29th January 2014
Dr Nikoletta Lofitou
Introduction
 Nutritional requirements
 Department of Health’s recommendations
 Breast feeding/bottle feeding
 Clinical conditions
 Clinical scenario
Infant Nutrition
Good nutrition is essential for:
 Survival
 Physical growth
 Mental development
 Productivity
 Health and well being
A short term issue?
A short term issue?
Differences in nutritional experiences during sensitive
periods in early life, both before and after birth, can
program a person's future development, metabolism,
and health (EARNEST, 2011)
Statistics
 Prevalence of
breastfeeding
 Prevalence of exclusively
breastfeeding
 81% at birth(76% in
 69% at birth
2005)
 69% at one week
 55% at six weeks
 34% at six months (25%
in 2005)
 46% at one week
 23% at six weeks
 1% at six months
More Statistics
 31% breastfed babies had received additional feeds
while in hospital
 73% had given their baby milk other than breast milk
by the age of six weeks and 88% by six months
 High correlation between intentions and actual initial
feeding behaviour
And more...
 Highest incidences of breastfeeding among mothers
>30 years old, from minor ethnic groups, left education
aged over 18, in managerial and professional
occupations, living in the least deprived areas
 Relationship between how mothers were fed
themselves as infants and and how their peers fed their
babies with how long they breastfed their own babies
Nutritional requirements
 Age dependent (the younger the child the higher their
energy needs per kilogram body weight)
0-3 months: Fluid
Calories
Protein
Na
K
100-150 mls/kg
100 kCals/kg
2.1 g/kg
1.5 mmol/kg
3 mmol/kg
Nutritional needs in Preterm babies (1)
Adequate nutrition should ensure that a pre-term infant
achieves a post natal growth that reinstates them on their
inter-uterine growth curve for length, weight and head
circumference.
Premature babies may have increased needs as :
- May have dropped down >2 centiles on neonatal unit
- May have CLD and need O2
- May have been IUGR
- May have GOR and be unable to tolerate large feed
volumes
Nutritional needs in Preterm babies (2)
 Fluid: 150-200ml/kg/day
 Energy requirements: 110-135kcals/kg/day
 Protein: according to weight
What are the Department of health’s
recommendations on feeding infants?
 Breast milk is the best form of nutrition for infants
 Exclusive breastfeeding is recommended for the first
six months of an infant’s life
 Six months is the recommended age for the
introduction of solid foods for infants
 Breastfeeding (and/or breastmilk substitutes, if used)
should continue beyond the first six months, along
with appropriate types and amounts of solid foods
Colostrum
 For 2-4 days post delivery.
 Contains more sodium
 High in Vit A and Vit K
 5x more protein than mature milk
 more IgA
 less fat and carbohydrate
 Mature breast milk is established by 4th week
Composition of breast milk vs formula milk
 Water: Equal amounts
 Calories: Approx 67kcal/100ml
 Protein: Human milk 1-1.5% protein(70% whey
protein), Cows milk 3.3% protein due to greater
content of casein
Composition of breast milk vs cows milk
 Carbohydrate: Human milk 7% (10% glycoproteins)
Cows milk 4.5% lactose
 Fat:
Approx 3.5% both principally triglycerides (olein, palmitin
and stearin). Olein is more easily absorbed and there is
twice as much in breast milk.
 Minerals:
Cows milk contains more of all the minerals (esp sodium,
calcium and phosphate) except iron and copper.
There is more iron in breast milk and it is more easily
absorbed
 Vitamins:
Cow’s milk is low in vitamin C and D
What are the health benefits of breast
feeding?
 Breastmilk provides all the nutrients a baby needs for
healthy growth and development for the first six
months of life.
 Contains growth factors and hormones to assist
development
 Anti infective properties: Macrophages,
lymphocytes and polymorphs, Secretory IgA,
Lyzozyme, Lactoferrin (inhibits growth of E.coli.),
anti-viral agents.
Long term benefits to infants
 Reduced risk of respiratory, gastrointestinal and urinary tract
infections
 Reduced risk of atopy
 Reduced risk of juvenile diabetes in susceptible infants
 Better dental health
 Reduced incidence of later obesity
 Improved neurological development
Maternal benefits
 Reduced risk of premenopausal cancer
 Promotes weight loss after pregnancy
 Lactational amenorrhoea
 Cheaper and more convenient
Down side of breast feeding
 Vitamin K deficiency
 Hypernatraemia at end of first week in babies with
inadequate intake
 Inhibits modern control culture
Factors affecting prevalence of breast
feeding in the UK
Favour
 Social class 1
 Mother educated
>18years
 Mother >30 years
 first baby
 breast fed previous baby
Against
 social class V
 maternal smoking
Contraindications to breast feeding
 Galactosaemia
 Maternal HIV infection in the UK
 Anti-neoplastic drugs
 Tetracyclines
 Lithium
Types of milk
 Infant formulas are suitable from birth and are usually based on
cows milk
 Whey based milks are usually first choice if not breast feeding
 Casein based milks are suggested for hungrier babies
 Soya infant milks
 Follow on formulas: Higher iron content than cows milk
 Specialised formulas for those who are preterm or have medical
conditions (lactose free, phenylalanine free)
Soya Infant Formula
 Similar to cows milk but protein derived from soya with
lactose replaced with other carbohydrates (glucose
syrups)
 Recommended for use on medical advice but should not
be the first choice for the management of CMP
intolerance
 Soya milks contain phytoestrogens which have been
shown to have an immunosuppressive effect in rodents
Bottle feeding
 Day 1: 60ml/kg/day
Day 2: 90ml/kg/day
Day 3: 120ml/kg/day
Day 4: 150ml/kg/day
 3-4 hourly
 Must be made up correctly (risk of hypernatraemia)
 Has caused high mortality in developing world due to
poor hygiene of equipment leading to gastroenteritis
Cow’s milk allergy
 A reproducible reaction to one or more cow’s milk
proteins mediated by one or more immune
mechanisms
 Affects about 1 in 50 infants
 Most affected infants present by 6 months of age -
rarely presents after 12 months
Cow’s milk allergy
IgE-mediated phenotype: symptoms are
stereotypical of allergy
1.



