Nutrition 2nd Yr Reviseda

Nutrition Module Notes Pediatric I – Second Year

Compiled By: Rebecca Abiog-Castro, M.D. Pediatric Gastroenterology & Nutrition

Faculty of Medicine & Surgery, UST

Objectives of the Course At the end of the course a Second Year Medical Student should be able: 4)

To explain the benefits and advantages of breastfeeding;

6)

To Identify the anatomical structures of the breast;

8)

To discuss the physiology of lactation (endocrine & autocrine factors);

10)

Discuss the factors involved for the successful maintenance of breastmilk supply;

Objectives of the Course 5) To discuss the manifestations of an adequate breastmilk supply; 6) To discuss the correct breastfeeding techniques; 7) To compare the composition of breast milk & cow milk; 8) To define complementary feeding;

Objectives of the Course 9) To discuss the art of introduction of complementary food;

10) To prescribe appropriate diet at various age group using the dietary prescription.

Nutrient Sources for Infants 1) HUMAN MILK: 

Preferred feed for all infants



Sufficient to provide nutrient needs until 6

months of life  

Continued until two years and beyond supplemented w/ complementary foods Serves as standard for all breastmilk substitutes

2) Breastmilk Substitute (Infant formula)



Advantages of Breast milk over Formula – – –

Antibodies Less sugar than infant formulas Contains Amino Acids, Fatty Acids, Cholesterol not found in formulas – Growth factors (epidermal growth factor, etc.) – GnRH – Delta sleep inducing peptide 

Disadvantages of Breast milk: – harmful substances ingested by mother can pass to baby

Protection Against Infection 

Reduces risk & severity of infectious illness among infants – – – – – – – – – – –

Diarrhea Otitis Media Lower Respiratory Infections Bacteremia Bacterial Meningitis Necrotizing Enterocolitis Infant Botulism Urinary Tract Disease Sudden Infant Death Syndrome (SIDS) Colic Wheezing

Anti-infective Properties 

Bifidus factor: stimulates bifidobacteria, which fight against pathogenic bacteria



IgA, IgM, IgG: immunoglobulins that guard the gut against infective bacteria



Lactoferrin: binds iron away from bacteria



Macrophages: phagocytosis of infective bacteria



B12 binding protein: removes B12 from bacteria

PREMATURE INFANT 

Breastfeeding and premature infants:



Premature infants fed their mother's milk were found to

– Decreased Incidences 1. Sepsis 2. Meningitis 3. Necrotizing enterocolitis

Breastmilk

Variations of Breastmilk –

Colostrum

(1st 3-5 days of life)

–

Term breastmilk

(mother’s own: 7 - 10 – 28 days)

–

Pre-term Milk

(7- 28 days)

–

Mature breastmilk

(>30 days)

–

Drip breastmilk

(30-90 days postpartum)

Type of Milk

Volume

Colostrum (1-5 d)

ml/d

Energy Kcal/100 ml

Protein

CHO

FAT

G/100mL

G/100 ml

G/100 ml

5.3

2.9

NA mmol/100ML

100

0.67

2.3

1.7

D7

558

0.73

1.95

6.72

3.52

0.97

D 14

591

0.67

1.62

6.97

3.88

1.27

Breastmilk

750

Term

(Mature>30 d)

0.69

1.1

7.4

4.2

0.70

Type of

Volume

ENERGY

PROTEIN

(ml/d )

KCAL/ml

G/100 ml

Milk

CHO

FAT

G/100 ml

G/100 ml

NA mmol/100 ml

Preterm D7

461

0.647

2.59

6.23

4.02

2.45

D14

413

0.68

2.29

6.21

4.71

2.2

D28

452

0.652

1.91

6.39

4.33

1.51

Drip BM(mature)

0.54

1.35

7.1

2.2

0.5

Cow

0.67

3.4

4.6

3.9

2.3

Colostrum 

1st postpartum week’s mammary secretion consisting of Yellowish (beta carotene) thick fluid; – Higher protein – Lower fat and lactose – Rich in » Vitamin A (3x > BM) » Vitamin E (3x) » Carotenoid (10x)



Protein content is rich in – sIgA – Mononuclear cells [immunologically competent]



Contains Antioxidants which trap neutrophil-generated Oxygen radicals

Comparison of Human Milk vs Cow’s Milk

Osmolality & Renal Solute Load Type of milk

Osmolality

Renal Solute Load mosmol/100kcal

Human milk

LOW, less than 300 mosmolar, gut can easily handle

13

Cow’s milk

HIGHer osmolality

46

Cow’s milk SKIM MILK w/ milk solids added

86

Infant formulas:

