Infant
nutrient needs
Basis/Approach
Public health vs individual
recommendations, guidelines,
education
Specific nutrients
water
energy
protein
fatty acids
vitamin K
Vitamin D
Iron
Fluoride
Basis of recommendations
• Growth and
development
• Physiology
– GI
– Renal
• Programming
• Public health vs
individual
• Optimize growth and
development
• Prevent deficiencies
• Safety
• Prevention of chronic
illness and optimize
health through life
cycle
Approaches to Estimating Nutrient
Requirements
• Direct experimental evidence (ie protein and amino
acids)
• Extrapolation from experimental evidence relating to
human subjects of other age groups or animal
models
– ie thiamin--related to energy intake .3-.5 mg/1000 kcal
• Breast milk as gold standard (average [] X usual
intake)
• Metabolic balance studies (ie protein, minerals)
• Clinical Observation (eg: manufacturing errors B6, Cl)
• Factorial approach
• Population studies
Challenges
• Strength of Evidence
• Individual vs population
– Public health approach
– Individual genetics
– Maternal-infant dyad
• In utero endowment
• Beliefs, values, choices
• Relationship/nurture
– Environmental factors
Public health vs individual
• Prevalence of nutrient deficiencies
• Balance incidence, burden, and treatment
– Eg: Vitamin K and hemorrhagic disease of
newborn
• Prevalence and evidence of chronic
conditions associated with dietary practices
• Etiology of nutrient deficiencies and/or
chronic conditions
– Eg: allergy, obesity, anemia, dental caries,…
Individual Requirements
–
–
–
–
–
Genetics
Adaptation
Environment
Behavior/activity
Choices, access,
resources
– other
1940’s
•
•
•
•
•
•
Rickets (D)
Pellagra (Niacin)
Scurvy (C)
Beriberi (Thiamin)
Xeropthalmia (A)
Goiter (Iodine)
United Nations 5th report on
World Nutrition: March 2004
Prevalence (%)
1990
2005
underweight
35.2
26.5
Iodine deficiency
35.2
United Nations 5th report on
World Nutrition: March 2004
• Vitamin A deficiency
– 140 million preschoolers
– 7 million pregnant women
• Iron Deficiency
– One of most prevalent
– 4-5 billion affected
• Reports in US of PEM, Rickets, Zinc
deficiencies
Causes
Nutrition - Disease
Access
Food
Health Care
Environment
Economics
Education
Programming by Early Diet
•
Nutrient composition in early diet may have long term effects on GI
function metabolism and health
•
Animal models show that glucose and amino acid transport activities
are programmed by composition of early diet
•
Animals weaned onto high CHO diet have higher rates of glucose
absorption as adults compared to those weaned on high protein diet
•
Barker Hypothesis:
– Association between BMI and chronic disease: HTN and cardiovascular,
SGA/IUGR
•
Other examples: early diet associations with allergy, obesity, diabetes
Allergies: Prevention by
Avoidance (Zeigler, Pediatr Allergy Immunol.
1994)
• High risk infants from atopic families,
intervention group n=103, control n=185
• Restricted diet in pregnancy, lactation,
Nutramagen when weaned, delayed
solids for 6 months, avoided highly
allergenic foods
• Results: reduced age of onset of
allergies
Allergies: Prevention by
Avoidance (Zeigler, Pediatr Allergy Immunol. 1994)
Definite or Probable Food Allergy
Age
Intervention Control
p
12 mo
5%
16%
0.007
24 mo
7%
20%
0.005
48 mo
4%
6%
ns
Allergies: Early Introduction of
Foods
(Fergussson et al, Pediatrics, 1990)
• 10 year prospective study of 1265 children in
NZ
• Outcome = chronic eczema
• Controlled for: family hx, HM, SES, ethnicity,
birth order
• Rate of eczema with exposure to early solids
was 10% Vs 5% without exposure
• Early exposure to antigens may lead to
inappropriate antibody formation in
susceptible children.
Early Introduction of Foods
(Fergussson et al, Pediatrics, 1990)
Proportional Hazard Coefficient (p<0.01)
For Risk of Chronic Eczema
No solid Food before 1.00
4 months
1-3 types of food
before 4 months
1.69
4+ types of foods
before 4 months
2.87
Allergies: Prevention by
Avoidance (Marini, 1996)
• 359 infants with high atopic risk
• 279 in intervention group
• Intervention: breastfeeding strongly
encouraged, no cow’s milk before one
year, no solids before 5/6 months,
highly allergenic foods avoided in infant
and lactating mother
Allergies: Prevention by
Avoidance (Marini, 1996)
% of Children With Any Allergic
Manifestations (cummulative incidence)
80
60
non-intervention
intervention
40
20
0
1 yr
2 yrs
3 yrs
Cochrane Review
• Osborn et al: Formulas containing hydrolysed protein for
prevention of allergy and food intolerance in infants 2006;18
• Concluded that use of hydrolysed formula in non breastfed
infants at risk for allergy (atopic dermatitis) for at least 4 months
reduces the incidence of allergy.
