infant nutrition Flashcards
why is nutrition important
- fundamental aspect of life
- first 1000 days - provide best start to life
- growth: increasing size, change in brain and body structure, composition and function
- prevention of disease
- prevention of malnutrition - responsible for ~50% of all preventable deaths <5y/o
recognised phases of childhood
neonate <4w
infant <12m
toddler ~1-2y
pre-school ~2-5y
school age
adolescent
recognised phases of growth and what drives them
infant - nutrition led
- rapid phase of growth in neonates and infants
child - growth hormone led
pubertal - sex steroid led
what influences birth size and weight
some genetics
maternal size
maternal health e.g. gestational diabetes
placental function
gestation - 95% of weight gain between 20-40wks, 10-16% of body weight is fat
average term infant weight
3.3kg
what is energy needed for
physical activity
thermogenesis
tissue maintenance
growth
what determines energy requirement
energy expended + energy deposited in new tissue
growth demands during childhood
~35% of energy intake in infants but falls for rest of childhood (0-3mths is when there is the highest energy requireement)
why is infant nutrition important
need to fuel rapid growth and maintenance
- infants can become rapidly malnourished
- high demands for growth and maintenance
- 100kcal/kg/day and 2g protein/kg day (adults 35kcal and 1g protein/kg/day)
infant is dependent on carer, low stores of fat and proteins and frequent illness
average weight gain for infants
0-3mths 200g/wk
3-6mths 150g/wk
6-9mths 100g/wk
9-12mths 75-50g/wk
double weight by 6mths and triple by 1yr
growth in children
after 1yr ~2kg and 5cm/yr until puberty
weight loss in children
4kg baby w/ 4wks of static weight - 20% underweight
like an adult losing 20kg
why is breastfeeding recommended
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: macrophages and lymphocytes, interferon, lactoferrin, lysozyme, bifidus factor
breast milk vs formula
BREAST MILK:
- ‘perfect’ nutrition for 6mths, ‘near perfect’ for up to 1yr
- tailor made passive immunity, development of infant’s active immunity, development of infant’s gut mucosa, reduced infection, antigen load minimal
- reduced risk of breast cancer for mum
FORMULA:
- no anti-infection properties, risk of contamination, high antigen load
- no transmission of BBVs/drugs, doesn’t need mum, accurate feed volumes, provides vit k, less jaundice
- expensive
what age is breastfeeding recommended until
exclusively BF till ~6mths
from 6mths, complementary feeding alongside solids, supported up to 2y/o or beyone
human milk fortifiers
commonly used as a dietary supplement when babies are premature - esp <33wks
UNICEF baby friendly - 10 steps
- written breast feeding policy
- train all health care staff in skills
- inform all pregnant women about pros/management of breasfeeding
- help mother’s initiate breastfeeding within 30mins of birth
- show mothers how to breasfeed and maintain lactation, even if they should be separated from their infants
- give newborn babies no food/drink other than breast milk unless medically indicated (meds, vits, oral rehydration)
- rooming in: allow mothers and infants to remain together 24h/day
- encourage breast feeding on demand
- no artificial teats or dummies to breastfeeding infants
- establishment of breast feeeding support groups and refer mothers to them on discharge from hospital/clinic
what to do if breast feeding isn’t possible
support families who formula feed to do so as safely as possible
standard formula are cow’s milk based
various brands available - no significant difference, use whey dominant ‘first milks’
powder or ready to feed
various compositions based on age
normal feeding patterns
types of milk for infants
standard first infant formula - cows and goat milk based, 66kcal and1.2g protein/100ml
hypoallergenic
lactose free
anti-reflux and comfort milks
standard infant formula availabel
other types of formula
pre-term: powder and ready to feed, 80kcal adn 2.6-2.9g protein/100ml
post discharge - poswer and ready to feed, 72-73kcal and 2g protein/100ml
nutrient dense - 100kcal and 2.6g protein/100ml
cow’s milk protein allergy - 1st and 2nd line formula feeds
1st line: extensively hydrolysed protein feeds, 90% should respond, palatability a problem in older babies
2nd line: aa based feeds: (for the 10% that react to 1st line) babies w/ severe colitis/enteropathy/symptoms on breast milk, overprescribed and expensive
HA formula no longer suitable for babies w/ cow milk protein allergy
cow milk protein formulae w/ added probiotic