18-25

Proteins

Whey or Soluble proteins:

– form very LIGHT CURDS & EASY TO DIGEST – Whey proteins in human milk high in anti-infective proteins » (mainly IgA)

– These Antibodies Coat the surface of the small intestine, blocking binding sites from bacteria and allergens

Casein: – forms very THICK CURDS & DIFFICULT TO DIGEST – Incidence of colic or pain in abdomen is generally higher in babies fed on cow’s milk because of thick curds that are formed from high amount of casein

Proteins …

Lipids

* Provide 50% of calorie content, thus, major source of calories * Composition:

   

Palmitic acid

  

PUFA: DHA, Arachidonic acid

Oleic acid Phospholipids Essential Fatty acids: Linoleic & Linolenic Acids Cholesterol Bile-salt stimulated lipase

Fats 

Breast milk contains 1. 2. 3.



Essential fatty acids Linoleic and linolenic acid Essential for development of BRAIN & EYES

Also contains

– Bile salt stimulated lipase 

Fats in breast milk bind less calcium as compared to other milks

Carbohydrates 



LACTOSE: – Not all Lactose in breast milk is absorbed – Some Fermented  Lactic Acid » Helps make pH of Lower Gut Acidic » Acidic pH  Inhibits Growth of pathogenic bacteria  reducing the chances of Diarrhea » Acidic pH  helps Keep iron in FERROUS form  Promoting IRON ABSORPTION GALACTOSE: – Used during MYELINIZATION of Nervous System

Vitamins

Iron

Calcium – Breast milk contains only about 1/3 of the Calcium compared to cow’s milk – Absorption of calcium from breast milk is much better due to low level of phosphates – High levels of lactose also promote absorption of calcium – Less binding of calcium by fats in the BREAST MILK also helps in promoting better calcium absorption

Benefits of Breastmilk 

Baby: – – – –



Protection against infection Higher Intelligence Quotient Bonding DHA content

Mother – Protection against several illnesses

Health Benefits for Infant



Enhanced immune response to immunizations 1. Polio 2. Tetanus 3. Diptheria 4. Haemophilus influenza

Other Breastfeeding Benefits for Baby      

Promotes Cognitive development Better Teeth & Jaw development Promotes Facial & Muscular Develpmnt Promotes Normal Weight Gain Promotes Strong Bond Less Spitting up

Longer-term Health Outcomes Maternal benefits 

Reduces risk of chronic illness in childhood – Some food allergies – Type-1 insulin dependent diabetes – Lymphoma – Asthma – Obesity

Health Benefits for the Mother 



  • •

Promotes more rapid return to prepregnancy weight Reduces risk for certain cancers (lower estrogen) – Breast cancer – Uterine, ovarian, and endometrial cancers Reduces post-partum hemorrhage Promotes maternal attachment to baby Reduces risk of osteoporosis Saves money (~$1200/year)

Excerpts from the American Academy of Pediatrics Policy Statement (Dec. 1997)   

 

Human milk is uniquely superior for infant feeding Human milk is the preferred feeding for all infants, including premature and sick newborns When direct breastfeeding is not possible, expressed human milk, fortified when necessary for the premature infant, should be provided Exclusive breastfeeding for approximately 6 months Continuation of breastfeeding for at least 12 months and thereafter for as long as mutually desired (WHO says 2 yrs. of age or beyond)

Neonatal Reflexes in Breast Feeding

Palate Teat

Tongue

Anatomy of the Breast

Physiology of lactation Endocrine control Three main phases of lactation under hormonal control (Endocrine): 1)

Mammogenesis or mammary growth

2)

Lactogenesis or initiation of milk secretion:

Stage I: 12 wks before parturition Stage II: 2-3 days postpartum Stage III of Lactogenesis or maintenance of milk secretion: 14-30 days

Endocrine Control of Lactation 

Milk Production Reflex: Prolactin is a key lactogenic hormone, stimulating initial alveolar milk production



Milk Ejection Reflex: Oxytocin contracts the myoepithelial; cells, forcing milk from the alveoli into the ducts and sinuses where it is removed by the infant

Physiology of Lactation Endocrine Control



Support Lactation 1. Cortisol 2. Insulin 3. Thyroid Hormone 4. Parathyroid Hormone 5. Growth Hormone