DRI
• Nutrition Recommendations from the
Institute of Medicine (IOM) of the U.S>
National Academy of Sciences for
general public and health professionals.
• Hx: WWII, to investigate issues that
might “affect national defense”
• Population/institutional guidelines
• Application to individuals.
DRI
• Estimated Average Requirement (EAR): expected to
satisfy the needs of 50% of the people in that age
group based on review of scientific literature.
• Recommended Dietary Allowance (RDA): Daily
dietary intake level considered sufficient by the FNB
to meet the requirement of nearly all (97-98%)
healthy individuals. Calculated from EAR and is
usually 20% higher
• Adequate intake (AI): where no RDA has been
established.
• Tolerable upper limit (UL): Caution agains’t excess
DRI’s for infants
• Macronutrients based on average intake of
breast milk
• Protein less than earlier RDA
• Energy: EER
DRI’s for infants
• Macronutrients based on average intake of breast
milk
• Protein less than earlier RDA
• AAP Recommendations
– Vitamin D: 200 IU supplement for
breastfed infants and infants taking <500
cc infant formula
– Iron: Iron fortified formula (4-12 mg/L),
Breastfed Infants supplemented 1mg/kg/d
by 4-6 months
Feeding Guidelines and
Recommendations
• Public health policy
• Health promotion
• Prevention
Recommendations/guidelines
• DRI: Dietary Reference Intakes
– AI
– UL
– EER
• AAP
• Bright Futures
• Start Healthy feeding guidelines
Comparison of individual intake data to a reference or
estimate of nutrient needs
• DRI: Dietary Reference
Intakes
periodically revised
recommendations (or
guidelines) of the
National Academy of
Sciences
– quantitative estimates
of nutrient intakes for
planning and
assessing diets for
healthy people
–
• AI: Adequate Intake
• UL: Tolerable Upper
Intake Level
• EER: Estimated Energy
Requirement
DRI’s for infants
• Macronutrients based on average intake of
breast milk
– Protein less than earlier RDA
– Factors to consider: fetal endowment,
individual variability, impact of diet on
bioavailability and need
The Start Healthy Feeding Guidelines
for Infants and Toddlers (JADA, 2004)
Bright Futures
• AAP/HRSA/MCHB
• http://www.brightfutures.org
• “Bright Futures is a practical
development approach to providing
health supervision for children of all
ages from birth through adolescence.”
Examples
•
•
•
•
•
•
Transition
Supplements to breastmilk
Safety
Allergy prevention
Dental health
other
Water
Water
• Water requirement is determined by:
– water loss
• evaporation through the skin and respiratory
tract (insensible water loss)
• perspiration when the environmental
temperature is elevated
• elimination in urine and feces.
– water required for growth
– solutes derived from the diet
Water
• Water lost by evaporation in infancy and
early childhood accounts for more than
60% of that needed to maintain
homeostasis, as compared to 40% to
50% later in life
• NAS recommends 1.5 ml water per kcal
in infancy.
Renal
• Limited ability to concentrate urine in
first year due to immaturities of nephron
and pituitary
• Potential Renal solute load determined
by nitrogenous end products of protein
metabolism, sodium, potassium,
phosphorus, and chloride.
Urine Concentrations
• Most normal adults are able to achieve urine
concentrations of 1300 to 1400 mOsm/l
• Healthy newborns may be able to
concentrate to 900-1100 mOsm/l, but isotonic
urine of 280-310 mOsm/l is the goal
• In most cases this is not a concern, but may
become one if infant has fever, high
environmental temperatures, or diarrhea
Renal solute load
• Samuel Foman J Pediatrics Jan 1999
134 # 1 (11-14)
• RSL is important consideration in
maintaining water balance:
•
•
•
•
In acute febrile illness
Feeding energy dense formulas
Altered renal concentrating ability
Limited fluid intake
Water Needs
Age
Amount of Water (ml/kg/day)
3 days
80-100
10 days
125-150
3 mo.
140-160
6 mo.
130-155
9 mo.
125-145
1 yr.
120-135
2 yr.
115-125
Water
•
•
•
•
•
Individual needs
Renal concentrating ability
Solute in diet
Health
environment
• Water vs fluid
• Concentrating formula decreases free
water and increases RSL
• What is the % water in 20 kcal/oz infant
formula?
