Infant Feeding And Disease Risk

Question 1

Methodology for infant feeding recommendations (observational studies, RCTs, follow up studies) and PROS and CONS

Answer 1

• observational: large sample sizes, disease end points available. But not randomised so cannot conclude causality, also different definitions of EBF, issues of reverse causality (alternation of behaviour due to disease outcome)
• RCTs: gold standard for causality. But unethical to randomise, expensive, and difficult to standardise due to different compositions of milk
• follow up studies: issues with selection bias, loss of power, high attrition rates

Question 2

Experimental study for breastfeeding: RCT with donor BM vs formula

Answer 2

• donor breastmilk versus formula for 1 month
• preterm babies
• breastmilk showed better blood lipids, better BP in adolescence, reduced NEC, tolerated EN better, lower requirements for PN

Question 3

Experimental study: PROHIBIT breastfeeding promotion study

Answer 3

• breastfeeding promotion
• 1 year: lower GI infections, atopic dermatitis
• 6 years: higher IQ, but no effect on BP or anthropometry
• at 11.5 years: no effect on adiposity, obesity, fat mass
• at 16 years: obesity was greater in the BF arm

Question 4

Key findings of the LANCET report on BF: impact on baby, mother, infection, obesity

Answer 4

• impact on baby: improved malocclusion, intelligence, reduction in overweight and diabetes, no difference in allergies/asthma/BP/cholesterol
• impact on women: reduces breast cancer, T2DM, ovarian cancer, improved birth spacing
• in LMIC babies had reduced diarrhoea and respiratory infection
• demonstrates a 26% protection against obesity

Question 5

Nutritional and non-nutritional reasons children need complementary feeding

Answer 5

• nutritional: need additional nutrients not present in high amounts in breastmilk (i.e Fe)
• non-nutritional: cultural preferences, behavioural, induction of tolerance and taste preferences

Question 6

Potential issues with introduction of complementary foods

Answer 6

• risk nutritional deficits
• hygiene
• food availability
• allergy
• risk of infection

Question 7

Aspects to consider: timing of complementary foods

Answer 7

• developmental readiness: do they have adequate neuromuscular development for a safe swallow?
• GI and renal development: can they handle radical nutritional changes?
• social and cultural factors
• maternal preference
• nutritional adequacy: how long can breastmilk meet requirements for? Some studies suggest just need additional vit D and K supplements, others suggest that Fe deficiency may occur with prolonged breastfeeding

Question 8

Expert opinions on EBF: WHO

Answer 8

• WHO recommend exclusive breastfeeding for 6 months with feeding continuing for 1 year
• based on an SLR
• mother: increased weight loss and reduced menses
• baby: no impact on infant mortality or growth, but may lower infant morbidity (diarrhoea and GI infection) but not in all countries

Question 9

Expert opinions on EBF: EFSA NDA panel

Answer 9

• commissioned a literature review
• did not include key health benefits of EBF, the effects of different textures and varieties of food
• concluded that current evidence doesnt give a specific age for more appropriate CF
• but, provided food was of appropriate texture and was nutritionally complete then there were no adverse outcomes associated with introduction of complementary foods
• skills for finger foods can be seen at 4 months

Question 10

Expert opinions on EBF: USDA

Answer 10

• CF at 4 months doesnt lead to any measurable negative outcomes versus 6 months
• early introduction of CF at 4 months doesnt improve Fe status
• early introduction of allergens doesnt increase allergy risk

Question 11

Conclusions on introduction of allergy foods

Answer 11

• general agreement that there is no need to delay introduction

Question 12

‘At risk’ nutrients with prolonged breastfeeding

Answer 12

• Fe, vitamin D, iodine, ALA, DHA

Question 13

What are the concerns with complementary feeding for LMIC versus HIC?

Answer 13

• HIC: too high energy density

- LMIC: provision of sufficient nutrients

Question 14

At 12 months, what is the proportion of food infants are eating and what is the size of their stomach?

Answer 14

• eating 12% of their body weight everyday

- 200 mL capacity stomach

Question 15

Complementary feeding and fat

Answer 15

• do not restrict- need to have high kcal density
• no link between fat intake and later adiposity
• need to avoid trans fats and focus on fats with essential nutrients: soybean and rapeseed oil

Question 16

Complementary feeding and protein

Answer 16

• should keep to <15% of kcal intake
• avoid cows milk for first year of life (too high in protein and poor Fe source)
• in LMIC need to focus on good biological sources of Fe such as eggs, fish
• biological sources of protein has lower levels of anti-nutrients

Question 17

Complementary feeding and carbohydrates

Answer 17

• dont want too high fibre or sugar
• no nutritional requirements for free sugars and may impact glycaemia and obesity risk
• lactose and fructose from fruits are completely fine

Question 18

Iron and zinc and complementary feeding

Answer 18

• requirements are very high in first 5 months of life
• Fe: 9x adult male, Zn 4x adult male
• inadequate intake leads to stunting, infection and anaemia
• high bioavailability in red meats and fortified cereals

Question 19

Baby led weaning

Answer 19

• not enough evidence that they are getting enough food for Fe stores, and denote and increased choking risk
• papers have found that it doesnt lead to reduced risk of overweight or healthier growth
• but can lead to greater enjoyment of food and reduced food fussiness
• instead, use responsive feeding: responding to infant hunger and satiety cues, not all crying is due to hunger, do not use food as comfort or reward

Question 20

WHO feeding principles

Answer 20

• EBF at 6 months and continue for 1 year
• CF at 6-8.9 months
• minimum dietary diversity at 6-23.9 months. Foods from >4 food groups in last 24 hours (dairy, legumes/nuts, fruit/veg, vit A fruit/veg, eggs, flesh foods, grains/roots/tubers)
• minimum meal frequency is at least 2 per day up to 8.9 months, >8.9 months is at least 3 per day
• Fe rich or Fe fortified foods

Question 21

Important considerations for HIC, LIC and both

Answer 21

• HIC: EBF for at least 4 months, protein <15% intake, avoid excessive cows milk
• LIC: EBF for at least 6 months, energy and nutrient dense foods, high quality protein sources (animal)
• both: no added sugars, good sources of Fe and Zn, allergenic foods treated like other CF, responsive feeding