aptamil pepti syneo: whey based extensively hydrolysed formula, bifidobacterum breve M-16V
neocate syneo: aa, bifidobacterium breve M-16v
milk ladder
milk-free diet for ~6mths-1yr
infants generally do well with the milk ladder
start with baked milk (less allergenic) build up quantity if tolerated, add cheese, yoghurt then cow’s milk
soya infant formula
not used in cow’s milk allergy - cross reactivity
carbohydrate source is maltodextrin - greater potential to cause dental caries
phytoestrogens posed a potential risk- most concern <6m/o, limited evidence on risks to reproductive safety
suitable for vegetarians - no vegan infant formulae available
millk over 1y/o
follow on formula - no evidence of any nutritional/health advantage in using
introduce non-formula milks - cow’s, soya, alternatives
- goat’s and sheep millk - many children w/ milk allergy will react to
- oat, pea, coconut, hemp and nut milks
- rice milk - not advised for <5y/o
some children w/ allergy may require prescription milk - aa (neocate jr)
lactose free infant formula
lactose intolerance isn’t an allergy
- seen to a minor degree in some breast fed babies
- also in certain ethnic groups post weaning
for 2y lactose intolerance:
- short lived condition e.g. post-gastroenteritis
- confused w/ cow’s milk proten intolerance
- lactose free milks aren’t CMP free
calories and calcium in full fat cow’s milk
65kcal/100ml and 120mg Ca/100ml
organic/unsweetened milk substitutes are low in calories
organic milks aren’t calcium supplemented
need 400-500ml of calcium fortified ‘milk’ to meet calcium requirements
supplements if <500ml calcium fortified substitute
well kids calcium liquid or calcium softies
breast feeding mums OTC supplement, accrete or cacit D3
stages of developmental progress - liquids
up to 6mths - breast/formula
~6mths - cp may be introduced w/ adult support, along w/ breast/bottle
6-9mths - baby continues to develop stability w/ cup drinking, normal to lose some liquid
12mths - tongue may protrude under the cup to provide stability
18mths - may bite on side of cup to stabilise
2yrs - should be able to stabilise cup
stages of developmental progress - solids
17wks-6mths - pureed foods
~6mths - thicker consistency, some lumps, soft finger foods introduced under supervision, may initially spit out food, gradually learn to suck from the spoon
6-9mths - increase variety of textures and tastes, finger foods gradually introduced under supervision
9-12mths - mashed, chopped and minced, finger foods gradually increased
12mths - mashed, chopped family foods, thicker food from a spoon, variety of finger foods
18mths - introduction of new tastes and textures, increasing variety of finger foods
solids - when are they introduced, how to tell baby is ready
complementary feeding alongside milk
baby is developmentally ready to actively accept foods
starts around 6mths (17-26wks) - look for signs of readiness, head control, interest in food
96% families wait until at least 4mths, 46% till 6mths
why are solids introduced into the baby’s diet
transition from milk to a mixed diet - nutritional and developmental changes
milk alone is inadequate - require new sources of protein/energy/vits/minerals/trace elements, encourage tongue and jaw movements in preparation for speech and social interaction
pre-term weaning - when is baby ready
support themselves in a seated position - premature babies might need extra support
hold their head in a stable position
show an interest in other people eating
lean forward and open their moth towards a spoon/food
put things to their mouth and make munching, up and down movements
- wait until you see a few of these signs before starting weaning
what is neophobia
fear of something new
food refusal is a normal part of child development - most resolve w/ time
rejection of novel/unknown foods in childhood, usually peaks around 18mths
what can influence neophobia
distaste, distrust, contamination influence intake
constipation, anaemia and GOR may be a factor
how to increase acceptance of food in neophobia
repeatedly offer a variety of foods
parents can exacerbate food refusal
GOR in babies
effortless passage of gastric contents into oesophagus w/ or w/o regurgitation and vomiting
doesn’t need special tests or affect growth
GORD in babies
when the reflux of gastric contents causes troublesome symptoms and/or complications
how common is GOR in babies
vomiting is common in babies
normal physiological phenomenon - effortless vomiting w/ no discomfort
40-70% of babies regurgitate 1-4x daily or more
peaks at 3-4mths
refluxed milk is pH neutral for 2hrs post feed
managing GOR in babies
babies are well
reassure parents over natural course