– 90%
– To achieve 100 ml/kg/d needs to consume
at least 110 cc/kg/d
Energy Requirements
• Higher than at any other time per unit of
body weight
• Highest in first month and then declines
• High variability - SD in first months is
about 15 kcal/kg/d
• Breastfed infants many have slighly
lower energy needs
• RDA represents average for each half
of first year
Energy Requirements, cont.
• RDA represents additional 5% over
actual needs and is likely to be above
what most infants need.
• Energy expended for growth declines
from approximately 32.8% of intake
during the first 4 months to 7.4% of
intake from 4 to 12 months
Energy Partition in Infancy
(kcal/kg/d)
Losses
Activity
Thermic effect
of feed
Growth
Resting
Metabolic rate
Total
Newborn
6 months
5
10
10
5
25
10
40
50
12
55
115
107
Energy Intakes by Breastfed and
Formula Fed Boys (kcal/kg)
Age in Mos.
1
2
3
5
6
Breastfed
115
104
95
89
86
Formula
120
106
95
95
92
2002 Energy DRI
EER
•
•
•
•
•
0-3 months (89 x wt -100) + 175
4-6 months (89 x wt -100) + 56
7-12 months (89 x wt -100) + 22
13-35 months (89 x wt -100) + 20
Equations for older children factor in
weight, height and physical activity level
(PAL)
Examples of EER by age and weight
Age
0-3 months
4-6 months
7-12 months
13-35 months
weight
total
per kg
2
3
4
6
7
8
9
10
11
12
14
253
342
431
490
579
668
723
812
901
988
1166
126
114
108
81
82
83
80
81
81
82
83
Energy
• Correlate
individual intake
with growth
2002 Carbohydrate DRI
Protein
• Increases in body protein are estimated
to average about 3.5 g/day for the first 4
months, and 3.1 g/day for the next 8
months.
• The body content of protein increases
from about 11.0% to 15.0% over the
first year
2002 Protein DRI
2002 Fat DRI
Essential Fatty Acids
• The American Academy of Pediatrics
and the Food and Drug Administration
specify that infant formula should
contain at least 300 mg of linoleate per
100 kilocalories or 2.7% of total
kilocalories as linoleate.
LCPUFA
DHA and ARA
LCPUFA: Background
n-6
n-3
18:2
Linoleic
18:3
Linolenic
18:3
 linolenic
20:5
EPA
20:4
Arachidonic
22:6
DHA
LCPUFA: Background
• Ability to synthesize 20 C FA from 18 C FA is
limited.
• n-3 and n-6 fatty acids compete for enzymes
required for elongation and desaturation
• Human milk reflects maternal diet, provides
AA, EPA and DHA
• n-3 important for neurodevelopment, high
levels of DHA in neurological tissues
• n-6 associated with growth & skin integrity
• DHA represents 10% of total FA in brain grey
matter, and 35% in rod and cone membranes
of retina
• Synthetic ability to convert linolenic acid to
DHA present when diet sufficient in w-3 FA
(alpha linolenic)
• Alterations in visual and neurodevelopmental
fx associate with insufficient DHA
Formula supplementation with long-chain
polyunsaturated fatty acids: are there
developmental benefits? Scott et al. Pediatrics,
Nov. 1998.
• RCT, 274 healthy full term infants
• Three groups:
– standard formula
– standard formula with DHA (from fish oil)
– formula with DHA and AA (from egg)
• Comparison group of BF
Outcomes at 12 and 14
months
• No significant differences in Bayley,
Mental or Psychomotor Development
Index
• Differences in vocabulary
comprehension across all categories
and between formula groups for
vocabulary production.
Conclusion
“We believe that additional research
should be undertaken before the
introduction of these supplements into
standard infant formulas.”
PUFA Status and Neurodevelopment:
A summary and critical analysis of the
literature (Carlson and Neuringer, Lipids, 1999)
• In animal studies use deficient diets
through generations - effects on
newborn development may be through
mothering abilities.
• Behaviors of n-3 fatty acid deficient
monkeys: higher frequency of
stereotyped behavior, locomotor activity
and behavioral reactivity
Efficacy and safety of docosahexaenoic acid and
arachidonic acid addition to infant formulas: can
one buy better vision and intelligence?
(Koo. J Am Coll Nutr. 2003 Apr;22(2):101-7)
• “Functional benefits in particular visual or
neural development from IF containing
LCPUFA remains controversial.”
• “Potential for excessive and/or imbalanced
intake of n-6 and n-3 fatty acids exists with
increasing fortification of LCPUFA to infant
foods other than IF.”
Formula Supplemented with DHA &
ARA: A Critical Review of the
Research (Wright et al, 2006)
• 10 RCTs from 1997-2003 of variable
quality
• Considered the strength of each study
by looking at indices of research quality.
Wright et al, cont.
