as the main milk drink.milk as the main milk drink.

More StatisticsMore Statistics

• 69% of women started breast feeding in 69% of women started breast feeding in UK.UK.

• At 6 weeks 43% were breast fed.At 6 weeks 43% were breast fed.

• At 4 months only 28% breast fed and at 6 At 4 months only 28% breast fed and at 6 months only 21%.months only 21%.

• Exclusive breast feeding is recommended Exclusive breast feeding is recommended for the first 6 months of life.for the first 6 months of life.

• Department of Health Feeding Survey 2000Department of Health Feeding Survey 2000

Breast is best?Breast is best?

• Contains all the nutrients an infant needs in Contains all the nutrients an infant needs in the right amounts and in an easily absorbable the right amounts and in an easily absorbable form. Its composition changes as the baby form. Its composition changes as the baby grows.grows.

• Contains growth factors and hormones to Contains growth factors and hormones to assist developmentassist development

• Anti infective properties: Macrophages, Anti infective properties: Macrophages, lymphocytes and polymorphs, Secretory IgA, lymphocytes and polymorphs, Secretory IgA, Lyzozyme, Lactoferrin (inhibits growth of Lyzozyme, Lactoferrin (inhibits growth of E.coli.), anti-viral agents. E.coli.), anti-viral agents.

Long term benefits to infantLong term benefits to infant

• Reduced risk of atopyReduced risk of atopy

• Better dental healthBetter dental health

• Reduced incidence of later obesity.Reduced incidence of later obesity.

• Improved neurological developmentImproved neurological development

• Reduced risk of SIDSReduced risk of SIDS

Maternal benefitsMaternal benefits

• Reduced risk of premenopausal Reduced risk of premenopausal cancer.cancer.

• Promotes weight loss after pregnancyPromotes weight loss after pregnancy

• Lactational amenorrhoeaLactational amenorrhoea

• Cheaper, easier more convenient and Cheaper, easier more convenient and portable.portable.

• No other equipment to prepare.No other equipment to prepare.

Breast milkBreast milk

• Varies greatly according to:Varies greatly according to:

• Hindmilk vs foremilkHindmilk vs foremilk

• Duration of lactation (reducing Duration of lactation (reducing protein concentration)protein concentration)

• Gestational age of babyGestational age of baby

• Maternal diet.Maternal diet.

Composition of breast milk vs formula Composition of breast milk vs formula milkmilk

• Colostrum: For 2-4 days post delivery. Has high Colostrum: For 2-4 days post delivery. Has high protein and mineral content but less protein and mineral content but less carbohydrate and fat. Mature breast milk carbohydrate and fat. Mature breast milk established by 4th week.established by 4th week.

• Water: Equal amountsWater: Equal amounts• Calories:Calories: Approx 67kcal/100ml.Approx 67kcal/100ml.• Protein:Protein:

Human milk 1-1.5% protein(70% whey protein)Human milk 1-1.5% protein(70% whey protein)Cows milk 3.3% protein due to greater content Cows milk 3.3% protein due to greater content of caseinof casein

Composition of breast milk vs Composition of breast milk vs

cows milkcows milk • Carbohydrate:Carbohydrate: Human milk 7% (10% glycoproteins)Human milk 7% (10% glycoproteins)

Cows milk 4.5% lactose Cows milk 4.5% lactose

• FatFat Approx 3.5% both principally triglycerides Approx 3.5% both principally triglycerides Olein is more easily absorbed and there is Olein is more easily absorbed and there is

twice twice as much in breast milk. as much in breast milk.

• MineralsMinerals Cows milk contains more of all the minerals Cows milk contains more of all the minerals (esp (esp sodium, calcium and phosphate) sodium, calcium and phosphate) except except iron and copper.iron and copper.

There is more iron in breast milk and it is There is more iron in breast milk and it is more more easily absorbed.easily absorbed.

• VitaminsVitamins Cows milk is low in vitamin C and D but more Cows milk is low in vitamin C and D but more thiamine thiamine and riboflavin.and riboflavin.

Factors Affecting Prevalence Factors Affecting Prevalence Of Breast Feeding in the UKOf Breast Feeding in the UK• Favourable:Favourable:

• -Social class 1-Social class 1

• -Mother educated -Mother educated

• -Mother >25 years -Mother >25 years

• -Live in London/SE-Live in London/SE

• -first baby-first baby

• -breast fed -breast fed previous babyprevious baby

• Against :Against :

• -social class V-social class V

• -maternal smoking-maternal smoking

Dangers of Unmodified Dangers of Unmodified Cows MilkCows Milk

High renal solute load:High renal solute load:

• HypernatraemiaHypernatraemia

• High blood urea and acidaemiaHigh blood urea and acidaemia

• HyperosmolalityHyperosmolality

• HypocalcaemiaHypocalcaemia

Contraindications to breast Contraindications to breast feedingfeeding

• GalactosaemiaGalactosaemia

• Maternal HIV infection in the UKMaternal HIV infection in the UK

• Anti-neoplastic drugsAnti-neoplastic drugs

• TetracyclinesTetracyclines

• LithiumLithium

Baby MilksBaby Milks

• Infant formulasInfant formulas are suitable from birth and are are suitable from birth and are usually based on cows milk. Composition usually based on cows milk. Composition controlled by EC and UK legislation.controlled by EC and UK legislation.

