Infant nutrient needs Basis Approach Specific nutrients water energy protein fatty acids vitamin K Vitamin D Iron Fluoride
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Infantnutrient needs
BasisApproachSpecific nutrients
waterenergyproteinfatty acidsvitamin KVitamin DIronFluoride
Basis of recommendations• Growth and development
– Preventing deficiencies– Meeting nutrient requirements
• Physiology– GI– Renal
• Programming– Preventing chronic conditions– Optimizing health through lifecycle
Goals and Objectives
• Optimal growth and development• Safety• Individual health• Population Health• Prevention and Chronic Illness
Challenges• Strength of Evidence• Individual vs population
– Public health approach– Individual genetics– Maternal-infant dyad
• In utero endowment• Beliefs, values, choices• Relationship/nurture
– Environmental factors
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 2005underweight 35.2 26.5
Iodine deficiency 35.2
• Vitamin A deficiency– 140 million preschoolers– 7 million pregnant women
• Iron Deficiency– One of most prevalent– 4-5 billion affected
United Nations 5th report on World Nutrition: March 2004
• Reports in US of PEM, Rickets, Zinc deficiencies
Causes
Nutrition - DiseaseAccess
FoodHealth Care
EnvironmentEconomicsEducation
Physiology - GI Maturation
Gut DevelopmentRegulatory Mechanisms
Genetic Endowment
Environmental Influences
Biological Clock
In utero
• Fetal GI tract is exposed to constant passage of fluid that contains a range of physiologically active factors:– growth factors – hormones– enzymes– immunoglobulins
• These play a role in mucosal differentiation and GI development as well as development of swallowing and intestinal motility
At Birth
• Gut of the newborn is faced with the formidable task of passing, digesting, and absorbing large quantities of intermittent boluses of milk
• Comparable feeds per body weight for adults would be 15 to 20 L
Renal
• Limited ability to concentrate urine in first year due to immaturities of nephron and pituitary
• Potential Renal solute load determined by nitrogenous end products of protein metabolism, sodium, potassium, phosphorus, and chloride.
Urine Concentrations• Most normal adults are able to achieve urine
concentrations of 1300 to 1400 mOsm/l• Healthy newborns may be able to
concentrate to 900-1100 mOsm/l, but isotonic urine of 280-310 mOsm/l is the goal
• In most cases this is not a concern, but may become one if infant has fever, high environmental temperatures, or diarrhea
Programming by Early Diet• Nutrient composition in early diet may have long term effects on
GI function and metabolism
• Animal models show that glucose and amino acid transport activities are programmed by composition of early diet
• Animals weaned onto high CHO diet have higher rates of glucose absorption as adults compared to those weaned on high protein diet
• Barker Hypothesis:– Association between BMI and chronic disease: HTN and
cardiovascular, SGA/IUGR
Nutrients• Guidelines• Recommendations• Education
– Genetics– Adaptation– Environment– Behavior/activity– Choices, access,
resources– other
Individual Requirements
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
• 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
DRI’s for infants• Macronutrients based on average intake of breast
milk– Protein less than earlier RDA
• AAP Recommendations– Vitamin D: 200 IU supplement for breastfed
infants and infants taking <500 cc infant formula– Iron: Iron fortified formula (4-12 mg/L),
Breastfed Infants supplemented 1mg/kg/d by 4-6 months
Water
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 NeedsAge 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
Water
• Individual needs• Renal concentrating ability• Solute in diet• Health• environment
Water
• Water balance– RSL in diet– Water in– Water out– Renal concentrating ability
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?– 90%– To achieve 100 ml/kg/d needs to consume
at least 110 cc/kg/d
Energy
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)
Newborn 6 months
Losses 5 5 Activity 10 25 Thermic effect of feed
10 10
Growth 40 12 Resting Metabolic rate
50 55
Total 115 107
Energy Intakes by Breastfed and Formula Fed Boys (kcal/kg)
Age in Mos. Breastfed Formula1 115 1202 104 1063 95 955 89 956 86 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)
2002 Energy DRI
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
2002 Protein DRI
2002 Carbohydrate DRI
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.