Endocrine Control of Lactation

Endocrine Control of Lactation

Autocrine Control of Lactation

Influence of of Local Factors Acting on the Breasts  It is not just the level of maternal hormones, but the efficiency of milk removal that governs the volume product in each breast  A protein factor called feedback inhibitor of lactation (FIL) is secreted with other milk components into the alveolar lumen

Autocrine Control of Lactation

 If milk is not removed, breasts remain full of milk;  FIL, the chemical inhibitor present, interacts with the alveolar cells of the breast  insensitive to prolactin  ↓ breast milk secretion

Autocrine Control of Lactation

FIL

FIL FIL

Breast Milk ADVANTAGES OF HUMAN MILK: •

Infant Nutrition

•

GIT Function

•

Host Defense

•

Psychological Well-being

•

Economic benefits

Nutritional Aspect Carbohydrate: Composition 

Lactose



Monosaccharides



Neutral and acid oligosaccharides



Peptide- and protein-bound CHO



Fucose All these CHO possess bifidus factor activity

Nutritional Aspects CARBOHYDRATE: LACTOSE (milk sugar):  Predominant CHO: disaccharide (Glu/Gal)  Enhances growth of L. bifidus as gut flora  more nonpathogenic fecal flora  Provides ready source of galactose  galactolipids  essential to CNS development  Plays important role for NB’s growth  Improves absorption of Ca and P  critical in the prevention of rickets among BF babies

Nutritional Aspects Whey protein  α -Lactalbumin:  one of the chief fractions in BM  Lactoferrin: Iron-binding protein  inhibits growth of irondependent bacteria in the gut  protection against GIT infection  Immunoglobulins:  Consists principally of Secretory IgA found high during the first few days then decline rapidly

 Lysozyme:  bacteriolytic against enterobacteriaceae and Gram (+) bacteria

Nutritional Aspects LIPIDS: PUFA: * Arachidonic: derived from Linoleic Acid * Docosahexanoic ( DHA): derived from Linolenic Acid * Both fatty acids are associated w/ cognition & vision * Only found in Human milk!!

Host Resistance Factors in BM 

Immunoglobulin: – sIgA, IgM, IgG – Cellular components: » » »



Macrophages Polymorphonuclear Lymphocytes

Non-immunoglobulin components: – Oligosaccharides – Mucin – Fatty acids

Host Resistance Factors in BM Non-immunoglobulin components: - Non-specific factors: » Bifidus factor » Resistance factor (Anti-staphylococcal factor) » Anti-viral factor » Anti-protozoal factors (Bile-salt stimulated lipase) – Enzymes: Lysozyme, lipoprotein lipase

Host Resistance Factors in BM

Antiviral Factors: 

sIgA: Active against – Enteroviruses (Polio, Coxackie, Echov.) – Herpes virus (CMV. H. simplex) – Respiratory Syncitial Virus – Rubella – Reovirus – Rotavirus



IgM, IgG: Active against – CMV, RSV, Rubella

Host Resistance Factors in BM 

Anti-inflammatory properties: – Poor initiators & mediators of inflammation » Complement system » Fibrinolytic » Coagulation system

– Rich in anti-inflammatory agents » sIGA » Lysozyme 

Provides good mucosal barrier – (growth factors)  prevents attachment of bacteria & antigen

Breastmilk GIT FUNCTION: • Gastric emptying time is FASTER • Large gastric residual volumes are LESS • Many factors Stimulate GIT growth and motility • Enhances GUT Maturity

Breastmilk

PSYCHOLOGICAL EFFECTS: • Maternal-infant BONDING enhanced • Long term Cognitive & Motor abilities developed

Infant Milk Formulas

TYPES OF INFANT FORMULA

• • •

Pre-term Formula Catch-up Growth Formula Standard Infant Formula Whey Dominant ( 60%) Casein Dominant ( 60%)

• • • •

Follow-on (up) Formula Growing-up Formula Whole cow’s Milk Evaporated Milk

Types of Infant Formulas



SPECIAL Formulas: – Hydrolysates: »Partial Hydrolysates »Complete Hydrolysates – Goats milk

Nutrient Sources: FOR INFANTS LESS THAN 2 YEARS

3 Indications for Use of Infant Formulas 

Substitute (or supplement) for human milk in infants whose mother choose not to breastfeed



Substitute for human milk in infants for whom breastfeeding is medically contraindicated



Supplement for infants who do not gain weight appropriately

Nutrient Sources: < 2 Years of Age  PRETERM

FORMULA:

Prescribed for premature until 35-36 weeks of gestation or gained 2 kilograms.  When given beyond recommended age may cause hypercalcemia Special Features: • Protein: Whey predominant formula at a level higher than breast milk & standard infant formula (2.0 2.5g/100ml.)