skin (eczema, urticaria)
gut (colic, vomiting, diarrhoea, FTT, blood in the
stools)
respiratory (rhinitis, stridor, cough and wheeze)
2. Non IgE-mediated phenotype: delayed onset allergy
symptoms
Do NOT confuse with lactose intolerance
Diagnosis and management of CMP allergy
IgE-mediated: clinical symptoms + skin prick test
2. Non IgE-mediated: clinical symptoms that improve or
resolve with exclusion of milk and reappear with
reintroduction of cow’s milk
1.
A food challenge may be necessary to confirm the diagnosis


diet free from cows’ milk for at least 1 year
Choice of milk is usually one of casein or whey extensive
hydrolysed formula, or amino acid formula
(Lactose free and partially hydrolysed comfort formula milks and goats
milk are not suitable for cows’ milk allergy)
Lactose intolerance
 rare in infants- more commonly in adolescence
 typically with a more subtle and progressive onset over
many years
 Usually secondary to gastrointestinal infection especially
rotavirus ,or neonatal gut surgery
 Usually transient but may need to remove lactose from
milk for 6+ weeks
Normal Growth
 All babies tend to lose 5-10% of birthweight over first
few days and regain it by about 10th day
 Feeding requirement is 150ml/Kg/day
 Normal weight gain 25-30g/day for first 6 months
(preterm 10-15g/kg/day)
 Most babies double their birthweight by 4-5 months
and treble by one year
Weaning
 DOH recommend introduction of solid foods at
around 6 months of age
 Trend towards mothers introducing solid foods later
(51% by 4 months in 2005, 30% in 2010)
 75% introduced solid foods by 5 months of age; not
following the guidelines
 Solid foods tended to be introduced to younger babies
among younger mothers and mothers from lower
socio-economic groups
Why introduce solid foods at six
months?
 Infants need more iron and other nutrients than milk
 At 6 months infants can spoon-feed (upper lip moving
down, chew, use the tongue to move the food from
front to back)
 Development of eye-hand co-ordination (finger foods)
 Introducing solids early before sufficient development
of the neuro-muscular co-ordination or before the gut
and kidneys have maturedrisk of infections and
development of allergies (eczema, asthma)
Weaning
 Babies need to be exposed rapidly to a variety of tastes and





