dr. ali joo
TRANSCRIPT
Infant feeding and intolerances
Dr Ali Bokhari
Consultant Paediatrician & Divisional Director for Women’s, Children and Clinical support Services
South London Health Care NHS Trust.
London
South London Health Care NHS Trust
• One of the UK’s largest maternity with over 12,000 births a year, 16,000 by 2016
• One of London’s busiest neonatal services with 3000 intensive care days per year
• 50 bedded in-patient Paediatric Unit• 2 Paediatric Ambulatory services• 50,000 Paediatric A&E attendances• UK’s largest POSCU
Infant feeding
• WHO 2009– Exclusive breast feeding for first 6 months (180 days)– Complimentary feeding from 6 months, breast feeding
continuing till 2 years of age, breast feeding may continue beyond 2 years
– Specific recommendations apply to HIV +ve mothers– Overall under 35% of babies are exclusively breast fed
for first 6 months– 1/3 of babies and children <5 deaths related to poor
feeding and nutrition related causes
Why Breast feed-Benefits for the baby
There is high quality evidence that both in developing and developed worlds breast feeding confers significant short and long term advantages:Decrease mortality compared with breast fed babies (X6-10)Decreases other infectious diseases like meningitis, OM and UTIsDecreased risk of childhood leukaemia, later onset atopic and immunologialc based conditions like asthma, Coeliac disease and Inflammatory bowel diseaseBF is protective against later onset obesity, hypertension, atherosclerosis and high cholesterol levelCognitive benefits
Why Breast feed-Benefits to mother
• Immediate benefits– Decrease in post-patrum haemorrhage when
mothers feed immediately after birth– Delays the return of fertility (<2% risk of
pregnancy)– Increase chances of pre pregnancy weight– Reduction in breast and ovarian cancer
Infant feeding & ARV in HIV +ve mothers and their infants
WHO infant feeding guidelines 2006 WHO infant feeding guidelines 2010
ARV taken from 28 weeks pregnancy until 1 week after labour or indef if taking for their own health
ARV taken from 14th week of
pregnancy until 1 week after labour or indef if taking for her own health
Short ARV regimen during BF period for either mother or infant
Long ARV regimen during BF period for either infant or baby
Exclusive BF for 6 months Exclusive BF for 6 months
Rapidly wean from BF Gradually wean from BF
No mixed feeding Mixed (complimentary) feeding from 6 months
Not recommended to BF after 6 months Recommended to BF and mix feed in conjunction with ARV
Types of Intolerances
• Protein IntoleranceCow’s milk protein (Casein 80%, Whey 20%)
• Sugar Intolerance Lactose, Sucrose, Galactose
Identification and Treatment of Milk intolerance in infants
Lactose IntolerancePresentation:
Severe unresolved colic, Continued diarrhoea after GE, Previous surgery, +ve reducing substances in stool
Treatment:Present in all standard formulae milk and breast feeding. If bottle feeding use reduced lactose formula milk, if breast feeding lactase drops can be tried
Notes:Congenital lactase deficiency is rare, Secondary lactase deficiency resolves in a few months, Can be secondary to CMPI
Lactose Intolerance
• Primary:Relative deficiency. 70% of world population. Highest amongst Asians
• Secondary: Post GE, CMPA, post chemo, Coeliac disease, Crohn’s disease
• Congenital: Extremely rare, no survival before 20th century
• Developmental: Premature babies <34 weeks
Identification and Treatment of Milk intolerance in infants
Cow’s Milk Protein IntolerancePresentation:
Regular large vomits post feed, GORD symptoms that don’t resolve, Abdominal pain and further syptoms- colitis/ rectal bleeding, diarrhoea, FTT/weight loss
Treatment: Breast fed babies-mothers to avoid milk, If formula fed try extensively hydrolysed formula initially, if rectal bleeding or in very young or fragile babies AA formula
Notes: Can be introduced gradually if babies don’t take willingly
Cow’s Milk Protein IntoleranceReported for infants 1-3 months 2-5%Can be IgE or non IgE mediatedMay be part of atopic spectrum of conditionsSPT +ve and RAST +ve have later recoverySPT -ve less likely to have atopy or multiple food
allergies1 parent or sibling atopic increases= 20-40% risk of
developing atopyBoth parents = 50-60% risk of developing atopy
Identification and Treatment of Milk intolerance in infants
Milk allergy- Immediate or delayed IgE responsePresentation:
Eczema/urticaria/ wheeze/sneeze, swelling of tongue, mouth, lips. Angiooedema, anaphylaxis
Treatment:
Use AA formula until old enough to try Soya based products, Mothers of BF babies to avoid the milk
Notes:
Can also have problems with fish, egg, Soya, salicylates and occ wheat. Need specific weaning advice designed to the patient
Alternative formula milks
Lactose free formula: Contains CMP, minimal lactose- SMA LF, Galactaomin , Enfamil Lactofree
Extensively hydrolysed formula: Pre-digestion and hydrolysis of CMP, low allergencity- Neutramigen, Neutramigen 2, Pepti Junior, Pepti , Pregegtamil, Prejomin, Peptide
Amino Acid Based formula: Protein source based on L AA, very low allergenicity and expensive, Neocate, Neutramigen AA,
Partially hydrolysed formula: Minor digestive problems- Nan-HA1&2, Comfort, Atamil easy digest
Unsuitable milks: Soya milk, Animal milk e.g. goat & sheep, Cereal milk (rice and oat), Enzyme treated milk e.g. lactacid lacto free
Finally
Thank you for your kind invitation