Infant Feeds Flashcards
Why is Nutrition Important?
- Fundamental aspect of life
- First 1000 days of life – provide best start to life
- Growth not just about increasing size but change in brain and body structure, composition and function
- Good nutrition prevents disease
what are the recognised phases of childhood?
- Neonate (<4w)
- Infant (<12m/1y)
- Toddler (~1-2y)
- Pre-school (~2-5y)
- School age
- Teenager/ Adolescent
Phases of Growth:
- Infant – _________ led
- Child – _______ _________ led
- Pubertal – ___ ________ led
nutrition
growth hormone
sex steroid
Birth size and weight depends on what things?
- Maternal size (Small mother wouldn’t really have a really big baby)
- Placental function (Problem with placenta function in utero = not as big as a baby)
- Gestation (preterm = smaller)
- More than genetic make up
- Average term infant 3.3 kg
Mother diabetic = bigger baby born
Nutritional Requirements - why?
- Energy is needed for: Physical activity, Thermogenesis, Tissue maintenance (repair of any damage), Growth
- Energy requirement = energy expended + energy deposited in new tissue
- Growth demands - about 35% of energy intake in infants but falls for rest of childhood
Infant Nutrition:
•Characteristic feature is the need to fuel both rapid growth and maintenance
what risks are there?
Infants can rapidly become malnourished.
Dependent on carer
High demands for growth and maintenance
- infants 100kcal and 2g protein/kg/day
- adults 35kcal and 1g protein/kg/day
Low stores (Fat and protein)
Frequent illness (if unwell then they don’t want to feed and can then lose weight and can impact on growth)
what is average weight gain?
- 0-3months 200g
- 3-6 months 150g
- 6-9 months 100g
- 9-12 months 75-50g
- Double weight by 6 months and triple by 1 year
- After 1 year approx 2kg and 5cm/year until puberty
- 4kg baby with 4 weeks of static weight ,20% underweight, like an adult losing 20kg.
Growth charts, plot and interpret
Why is Breast best?
•Nutritionally complete feed for full term babies
- Well tolerated
- Less allergenic
- Low renal solute load
- Ca:PO4, Iron, LCP FAs
- Improves cognitive development
- Reduces risk of infection
Best nutrition
Breast milk vs. Formula
what age should breastfeeding be done?
- Recommended to exclusively breast feed to around 6 months of age
- From 6 months, complementary breast feeding alongside solids is supported
If Breast Feeding is not possible what should be done?
- Families who formula feed should be supported to do so as safely as possible
- Standard formula are cows milk based
- Various brands available - No significant difference, Use whey dominant “first milks”
- Powder or ready to feed
- Various compositions based on age
- Milk is the exclusive feed for 4-6 months (breast milk or formula)
- Breast is Best- WHO recommendation
What are the Types of Milk for Infants?
- Standard formula (Cows milk based)
- Specialised - for cows milk protein allergy, nutrient dense, disease specific
- Cows milk not as main drink until 1 year - Contains no iron (runs risk of iron deficiency anaemia)
Other formulae - Pre-term formulae, Nutrient dense formulae, Cows milk protein allergy, Disease specific
Normal feeding patterns - how does the number of feeds per day change with age?
decreases
What is used if there is Cows milk protein allergy?
•First line feed choice (top photo)
- Extensively hydrolysed protein feeds
- 90% should respond (10% react)
- Palatability a problem in older babies
•Second line feeds (bottom photo)
- Amino acid based feeds
- Babies with severe colitis/enteropathy/symptoms on breast milk
what is the milk ladder?
1 year – increasing small amounts of dairy in diet
Start with biscuit with small amount of milk powder in it as you tend to tolerance a milk derivative that has been cooked well
Heat processing will denature the protein so you tend to tolerate that better
Moves up to a less processed and bigger dose of dairy
Ultimate goal is to reach milk as cows milk at the top of the ladder
Lactose Free Milks - what is lactose intolerance?
Not allergy.
Reduced levels of the enzyme (lactase)
Seen to minor degree in some breast fed babies
Post gastro enteritis (Transient and self resolving)
Also in certain ethnic groups post weaning
Lactose Free Milks can also be used For secondary lactose intolerance, what is it?
Short lived condition eg post gastro-enteritis
Confused with cow’s milk protein intolerance
Lactose free/ “Comfort” milks are not CMP free
what are soya milks?
- Phytoestrogens - Most concern in under 6 months
- Cross reactivity with cows milk (1/3 with CMP intolerance also have soya intolerance)
- Soya indications
- Milk allergy when hydrolysed formulae refused
- Vegan families, if not breast fed
- Consider for children>1 year still on milk free diet
Over 1 year can introduce non formula milks such as what?
- Rice Milk - Not advised for children under 5 years
- Goats’ and Sheep’s milk* - Not suitable for under 1’s. Many children will react
- Oat and nut milks - Organic versions are not calcium fortified
Calories and calcium - what is required?
Full fat cows milk - 65kcal/100ml and 120 mg calcium/100ml. Organic/unsweetened milk substitutes low in calories and Organic milks are no calcium supplemented
- Need 400-500ml of a calcium fortified “milk” to meet calcium requirements
- Supplement if <500ml calcium fortified substitute
Solids - What and Why?
- Complementary feeding
- Transition from milk to a mixed diet - nutritional and developmental changes
- Developmentally ready to actively accept foods. Starts around 6 months of age (17-26 weeks) - Look for signs of readiness such as head control, interest in food
Wouldn’t get all nutrition form beast milk as they get older
Why introduce solids?
•Milk alone inadequate
- Variety of solids provide a source of protein, energy, vitamins, minerals and trace elements
- Encourage tongue and jaw movements in preparation for speech and social interaction
what is Neophobia?
