Transcript טעם החיים המוקדמים נושאים בתזונת תינוקו

‫טעם החיים המוקדמים‬
‫נושאים בתזונת תינוקות‬
‫וילדים‬
‫דר' רון שאול‬
‫מרכז רפואי בני ציון‬
‫מהי כלכלה ים תיכונית בריאה‬
‫• מה כן‬
‫– ירקות ‪ ,‬פירות‪ ,‬קטניות‪ ,‬אגוזים ודגים‪,‬‬
‫– אלכוהול בכמות מתונה‪.‬‬
‫• מה לא‬
‫– בשרים ומוצרי חלב עתירי שומן‬
‫• ירידה בתמותה ממחלות לב ומסרטן‬
‫שעורי תמותה ביחס לצריכת‬
‫כלכלה ים תיכונית‬
Introduction
• Human milk is the most appropriate milk for
the newborn infant.
• Major research has been going on over the
last years towards the development of
enteral formulas that would be as close as
possible to the composition of breast milk.
Introduction
• The major nutrients of interest include
–
–
–
–
–
–
Glutamine
Taurine
ω-fatty acids
Nucleotides
probiotics, and prebiotics.
Antioxidants
•
ω-fatty acids
LC – PUFA
ω-3 AND ω-6 FATTY ACIDS
• The ω-3 and ω-6 fatty acid families also
are referred to as essential fatty acids
because of absent de novo synthesis.
• The ω-6 series are the precursors for
arachidonic acid (AA), which has several
biologic roles, including structural
component of cell membranes and precursor
for prostaglandins and leukotrienes
LC – PUFA
ω-3 AND ω-6 FATTY
ACIDS
• ω-3 Fatty acids, especially
docosahexaenoic acid DHA, may be
important for proper functioning of
cellular membranes in neuronal tissues,
such as the retina and the brain.
LC – PUFA
ω-3 AND ω-6 FATTY
ACIDS
• The brain and retina are rich in ω-3
fatty acids, particularly DHA.
• These fatty acids are present in
human milk
• AA and DHA may be necessary for
neural development, cognitive
function
• There are 14 controlled trials in term infants
that have included formula feeding with or
without LCPUFA and functional assessment
of visual and other measures of neural
development; in addition, 7 have evaluated
specific measures related to cognitive
development.
• They examined the effect of DHA dose
provided daily on the development of visual
acuity to explain the differences in visual
acuity responses across randomized
studies.
• Results indicate a strong and significant
effect of DHA equivalent dose on
magnitude of the visual acuity response at
all conversions tested
• Most studies showed no advantage for
LCPUFA on neurodevelopment.
• They concluded that there is a
significant relation between the total
DHA equivalents provided and
effectiveness as defined by visual
acuity measurements at 4 months of
age.
J Pediatr 2003;143:S17-S25
Long chain polyunsaturated fatty
acid supplementation in infants
born at term
• Conclusions: At present there is little evidence
from randomised trials to support the
hypothesis that LCPUFA supplementation
confers a benefit for visual or general
development of term infants.
• Minor effects on VEP acuity have been
suggested but appear unlikely when all studies
are reviewed.
Cochrane Database of Systematic Reviews. 3, 2005
Long chain polyunsaturated fatty
acid supplementation in infants
born at term
• A beneficial effect on information
processing is possible but larger
studies over longer periods are
required.
• Data from randomised trials do not
suggest that LCPUFA supplements
influence the growth of term infants.
Cochrane Database of Systematic Reviews. 3, 2005
• Objective: The objective was to determine the
effect of supplementing infant formula with longchain polyunsaturated fatty acids (LCPUFAs) on
the growth of term infants.
• Design: they reviewed all known randomized
controlled trials that involved LCPUFA
supplementation of infant formula fed to term
infants.
• Outcome measures were weight, length, and head
circumference.
• Results: They identified 14 eligible trials that had
data available for meta-analysis (1846 infants).
• Trial quality was generally high.
• Meta-analysis showed no significant effect of LCPUFA
supplementation on infant weight, length, or head
circumference at any assessment age.
• Similarly, subgroup analyses showed that
supplementation with only n3 LCPUFAs or different
sources of LCPUFA (phospholipid or triacylglycerol)
also did not significantly affect infant growth.
Soy based formulas
Background
• Soy-based infant formulae, initially developed
for infants who were lactose intolerant or
allergic to cow’s milk–based formulae, now
account for >25% of the infant formulae sold
in the United States.
• Formulations have changed over the years to
improve digestibility, the stability and
availability of minerals, and protein quality.