• Whey based milks are usually first choice if not Whey based milks are usually first choice if not breast feeding.breast feeding.

• Casein based milks are suggested for hungrier Casein based milks are suggested for hungrier babiesbabies

• Soya infant milksSoya infant milks• Follow on formulasFollow on formulas: Higher iron content than : Higher iron content than

cows milk. Composition less controlledcows milk. Composition less controlled• Specialised formulas for those who are preterm Specialised formulas for those who are preterm

or have medical conditionsor have medical conditions

Soya Infant FormulaSoya Infant Formula

• Recommended for use on medical Recommended for use on medical advice but should not be the first advice but should not be the first choice for the management of CMP choice for the management of CMP intolerance.intolerance.

• Similar to cows milk but protein Similar to cows milk but protein derived from soya with lactose derived from soya with lactose replaced with other carbohydrates replaced with other carbohydrates (glucose syrups).(glucose syrups).

Preterm RequirementsPreterm Requirements

• The aim of feeding premature babies is to achieve a The aim of feeding premature babies is to achieve a rate of growth which is similar to intra-uterine growth rate of growth which is similar to intra-uterine growth at the same gestational age. Preferably the feed at the same gestational age. Preferably the feed should be of constituents that do not load the should be of constituents that do not load the metabolism and promote development of metabolism and promote development of gastrointestinal function.gastrointestinal function.

• Special NeedsSpecial Needs• 1)Glycogen stores are small. Minimal fat stores. 1)Glycogen stores are small. Minimal fat stores.

Reduced response to hypoglycaemia.Reduced response to hypoglycaemia.• 2)Increased energy requirements (100-120 2)Increased energy requirements (100-120

kcal/kg/day)kcal/kg/day)• 3)Higher protein synthesis than term infants.3)Higher protein synthesis than term infants.• 3)Nervous system potentially at risk if inadequate 3)Nervous system potentially at risk if inadequate

nutrition provided.(LCPs)nutrition provided.(LCPs)

Bottle feedingBottle feeding

• Start with small amounts Start with small amounts 20-60ml/kg/day20-60ml/kg/day

• Increase to 150ml/kg/day by day 4-5. Increase to 150ml/kg/day by day 4-5. Usually given 3-4 hourly.Usually given 3-4 hourly.

• Follow instructions: risk of Follow instructions: risk of hypernatraemiahypernatraemia

• Hygiene issues.Hygiene issues.

Normal GrowthNormal Growth

• All babies tend to lose 5-10% of All babies tend to lose 5-10% of birthweight over first few days and birthweight over first few days and regain it by about 10regain it by about 10thth day. day.

• Feeding requirement is 150ml/Kg/dayFeeding requirement is 150ml/Kg/day

• Normal weight gain 30g/day for first 6 Normal weight gain 30g/day for first 6 months.months.

• Most babies double their birthweight Most babies double their birthweight by 4-5 months and treble by one year.by 4-5 months and treble by one year.

Plotting growth on the Plotting growth on the centilescentiles

Statistics againStatistics again

• By 17 weeks, 49% of mothers had By 17 weeks, 49% of mothers had introduced solid food.introduced solid food.

• 49% had introduced solids between 49% had introduced solids between 17- 26 weeks.17- 26 weeks.

• At 4-5 months 62% will use At 4-5 months 62% will use commercially prepared food.commercially prepared food.

• At 8-9 months only 52% using At 8-9 months only 52% using commercial food.commercial food.

WeaningWeaning

• For the first 6 months babies cannot For the first 6 months babies cannot properly digest solid food.properly digest solid food.

• Commence weaning at 6months old and Commence weaning at 6months old and increase so that by 12 months solids are increase so that by 12 months solids are the main part of the diet with milk to drink the main part of the diet with milk to drink along side.along side.

• Do not rush or force-feed.Do not rush or force-feed.

• Full fat cows milk can be used from 12 Full fat cows milk can be used from 12 months.months.

Foods to avoid in weaningFoods to avoid in weaning

• SaltSalt• SugarSugar• TeaTea• HoneyHoney• Nuts: Do not give Nuts: Do not give

any type of whole any type of whole nut to children nut to children under 5 yrs due to under 5 yrs due to risk of choking.risk of choking.