Normal part of child development
To reject novel or unknown foods in childhood
Associated with maternal neophobia
Increase acceptance by repeatedly offering a variety of foods
what is weaning?
Introducing your baby to solid foods, also referred to as weaning or complementary feeding, starts when your baby is around 6 months old. Your baby should be introduced to a varied diet, alongside their usual breast milk or first infant formula
Individual to baby
Can manage solids and good head control
Stages of developmental progression - Liquid
Stages of developmental progression - Solid
What about vitamins - what vitamin are we often lacking?
•Vitamin D
- Dark skinned children not on vitamin drops at risk
- Prolonged breast feeding and mum not on Vit D
- Poor vitamin D status amongst Scots
- Higher risk of poor musculoskeletal health such as rickets and poor muscle strength
- Cannot synthesise Vit D from September to April
- Diet is a poor source
what supplements should children use?
All babies from birth to one year of age - 8.5-10 ug Vitamin D, Not required if infant formula >500ml
Everyone over one year of age - 10 ug Vitamin D
Healthy start vitamins (>1 month)
Those sicky babies - what is GOR and what is GORD?
- GOR - effortless passage of gastric contents into oesophagus with or without regurgitation and vomiting
- GORD - when the reflux of gastric contents causes troublesome symptoms and/or complications
what is GOR?
- Vomiting is common in babies, “Normal” physiological phenomenon, Effortless vomiting with no discomfort
- Does not need special tests or affect growth
- 40-70% of all babies regurgitate 1-4 times daily or more - Peaks at 3-4 months
Reassurance over natural course
Advice on feeding. Overfed?
Improving from 6 months with solids and sitting up
Need no specific treatment
•Thickened formula/thickener or if no improvement consider 2-4 week trial of milk free diet
what htickners can be used?
- Infant Gaviscon sachets (NOT an antacid)
- Carobel
- Use large hole or variable flow teat
- Pre-thickened feeds, not normally recommended
- Ask for help from colleagues or refer to specialist for advice
what are red flag signs?
- Weight loss or poor weight gain
- Recurrent or bilious vomiting
- GI bleeding
- Persisting diarrhoea
- Dysphagia
- Stridor/cough/hoarseness
- High risk groups - Preterm babies, neurological impairment, chronic respiratory illness, anatomical, some genetic disorders e.g. Down’s syndrome
- More severe cases, likely under specialist teams
what are GORD treatments?
- Medical referral
- Require acid supression - Reduced gastric acid may increase risk of pneumonia, gastroenteritis and candidiasis
- Trial of milk free diet (increase this is cause)
- Continuous NG/jejunal feeds
- Consideration of anti reflux surgery
- Drug therapy
what drug therapy can you use for GORD?
- Gaviscon Liquid - Not advised<1 year
- H2 receptor
- PPIs decrease the acidity
- Pro-kinetics:
- Domperidone promote gastric emptying - From April 2014 use restricted to short term only for nausea/vomiting not long term use in GORD
- Low dose erythromycin
- Alimemazine (anti histamine)
Feeding Problems:
- Refusal to feed and excessive crying in a well baby is not always ______
- Babies cry !!
- Mean of 110-118 mins /day 0-6 weeks
- Reducing to 72 mins /day by 10-12 weeks
reflux
what is Colic?
- Diagnosis of exclusion
- Inconsolable crying in a baby - <3 months of age, >3hours/day, >3 days/week
- For at least a week
- No red flag symptoms
how do you manage colic?
Explanation and reassurance
Probiotics
Trial of cows milk protein avoidance
Lactase drops
Anti spasmodics
whata re some other potential feeding problems?
•Breast fed baby
- Functional lactose overdose
•All babies
- Consider cow’s milk protein allergy
- Psychosocial issues
- Maternal mental health
what is important to know in regards to iron?
- Most common nutritional deficiency in the world
- Iron status at birth is the most important determinant of iron status throughout infancy
- Breast fed/Pre term
- Cow’s milk - Introducing cow’s milk as a drink before 1 year of age. No more than 500ml to drink after 1 year of age
- Too much juice - Drink after meals and with snacks. Only milk and water are tooth friendly
Factors associated with lower iron status at birth include low infant birthweight, and maternal iron deficiency anaemia, obesity, smoking status and gestational hypertension
- No structure to meals/snacks & offering choices ++
- ? Constipated
what is norml bowel function?
Normal to open bowels from 3 times a day to 3 times a week
Aim for type 4 stools
ERIC – The children’s bowel and bladder charity
Constipation can occur at any age and is prevalent in 5-30% children (can affect oral intake aswell)
what is constipation?
- No bowel movement for three or more days
- Passing lots of small hard stools
- Holding on to stools:
- pushing with signs of or her face becoming red
- using avoidance techniques
- soiling, loose stools that leak into pants, pyjamas and bedclothes. This happens when the bowel is full
how do you manage constipation?
•Laxatives
- Lactulose in infants
- Movicol/Laxido in older children
- Adequate fluid intake encouraged
- Fruit, vegetable and wholegrains intake encouraged
- Constant routine – sitting on potty or toilet after meals
- Give praise and encouragement
Nutrition issues beyond infancy…
what are nutrition issue in toddlers and pre-school?
- Learning to feed self and find food
- Picky eaters/excess milk
- Dependent on carer
- Frequent illness
Nutrition issues beyond infancy…
what are nutrition issue in school age?
- Learning to be independent
- Chronic disease
- Obesity
•12 % of Aberdeen primary 1’s are overweight and 10% obese
Nutrition issues beyond infancy…
what are nutrition issue in adolescents?
Independent, puberty ,eating disorders
