Infant nutrition

Gábor Veres, MD, PhDIst Dept. of Pediatrics

Semmelweis University, BudapestLecture of Habilitation, 04.10.2011

What is the most important question in infancy?

Weight gain?

Content

• Breast feeding• Composition of breast milk• Eosinophilic enteropathy, Reflux (GOR)• Formulas, solids• Iron, vitamins

Three basic principles of infants feeding

• Until 6 months exclusive breast feeding.

• Demand feeding.• Milk or diluted milk can not be given

even between 6-12 months. Follow-on formulas are recommended.

Until 6 months exclusivebreast feeding, BUT:

• Introduction of gluten and solids• Between 4-7 months (+ breast feeding)

• Decrease of celiac disease and foodallergy

Silano M, Agostoni C, Guandalini S. Effect of the timing of gluten introduction on the development of celiac disease. World J Gastroenterol. 2010 16:1939-42.

Demand feeding, BUT:

• Jaundice: sleepy infant, wake-up!

• Infantile colic: not every crying means

baby is hungry

Energy content of the breast milk (BM)

• Exclusive breast feeding covers theenergy needs of infants until 6 months

• Energy needs: 90-120 kcal/kg/die• Energy of BM 60-70 kcal/100ml• 5000g baby: 500kcal BM pro day

750ml BM / day

Advantages of breast feeding I.

• Composition of breast feeding is optimal for the development of infants

• PUFA content is necessary for the development of retina and brain

• Breast milk is easier digestable than the different formulas

Advantages of breast feeding II.• Breast milk, especially colostrum ensures

immune defense• It contains antibacterial and antiviral

antibodies, as well as T-cells and macrophages

• Stool pH is lower, bacterial microflora bifidogen inhibiting enteral infections

Advantages of breast feeding III.

• Frequency of obesity, hypertonia, IBD and Type I. diabetes mellitus are rare

• Favourable psychological relationship between the mother and child

• Atopic dermatitis, allergy ???

Immunoglobulins and cytokines in BM

• IgA neutralizes pathogens, does not activatecomplement system (oral tolerance)

• TGF-beta (transforming growth factor)

inhibits immune activation

less allergy in breast fed infants

Tomicić et al. Pediatr Res. 2010;68:330-4.

BUT:Breast fed infants do have:

• Atopic dermatitis• Allergic-eosinophilic esophagitis• Allergic-eosinophilic colitis

Foreign proteins in breast milk

Eosinophilic esophagitis

• Main problem: reflux• BUT: pH is normal, therapy resistant, • 75% in males• Food allergy in 50%, eosinophilia 42%

• Dg: upper endoscopy• WHEN ???

Eosinophilic esophagitis (upper endoscopy)

Granulation (eosinophilic clusters)

Conc. rings and furrows(reversible fibrosis)

Eosinophilic esophagitis (histology)

• Papilla elongation

• min. 20 eosinophil /HPF

• Epithelial eosinophil

„cluster”

Hematochezia (fresh blood in feces)

• 3 months old infant, breast feeding• No family history for polyposis• CRP, blood picture, coagulogram: normal• Feces: no bacteria• RDE: no fissures, no obstipation

Dg: ALLERGIC COLITIS

Mother’s elimination diet (cow’s milk)

Lymphonodular hyperplasia

• Colonoscopy: rectosigmoidregion• Allergic colitis (cow’s milkprotein induced)• Similar to M. Crohn• Special aminoacid formula (Neocate)

blood in feces disappearedTroncone: Colon in food allergy. JPGN.2009;48 Suppl 2:S89-91.

Percentage of breast fed infants in Sweden (%)

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Adatsor1

%

1945 1970 1999

34%

42%40%

34%

50%54%

60%

96%

61%68%

89%83%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12

Percentage of breast feeding(Hungarian data)

months

• 3 months: 75%

• 6 months: 60% MGYT, 2009

Composition of breast milk Newburg DS: Handbook of milk composition. Academic Press 1995;pp 273-349

• Lactose 55-60 g/l

• Proteins 10 g/l

• Lipids 40 g/l

• Nucleotids, Erythropoietin, IgA, TGF-beta

I. Lactose in BM (55-60 g/l)

• Main sugar/energy source• Enzyme: lactase• After 34. weeks lactase activity matures• Lactase activity after the age of 3y.

• Congenital absence of lactase: very rare

galactose glucose

II. Proteins in BM (10 g/l)Age (month) Breast milk

consumtion(g/day)

Proteinintake(g/kg/day)

1 794 1,95-2,04

2 766 1,41-1,48

3 764 1,19-125

4 812 1,27-1,33

5 782 1,11-1,16

6 881 1,05-1,11

Proteins (1%=1g/100ml)

• Protein content of colostrum and early milk is higher

• Mature breast milk contains less secretory IgA and lactoferrin

• Ratio of whey and casein is also high (80/20) which is gradually decreasing to 60/40

Whey/casein ratio (BM=60:40)

Whey:• Intestinal transport, motility• More digestable

Casein:• Viscosity , anti-reflux effect

Recommended protein content of formulas

g/100 kcal g/lESPGHAN 1,8-2,8 12-19AAP 1,8-4,5 12-30Räihä 1,6-1,8 11-12

At decreased protein content the serum urea level will be similar to that found at exclusively breast fed infants

Low protein intake in infancy is beneficial for future life I.