• Growth (7 studies)
– no differences in weight, length, OFC
• FA in blood (7 studies)
– DHA & ARA higher with supplementation
– those supplemented with only DHA had lower
levels of ARA than those on standard formula
– Supplementation with LCPUFA for only 17 weeks
lead to higher EFA levels at 1 year of age
Wright et al, cont.
• Vision (6 trials)
– 2 found better visual function with LCPUFA
, 4 did not
• Neurodevelopment
– 1 of 4 found positive results on Bayley
Scales of Infant Development II
– 2 of 5 found positive information
processing/IQ/cognitive effects
Wright et al, cont
• Conclusions
– No detrimental effects found
– Possibly a small improvement in visual
acuity, but significance of this small effect
in global development is questionable
– “thoughtful consideration is advised before
recommending more expensive formula for
term infants.”
Longchain polyunsaturated fatty acid
supplementation in infants born at term
(Cochrane, 2001).
• At present there is little evidence from randomised
trials of LCPUFA supplementation to support the
hypothesis that LCPUFA supplementation confers a
benefit for visual or general development of term
infants.
• A beneficial effect on information processing is
possible but larger studies over longer periods are
required to conclude that LCPUFA supplementation
provides a benefit when compared with standard
formula.
• Data from randomised trials do not suggest that
LCPUFA supplements influence the growth of term
infants
Omega-3 FA and Neural Development to 2 years of Age: Do we
Know enough for Dietary Recommendations: Innis JPGN
48:S16-24:2009
• Estimated requirement and variability
among individuals necessary to set DRI
• Dietary recommendations affect food
supply and supplements and are used
in labeling
• When scientific information is
incomplete, consideration must be given
to implications of recommendations
Omega-3 FA and Neural Development to 2 years of Age: Do we
Know enough for Dietary Recommendations: Innis JPGN
48:S16-24:2009
• “ While there is no doubt that DHA is critical for the developing
brain, western diets poor in w-3 FA and rich in w-6 FA are
becoming increasingly implicated in contributing to risk of poor
neurodevelopment and function…..The w-3 FAs are clearly
essential nutrients, suggesting that dietary recommendations,
such as AI, to minimize risk of poor CNS development can be
justified, and are consistent with a philosophy of dietary advice
that promotes optimal child development and health. However,
because dietary recommendations often promulgate changes in
the food supply and supplement use…..premature
recommendations based on incomplete science that focus on
individual nutrients rather than dietary practices such as
breastfeeding and foods such as fish rich in DHA are not
necessarily in the best public interest”
Vitamin K
Vitamin K
• 2 forms: K1 or phylloquinone (plant
form) and K2 (synthesized by bacteria)
• Function: cofactor inmetabolic
conversion of precursors of Vitamin K
dependent proteins to active form ( eg:
prothrombins, osteocalcin)
Vitamin K
• Lack of specific information regarding
an infant’s requirement
• Vitamin K concentration of breastmilk is
low and for the breastfeeding infant a
deficiency state has been described
• No “gold standard” available
Vitamin K
•
•
•
•
DRI for infants 2-2.5 ug/day
Formula provides 7-9 ug/kg/d
BM contains < 10 ug/L
Hemorrhagic disease of the
Newborn…Vitamin K deficiency
• Prophylaxis: 1 mg Vitamin K IM for all
newborn infants
Vitamin K Controversy
• Adequacy of BM
• Maternal Diet and Vitamin A content of
BM
• ? Significance/prevalence of
hemorrhagic disease of newborn
• IM injections of all newborns
Controversies Concerning Vitamin K and the
Newborn: AAP Policy Statement, 2003
Vitamin K Deficiencydefinitions – AAP, 2003
Term
Age and
Incidence
Symptoms
Early vitamin K
deficiency bleeding
(VKDB)*
First week of life: Unexpected bleeding in
previously healthy-appearing
neonates
Late VKDB
2-12 weeks of
age
unexpected bleeding
attributable to severe vitamin
K deficiency
* Formerly known as classic hemorrhagic disease of the newborn
Incidence of VKDB
• Early: 0.25%–1.7% incidence
• Late:
– No vitamin K prophylaxis: 4.4 to 7.2 per 100,000
births
– Single oral vitamin K prophylaxis:1.4 to 6.4 per
100 000 births
– IM vitamin K prophylaxis: 0
• Oral vitamin K has effect similar to IM in preventing
early VKDB, but not in preventing late VKDB
Danielson et al Arch Dis Child 2004 89:F546-550
• Late onset vitamin K deficient bleeding in infants who
did not receive prophylactic vitamin K at birth in
Hanoi province
–
–
–
–
Incidence: 116 per 100,000 births
Higher in rural areas
9% mortality
42% impaired neurodevelopmental status at discharge in
survivors
Incidence
• Netherlands 2005: 3.2 per 100,000
births
• Canada 2004: 0.45 per 100,000 births
– Conclude low incidence associated with
current practice of prophylactic Vitamin K
at birth
Closing the Loophole:Midwives and the
Administration of Vitamin K in the Neonate
• Adame and Carpenter J Pediatr 2009 154:769-771
• Case Report of a previously healthy, exclusively
breastfed 6 week old infant delivered by a midwife on
the south Texas border. Did not receive Vitamin K at
birth. Admitted with severe intracranial hemorrhage,
cooagulopathy, and seizures, unresponsive, pupils
fixed and dialated
Cochran Prophylactic Vitamin K for
preventing haemorrhagic disease in
newborn infants
• Vitamin K deficiency can cause
bleeding in an infant in the first weeks of
life. This is known as Haemorrhagic
Disease of the Newborn (HDN) or
Vitamin K Deficiency Bleeding (VKDB).
