The principles of the proper nutri0on in childhood

AgnieszkaWegnerMD,PhDDepartmentofPediatricNeurology

MedicalUniversityofWarsaw

85% mom believes she has enough knowledge to properly feed the children ...

•  Theaveragenumberofmeals:8(6monthsofage)and7.7(12monthsofage)• Max.numberofmeals:15-20/day!•  AddiQonalsnacks:24%-75%•  Juices(notforinfants)25%

•  Complementaryfoodsfrom4monthsofage-21%ofparents•  50%ofparentssaltmealsforbabies•  20%useskimmedmilk

A.Stolarczyk,2011

FeinSB,Pediatrics2008

Main stage of ea0ng development

1-4m.ż. 7-12m.ż.5-6m.ż.

BreasAeeding

Exclusivebreas[eedingforthefirst6monthsofageü Howlong?

STANDARDYMEDYCZNE/PEDIATRIA2014T.11225-230WHO-54thWorldHealthAssemblyonMay18,2001;Policystatement:breas[eedingandtheuseofhumanmilk.AAPPediatrics,2005

WHO:exclusivebreas[eedingforthefirst6monthsofageandconQnuedforatleast2years

AAP:exclusivebreas[eedingforthefirst6monthsofageandconQnuedatleastunQl12monthsofage

Age(m.ż.)

Noofmeals

AmountofporQon(m) AbiliQes NutriQonalbasis Typeandconistensyof

meals Mealsexemples

1 7 110 •  Succing,swallowing

Breas[eedingormodified

milk

•  liquides •  Breast milk or infant formula 2-4 6 120-140

5-6 5 150-160 •  smoothpuree•  4dairymeals

•  Cookedmixedvegetables(eg.Carrots)andfruits(eg.Apple,banana),meat,eggorpotatopuree

•  Porridge/gruelgluten-free•  CerealproductsinsmallquanQQesnoearlier

than5monthsofage,nolaterthan6monthsofage.

•  WaterwithoutrestricQons•  100%juice,nosugar,150mlperday(porQon

calculatedfromtheamountofintakeoffruit)

7-8 5 170-180

•  Anincreaseddiversityofgroundorchoppedfood

•  Productstakebyhand

•  3mealsmilkfrom7-8.monthsofage.

•  Mixed/finelychoppedmeat,fish•  Mashedcookedvegetablesandfruits•  Choppedrawvegetablesandfruits(eg.Apple,

pear,tomato)•  Sohpiecesofvegetables,fruit,meatfedtothe

hand•  Cereal,bread,yoghurt,cheese,kefir•  Wholemilkcowsaher12monthsofage.•  WaterwithoutrestricQons•  100%juice,nosugar,150mlperday

9-12 4-5 190-220

Breast milk

•  Colostrum-colostrumisproducedforthefirst5days•  ComposiQon:High-proteinanQbodies,mineralsandgrowthmodulators•  Milktemporary-unQltheendofthesecondweekaherbirth•  Milk"mature"

•  DuringfeedinginiQallysecretedmilkismoredilutedandsweet,thenahighercontentofproteinandfat

Breast feeding

•  ThequanQtyofmilk-800ml(500-1200ml)perday•  QuanQtyiscontrolledbyprolacQndependingonthechild'sappeQte•  Themoreandmorebabysucklesthebreast,thehighertheconcentraQonofprolacQnandagreaterquanQtyofmilk•  Exclusivebreas[eedingandfrequenttakingbabytothebreastisthemosteffecQvewaytomaintainlactaQon

Breast feeding

•  ItshouldbeiniQatedasearlyaspossible,preferablyinthefirsthouraherbirth•  AherchildbirthwithC-secQonnolaterthan6-8hoursoflife•  Atthefeedefficiencyhasadecisiveinfluencefeedingtechnique•  Feedingyourbabyshouldbe"ondemand"(bothdayandnight)•  Theinfanteatsusually8-10Qmesaday•  Exclusivebreas[eedingshouldbemaintainedforatleast4-6months

Breast feeding adventages

•  Bepercontactthemother-child•  PrevenQonofinfecQousdiseases,eg.lowerincidenceofdiarrhea•  PrevenQonoffoodallergy•  Lessfrequentoccurrenceofdiseasesassociatedwiththedevelopmentoftheimmunesystem,eg.typeIdiabetes,lymphomas•  Lowerincidenceoflifestylediseaseseg.hypertension,obesity•  Improvedintellectualdevelopmentofchildren

Contraindica0on to breast feeding

•  MaternalinfecQousdisease-HIV•  IEMdiseases-maplesyrupdisease,galactosemia,phenylketonuria•  Tuberculosis•  Drugsusedbythemotherforexample:tetracyclines,ketoconazole,aspirin

Formula feeding

ModificaQonofcow'smilk->•  ReducQonofthetotalproteinandchangeitsqualitybyaddingdemineralizedwhey•  SubsQtuQonamountandqualityoffatbytheaddiQonofvegetablefats(unsaturatedfapyacids)•  Supplementlactose,vitaminsandsometraceelements