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
LCPUFA: Backgroundn-6 n-318:2
Linoleic18:3
Linolenic
18:3 linolenic
20:5EPA
20:4Arachidonic
22:6DHA
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 supplementation with long-chain polyunsaturated fatty acids: are there
developmental benefits? Scott et al. Pediatrics, Nov. 1998.
• RCT, 274 healthy full term infants• Three groups:
– standard formula– standard formula with DHA (from fish oil)– formula with DHA and AA (from egg)
• Comparison group of BF
Outcomes at 12 and 14 months
• No significant differences in Bayley, Mental or Psychomotor Development Index
• Differences in vocabulary comprehension across all categories and between formula groups for vocabulary production.
Bayley Scales at 12 monthsHumanMilk
Std.Formula
AA +DHA
DHA
MDI 108 105 105 104
PDI 100 105 98 101
MacArthur Communicative Development Inventories at 14 Months of Age
HumanMilk
Stdformula
AA +DHA
DHA
VocabularyComprehen-sion
101 100 98 92
Vocabularyproduction
97 101 99 91
Conclusion
“We believe that additional research should be undertaken before the introduction of these supplements into standard infant formulas.”
PUFA Status and Neurodevelopment: A summary and critical analysis of the literature (Carlson and Neuringer, Lipids, 1999)
• In animal studies use deficient diets through generations - effects on newborn development may be through mothering abilities.
• Behaviors of n-3 fatty acid deficient monkeys: higher frequency of stereotyped behavior, locomotor activity and behavioral reactivity
Efficacy and safety of docosahexaenoic acid and arachidonic acid addition to infant formulas: can
one buy better vision and intelligence?
(Koo. J Am Coll Nutr. 2003 Apr;22(2):101-7) • “Functional benefits in particular visual or
neural development from IF containing LCPUFA remains controversial.”
• “Potential for excessive and/or imbalanced intake of n-6 and n-3 fatty acids exists with increasing fortification of LCPUFA to infant foods other than IF.”
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.• 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.
• 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
• 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.”
Longchain polyunsaturated fatty acid supplementation in infants born at term
(Cochrane, 2001). • At present there is little evidence from randomised
trials of LCPUFA supplementation to support the hypothesis that LCPUFA supplementation confers a benefit for visual or general development of term infants.
• A beneficial effect on information processing is possible but larger studies over longer periods are required to conclude that LCPUFA supplementation provides a benefit when compared with standard formula.
• Data from randomised trials do not suggest that LCPUFA supplements influence the growth of term infants
Vitamins and Minerals
• Need for minerals and vitamins increased per kg compared to adults: – growth rates– mineralization of bone & increases in bone
length– Increased blood volume– energy, protein, and fat intakes
Vitamins and Minerals
• Focus on nutrients with controversies and/or recent research:– Vitamin K– Vitamin D– Iron– Fluoride
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
Vitamin K Controversy
• Adequacy of BM• Maternal Diet and Vitamin A content of
BM• ? Significance/prevalence of
hemorrhagic disease of newborn• IM injections of all newborns
Controversies Concerning Vitamin K and the Newborn: AAP Policy Statement, 2003
Vitamin K Deficiency- definitions – AAP, 2003
Term Age of onset
Symptoms
Early vitamin K deficiency bleeding (VKDB)*
First week of life
Unexpected bleeding in previously healthy-appearing neonates
Late VKDB 2-12 weeks 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
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).
Cochran
• Vitamin K is necessary for the synthesis of coagulation factors II (prothrombin), VII, IX and X in the liver.
• In the absence of vitamin K the liver will synthesize inactive precursor proteins, known as PIVKA’s (proteins induced by the absence of vitamin K).
• HDN is caused by low plasma levels of the vitamin K-dependent clotting factors. In the newborn the plasma concentrations of these factors are normally 30-60% of those of adults. They gradually reach adult values by six weeks of age
Cochran
• HDN is divided into three categories: early, classic and late HDN. Early HDN occurs within 24 hours post partum and falls outside the scope of this review.