PRETERM FORMULA



Pre-Aptamil (Milupa):

1:1 dilution



Enfalac Premature:

1:1 dilution



Pre-Nan:

1:1 dilution



S-26 LBW:

1:2 dilution

STANDARD INFANT FORMULA 

Recommended during first 6 –12 months of life



Extensively modified from what was originally produced by the cow;



Very little difference between brands



Example: 1. S-26 2. Enfalac 3. Nan 4. Similac 5. Mylac 6. Aptamil 7. Bonna 8. Nestogen

FOLLOW-UP FORMULA 

Liquid part of the weaning diet for infants & children

12 mos - 3 years of age 

Distribution of calories & nutrients is in between standard infant formula & whole cow’s milk



Protein is higher w/ the ratio – 20% Whey – 80% Casein



Example: 1. Promil 2. Nan 2 3. Gain 4. Milumil

COMPOSITION OF VARIOUS NUTRIENT SOURCES

Energy kcal/100ml

BM 65

Protein G/100 ml Whey Casein

1.1

COW 67

A 65

PREM 81

FF-UP 65

1.5 60% 80%

2.4 20%

2.8

40%

3.5 60% 40%

Fat G/100 ml

4.5

3.7

3.6

4.4

2.64

CHO G/100 ml

6.8

4.9

7.2

8.6

8.18

CA mg/100 ml P mg/100 ml

34 14

117 92

44 33

95(75) 53(40)

NA mmol/100 ml

0.7

2.2

0.64

1.4

1.57

GROWING –UP FORMULA: 

Product for children above 2 years - 10 years



Provides nutrient necessary as they undergo transition from infant  adult formulation.

• Protein is high (3 g/100 ml) from Sodium • Casseinate & Soya protein 

CHO contains a blend of 1. 2. 3.

Cornstarch Sucrose Very Minimal Lactose

GROWING-UP FORMULAS 

NESLAC (Nestle):

1:1 dilution



ENFAGROW (MJ):

1:1 dilution



LACTUM (MJ):

1:1 dilution



GROW (Abbott):

1:2 dilution



PROGRESS (Wyeth):

1:2 dilution

Whole Cow’s Milk 

May be given as SUPPLEMENT to a

12 months above balanced diet from



No modification done to suit the needs of infants &children

 Example:

1.Alaska 2.Bear Brand

Protein Hydrolysates 

Definition: Product of an enzymatic degradation of protein to proteose, peptone, peptide-AA mix and finally free AA mix.



Types: –

Partial Hydrolysate: Degradation of protein to big, medium size peptides  LESS antigenicity

–

Complete Hydrolysate: Degradation of protein into small peptides and free AA

Protein Hydrolysates 

Partially Hydrolyzed Formula:

–

For prophylaxis on high risk infants: » FH of atopy, asthma, food allergy – Preparation: » Nan-HA



Extensively Hydrolyzed Formula: – For treatment of food allergy during infancy – Preparations: » » »

Pregomin (Milupa) Pregistimil (MJ) Alfare (Nestle)

“Introduction of Complementary Food”

Complementary Food (CF)

Definition: It refers to SUPPLEMENTAL foods (milk & solid foods) given to infants when breastmilk is no longer adequate to sustain normal growth

WHY should CF be given?

Three Infant Feeding Periods:   

Nursing Period (1st6 m of life) Transitional Period (6m-10m) Modified Adult Period (>10m)

WHY should CF be given? Three Infant Feeding Periods: Nursing Period (1st 6 months of life): 

Breastmilk / standard infant formula is U to provide nutritional requirements for normal growth



MILK should be the ONLY source of nutrient

Nursing Period (1st 6 months of life):

♣

Well developed ♣ ♣ ♣

♣

Digestive Mucosal barrier Renal functions

NOT fully developed 1. Neuro-developmental

Nursing Period : (1st 6 months of life)

♣

Addition of solid foods at this time 

↓

breastmilk /milk consumption proportionally 

Growth Failure!! Stuff et al, J pediatr,1990

Transitional Period (6-10 months) ♣ It is the TRANSITION from Nursing period  Adult Modified period ♣