• Serious nut allergy Serious nut allergy affects less than 1% affects less than 1% of the population. of the population. Those most at risk Those most at risk have FH of atopy. have FH of atopy. Avoid giving Avoid giving peanuts and peanut peanuts and peanut products until the products until the child is 3 yrs old if child is 3 yrs old if FH of atopy.FH of atopy.

WeaningWeaning

• Finger foods promote chewing practice and Finger foods promote chewing practice and independence.independence.

• Soft lumps are often manageable from 6 Soft lumps are often manageable from 6 months. Chewing encourages development of months. Chewing encourages development of speech muscles.speech muscles.

• Feeding should always be supervised.Feeding should always be supervised.

• Approx 1 pt of milk should be given plus clear Approx 1 pt of milk should be given plus clear fluids with meals. The bottle should be phased fluids with meals. The bottle should be phased out by 1 yr of age. Avoid fruit juice until out by 1 yr of age. Avoid fruit juice until >6months.>6months.

VitaminsVitamins

• Vitamin K deficiency results in HDNVitamin K deficiency results in HDN

• If still breast feeding > 6months of age If still breast feeding > 6months of age use Vitamin A,C and D drops. Not use Vitamin A,C and D drops. Not required if taking > 1pt of formula/day.required if taking > 1pt of formula/day.

• Give vitamin drops to all children of 1-5 Give vitamin drops to all children of 1-5 years.years.

• Half an hour playing outside is sufficient Half an hour playing outside is sufficient to meet daily Vit D requirements.to meet daily Vit D requirements.

Vitamins continuedVitamins continued

• Iron deficiency anaemia is a common Iron deficiency anaemia is a common problem in toddlers worldwide, problem in toddlers worldwide, particularly in urban populations(10-particularly in urban populations(10-30%) in the UK. It has been shown to be 30%) in the UK. It has been shown to be associated with developmental delay associated with developmental delay and increased susceptibility to infection. and increased susceptibility to infection. Iron supplemented milk is Iron supplemented milk is recommended until at least the age of 1 recommended until at least the age of 1 year in all infants. BMJ 13/3/99, Archives year in all infants. BMJ 13/3/99, Archives Feb 99.Feb 99.

Failure To ThriveFailure To Thrive

• Occurs when child’s growth fails to meet Occurs when child’s growth fails to meet expected potential for age.expected potential for age.

• A single plot on a chart is of limited valueA single plot on a chart is of limited value

• Need to consider parental heightNeed to consider parental height

• Not a diagnosis but a term which describes Not a diagnosis but a term which describes the end result of a number of different the end result of a number of different conditions which may be organic conditions which may be organic (gastrointestinal or non gastro), (gastrointestinal or non gastro), nonorganic (psychosocial) or mixed.nonorganic (psychosocial) or mixed.

Failure to thriveFailure to thrive

• Four basic reasonsFour basic reasons

-Inadequate intake-Inadequate intake

-Abnormal losses from -Abnormal losses from vomiting/diarrhoeavomiting/diarrhoea

-Underlying illness eg CF-Underlying illness eg CF

-Abnormal baby (dysmorphic)-Abnormal baby (dysmorphic)

Approach to FTTApproach to FTT

• Check weight against centile chart.Check weight against centile chart.

• Check type, amount and making up of Check type, amount and making up of feed. Dietary assessment.feed. Dietary assessment.

• Observe a feed and infant responseObserve a feed and infant response

• Assess stoolAssess stool

• Examine for underlying illness.Examine for underlying illness.

• Consider admission to observe response Consider admission to observe response to feedingto feeding

Task!Task!

• You are asked to see a 4 week old You are asked to see a 4 week old baby because mum says the baby baby because mum says the baby will not settle. Birth weight was will not settle. Birth weight was 3.5kg. The baby is bottle feeding 3.5kg. The baby is bottle feeding every 4 hours and taking 3-4oz (90-every 4 hours and taking 3-4oz (90-120ml) each feed. 120ml) each feed.

• How much is the daily intake?How much is the daily intake?

• How much does the baby require?How much does the baby require?

Task part twoTask part two

• The baby weighs 4.2kgThe baby weighs 4.2kg

• Is this adequate weight gain?Is this adequate weight gain?

• What is the milk requirement?What is the milk requirement?

Further ReadingFurther Reading

• Birth To Five, Department Of HealthBirth To Five, Department Of Health

• Allergy UK, Allergy UK, www.allergyfoundation.comwww.allergyfoundation.com

• Infant Feeding 2000, Department of Infant Feeding 2000, Department of Health Feeding survey.Health Feeding survey.

Any questions?Any questions?