• Classic HDN occurs on days 1-7. Common bleeding sites are gastrointestinal, cutaneous, nasal and from a circumcision. Late HDN occurs from week 2-12.
• The most common bleeding sites in this latter condition are intracranial, cutaneous, and gastrointestinal (Hathaway 1987 and von Kries 1993).
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
Cochran
• In different parts of the world, different methods of vitamin K prophylaxis are practiced.
The problem:
• Oral vitamin K has effect similar to IM in preventing early VKDB, but not in preventing late VKDB
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
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 .
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.
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 meta-analysis 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.
Brousson and Klien, Controversies surrounding the administration of vitamin K
to newborns; a review. CMAJ. 154(3):307-315, February 1, 1996
• Conclusion: There is no compelling evidence to alter the current practice of administering vitamin K intramuscularly to newborns.
AAP Recommendations
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
Cochran
• HDN is divided into three categories: early, classic and late HDN. Early HDN occurs within 24 hours post partum and falls outside the scope of this review.
• Classic HDN occurs on days 1-7. Common bleeding sites are gastrointestinal, cutaneous, nasal and from a circumcision. Late HDN occurs from week 2-12.
• The most common bleeding sites in this latter condition are intracranial, cutaneous, and gastrointestinal (Hathaway 1987 and von Kries 1993).
Vitamin D
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
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 g (400 IU) per day for breastfeed infants
• 2003: American Academy of Pediatrics recommends supplements of 5 g (200 IU) per day for all infants as recommended in DRIs.
• 10/14/2008: AAP updates guidelines vor 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 the recommended vitamin D intake of 200 IU per day.
• If intake is less than 500 ml recommend additional supplement of vitamin D
Summary of AAP Recommendations, 2003
• 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 at least 500 mL per day of vitamin D-fortified milk, or do not take a daily multivitamin supplement containing at least 200 IU of vitamin D.
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
Iron
Iron• Function• Source
– Formula, breast milk, other foods– Bioavailability:
• Breast milk• Soy formula
• Deficiency– Anemia
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
• Iron absorption from soy formulas is less
• Greater bioavailabilty of iron in breastmilk
Iron in Formula• Infant formulas have been classified as
low-iron or iron-fortified based on whether they contain less or more than 6.7 mg/L of iron. – Current mean content of low iron formula is 1.1 to 1.5 mg/L
of iron and high iron is 10 to 12 mg/L.
– One company recently increased to 4.5 for low iron.
– European formulas are 4-7 mg/l
– Foman found same levels of iron deficiency at 8 and 12 mg/l
Percent Reported Absorbed
Study
Human Milk 48%
Hallberg et al
Human Milk – in 5 to 7 month olds who are also eating solid foods.
21% Abrams et al
Iron Fortified Cow’s milk based Formula
6.7% Hurrel et al
Infant Cereals 4 to 5%
Fomon et al
Iron Absorption In Infancy
Iron deficiency
• Anemia– Inadequate iron in diet– Loss
– GI bleeding, cows milk proteins, infectious agents
– Other causes• Genetics• Lead• Other nutrients
Iron Fortification of Infant FormulasPediatrics, July 1999 v104 i1 p119
• During the first 4 postnatal months, excess fetal red blood cells break down and the infant retains the iron. This iron is used, along with dietary iron, to support the expansion of the red blood cell mass as the infant grows. The estimated iron requirement of the term infant to meet this demand and maintain adequate stores is 1 mg/kg per day.
• Infants born prematurely and those born to poorly controlled diabetic mothers are at higher risk of iron deficiency
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%.”
Iron Fortified Formula: Iron Deficiency
• 9-30% of current US sales are low-iron formulas
• Iron deficiency leads to reduction of iron-containing cellular protein before it can be detected as iron deficiency anemia by hct or hgb
• Permanent effects of Fe deficiency on cognitive function are of special concern.
Iron Deficiency Prevalence at 9 Months
1.1 mg iron per L plussupplemental foods
28-38%
12-15 mg iron per L 0.6%
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.