• Danish survey, 631 intants• At birth, 3 months, 18 months (US, blood)

Higher protein intake (formula fed infants):• Increased size of kidney• Higher urea in blood

Schmidt, Pediatr Nephrol, 2004;19: 1137-44

• Protein intake in infancy• DONALD study (203 children, mean age, 7 years)

• BMI and BF (body fat)• If high protein intake in infancy

• BMI and BF were increased (at 7 years)

Günther, Am J Clin Nutr 2007

Low protein intake in infancy is beneficial for future life II.

Which mammals has the lowest protein in the BM ???

• Human breast milk

III. Lipids in BM (40 g/l)

Importance of lipids

• High energy content• Beta-palmitate trygliceride is high in BM

(70%)• Significance of p oly-u nsaturated f atty a cids

(PUFA)

Structure of triglicerides(αααα) CH3 - O - R1

|(ββββ) CH2 - O - R2

|(αααα) CH3 - O - R3

Pancreas lipase split the palmitic acid located in αααα position

The advantage of tryglicerides containing beta-palmitate

• In this position the lipase does not split the palm itic residue

• Can be absorbed !!!

• Free palmitic acid forms with calcium unsoluble calcium soap which is not able to absorbe

• Therefore it decreases energy and calcium supply

Significance of LC-PUFA in infant nutrition

• Linolic and linolenic acid is not synthesized in the human body (essential fatty acids)

• Docosahexaenoic acid is indispensable to the normal function of cell membrane

Somatic development of breast fed infants

• After two months the length and weight of breast fed infants are slightly less than those of formula fed

• At the preparation of reference curves a preponderance of formula fed babies occured

• Not the maximal but optimal development is advantageous

Infant mortality (1000 newborns ? at 1 year)

• Prehistoric man, chimpanzee infant mortality: 250 ‰

• End of XIX. is the same for men

• One of the reasons: NO infant formula 1903 (Derby) infant mortality:

- arteficial feeding: 230 ‰- breast fed: 70 ‰

Infant formulas

For healthy babies Special formulas

1. Standard formula2. Follow-on3. Baby’s milk

1. Standard formulas

• Strict criteria• Range of energy : E:60-75 kcal/100ml

Trend toward less protein• Whey/casein = 60 : 40 • Taurin: development of retina and

CNS• Carnitin: lipid metabolism

Why is not optimal to give cow’s milk to infants under one year?

• It contains too much– protein– sodium

• It contains too less– linolic acid– iron– vitamins (C, D, E)

Cow’s milk feeding may cause:

• Iron-deficiency anaemia

• Blood in feces• Atopic dermatitis• Increased osmotic load

for kidneys

3. Baby’s milk

• Recommended from 7-9 months• Until 1-3 years• More expensive than cow’s milk• Price: 1.5-2x than cow’s milk

Special formulasAnti-reflux

• seads of Saint John’s bread-tree (KAREB/CARAT)

• Corn-starch (AR) or potato-starch• HA and anti-reflux together (HA/AR)

Reflux, regurgitation• Size of stomach: 30 ml• Adults: 1500 ml• 5kg infant: 200 ml BM• 70kg adult: 2.8 litre !!!• Growing well?

• Exclude other causes(pyloric stenosis, intest. stenosis,

CAH, infections, metabolic etc.)

Solids• Foods besides breast milk and

formulas• Introduction between 4-7 months

– fruits– cereals– vegetables– meat

Iron deficiency• 1 billion people affected• Developed country: 12%, developing: 51%• Hungary: 8-36 months: 30%

4-6 years: 51% iron deficiency !• Iron psychomotorial and cognitive

function

• In iron deficiency: lead absorption

Bioavailablity of ironIron content % of absorption

breast milk 0.5-1 mg/l 50%

cow’s milk 0.5-1 mg/l 10%

meat 2.5 mg/100g 30%

iron fortif. formula 12 mg/l 7%

Iron and everyday practice

• First: measure iron level• Bacteria needs iron for growing• Do NOT give iron in bacterial

infection!• Term baby: no supplementation in 6-

9 months source: red blood cells

• Preterm baby: 2mg/kg after 2 months

Vitamin K

• Vitamin K dependent coagulatory proteins (prothrombin, VII, IX, X)

• BM contains low level, supplementation• At birth, 1 week, once/months per os, 2mg• Formula contains vitamin K

• Intestinal bacteria produce vitamin K• Liver, soybean, spinach, tomatoes, kale

Vitamin D

• Low level in BM• Supplementation: 400U/day• After 2 weeks - 1-1.5 years• Formula contains vitamin D

Allergy, atopic dermatitis

Probability of atopy in positive family history

• No atopy in the family : 10%• One parent / one sibling : 30%• Both of parents : 50%• Both p. with the same manifest. : 70%

Allergy prevention of infants

• (Diet of mother during pregnacy: NO effect!!!)

