INFANT NUTRITION

Sinéad Feehan Department of Nutrition & Dietetics A.M.N.C.H.

August 2009

Overview Assessing growth Requirements Breastfeeding Formula Feeding Introducing Solid Foods Iron & Vitamin D

Normal Growth: Weight Normal birth weight 3.5kg Regain birth weight by 2 weeks Expected gain

200g per week for 1st 3 months 150g per week for 2nd 3 months 100g per week for 3rd 3 months 50-75g per week for 4th 3 months

NB standardisation of measurements

Normal Growth : Length Normal birth length 50cm Expected growth

1st year 25cm 2nd year 12cm 3rd year onwards 10-6cm per year

until puberty Supine length until age 2

Normal Growth: OFC Normal head circ at birth 35cm >0.5cm per week (48cm by 1 yr) Reflects brain growth Above eyes, upright, looking

straight ahead

Centile Charts Various charts available Calculate age in weeks <37/40: correct until 2 years Weight at 4-8 weeks predictive View growth in relation to normal

population

Reference Nutrient Intakes

Age(months)

Weight(kg)

Fluid(mls)

Energy(kcals/kg)

Protein(g/kg)

0 - 3 4.4 150 115 – 110 2.8

4 - 6 7.2 130 95 1.8

7 - 9 9.0 120 95 1.5

10 – 12 10.0 110 95 1.5

WHO RECOMMENDATION Exclusively Breastfeed for 6

months Continue to breastfeed after that,

in combination with appropriate complementary foods, until the age of 2 years or beyond

WHO guidelines have been accepted and endorsed by the DOHC

Breastfeeding Benefits Immunological:

Breastfed babies are at lower risk of infection.

Nutritional:Easy to digest, optimal blend of nutrients, low risk of contamination.

Psycho/social:Bonding, pain relief, maternal confidence & empowerment.

Financial:Milk is always available: shorter hospital stay.

Benefits Optimal nutrition for human infant

Correct nutrient composition – macro/micronutrients Nutritionally complete until 6 mths

Immunological advantages Macrophages: lysozymes and lactoferrin Lymphocytes: interferon and IgA Bifidus factor Antibodies Anti-trypsin factor

Possible Contra-indications

Medications IV Drug Abuse HIV Galactosaemia, Alactasia

Note: Very low birth weight/premature, can be fed expressed breast milk

Colostrum Protein rich – Arginine & Tryptophan Essential fatty acids Vitamins (A, D & B12) and minerals Frequent suckling – increases hormone

production (Prolactin & Oxytocin) which increases milk production

Mature Breast Milk Fore milk & hind milk Less protein, more fat and energy Antibodies & anti-infective agents Digestive enzymes – lipase and amylase Vitamins, minerals and trace elements High bioavailability of nutrients 67 -70 kcals/100mls

Formula Feeding Approved formulae – nutritionally

complete

No immunological/enzymic properties

Cows milk based, modified to mimic the nutrient profile of mature breast milk

Provide 65-69 Kcals / 100mls

Demand feed: 150 – 200mls/kg/day

W h ey B a sed C a se in B a sed

In fan t Fo rm u la

Standard Products Whey based/ first milks

Cow & Gate First Infant Milk Farley’s First Milk Milupa Aptamil First Infant Milk SMA First Infant Milk

Caesin based/ “milk for hungrier babies” Cow & Gate Second Infant Milk Farley’s Second Milk Milupa Aptamil Extra Hungry SMA Extra Hungry

Follow-on Formulae Follow-on milks

Cow & Gate Follow-on MilkFarley’s Follow-on MilkMilupa Aptamil Follow-on MilkSMA Follow-on Milk

Marketed for babies > 6 months Higher Energy, Iron & Vitamin D than

term formulae

Specialised Formula (Non-Px) Anti-regurgitation Formula

Enfamil AR SMA Staydown

Not effective with ant-acid medications

Lactose-free Formula Enfamil 0-Lac SMA LF

Glucose syrup instead of lactose Lactose intolerance usually transient - avoid

prolonged use

Special Formula (Non-Px)

Soya milks Farley’s Soya Formula SMA Wysoy

Lower biological value Limited clinical indications – Galactosaemia Not indicated in colic, lactose intolerance,

CMPI Contra-indicated under 6 months (BDA)

Prescribable Specialised Formulae Nutrient dense

SMA High Energy, Infatrini Hydrolysed

Pepti-Junior, Pepdite, Nutramigen 1 and 2, Pregestimil, Nutrilon Pepti, Prejomin, MCT Pepdite