Cochran
• The risk of developing vitamin K
deficiency is higher for the breastfed
infant because breast milk contains
lower amounts of vitamin K than formula
milk or cow's milk
Cochran
• In different parts of the world, different
methods of vitamin K prophylaxis are
practiced.
Cochran
• Oral Doses:
• The main disadvantages are that the
absorption is not certain and can be
adversely affected by vomiting or
regurgitation. If multiple doses are
prescribed the compliance can be a
problem
Cochran
• I.M. prophylaxis is more invasive than
oral prophylaxis and can cause a
muscular haematoma. Since Golding et
al reported an increased risk of
developing childhood cancer after
parenteral vitamin K prophylaxis
(Golding 1990 and 1992) this has been
a reason for concern .
Cochrane Conclusions, 2000
• A single dose (1.0 mg) of intramuscular vitamin K
after birth is effective in the prevention of classic
HDN.
• Either intramuscular or oral (1.0 mg) vitamin K
prophylaxis improves biochemical indices of
coagulation status at 1-7 days.
• Neither intramuscular nor oral vitamin K has been
tested in randomized trials with respect to effect on
late HDN.
• Oral vitamin K, either single or multiple dose, has not
been tested in randomized trials for its effect on
either classic or late HDN.
Brousson and Klien, Controversies
surrounding the administration of vitamin K
to newborns; a review.
CMAJ. 154(3):307-315, February 1, 1996.
• Study selection: Six controlled trials met the selection
criteria: a minimum 4-week follow-up period, a
minimum of 60 subjects and a comparison of oral and
intramuscular administration or of regimens of single
and multiple doses taken orally. All retrospective
case reviews were evaluated. Because of its
thoroughness, the authors selected a meta-analysis
of almost all cases involving patients more than 7
days old published from 1967 to 1992. Only five
studies that concerned safety were found, and all of
these were reviewed
Brousson and Klien, Controversies
surrounding the administration of vitamin K
to newborns; a review.
CMAJ. 154(3):307-315, February 1, 1996.
• Data synthesis: Vitamin K (1 mg, administered
intramuscularly) is currently the most effective
method of preventing HDNB. The previously reported
relation between intramuscular administration of
vitamin K and childhood cancer has not been
substantiated. An oral regimen (three doses of 1 to 2
mg, the first given at the first feeding, the second at 2
to 4 weeks and the third at 8 weeks) may be an
acceptable alternative but needs further testing in
largeclinical trials.
Brousson and Klien, Controversies
surrounding the administration of vitamin K
to newborns; a review.
CMAJ. 154(3):307-315, February 1, 1996
• Conclusion: There is no compelling
evidence to alter the current practice of
administering vitamin K intramuscularly
to newborns.
AAP Recommendations:
Pediatrics:Vol112#1 July 2003
1. Vitamin K1 should be given to all
newborns as a single, intramuscular
dose of 0.5 to 1 mg.
2. Further research on the efficacy,
safety, and bioavailability of oral
formulations of vitamin K is warranted.