GI Effects Attributable to Iron
• Double blind RTC have not found effects.• Most providers know that, but parents
often want to change to low iron…..• “yet it may remain temptingly easier to
prescribe a low-iron formula, achieve a placebo effect, and ignore the more insidious long-term consequences of iron deficiency.”
AAP Iron Recommendations1. In the absence of underlying medical factors
(which are rare), human milk is the preferred feeding for all infants.
2. Infants who are not breastfed or are partially breastfed should receive an iron-fortified formula (containing between 4.0-12 mg/L of iron) from birth to 12 months. Ideally, iron fortification of formulas should be standardized based on long-term studies that better define iron needs in this range
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 Iron Recommendations1. In the absence of underlying medical factors
(which are rare), human milk is the preferred feeding for all infants.
2. Infants who are not breastfed or are partially breastfed should receive an iron-fortified formula (containing between 4.0-12 mg/L of iron) from birth to 12 months. Ideally, iron fortification of formulas should be standardized based on long-term studies that better define iron needs in this range
AAP Iron Recommendations3. The manufacture of formulas with iron
concentrations less than 4.0 mg/L should be discontinued. If these formulas continue to be made, low-iron formulas should be prominently labeled as potentially nutritionally inadequate with a warning specifying the risk of iron deficiency. These formulas should not be used to treat colic, constipation, cramps, or gastroesophageal reflux.
AAP Iron Recommendations4. If low-iron formula continues to be
manufactured, iron-fortified formulas should have the term "with iron" removed from the front label. Iron content information should be included in a manner similar to all other nutrients on the package label.
AAP Iron Recommendations
• Parents and health care clinicians should be educated about the role of iron in infant growth and cognitive development, as well as the lack of data about negative side effects of iron and current fortification levels.
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.
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 least 16 y
1.00 0.50 0.00
American Dental Association, American Academy of Pediatrics, American Academy of Pediatric Dentistry, 1994.
Feeding Guidelines and Recommendations
• Public health policy• Health promotion• Prevention
The Start Healthy Feeding Guidelines for Infants and Toddlers (JADA, 2004)
Examples
• Transition• Supplements to breastmilk• Safety• Allergy prevention• Dental health• other
Some Issues: Foman, 1993• “For the infant fed an iron-fortified formula,
consumption of beikost is important in the transition from a liquid to a nonliquid diet, but not of major importance in providing essential nutrients.”
• Breastfed infants: nutritional role of beikost is to supplement intakes of energy, protein, perhaps Ca and P.
• Nutrient content of breastmilk is a compromise between maternal and infant needs. Most human societies supplement breastmilk early in life.
C-P-F: Recommendations• No strong evidence for benefits from fat
restriction early in life• AAP recommends:
– high carbohydrate infant foods may be appropriate for formula fed infants
– no fat restriction in first year– a varied diet after the first year– after 2nd year, avoid extremes, total fat intake of
30-40% of kcal suggested
Allergies: Early Introduction of Foods
(Fergussson et al, Pediatrics, 1990)
• 10 year prospective study of 1265 children in NZ• Outcome = chronic eczema• Controlled for: family hx, HM, SES, ethnicity,
birth order• Rate of eczema with exposure to early solids
was 10% Vs 5% without exposure• Early exposure to antigens may lead to
inappropriate antibody formation in susceptible children.
Early Introduction of Foods(Fergussson et al, Pediatrics, 1990)
Proportional Hazard Coefficient (p<0.01)For Risk of Chronic Eczema
No solid Food before4 months
1.00
1-3 types of foodbefore 4 months
1.69
4+ types of foodsbefore 4 months
2.87
Allergies: Prevention by Avoidance (Marini, 1996)
• 359 infants with high atopic risk• 279 in intervention group• Intervention: breastfeeding strongly
encouraged, no cow’s milk before one year, no solids before 5/6 months, highly allergenic foods avoided in infant and lactating mother
Allergies: Prevention by Avoidance (Marini, 1996)
0
20
40
60
80
1 yr 2 yrs 3 yrs
% of Children With Any Allergic Manifestations (cummulative incidence)
non-interventionintervention
Allergies: Prevention by Avoidance (Zeigler, Pediatr Allergy Immunol.