textures between 6-8 months
Approximately 1 pt of milk should be given plus clear
fluids with meals
Is waiting to introduce solids until six months likely to
produce “fussy eaters”: NO (RCTs)
Encouragement of finger food- promotes chewing practice
and independence
Chewing encourages development of speech muscles
Feeding should always be supervised.
Vitamins
 All children from six months to five years old should
be given a vitamin supplement containing vitamins A,
C and D, unless they are receiving more than 500 ml of
infant formula per day
 If mothers did not take vit. D during pregnancy and if
breast fed, start Vit D at 1 month
 Iron supplemented milk is recommended until at
least the age of 1 year in all infants
 Iron deficiency anaemia is a common problem in toddlers worldwide-
associated with developmental delay and increased susceptibility to
infection
Faltering growth
Significant interruption in the expected rate of growth
compared with other children of similar age and sex
during early childhood
 affect around 5% of children under the age of two at
some point
 A single plot on a chart is of limited value
 Need to consider parental height
Faltering growth
Causes of faltering growth
Organic causes
1.






Inability to feed (cleft palate, CP)
Increased losses (diarrhoea/vomiting, GORD)
Malabsorption (CF, post infective/allergic
enteropathy)
Increased energy requirements (CF, malignancy)
Metabolic (hypothyroidism, CAH)
Syndromes
Causes of faltering growth
2. Non-organic causes

Insufficient breast milk or poor technique

Maternal stress/ Maternal depression/psychiatric
disorder

Disturbed maternal-infant attachment

Low socio-economic class

Neglect
Approach and management to faltering
growth
 Recheck weight-plot weight against centile chart
 Check type and amount of feed
 Observe feeding technique
 Assess stool
 Examine for underlying illness- appropriate
investigations
 Consider admission to observe response to feeding
 Dietician involvement
 Inform GP/health visitor/community nurse
Clinical scenario
A 4/52 baby presented to CED with vomiting.
Birth weight 3.5kg. Current weight 4.3kg.
The baby is bottle feeding and taking 150ml 4 hourly.
Clinical scenario
A 4/52 baby presented to CED with vomiting.
Birth weight 3.5kg. Current weight 4.3kg.
The baby is bottle feeding and taking 150ml 4 hourly.
Differential diagnosis?
Clinical scenario
Differential diagnosis
1. Symptoms suggesting infection (UTI, meningitis,
gastrointestinal infection)
2. Pyloric stenosis (projectile vomiting, age)
3. GORD
4. Intestinal obstruction (bilious vomit, abdominal
distension)
5. CMP allergy
6. Overfeeding
Clinical scenario
 Adequate weight gain?
30 x 28 = 840g
3.5 + 0.84 = 4.3 kg
 How much does the baby require?
150 x 4.3 = 645ml
 How much is the daily intake?
150 x 6 = 900 ml
Clinical scenario
 Adequate weight gain?
30 x 28 = 840g
3.5 + 0.84 = 4.3 kg
 How much does the baby require?
150 x 4.3 = 645ml
 How much is the daily intake?
150 x 6 = 900 ml
Vomiting likely 2o to overfeeding
THANK YOU
References
 Infant Feeding Survey 2010, National Statistics
 Infant Feeding Recommendation, Department of Health
 Breast-feeding: A Commentary by the ESPGHAN Committee on
Nutrition, Journal of Pediatric Gastroenterology and Nutrition 2009
 www.pediatricsconsultant360.com
 BMJ 13/3/99, Archives Feb 99