AAP Recommendations
3. Health care professionals should promote awareness
among families of the risks of late VKDB associated
with inadequate vitamin K prophylaxis from current
oral dosage regimens, particularly for newborns who
are breastfed exclusively
4. Earlier concern regarding a possible causal
association between IM vitamin K and childhood
cancer has not been substantiated
• Note put recent articles on reemergence of HDNB texas, ? Japan
Vitamin D
Vitamin D
• Role
• Source
– Dietary
– sunlight
• Deficiency
– Rickets
Role
• Enhances intestinal absorption of Ca
• Increase tubular resorption of Ph
• Mediation of recycling of Ca and Ph for
bone growth and remodeling
• Sterol hormone
– Deficiency: Rickets
Role
• Extraskeletal effects of Vitamin D
– Modulates B and T Lymphocyte fx and
deficiency may be associated with
autoimmune diseases (diabetes, MS
associations)
– Regulation of cell growth (assoc with
breast, prostrate, and colon cancer)
Prevalence
• Thought to be disease of past (prior to
1960’s)
– Disappeared secondary to recognition of
role of sunlight, fortification of milk, use of
multivitamins, AAPCON recommendation
for 400 IU supplementation of infants
Prevalence
• Increased incidence and case reports 1970’2
• No national data in US
– Georgia 1997-99: 9 per million hospitalized
children
– National Hospital Discharge Survey: 9 per
million
– Pediatric Research in Office Setting (AAP):23-32
hospitalized cases reported 1999-2000
Prevalence
• Literature Review
– 13 articles published between 1996-2001
– 122 case reports
Prevention of Rickets and
Vitamin D Deficiency: New
Guidelines for Vitamin D Intake
PEDIATRICS Vol. 111 No. 4 April
2003, pp. 908-910
Vitamin D and Sunlight
• Vitamin D requirements are dependent on the
amount of exposure to sunlight.
• Dermatologists recommend caution with sun
exposure.
– Sunscreens markedly decrease vitamin D
production in the skin
– Decreased sunlight exposure occurs during the
winter and other seasons and when sunlight is
attenuated by clouds, air pollution, or the
environment
– AAP recommends against exposing infants < 6
months to direct sun
Breastfeeding and Vitamin D
• Breastmilk has < 25 IU/L
Recommended adequate intake can
not be met with breastmilk alone
• Formerly stated that needs could be
met with sun exposure, but now, due to
cancer concerns recommend against
this
Vitamin D Recommendations
• Before 2003 AAP recommended 10 mg (400 IU) per
day for breastfeed infants
• 2003: American Academy of Pediatrics recommends
supplements of 5 mg (200 IU) per day for all infants
as recommended in DRIs.
• 10/14/2008: AAP updates guidelines vor vitamin D
intake for infants, children, and teens to be published
in Nov 5th ed Pediatrics
– 400 IU per day intake of vitamin D beginning in first few days
of life
Formulas
• if an infant is ingesting at least 500 mL
per day of formula (vitamin D
concentration of 400 IU/L), he or she
will receive the recommended vitamin D
intake of 200 IU per day.
• If intake is less than 500 ml recommend
additional supplement of vitamin D
Summary of AAP
Recommendations, 2003
•
All breastfed infants unless they are weaned to at
least 500 mL per day of vitamin D-fortified formula
or milk.
•
All nonbreastfed infants who are ingesting less than
500 mL per day of vitamin D-fortified formula or
milk.
•
Children and adolescents who do not get regular
sunlight exposure, do not ingest at least 500 mL
per day of vitamin D-fortified milk, or do not take a
daily multivitamin supplement containing at least
200 IU of vitamin D.
AAP Recommendations for
Vitamin D
• 2008
– Intake of 400 IU beginning in first few days of life
• Supplement breastfed, partially breastfed, infants and
children consuming less than 1 liter formula or vitamin D
fortified whole milk
• Wagner et al: Prevention of Rickets and Vitamin D
Deficiency in Infants, Children, and Adolescents:
Pediatrics 2008;122;1142-1152
Vitamin D
• DRI: B-6 months 200 IU, 7-12 months
250 IU
• UL: 1000 IU
Iron
Iron
• Function
• Source
– Formula, breast milk, other foods
– Bioavailability:
• Breast milk
• Soy formula
• Deficiency
– Anemia
Anemia
• Anemia (low Hct, Hgb: not specific for iron
deficiency)
Causes:
– Inadequate iron in diet
– Loss
– GI bleeding, cows milk proteins, infectious agents
– Other
• Genetics
• Lead
• Other nutrients
Iron
• Biological function
– Oxygen transport primarily in hemoglobin
– Component of other proteins including
cytochrome a, b, c, and cytochrome
oxidase essential for electron transport and
cellular energetics
Iron deficiency (ID and IDA)
• Anemia: Hgb <11 g/dl 12-36 months
• Iron deficiency Anemia (IDA): anemia
due to iron deficiency
• Iron deficiency: Insufficient iron to
maintain normal physiologic functions
leading to decrease in iron stores as
measured by serum ferritin with or
without IDA
• Association between ID an IDA and
neurobehavioral development
– Lozoff
– McCann and Ames
– Cochrane review