Introduction
• Results suggest that modern soy-based
formulae support normal growth and
nutritional status in healthy term infants
at the age of 1 year.
• However, there are very limited data on
sexual and reproductive development or
outcomes such as immune function, visual
acuity/cognitive development and thyroid
function.
Mendez MA, et al. J Nutr 2002;
1322127-2130:)8(
• Recent concerns have been raised
regarding the phytoestrogenic
isoflavone content (x40 in comparison
to breast milk) of soy-based formula
• Objective To examine the association between
infant exposure to soy formula and health in
young adulthood, with an emphasis on
reproductive health.
• Design, Setting, and Participants Retrospective
cohort study among adults aged 20 to 34 years
who, as infants, participated in controlled feeding
studies conducted at the University of Iowa
• 248 were fed soy formula and 563 were fed cow
milk formula during infancy.
JAMA 2001
• Conclusions: Exposure to soy formula
does not appear to lead to different
general health or reproductive
outcomes than exposure to cow milk
formula.
• The findings are reassuring about
the safety of infant soy formula.
• 1. In term infants whose nutritional needs are not
being met from maternal breast milk or cow milk
based formulas,
• 2. They are appropriate for use in infants with
galactosemia and hereditary lactase deficiency.
• 3. Parents seeking a vegetarian-based diet for a
term infant.
• 4. Isolated soy protein-based formulas are
indicated for acute gastroentitis when lactose
intolerance has been documented.
• 5. Soy protein-based formula has no proven value
in the prevention or management of infantile colic.
• 6. Soy protein-based formula has no proven value
in the prevention of atopic disease in healthy or
high-risk infants.
• 7. Infants with documented cow milk proteininduced enteropathy or enterocolitis frequently
are as sensitive to soy protein and should not be
given isolated soy protein-based formula
routinely.
• 8. Most infants with documented IgE-mediated
allergy to cow milk protein will do well on isolated
soy protein-based formula.
• 9. Soy protein-based formulas are not designed or
recommended for preterm infants who weight
<1800 g.
Pediatrics, January 1998
Soy for allergy prevention
• Conclusions: Feeding with a soy
formula should not be recommended
for the prevention of allergy or food
intolerance in infants at high risk of
allergy or food intolerance.
Osborn DA, et al. Soy formula for
prevention of allergy and food intolerance in
infants. Cochrane Database Syst Rev 2004
• Soy allergy occurs in only a small
minority of young children with IgEassociated CMA.
• As such, soy formula may provide a safe
and growth-promoting alternative for
the majority of these children.
J Pediatr 1999;134:614-22
• Infants (n = 170) with documented cow’s milk
allergy were randomly assigned to receive either a
soy formula or an extensively hydrolyzed formula.
• If it was suspected that the formula caused
symptoms, a double-blind, placebo-controlled
challenge (DBPCFC) with the formula was
performed.
• The children were followed to the age of 2 years,
and soy-specific IgE antibodies were measured at
the time of diagnosis and at the ages of 1 and 2
years.
• Conclusions: Soy formula was well
tolerated by most infants with IgE
associated and non–IgE-associated cow’s
milk allergy.
• Development of IgE-associated allergy to
soy was rare.
• Soy formula can be recommended as a
first-choice alternative for infants >6
months of age with cow’s milk allergy.
‫המלצת הועדה המקצועית של‬
‫משרד הבריאות‬
‫•‬
‫•‬
‫•‬
‫•‬
‫•‬
‫בהמלצות הועדה המקצועית מטעם משרד הבריאות‪ ,‬בראשות‬
‫פרופ‪ ′‬צבי ויצמן שסקרה את הנושא לעומקו הומלץ‪:‬‬
‫לעודד הנקה או שימוש בתרכובות חלב פרה באוכלוסיות‬
‫הצורכות תכשירי סויה מטעמי כשרות‪,‬‬
‫להגביר הסברה בנושא הנזקים האפשריים משימוש בתכשירי‬
‫סויה הן לציבור והן לכלל עובדי הרפואה (בעיקר רופאי ילדים‪,‬‬
‫רופאי משפחה‪ ,‬דיאטניות ואחיות בריאות הציבור)‪.‬‬
‫ביצוע מחקרים התערבותיים ארוכי טווח כדי לבחון את בטיחות‬
‫השימוש בתכשירי סויה בתינוקות ובילדים‬
‫ניטור רמות הטירוקסין בדם בתינוקות ובפעוטות עם תת‪-‬‬
‫פעילות של בלוטת התריס‪ ,‬הניזונים מתכשירים על בסיס סויה‪.‬‬
Lactose Free formulas
Background
• Although few infants are likely to manifest
lactose intolerance, the use of lactose-free
formulas has increased rapidly in the past
several years.