Types of formula

•  Formula-from0to4monthsofage•  TheircomposiQonshouldbeveryclosetobreastmilk•  Bebiko1,Bebilon1,Nan1,Humana1,Gerber1

•  Formulafrom5to12months•  enrichedthetaurine,carniQne,iron•  Bebiko2,Bebilon2,Nan2,Humana2,Gerber2

•  FormulaJuniorforchildrenover1yearofage

Vitamin suplementa0on

• VitaminD-400IU/dayQll6months,400-600IU/daydependingondiet6-12months•  >1yrVitaminD600-1000IU/dayseptember-april• VitaminK-2week-3month25ug/day

hpp://en.wikipedia.org/wiki/Vitamin_D

Preterm infants

•  DependingontheclinicalcondiQonofthenewbornisusedenteralorparenteralnutriQon,butwecanusedthemboth•  EnteralnutriQonisintroducedaherhearinggutmoQlity,prematureinfants>1500gusuallyinthefirstdayoflife•  TheearlyintroducQonofenteralnutriQonresultsinabepersQmulaQonofthedevelopmentofthedigesQvetract,beperweightgain(trywatering5%glucose)•  InmostinfantsenteralnutriQoncanbestartedwithinthefirst3daysoflifecomingtofullenteralnutriQonat2-3weeksofage,eveninthesmallestprematurebabies•  NOTE-toointenseenteralnutriQoncanleadtothedevelopmentofnecroQzingenterocoliQs

•  Milkwomenwhowerebornprematurelyisricherinenergy,proteinandsodiumThehighestcalorificvalueofmilkisdischargedaher2-3minutesthefeed(approximately82kcal/100ml)•  ConcentraQonofCaandPinmaturemilkisinsufficienttobalancethedemandandlossesthroughtheexcretorysystemimmaturepreterminfants•  BMF-BreastMilkForQfier-5kcal0.35gprotein,1gofmaltodextrin,30mgcalciumphosphate20mgand2mgofmagnesium•  NOTE-ThepreparaQonBMFcannotbegiventomixtures

Preterm infants

Preterm infants

•  Formulas:Nenatal,HumanaO,EnfamilPremature,BebilonNenatal•  Theseformulasarehighincalories-70-81kcal/100ml•  Theyincludetaurine,MCT,linoleicacid,vitamin,iron,mikoelements•  Aherreaching2500gweightitshouldbechangedtoinfantmilk

Complementary food

Notearlierthan17weekoflifenotlaterthan26wekoflife.

STANDARDYMEDYCZNE/PEDIATRIA2014T.11225-230

Age(m.ż.)

Noofmeals

AmountofporQon(m) AbiliQes NutriQonalbasis Typeandconistensyof

meals Mealsexemples

1 7 110 •  Succing,swallowing

Breas[eedingormodified

milk

•  liquides •  Breast milk or infant formula 2-4 6 120-140

5-6 5 150-160 •  smoothpuree•  4dairymeals

•  Cookedmixedvegetables(eg.Carrots)andfruits(eg.Apple,banana),meat,eggorpotatopuree

•  Porridge/gruelgluten-free•  Cerealproduct-gluten,sinsmallquanQQesno

earlierthan5monthsofage.,Nolaterthan6monthsofage.

•  WaterwithoutrestricQons•  100%juice,nosugar,150mlperday(porQon

calculatedfromtheamountofintakeoffruit)

7-8 5 170-180

•  Anincreaseddiversityofgroundorchoppedfood

•  Productstakebyhand

•  3mealsmilkfrom7-8.monthsofage.

•  Mixed/finelychoppedmeat,fish•  Mashedcookedvegetablesandfruits•  Choppedrawvegetablesandfruits(eg.apple,

pear,tomato)•  Sohpiecesofvegetables,fruit,meatfedtothe

hand•  Cereal,bread,yoghurt,cheese,kefir•  Wholemilkcowsaher12monthsofage.•  WaterwithoutrestricQons•  100%juice,nosugar,150mlperday

9-12 4-5 190-220

Does small child can decide what she/ he eats?

YESNONormally,thechilddecides-doesshe/

heeatsandhowmuchshe/heeats.Theparentdecideswhatchildeats.

Complementary food

• When?

• What?GroatsVegetablesFruitsWater,juices

Variety!MulQpleexposure!

Complementary food

• How?•  Howmanymeals?• WhatporQonoffood?• WhatconsisQencies?•  Howtoserve?

Age(m.ż.)

Noofmeals

AmountofporQon(m) AbiliQes NutriQonalbasis Typeandconistensyof

meals Mealsexemples

1 7 110 •  Succing,swallowing

Breas[eedingormodified

milk

•  liquides •  Breast milk or infant formula 2-4 6 120-140

5-6 5 150-160

•  IniQally-grindingfoodsbytongue

•  Strongsucking•  Pushthefood

fromthemouthwiththetongue(transientresponse)

•  Openingthemouthwhenapproachingteaspoon

•  smoothpuree•  4dairymeals

•  Cookedmixedvegetables(eg.Carrots)andfruits(eg.Apple,banana),meat,eggorpotatopuree

•  Porridge/gruelgluten-free•  Cerealproduct-gluten,sinsmallquanQQesno

earlierthan5monthsofage.,Nolaterthan6monthsofage.