Elemental Neocate

LBW/ Premature Nutriprem 1 and 2, SMA Gold Prem, BM Fortifier

Disease specific Caprilon, Kindergen, Galactomin 17 and 19, Monogen,

Locasol

Volumes Feed on demand Initially small frequent feeds Volumes increase, frequency decreases

Example 4 week old infant weighing 4.3kg Fluid requirement 150mls/kg = 645mls/day

80mls 3 hourly x 8 or95mls 3.5 hourly x 7 or110mls 4 hourly x 6

All suitable, baby dictates, don’t restrict hungry baby

Formulae :Possible Problems

Over-concentration Hypernatraemia and dehydration Inappropriate calorie density

Over-dilution Excess volume Vomiting and hyponatraemia FTT and malnutrition

HygieneSafefood: “How to prepare your babys bottle feed”

Weaning Solid food should be introduced at 6

mths ? Not before 4 months:

-milk meets all nutrient requirements-immature GIT & limited renal capacity-Poor neuromuscular co-ordination

? by 6 months:-increasing energy & nutrient needs -decreased body stores : Fe & Zn-aids chewing & speech development-food refusal less likely

Weaning cont’d First foods (6mths):

- puree fruit, veg, rice/ gluten-free cereals- puree meat/chicken/fish- offer variety of tastes & textures

Next foods:-introduce wheat, gluten, eggs*,citrus fruit

-don’t add salt or sugar-more lumpier/mashed consistency -introduce finger foods

- include iron-rich foods

Weaning cont’d Cow’s milk not as drink before 1 year Potential allergens

No evidence to delay introduction Eggs – well cooked after 6 months Nuts – avoid whole until 5 years; fhx avoid for 3 years

Gluten Currently > 6 months Literature 4 – 7 months, gradual intro while BF

Vegetarian Ensure 500mls of BM/ formula

Vegan Not recommended

Suitable Drinks Breast milk / formula & water only Unmodified cows, goats, sheeps milk unsuitable Juice – not required but not before 6 mths and not

in quantities > 120-180mls per day. Offer diluted. Tea, aerated drinks, mineral waters, coffee :

unsuitable No additions to bottles Encourage cup from 6 months Discourage bottle from 1 year NB dental care

Current Practices:Tarrant et al 2006

23% of infants weaned to solids <12 weeks

9% <10 weeks 10% at 6 months crisps/choc/biscuits

>4/week 6% add solids to bottles 31% add gravy to weaning foods 16% add sugar to weaning foods 5% add salt to weaning foods

Current Practices:Tarrant et al 2006 (contd.)

4% have tea/lemonade/cola at 6 months 2% have these drinks regularly 6% have >180ml juice per day at 6

months 4% have sugar water as a drink at 6

months 20% mothers avoid meat in weaning

diets

By 1 year…. Eat family meals Wide range of textures and tastes Approx 1 pint cow’s milk per day Drinking from cup not bottle

Common feeding problems

FALTERING GROWTH

IRON DEFICIENCY ANAEMIA

VITAMIN D DEFICIENCY & RICKETTS

Faltering Growth Downward deviation in weight across 2 or

more centiles from the max centile achieved at 4-8 weeks for a period of a month or more

Possible Causes:-inadequate dietary intake

-malabsorption/excessive losses-increased nutrient requirements-inability to utilise nutrients, e.g. metabolic conditions-psychological problems, e.g. poor parenting skills

Faltering Growth : Management

Increase feed volume, if inadequate

Consider Nasogastric feeding Supplement feeds to increase

energy density Aim For: 130 - 150 Kcals/Kg

3 - 4.5g protein/Kg

Iron Deficiency Anaemia

Definition: Hb < 11g/dl, Ferritin < 10microg Symptoms include - apathy, poor appetite,

poor growth, psychomotor delay Possible causes are prematurity and

inadequate weaning diet Inhibitors of iron are tannins, phytic acid,

phosphoproteins Prevention = Breast milk/Fe fortified formula

Weaning foods rich in haem iron Adequate vitamin C

Vitamin D Re-emergance of rickets Low vitamin D levels in normal

population Risk factors

Latitude, lack of sunlight exposure Pigmented skin Poor maternal status Prolonged breastfeeding, poor weaning diets

FSAI recommend 5μg daily for all infants Await policy…….

Infant Nutrition Breast/Formula feed up to One year

old Introduce solids from 6 months Include iron-rich foods in weaning

diet Offer variety of tastes & textures Encourage drinking from a cup from

6-8 months