1994)
• High risk infants from atopic families, intervention group n=103, control n=185
• Restricted diet in pregnancy, lactation, Nutramagen when weaned, delayed solids for 6 months, avoided highly allergenic foods
• Results: reduced age of onset of allergies
Allergies: Prevention by Avoidance (Zeigler, Pediatr Allergy Immunol. 1994)
Definite or Probable Food Allergy
Age Intervention Control p
12 mo 5% 16% 0.007
24 mo 7% 20% 0.005
48 mo 4% 6% ns
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: Cost
• $1,000 - $3,000 for repair• Increased risk of developing new
lesions in primary and permanent teeth
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
Bright Futures
• AAP/HRSA/MCHB• http://www.brightfutures.org• “Bright Futures is a practical
development approach to providing health supervision for children of all ages from birth through adolescence.”
Newborn Visit: Breastfeeding
• Infant Guidance– how to hold the baby and get him to latch on properly;– feeding on cue 8-12 times a day for the first four to six
weeks; – feeding until the infant seems content.– Newborn breastfed babies should have six to eight wet
diapers per day, as well as several "mustardy" stools per day.
– Give the breastfeeding infant 400 I.U.'s of vitamin D daily if he is deeply pigmented or does not receive enough sunlight.
Newborn Visit: Breastfeeding
• Maternal care– rest– fluids– relieving breast engorgement– caring for nipples– eating properly
• Follow-up support from the health professional by telephone, home visit, nurse visit, or early office visit.
Newborn Visit: Bottle-feeding
• type of formula, preparation• feeding techniques, and equipment. • Hold baby in semi-sitting position to feed. • Do not use a microwave oven to heat
formula. To avoid developing a habit that will harm your infant's teeth, do not put him to bed with a bottle or prop it in his mouth.
First Week• Do not give the infant honey until after her
first birthday to prevent infant botulism. • To avoid developing a habit that will harm
your infant's teeth, do not put her to bed with a bottle or prop it in her mouth.
One Month• Delay the introduction of solid foods until the
infant is four to six months of age. Do not put cereal in a bottle.
Four Months– Continue to breastfeed or to use iron-
fortified formula for the first year of the infant's life. This milk will continue to be his major source of nutrition.
– Begin introducing solid foods with a spoon when the infant is four to six months of age.
– Use a spoon to give him an iron-fortified, single-grain cereal such as rice.
Four Months, cont.– If there are no adverse reactions, add a new pureed
food to the infant's diet each week, beginning with fruits and vegetables.
– Always supervise the infant while he is eating. – Give exclusively breastfeeding infants iron supplements. – Continue to give the breastfeeding infant 400 I.U.'s of
vitamin D daily if he is deeply pigmented or does not receive enough sunlight.
– Do not give the infant honey until after his first birthday to prevent infant botulism. .
Six Months• Continue to breastfeed or use iron-fortified formula
for the first year of the infant's life. This milk will continue to be her major source of nutrition.
• Avoid giving the infant foods that may be aspirated or cause choking (e.g., peanuts, popcorn, hot dogs or sausages, carrot sticks, celery sticks, whole grapes, raisins, corn, whole beans, hard candy, large pieces of raw vegetables or fruit, tough meat).
• Learn emergency procedures for choking.
Six Months, cont.• Let the infant indicate when and how much
she wants to eat. • Serve solid food two or three times per day. • Begin to offer a cup for water or juice. • Limit juice to four to six ounces per day. • Give iron supplements to infants who are
exclusively breastfeeding.
Nine Months• Start giving the infant table foods in order to
increase the texture and variety of foods in his diet. • Encourage finger foods and mashed foods as
appropriate.• Closely supervise the infant while he is eating. • Continue teaching the infant how to drink from a
cup. • Continue to breastfeed or use iron-fortified formula
for the first year of the infant's life.
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