•  WaterwithoutrestricQons•  100%juice,nosugar,150mlperday(porQon

calculatedfromtheamountofintakeoffruit)

7-8 5 170-180 •  Takingwithlipsfoodfromaspoon

•  ThedevelopmentofskillsandcoordinaQontomaintainindependentfeeding

•  Anincreaseddiversityofgroundorchoppedfood

•  Productstakebyhand

•  3mealsmilkfrom7-8.monthsofage.

•  Mixed/finelychoppedmeat,fish•  Mashedcookedvegetablesandfruits•  Choppedrawvegetablesandfruits(eg.Apple,

pear,tomato)•  Sohpiecesofvegetables,fruit,meatfedtothe

hand•  Cereal,bread,yoghurt,cheese,kefir•  Wholemilkcowsaher12monthsofage.•  WaterwithoutrestricQons•  100%juice,nosugar,150mlperday

9-12 4-5 190-220

BLW = Baby Led Weaning

TheCarolineWalkerTrust:Ea#ngwell:thefirstyearoflife

Children 1-3 years

•  Changeofgrowthrate-at12monthsofagetheinfantusuallytriplesitsbirthweight,and2-3-year-oldyeargainingweight2-3kg•  IndependentwayofeaQng•  Varietyofmeals•  SelecQonofappropriatefoods•  ExcessivefragmentaQonproductscaninhibitthepsychomotordevelopment

1.  Varietyofingredients2.  To2yearsold-notlowfatandcholesteroldiet-the

developmentofCNS3.  DrivingtheappeQteandphysicalacQvityofthechild

preventstheoverfeedingormalnutriQon4.  3-5mealsadayandavoidsnacking5.  Donotgrindexcessivelyproducts6.  Vegetariandietandothernon-convenQonaldietsare

inappropriateforthechild7.  Thebestsourceofsimplesugarsarefruitsandvegetables

Children 1-3 years

Preschool age

•  4-5mealsaday-3mealsbasic,secondbreakfastandahernoonteameal•  Diet:dairyproducts,leanmeats,fishandpoultry,variedspeciesofbread,flourproducts,cereal,pasta,fruit,vegetables•  Numberofeggs:3-4week•  Restrictfoodsrichinsaturatedfatsandcholesterol•  Controltheintakeofsweets,drinkingfizzydrinksandsnackingbetweenmeals

School age

•  PrinciplesofraQonalnutriQon•  Variety-awiderangeoffoodproducts•  ModeraQon-notoverfeeding•  Avoiding-excesssaltandsugar•  Regulate-fixeddateandthenumberofmealsperday

Food allergy

•  8-10%ofthepopulaQonarehypersensiQvetovariousfoods•  2.2-2.8%ofchildrenupto4yearsofageareallergictocow'smilkprotein•  Cow'smilkprotein20differentfacQonsofpotenQalallergenic•  ß-lactoglobulin•  SymptomsofatopicdermaQQs,urQcaria,angioedema,vomiQng,diarrhea,asthma,chronicrhiniQs,cough,oQQs,emoQonaldisorders

Food allergy

•  EliminaQonofthefoodortheingredientthatcausingproblems•  EliminaQondietmustbebalanced•  Breas[eeding-mother'sDiet•  ArQficialnutriQon:•  Hydrolysatesofcows'milkprotein(caseinandwheyproteins)•  Freeaminoacidsformula

Food allergy treatment

•  Caseinhydrolysates-Nutramigen• Wheyhydrolysates-BebilonPepQ,BebilonPepQMCT•  Thehigherthedegreeofhydrolysis,themorefavorablearethecharacterisQcsofadrug,butworsenstheflavorandincreasingosmolality.AlsoincreaseproducQoncosts.•  AminoacidpreparaQonsaredesignedforchildrenwithallergieswhicharenottreatablebyproteinhydrolysates-Neocate,Bebilon-Amino•  L-aminoacidshaveasourtaste,theyarepoorlytoleratedbyinfantsandarethemostexpensive

Preven0on of the food allergy

•  Breas[eedingforatleast6monthsofage

•  EliminaQondietinthemother•  MixturesHAhypoallergenic(parQallyhydrolysed):NANHA,AptamilHA,HAEnfamil

Refferences and literature

•  NelsontextbookofPediatrics,19thEdiQon,Kliegman,Behrman,Schor,Stanton,St.Geme•  Pediatria,Kawalec,Grenda,PZWL,Warszawa2013

•  IllutratedtextbookofPediatrics,4thEdiQon•  STANDARDYMEDYCZNE/PEDIATRIA2014T.11225-230

•  WHO-54thWorldHealthAssemblyonMay18,2001;Policystatement:breas[eedingandtheuseofhumanmilk.AAPPediatrics,2005

•  Google.com

•  Slideshare.net