QUANDO INTRODURRE IL LATTE
VACCINO NELLA DIETA DEL BAMBINO
Carlo Agostoni
Dipartimento di Scienze
Cliniche e di Comunità
IRCCS Policlinico Cà Granda
Università degli Studi di Milano
Il latte nel divezzamento (e oltre)
Quale latte?
• Latte materno
• Formule
• Latte vaccino
LATTE MATERNO
24 mesi e anche oltre se la mamma o il bambino lo desiderano
WHO
IGF-I at 9 Months and Number of Breastfeedings
SKOT Cohort
P=0.0006
n=115 n=88 n=46 n=3
Madsen AL, et al. Growth Hormone IGF Res. 2011;21:199-204.
4
In all infants recorded different daily intakes of cow’s milk, infant formula and meat
Fasting Insulin at 9 Months and Number of Breastfeedings
SKOT Cohort
P=0.0015
n=115 n=88 n=46 n=3
Madsen AL, et al. Diabet Med. 2010;27:1350-1357.
5
Allattamento al seno e prevalenza di sovrappeso e obesità
in 9357 bambini di età compresa tra 5 e 6 anni
(Von Kries R et al, BMJ 1999; 319:147)
0
2
4
6
8
10
12
14
never
breastfed
breastfed < 2 mos 3-5mos 6-12mos >12 mos
breastfeeding duration (months)
pre
vale
nce
(%
)
overweight°
obese'
sovrappeso : BMI> 90o percentile per età e sesso
obesità: BMI>97o percentile per età e sesso
Breastfeeding and prevalence of overweight° in over
15000 adolescents aged 9-14 years. (adapted from
Gillmann et al, JAMA 2001:285:2461-67)
0
2
4
6
8
10
12
14
never
breastfed
breastfed <1 mos 1-3 mos 4-6 mos 7-9 mos >9 mos
breastfeeding duration (months)
prevale
nce %
prevalence of
overweight°
°Overweight was BMI>95th percentile for age and sex
Taveras EM et al 2004; 114: e577
Life expectancy at birth in EU member states has increased by over 6
years between 1980 and 2010. On average across the European Union,
life expectancy at birth for the three-year period 2008-10 was 75.3 years
for men and 81.7 years for women.
Most European countries have reduced tobacco consumption via public
awareness campaigns, advertising bans and increased taxation
Alcohol consumption has also fallen in many European countries.
In the European Union, 52% of the adult population is now overweight
and 17% is obese. The obesity rate has doubled since 1990 in many
European countries. Obesity tends to be more common among
disadvantaged social groups, and especially women
Il latte materno
• 1. Basso apporto proteico (< 1 g / 100 ml; latte
vaccino 3.5 g/100 ml, formule non meno di 1.2-
1.4 g/100 ml)
• 2. Ottimale rapporto energia/proteine
• 3. Presenza di numerosi fattori anti-infettivi
• 3. Grassi e carboidrati con valore funzionale
(LCPUFA, oligosaccaridi)
Ljung K et al
Formule : quali
• Formule standard
fino a 6 o 12 mesi
• Formule di seguito
tra 6 e 12 mesi
• Formule di crescita
2 e 3 anni
Elementi chiave delle formule
1. Proteine (quantità e qualità)
2. Grassi (quantità e qualità acido
linolenico, acido docosaesaenoico)
3. Qualità carboidrati (digeribili/non
digeribili)
4. Minerali e micronutrienti (ferro, zinco,
calcio, Vitamina D), altri composti
“funzionali”
Is Cows' Milk Harmful
for a Child's Health ?
Key-note lecture - NUTRITION
Carlo Agostoni
Fondazione IRCCS Cà Granda
Ospedale Maggiore Policlinico
University of Milan, Italy
CHAIR PERSON: Dominique Turck, Lille, France
Conclusions: Cow’s Milk harmful?