Milk (Breastmilk / Standard Infant Formula)

♣

 NO longer adequate to sustain the nutritional needs of growing infants

Transitional Period (6-10 mos) ♣

Well Developed ♣ Digestive ♣ Renal systems ♣ Taste

♣

Fully developed 1. Skills needed for feeding

Transitional Period ( 6-10 months)

FAILURE

to offer supplemental

foods at this time  difficulty in accepting them later

“Critical Learning Period” 6-15 months

6-15 months “CRITICAL LEARNING PERIOD” for feeding:

♣ ♣

♣

chewing & swallowing coordination is being developed

FAILURE of infants to go through this process  Feeding Problems

♣

– – –

Dependence to MILK as source of nutrient Picky eaters / Neophobic Malnutrition (obesity / wasting , anemia)

Modified Adult Period (>10 months) ♣

Physiologic Mechanisms  matured to near adult proficiency

♣

Most of the Nutrients MUST come from Table Foods w/ Minimal Alteration(cut into small pieces, bland)

♣

Taste ability & Preferences have become established

Question no 9: What kind of food would you give?

Scientific Rationale: – “Critical Window” for introducing “lumpy” solid foods: if these are delayed beyond 10 mos  increased risk of feeding difficulties later on – Ingestion of the types of foods depend on the neuromuscular development of infants

WHEN should CF be given? 6 months

Signals that indicate readiness of the infant for CF: ♣ Birth weight has doubled; ♣ Extrusion reflex has completely disappeared; ♣ Has good head and neck control; ♣ Sits up with support;

WHEN should CF be started? Signals that indicate readiness of infant

for CF:

♣ Opens mouth if wants food; turns head away when not

interested anymore; ♣ Has good chewing & swallowing coordination; ♣ Consumes about 32 oz of milk and wants more; ♣ Breastfeeds > 10x and wants more

Art of Introducing Complementary Food

♥ Introduce one new food at time to allow infant to get use to it; continue same food for 3-4 days before giving another food; ♥ Give very small amount of any new food at the beginning, 1-4 tsp;

Art of Introducing Complementary Food

♣ Use thin puree consistency initially --> shift gradually to a more viscous calorie-dense food ♣ Mix foods with ones baby likes, to enhance acceptability and nutrient content Cereals +BM: Enhanced acceptance of cereal during weaning! Mennella et al, Pediatr Res, 1997

Art of Introducing Complementary Food

♣ Once infant can sit with support at about 6 mos , give fluid (milk or water) using trainer’s cup; ♣

By 12 months of age milk should be given by the cup or glass;

♣

BOTTLES should be OUT by this time!

Art of Introducing Complementary Food ♥ Avoid adding salt and sugar ♥

When baby is able to chew at about 8-10 months, gradually switch to finely chopped foods

♥

DO NOT continue soft smooth foods for too long

♥

Feeding Frequency: ♥ ♥ ♥

6-8 months: 9-11 months: > 12 months:

2 -3 meals a day 3-4 meals; 1-2 snacks 3-4 meals: 1-2 snacks

Art of Introducing Complementary foods

♥ By 12 months, most of the nutrient should come from table food (modified); infants have attained physiologic maturity of adult proficiency; ♥ Encourage infant to try new flavors as a variety of foods is important ! * FNRI-DOST, Nutrition Guidelines for Filipinos, 2000 * Pediatric Nutrition Handbook, 4th Edition AAP

References: 

FNRI Food Guidelines, 2002



Lawrence, Ruth, 4th Edition, 1994; Breastfeeding A Guide for the medical profession



Nelson Textbook of Pediatrics, 16th Edition, W.B. Saunders Company



Pediatric Handbook in Nutrition, 4th Edition American Academy of Pediatrics

Practice Questions: 

Compute for the Total Caloric and fluid requirements of a 2 year old boy with a weight of 14 kg; length of 90 cm.



Breastfeeding: 2.1 How long can you BF exclusively? 2.2 Discuss the advantages of BF. 2.3 Discuss the endocrine and autocrine control of lactation 2.4 Differentiate breastfeeding & breastmilk jaundice

3)

Breastmilk substitutes: 3.1 What breastmilk substitute can be given to a 6 months, 10 months old infant if breastmilk is not available? 3.2 What nutrient source do you give infants with cow’s milk allergy?

4)

Complementary Food: 4.1 Why and when do you introduce CF? 4.2 When is the ‘critical learning period’ for feeding? 4.3 Discuss the art of introduction of CF