– Carter
– Recent sleep studies
Iron Deficiency Anemia
• Impact on social, neurobehavioral and
sleep
– Peirano et al: Sleep and Neurofunction Throughout Child
development: Lasting Effects of Early Iron Deficiency J Ped
Gastroenterology and Nutr 2009 48:S8-S15
– Lozoff et al: Dose-Response Relationships between Iron
deficiency with or without anemia and Infant Socialemotional Behavior J Pediatr 2008 152:696-702
Peirano
• Slower neurotransmission in auditory
and visual systems
• Different motor activity patterning sleepwaking and sleep state organization
• Alterations in behavioral and cognitive
function
Lozoff
• N=77
• “Infant social-emotional behavior
appears to be adversely affected by iron
deficiency with or without anemia”
– Shyness, orientation engagement,
soothability
Carter et al: Iron Deficiency Anemia and Cognitive
Function in Infancy: Pediatrics 2010 126;2427-e434
• N= 87 (28 IDA, 49 no anemia)
• Methods: at 9 and 12 months series of
cognitive, intellegent and behavioral
tests administered (Fagan test of infant
intellegence (FTII), Emotionality, Activity
and Sociability Temperment Survey,
and Behavior Rating Scale (BRS))
Carter et al: Iron Deficiency Anemia and Cognitive
Function in Infancy: Pediatrics 2010 126;2427-e434
• N= 87 (28 IDA, 49 no anemia)
• Methods: at 9 and 12 months series of
cognitive, intellegent and behavioral
tests administered (Fagan test of infant
intellegence (FTII), Emotionality, Activity
and Sociability Temperment Survey,
and Behavior Rating Scale (BRS))
Carter et al: Iron Deficiency Anemia and Cognitive
Function in Infancy: Pediatrics 2010 126;2427-e434
• Results
– Sociodemographic background similar
between 2 groups
– IDA infants less likely to exhibit object
permanence, less novelty preference on
the FTII, lower BRS scores, and decrease
engagement/orientation, described as
“shyer”
Iron Deficiency
• Among children in developing world,
iron is the most common single nutrient
deficiency
• No national statistics for prevalence of
ID or IDA < 12 months
Iron Fortification of Formula
• “The increased use of iron-fortified infant
formulas from the early 1970s to the late
1980s has been a major public health policy
success. During the early 1970s, formulas
were fortified with 10 mg/L to 12 mg/L of iron
in contrast with nonfortified formulas that
contained less than 2 mg/L of iron. The rate
of iron-deficiency anemia dropped
dramatically during that time from more than
20% to less than 3%.”
ID and IDA 12-35 Months
NHANES 2002
Population
General US
Above poverty
Below poverty
Enrolled in
WIC
Mexican
American
Other ethnicity
ID (%)
9.2
8.9
8.6
10.7
IDA (%)
2.1
2.2
2.3
3.2
13.9
0.9
15.2
4.4
Iron
• Iron absorption from soy formulas is
less
• Greater bioavailabilty of iron in
breastmilk
Iron Absorption In Infancy
Human Milk
Human Milk – in 5 to
7 month olds who
are also eating solid
foods.
Iron Fortified Cow’s
milk based Formula
Infant Cereals
Percent
Reported
Absorbed
48%
Study
Hallberg et al
21%
Abrams et al
6.7%
Hurrel et al
4 to 5%
Fomon et al
Iron Deficiency in
Breastfeeding
• At 4 to 5 months prevalence of low iron stores
in exclusively breastfed infants is 6 - 20%.
• A higher rate (20%-30%) of iron deficiency
has been reported in breastfed infants who
were not exclusively breastfed
• The effect of iron obtained from formula or
beikost supplementation on the iron status of
the breastfed infant remains largely unknown
and needs further study.
Foman on Iron - 1998
• Proposes that breastfed infants should have
supplemental iron (7 mg elemental) starting
at 2 weeks.
• Rational:
– some exclusively breastfed infants will have low
iron stores or iron deficiency anemia
– Iron content of breastmilk falls over time
– animal models indicate that deficits due to Fe
deficiency in infants may not be recovered when
deficiency is corrected.
AAP recommendations for Dx and
prevention of ID and IDA:2010
Pediatrics 2010 126 #5
• Birth-6 months: 0.27 mg/d
– Assuming average content Breastmilk 0.35
mg/L and average intake 0.78 L/day
– Noted variability of iron content of
breastmilk, high risk populations (IUGR,
LGA associate with maternal IDM,
maternal anemia, Preterm birth)
AAP recommendations for Dx and
prevention of ID and IDA:2010
Pediatrics 2010 126 #5
• 7-12 months: 11 mg/d
– Factorial approach: iron loss, iron needed
for increased blood volume, tissue mass,
and stores
– Noted that there isn’t a sudden increase in
needs from 6 to 7 months.
AAP recommendations for Dx and
prevention of ID and IDA:2010
Pediatrics 2010 126 #5
• Diagnosis:
– Iron status is a continuum with IDA at one
end of the spectrum
– No single measurement is currently
available to characterize iron status
– HgB limitations include specificity and
sensitivity. Identifies anemia but not
necessarily ID or IDA
AAP recommendations for Dx and
prevention of ID and IDA:2010
Pediatrics 2010 126 #5
• Term, healthy infants have sufficient Fe to 4 months.