• Many parents prefer lactose-free formula,
apparently because they believe infants
tolerate it better than they do formulas
containing lactose.
Introduction
• Lactose is a disaccharide that is present in almost all
mammalian milks.
• It is digested in the small bowel by the lactase located
on the brush border of the enterocyte.
• On digestion, lactose is broken down into two
components, glucose and galactose.
• If lactose is not digested or is digested minimally, the
intact sugar moves into the large bowel where it is
fermented by enteric bacteria.
• This fermentation produces acids, carbon dioxide,
methane, and hydrogen, and usually results in
borborygmi and abdominal discomfort.
Introduction
• Lack of digestion of lactose results in an
increased number of solute particles in the
large bowel with a concomitant increase in
osmotic pressure.
• It has been suggested that the diarrhea
associated with lactose intolerance occurs
when the capacity of the bacteria to
metabolize carbohydrate in the colon has been
exceeded.
• Most of the people of the world are unable to
digest lactose in adult life.
Introduction
• In general, evidence for malabsorption of
lactose as a clinical problem is not manifest
until after 5 to 7 years of age, although this
age can be variable.
• Individuals can increase their tolerance to
dairy products by ingesting fermented
products such as yogurt, hard cheeses and
cottage cheese.
• Even children hypersensitive to CM are
clinically tolerant to lactose and can safely
consume foods and drugs with lactose from
bovine sources.
• Although reduction in intestinal brushborder lactase levels is often associated
with diarrhea, most infants with
decreased lactase levels will not have
clinical signs or symptoms of
malabsorption.
• Infants fed human milk can be nursed
safely during episodes of diarrhea
• Recently, a major comprehensive
report concluded that it is unwise to
discourage the use of milk in children
from a population with a high rate of
lactose malabsorption unless these
children are suffering from severe
diarrhea or show a definite intolerance
to milk or milk products.
American Academy of Pediatrics Committee on
Nutrition: Practical significance of lactose
intolerance in children: supplement. Pediatrics
1990; 86:643-644
• A meta-analysis was performed to
evaluate the use of lactosecontaining feedings in children with
diarrhea and concluded that 80% or
more of children with acute diarrhea
can tolerate full-strength milk safely
Brown KH, et al. Pediatrics 1994; 93(1):17-27
• Despite the lack of proven efficacy, lactose
free formula is also widely used in diarrheal
illnesses.
• The growth of infants fed lactose-free
formulas is comparable to that of infants fed
lactose-containing formulas
• Questions remain, however, regarding the
mineral bioavailability and optimal mineral
contents of these lactose-free formulas.
• The formula should not be used for
galactosemia patients !!!!!
So who should get the
formula ?
• It might be helpful in cases of
diarrhea among malnourished children
or among children with a severe
enteropathy
Hypoallergenic formulas
Background
• Hypoallergenic formulas are processed by
enzymatic hydrolysis of different protein
sources followed by further processing ( heat
treatment and/or ultrafiltration), or they are
based on amino acid mixtures.
• The products have been classified according
to the degree of protein hydrolysis as
extensively or partially hydrolysed protein
products
Background
• Only pure amino acid mixtures are
considered to be nonallergenic.
• Other hypoallergenic products contain
residual allergenicity.
• Hypoallergenic formulas for treatment
of cow’s milk protein allergy should be
tolerated by at least 90% of infants
with documented cow’s milk protein
allergy.
• Feeding high-risk infants hypoallergenic
formula combined with avoidance of solid foods
during the first 4–6 months reduces the
cumulative incidence of cow’s milk protein
allergy and atopic dermatitis as compared with
a standard cow’s-milk-based formula.
• Partially hydrolysed formulas may have an
effect, though it seems to be less than that of
extensively hydrolysed formulas at present.
Host A et al. Allergy 2004
• Thus, if exclusive breastfeeding for
4–6 months is not possible in highrisk infants, a documented
hypoallergenic formula and avoidance
of solid foods are recommended for
the first 4 months of life
• Solid foods should not be introduced
into the diet of high-risk infants
until 6 months of age, with dairy
products delayed until 1 year, eggs
until 2 years, and peanuts, nuts, and
fish until 3 years of age.
American Academy of Pediatrics.
Hypoallergenic infant formulas.