• Longer breast feeding• Avoid food with high allergenicity (also

during breast feeding)• Hypoallergen formulas• Probiotics (Kalliomaki, Lancet, 2001)

Probiotics („Good” bacteria)

• 1-1.5kg bacteria in the intestinal tract

• 400 bacterium species• 10 times more

bacteria than cells in the body

• „Good” bacteria:Bifidobacteria, Lactobacillus species

Probiotics and atopy• Kalliomaki, Lancet, 2001

• Lactobacillus GG was given to mother before delivery and to children for 6 months

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probiotikum kontroll

Frequency of atopy at 1 year %

%

%

Probiotics Controls

Feeding of preterms

• Carnitin, taurin• LC-PUFA, MCT• Phosphate crosses

placenta in the last 3 months

• Iodine, selenium

Rachitis (rickets) and

pretermsIf you think, the

preterm baby has rickets, first check serum phosphorusbefore giving more vitamin D

Swelling of metaphyses at wrists

Rachitic rosary

Somatic development of breast fed infants II.

• After 3 years no difference can be detected in length of breast fed and formula fed children

• The weight of formula fed babies is

always higher, among them the

frequency of obesity is high

Contraindications of breast feeding

• From the mother’s part– Severe acut or chronic infections (typhus,

erysipelas, tuberculosis, AIDS)– Sepsis– Postpartum psychosis

• From the infant’s part– Some types of inborn error of metabolism

(galactosaemia, some forms of glycogenosis)

Difficulties of breast feeding• Mother’s side

– Mamilla rhagad– Papilla plana– Papilla plana inverta

• Infant’s side– Cleft palate– Missing sucking reflex (prematurity,

cerebral impairment)– Severe rhinitis

Fruits

• First apple and peach• other recommended fruits seasonal

fruits– sour cherry – cherry– pealed plum– pear– orange, lemon, banana

• Fruit juices and mashed form

Vegetables

• First is the potato• Following with carrots, beetroot,

lettuce, pumpkin, Brussels sprout, spinach, bean, green peas, asparagus

• Savoy, cauliflower only after 8 months

• Spinach, sorrel have high oxalate content therefore only once a week

Meats and egg

• Fish is advantageous because of its fatty acid composition, but it may cause allergic reactions.

• Chicken liver once a week• Egg yolk after 8 moths• Egg white after 1 year

Zug-Frauenf eld Study (ZUFF ) Exl, EJN, 2000

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HA

Kontroll

Zug: 564 infants, allergy prevention group (HA)Frauenfeld: 566 infants, controls

%

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49

3 month 6 months

Ten Steps to Successful Breastfeeding(WHO/UNICEF)

1. Have a written breastfeeding policy that is routinely communicated to all health care staff

2. Train all health care staff in skills necessary to implement this policy

3. Inform all pregnant women about the benefits and management of breastfeeding

Ten Steps to Successful Breastfeeding(WHO/UNICEF)

4. Help mothers initiate breastfeeding within a half-hour of birth

5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants

6. Give newborn infants no food or drink other than breastmilk, unless medically indicated

7. Practice rooming-in: allow mothers and infants to remain together 24 hours a day

Ten Steps to Successful Breastfeeding(WHO/UNICEF)

8. Encourage breastfeeding on demand9. Give no arteficial teats or pacifiers

(also called dummies or soothers) to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

Utilization of breast milk’s proteins

• Total protein content 11 g/l, from which only 9 g/l is utilized for nutrition.

• Secretory IgA, lactoferrin and lizozym are not used for nutrition

• Only 13 % of urea can be used for aminoacid synthesis

How to decrease allergenity?

• Heating, home-canning is good: apple, celery, fish

BUT not good: cow’s milk, eggs• Gene technology (rice, wheat)• Enzymatic hydrolysis

Special formulas: hypoallergen (HA)

Why should not be given formula instead of breast milk after birth?

• Frequency of cow’s milk allergy in breast fed infants 0.4%

• But: every child was given formula in the hospital!Host, Acta Paed Scand, 1988

40 ml cow’s milk contains:ββββ-lactoglobulin (main allergen in cow’s milk)

1 litre of breast milk/day for 21 years !!!

Role of nucleotides I.

• Although they can be synthetised, in infants nucleotides are semiessencial compounds as the rate of their endogen synthesis is not sufficient to the normal functions

• Breast milk contains nucleotides in higher concentration than the cow’s milk and formulas

Role of nucleotides II.

• Nucleotids help the development of intestinal mucosa and improve the absorption of different nutritients

• They promote the growth of Bifidobacteria• Increase the cellular and humoral immune

response

Erythropoietin (Epo)

• Breast milk (BM): Epo (Kling, Pediatr Res, 1998)

• Per os Epo can be absorbed

BM protectsProtease activity

Intestinal permeability

What is the role of EPO in BM?• No effect on erythropoesis

• Epo: trophic factor in the intestine (Juul, Gut, 2001)

Epo receptor

intestine

EPO