• Formula fed: Fe needs met by standard infant
formula with 12 mg/dl and introduction of
complementary foods after 4-6 months. Whole milk
shouldn’t be used < 12 months
• Breastfed: Exclusively breastfed infants are a
increasing risk of ID >4 months and should be
supplemented with 1 mg/kg/d oral Fe until
appropriate complimentary food are introduced
AAP recommendations for Dx and
prevention of ID and IDA:2010
Pediatrics 2010 126 #5
• 6-12 months
– 11 mg/d
– Use complimentary foods with higher iron
content. Liquid supplement may be needed
to augment complimentary foods
AAP recommendations for Dx and
prevention of ID and IDA:2010
Pediatrics 2010 126 #5
• Univeral screening should be done at
12 months with Hgb and risk
determination
• Additional screening can be preformed
at any time if there is a risk of ID/IDA
including inadequate intake
Lead and Anemia
Fluoride
• Fluoride and dental caries
– At beginning of 20th century dental caries
was common with extraction only treatment
available
– Failure to meet minimum standards of 6
opposing teeth was common cause of
rejection from military service in WWI and
WWII
Fluoride
• 1901 Dr. Frederick S Mckay noted
mottled teeth (fluorosis) in practice in
Colo Springs Colo that were resistent to
decay
• 1909 Dr. FC Robertson noted same
mottling in his area of practice after a
new well dug
– Believed was due to something in the
water
Fluoride
• 1945 study was conducted in 4 city
pairs (Michigan, NY, Illinois, Ontario)
• Followed 13-15 years
• 50-60% reduction in dental caries
Fluoride
• Proposed mode of action
– Promotes remineralization of areas of
cariogenic lesions
– Increases resistance to acid
demineralization
– Interferes with formation and function of
plaque forming microorganisms
– Improves tooth morphology
Fluoride
• Concerns
– Excess
– Fluorosis
– Cancer
– other
Fluoride
• Fluoride Recommendations were changed in
1994 due to concern about fluorosis.
• Breast milk has a very low fluoride content.
• Fluoride content of commercial formulas has
been reduced to about 0.2 to 0.3 mg per liter
to reflect concern about fluorosis.
• Formulas mixed with water will reflect the
fluoride content of the water supply. Fluorosis
is likely to develop with intakes of 0.1 mg/kg
or more.
Fluoride, cont.
• Fluoride adequacy should be assessed
when infants are 6 months old.
• Dietary fluoride supplements are
recommended for those infants who
have low fluoride intakes.
Fluoride Supplementation Schedule
Age
Fluoride Concentration in Local
Water Supply, ppm
< 0.3
0.3-0.6
>0.6
6 mo. to 3 y
0.25
0.00
0.00
3-6 y
0.50
0.25
0.00
6 y to at
1.00
0.50
0.00
least 16 y
American Dental Association, American Academy of
Pediatrics, American Academy of Pediatric Dentistry, 1994.
Early Childhood Caries
• AKA Baby Bottle
Tooth Decay
• Rampant infant
caries that develop
between one and
three years of age
Early Childhood Caries: Etiology
• Bacterial fermentation of cho in the
mouth produces acids that demineralize
tooth structure
• Infectious and transmissible disease
that usually involves mutans
streptococci
• MS is 50% of total flora in dental plaque
of infants with caries, 1% in caries free
infants
Early Childhood Caries: Etiology
• Sleeping with a bottle enhances
colonization and proliferation of MS
• Mothers are primary source of infection
• Mothers with high MS usually need
extensive dental treatment
Early Childhood Caries:
Pathogenesis
• Rapid progression
• Primary maxillary incisors develop white
spot lesions
• Decalcified lesions advance to frank
caries within 6 - 12 months because
enamel layer on new teeth is thin
• May progress to upper primary molars
Early Childhood Caries:
Prevalence
• US overall - 5%
• 53% American Indian/Alaska Native
children
• 30% of Mexican American farmworkers
children in Washington State
• Water fluoridation is protective
• Associated with sleep problems & later
weaning
Early Childhood Caries: Cost
• $1,000 - $3,000 for repair
• Increased risk of developing new
lesions in primary and permanent teeth
Early Childhood Caries:
Prevention
• Anticipatory Guidance:
–
–
–
–
importance of primary teeth
early use of cup
bottles in bed
use of pacifiers and soft toys as sleep aides
Early Childhood Caries:
Prevention
• Chemotheraputic agents: fluoride
varnishes and supplements,
chlorhexidene mouthwashes for
mothers with high MS counts
• Community education: training health
providers and the public for early
detection
Infant Feeding
• Implications
• Translation into practice
• Recommendations