advice of feeding - overfed? (check vol 150ml/kg)
improves from 6mths w/ solids and sitting upright - may suggest early weaning, minimum 17wks
need no specific treatment
thickened formula/thickener or if no improvement consider 2-4wk trial of milk free diet
thickeners and thickened infant formula
infant gaviscon sachets - not an antacid
carobel 5kcal/100ml
use large hole or variable flow teat
thickened milks (not normally recommended) - contain potato starch/carob/locust bean gum), mix w/ cool water
red flags in reflux
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 resp illness, anatomical, some genetic disorders e.g. Down’s syndrome
GORD treatments
medical referral
require acid suppression - reduced gastric acid may increase risk of pneumonia, gastroenteritis and candidiasis
trial of milk free diet
continuous gastric feeds or move to jejunal feeds
consideration of anti reflux surgery
drug therapy
drug therapy for GORD
alginate therapy - e.g. gaviscon liquid, ?1ml after feeds for babies, lnot advised <1yr
H2 receptor - ranitidine
PPIs - decrease acidity but we are looking to reduce quantity of acid produced, omeprazole/lansoprazole/esomeprazole for tubes
pro-kinetics - domperidone to promote gastric emptying, use restricted to short term only for N/V not long term use in GORD, ECG prior to use
anti-histamine - alimemazine, reduces nausea
feeding problems in babies
refusal to feed and excessive crying in a baby isn’t always reflux
how often do babies cry
110-118mins/day 0-6wks
72mins/day 10-12wks
what is colic
diagnosis of exclusion
inconsolable crying in a baby - <3mths old, >3hrs/day, >3days/wk for at least 1 wk
no red flag symptoms
management of colic
explanation and reassurance
probiotics
trial of cows milk protein avoidance
lactase drops
anti spasmodics
other issues in babies w/ difficulty feeding
breast fed - functional lactose overdose
all babies - cows milk protein allergy, psychosocial issues, maternal mental health
normal bowel function in babies
normal to open bowels 3x/day to 3x/wk
aim for type 4 stools (sausage)
constipation can occur at any age, ⅓ of children
constipation in children
no bowel movement for 3 or more days
passing lots of small hard stools
when the bowel is full - soiling, loose stools that leak
holding on to stools - pushing, red face, avoidance techniques
management of constipation
laxatives - lactulose in infants, movicol/laxido in older children
adequate fluid intake encouraged
fruit, veg and wholegrain intake encouraged
constant routine - sitting on potty/toilet after meals
praise and encouragement
comfort infant formula
for the dietary management of colic and constipation
- no evidence based benefit
- use of prebiotics and palminate
- partially hydrolysed whey protein
vitamin D - who is at risk of deficiency
reduction when housebound or during COVID lockdown
dark skinned children not on vitamin drops are at risk of deficiency
also risk of deficiency when prolonged breast feeding and mum not of vit D
poor vit D status among scots
higher risk of poor MSK health e.g. rickets, poor muscle strength
can synthesise vit D from april-sept 11am-3pm
diet is a poor source
supplements for children
all babies from birth-1yr - 8.5-10ug vit D, not required if infant formula >500ml
everyone >1 - 10ug vit D
healthy start vitamins - >1mth, 233ug A, 200mg C, 7.5ug D
abidec/dalivit - 0.3ml (<1), 0.6ml (>1yr)
suggest OTC children’s vitamins
iron deficiency
most common nutritional deficiency worldwide
iron status at birth is the most important determinant of iron status throughout infancy
what are the periods of peak brain development
neonatal
6mths-3yrs
- if iron deficiency present, check FBC/ferritin
causes of iron deficiency
breast fed/pre term
cow’s milk - introducing as a drink before 1y, more than 500ml to drink after 1y
too much juice - drink after meals and with snacks, only milk and water are tooth friendly
no structure to meals/snacks and offering choices
nutrition issues in toddlers and pre-school children
learning to feed self and find food
picky eaters
XS milk intake
dependent on carer, frequent illness
nutrition issues in school age
learning to be independent
chronic disease
obesity
nutrition issues in adolescents
independent, puberty, eating disorders
other considerations to nutrition issues beyond infancy
high levels of deprivation
- infants born to parents in the most deprived areas are 1.7x more likely to be born w/ low birth weight compared to the most affluent area
- children who live in the most deprived areas are 2x as likely to be obese at 5y/o compared to the most affluent area
impact of COVID