• Negative effects on iron status up to 9-12 months,
then no negative effects if adequately complemented with iron enriched foods
• Lactose intolerance easily managed
• Allergy to WCM proteins may be transient. Atopics may independently be at risk of poor growth
• A cause-effect relationship with T1D is not established, and the same for ASDs
• Cow’s milk stimulates IGF-1 and may affect linear growth , but associations with non-communicable diseases is still not convincing
Conclusions: Cow’s Milk Safety
• From 12 months of life onwards
• Up to around 500 mL per day
• 250 mL in lactose intolerants
• Fat-reduced milks after 24-36 months on
individual basis
Reports of nutrient intakes in European
Countries in the 8-24 mos period
Country age(mos) Pg/kg P % Lip% Cho%
• Spain 9 4.4 15.7 26.4 58
• France 10 4.3 15.6 27.1 57
• Italy 12 5.1 19.5 30.5 50
• Denmark 12-36 3.3 15 28 57
Rolland-Cachera et al. Acta Paed 1999; 88:365
Protein/obesity association
Author Prot% Age Observation: P (obesity, BMI)
Rolland-Cachera 1995 >14.8 2 yrs 8 yrs <0.05
Int J Obes Rel Dis 19:573
Scaglioni 2000 22 1yr 5 yrs <0.05
Int J Obes Rel Dis 24:777
Dorosty 2000 14 18ms Adiposity Rebound NS
Pediatrics 105: 1115
Hoppe 2004 13,F, 14,M 9ms 10yrs NS
Am J Clin Nutr 79:494
Scaglioni 2004 14 1y 8yrs NS
Acta Paediatrica 93:1596
LARN 2012- PROTEINE AR e PRI
Anni kg AR g/d PRI g/d En%* 0.5-0.99 8.6 9 11 --
1-3 13.7 11 14 4M, 3.7F
4-6 20.6 16 19 4.1M, 4.3F
7-10 31.4 25 31 5M, 5.4F
11-14M 49.7 39 48 5.7M
11-14F 50.7 39 48 6.5F
15-17M 66.6 50 62 6.25M
15-17F 55.7 40 50 6.3F
*En% calcolata come AR (fabbisogno medio) proteine vs
mediana (kcal/die) fabbisogno energetico per LAF
Come ridurre le proteine ?
• Latte vaccino 500 mL (o equivalente) circa
3.5 g/dL 18 g proteine 72 kcal
• Latte “formula” 1.5 g dL circa 7.5 g
proteine 30 kcal
• In una dieta giornaliera intorno a 1000 kcal il
bambino (con 500 mL di prodotto) passerebbe
da circa 45 g proteine (180 kcal, 18% energia)
a circa 35 grammi proteine (140 kcal, 14%
energia)
Influence of Protein Intake on
Metabolic-endocrine Response in Infants
0
10
20
30
40
50
60
Pla
sm
a IG
F-I
(n
g/m
L)
6 Months
IGF-I Levels According to Feeding
Higher ProteinFormula
Lower ProteinFormula
Breastfed
0
20
40
60
80
100
120
140
160
C-p
ep
tid
e:
cre
ati
nin
e (
ng
/mL
)
6 Months
Insulin Secretion According to Feeding
Higher ProteinFormula
Lower ProteinFormula
Breastfed
Socha P, et al. Am J Clin Nutr. 2011.
FORMULA TYPE AND PROTEIN INTAKE g/d (SD)En%
Time HP LP P EFSA 2012 PRI g/d
T1 14 (3) 11 9 (1) 7 0.001 m f
T6 10 9
T12 12 11
T18 12 11
T24 12 12
T2 16 (2) 11 9 (1) 7 0.001
T3 17 (3) 11 10 (1) 7 0.001
T4 18 (3) 11 11 (2) 7 0.001
T5 21 (5) 13 13 (2) 7 0.001
T6 24 (5) 14 15 (4) 8 0.001
T7 28 (6) 15 20 (5) 10 0.001
T8 30 (7) 15 22 (6) 11 0.001
T9 30 (7) 15 24 (7)11 0.001
T12 35 (9) 15 29 (8)13 0.001 31 (9) 14 0.001 0.028
T18 42(12) 16 42 (12) 16 0.626 39 (10) 15 0.004 0.013
T24 45(12) 16 45 (13) 16 0.679 43 (11) 16 0.025 0.073
BF P vs HP P vs LP
Energy and nutrient content per 100 ml of different milk based products
for young children (modified from Nutrition Committee, Germany, 2011)
2.9%
6.9%
5.3%
Changing protein requirements in relation to different energy intakes:
example in young adults
Nutrient:energy
ratio requirement
depends upon the
activity level of
the individuals in a
population
29
REE, resting energy expenditure predicted with the equations of
Henry (2005) using body mass and height.