Pediatrics 2000
Cochrane review
• There is no evidence to support feeding with
a hydrolysed formula for the prevention of
allergy in preference to exclusive breast
feeding.
• In high risk infants who are unable to be
completely breast fed, there is evidence that
prolonged feeding with a hydrolysed
compared to a cow's milk formula reduces
infant and childhood allergy and infant CMA.
Osborn DA, Sinn J. Formulas containing hydrolysed
protein for prevention of allergy and food intolerance in
infants. Cochrane Database Syst Rev 2003
Indications
• Cow’s milk allergy mainly non IgE mediated
(for at least 6 months)
• Allergic disease prevention in high risk
infants ?
• Severe infantile colic
• Short bowel syndrome
• Intractable diarrhea
• Cholestatic liver disease (MCT enriched)
Introduction of solids
American Academy of Pediatrics
Recommendations for
Complementary Feeding
• Recommendations for complementary
feedings of infants and young children
have not varied significantly over the past
40 years.
• The American Academy of Pediatrics
recommends the introduction of solid
foods at 4 to 6 months of age
• recommends introducing single-ingredient
complementary foods one at a time for a
several day trial.
American Academy of Pediatrics
Recommendations for
Complementary Feeding
• The Academy cautions against the feeding
of hard, small particulate foods during the
first 2 to 3 years of life
• The guidelines suggest that fruit juice is
not a necessary part of an infant's diet
and that, in any event, fruit juice intake be
limited to 240cc per day after its initial
introduction at 6 months of age.
WHO/UNICEF Guidelines
on Complementary Feeding
• The optimal age of introduction of complementary
foods remains controversial.
• The appropriate time may represent a compromise
between 2 competing health issues.
• 1) if introduced too late when breast milk alone no
longer meets all the infant's energy and nutrient
needs, nutrient deficiencies and growth faltering may
occur.
• 2) On the other hand, because these foods are often
contaminated, premature introduction carries an
unnecessary risk of infection
WHO/UNICEF Guidelines
on Complementary Feeding
• A sizeable number of observational studies
and 2 randomized trials have failed to
identify any benefit of complementary
foods for infant growth before 6 months
of age, even in low birth weight term
infants.
• By contrast, several studies have
documented a twofold or greater risk of
enteric and other infections when these
foods are provided before 6 months.
WHO/UNICEF Guidelines
on Complementary Feeding
• the authors of the WHO/UNICEF
report concluded that the optimal
age of introduction of complementary
foods is about 6 months.
• Methods
• 9360 Infants were divided into three groups
based on the age at which they were first
introduced to `lumpy' solids: 10.7% were
introduced before 6 months of age, 71.7% were
introduced between 6 and 9 months and 17.6%
were introduced after 10 months of age.
• The foods eaten by those introduced before 6
months and after 10 months were compared to
those introduced between 6 and 9 months.
• Results
• At each age, those introduced late
(10 months or older) to lumps were
more difficult to feed and had more
definite likes and dislikes.
• The introduction of four or more
solid foods by or before 17 weeks
post-term was a significant risk
(odds ratio3.49) for the development
of eczema by 12 months post-term.
• Male infants were at significantly
higher risk (odds ratio 1.84).
Thank you
ESPGHAN committee of
nutrition 2004: probiotics
• there are only limited published data on
the safety and clinical efficacy of infant
formula supplemented with probiotics.
• There are indications for possible short
term benefits of some probiotic strains in
infants and young children, in particular
regarding infectious diarrhea.
• However, there is no published evidence on
long-term effects on intestinal colonization
and its potential effects on long term
gastrointestinal and immune functions
ESPGHAN committee of
nutrition 2004: probiotics
• Some data suggest that bacteria
ingested during early infancy are
more likely to permanently colonize
the intestine than those ingested
during later life.
ESPGHAN committee of
nutrition 2004: probiotics
• The Committee recommends that in adding
probiotics to dietetic products for infants,
only such bacterial strains should be used
for which identity and genetic stability has
been demonstrated.
• The content of viable bacteria in a dietetic
product must be of a dose shown to be
safe and effective with regard to defined
outcomes in clinical trials, throughout the
shelf-life of the product.
ESPGHAN committee of
nutrition 2004: probiotics
• The Committee is concerned that the
available data are not sufficient to support
the safety of probiotics in healthy newborn
and very-young infants with immature
defense systems, immunocompromized
infants, premature infants, and infants
with congenital heart disease.
• The Committee concludes that further
evaluation of safety and efficacy of the
addition of probiotic bacteria to dietetic
products to infants is necessary.