LARN
1120
1382
LARN
1040
1346
mediana
Time HP LP EFSA 2013 AR M F
BF
T1 509.9 (118) 512.46 (110)
T2 563. (117) 559.2 (113)
T3 595.7 (116) 588.9 (118)
T4 631.1 (113) 632.3 (116)
T5 667.0 (115) 678.8 (131)
T6 700.9 (140)* 726.6 (147)*
T7 754.4 (143) 765.7 (153) 636 573
T8 791.4 (155) 810.2 (162) 661 599
T9 814.8 (155) 837.8 (188) 688 625
T12 891.5 (184)a 881.9 (176)a 777 712 792.5(224)b
T18 1043.3 (223) 1045.1 (223) 988.8 (195)
T24 1119.7 (240) 1112.6 (253) 1028 946 1079.4 (222)
FORMULA TYPE AND ENERGY INTAKE kcal/day
Time HP LP EFSA 2013 AR M F
BF
T1 509.9 (118) 512.46 (110)
T2 563. (117) 559.2 (113)
T3 595.7 (116) 588.9 (118)
T4 631.1 (113) 632.3 (116)
T5 667.0 (115) 678.8 (131)
T6 700.9 (140)* 726.6 (147)*
T7 754.4 (143) 765.7 (153) 636 573
T8 791.4 (155) 810.2 (162) 661 599
T9 814.8 (155) 837.8 (188) 688 625
T12 891.5 (184)a 881.9 (176)a 777 712 792.5(224)b
T18 1043.3 (223) 1045.1 (223) 988.8 (195)
T24 1119.7 (240) 1112.6 (253) 1028 946 1079.4 (222)
FORMULA TYPE AND ENERGY INTAKE kcal/day
Circa 20%
energia in più
dell’AR raccomandato
Z- score of caloric intake per Countries
-0,8
-0,6
-0,4
-0,2
0
0,2
0,4
0,6
time
z-s
co
re k
cal GE
BE
IT
PL
ES
T1 T2 T3 T4 T5 T6 T7 T8 T9 T12 T24
Energy costs of fat and protein deposition in the human infant
Am J Clin Nutr 1988; 48:951
Total energy requirement for deposition 1.17 kJ/kJ (kcal/kcal)
deposited for fat (ie, 1 kJ deposited and 0.17 kJ expended for
deposition, and 2.38 kJ/kJ (kcal/kcal) for protein.
The metabolizable-energy requirement for weight gain during infancy
was calculated (range, 12.2-25.1 kJ/g, or 2.9-6.0 kcal/g; means, 18.7
kJ/g, or 4.5 kcal/g) from the energy costs of fat and protein deposition
and published information on changes in body composition during
the first year of life.
Energy expended by low birth weight infants in the deposition of
protein and fat.
Pediatr Res 1997 ;41:584
Using multiple regression analysis of energy expenditure against protein
stored, and metabolizable energy, the energy expended in the deposition
of protein was calculated to be 5.5 kcal/g +/- 1.1 kcal/g (SE) and the
energy cost of fat deposited was 1.6 kcal/g +/- 0.3 kcal/g (SE).
Ghisolfi et al, Public Health Nutr, 2013; 16:524
AGE 17 (GUM) – 19 (CM) months
961 + 33
967 + 18
46
Quando introdurre il latte vaccino ?
• Non prima del dodicesimo mese latte materno fino ad un
anno, anche più a lungo
• Dopo il 12° mese può essere introdotto il latte vaccino
(limitare la quantità?)
• Tra il 12° ed il 36° mese una formula di crescita - GUM-
può migliorare il bilancio dei nutrienti effetti funzionali
non noti, mancano dati “diretti” su parametri ematici
ATTENZIONE al bilancio energetico nel suo complesso
puo’ vanificare ogni altro tentativo di riequilibrio
qualitativo e quantitativo