Transcript Pediatric Nutrition - University of Toronto

Pediatric Nutrition
The first two years
Joan Brennan
Clinical Dietitian
Early Recommendations
• Breastfeeding and Human Milk
• exclusive human milk feeding for first 4-6 months
of life
• breastfeeding may continue until two years of age
and beyond
• vitamin D supplementation of 400 IU to all human
milk fed infants from birth until diet provides a
source of vitamin D
Human Milk Feeding
• either by breast or as expressed human milk using manual
expression or pump and given by bottle/tube
• various pumps available
– manual vs. electric
– electric most efficient and effective – best one is rental from
pharmacy
• may take 7-10 days to establish breastfeeding
• frequent feedings will help establish milk supply
• number of wet diapers in a 24 hour period good indicator
of whether baby is getting enough
• supplemental formula may obstruct establishment
breastfeeding
Infant Formulas
• when an informed mother chooses not to breastfeed,
commercial infant formulas are the most acceptable
alternative to human milk
• nutrient content of iron-fortified infant formula is designed
to meet the nutritional needs of healthy term infants until
12 months of age
• composition, processing, packaging, labeling are regulated
under the Canadian Food and Drug Regulations
Infant Formula - Cow’s Milk
Based
• designed for most preterm infants > 2000g and healthy
term infants with no family history of allergy
• designed to resemble human milk in nutrient composition
and digestibility
• available low in iron or as iron-fortified
• iron-fortified recommended until 9-12 months of age and
consuming a variety of foods
• Eg Enfamil A+, Similac Advance
Infant Formula - Follow-up
• designed for infants in the second six months of life who
are eating solid foods
• more appropriate quantities and forms of nutrients
compared to cow’s milk
– lower renal solute load
– iron-fortified
• not superior to starter formulas
• eg Next Step, Follow-up
Infant Formula - Lactose-free,
cow’s milk based
• suitable for infants with lactose intolerance
– primary lactose intolerance due to congenital lactase
deficiency (rare)
– secondary due to acute gastroenteritis or chronic
conditions
• glucose polymers from corn syrup are substituted for the
lactose
• eg Enfalac Lactose-free
Infant Formula - Soy
• soy protein and glucose and/or sucrose have been
substituted for milk protein and lactose; only available
iron-fortified
• approximately 40 % of infants allergic to milk will also be
allergic to soy
• not suitable for use in children with a family history of
allergy
• suitable for infants with galactosemia or vegan lifestyle
Infant Formula - Protein
Hydrolysate
• Two types available in Canada
– less extensively hydrolyzed
• eg Good Start
• for use in infants at risk for atopy
– extensively hydrolyzed (casein-based)
• eg Nutramigen
• for infants at high risk for allergy to cow’s milk or
soy protein
Infant Formula - Specialized
• designed for infants with disorders of digestion, absorption
and/or metabolism of protein, fat or carbohydrate
• expensive, less palatable, for use under supervision of a
health care practitioner
• eg Pregestimil, Neocate, Alimentum, Portagen
Infant Formula - Distribution of
Energy
Nutrient
Human
Milk
Standard Whole
Formula Cow’s
Milk
Protein
6%
8–9%
20%
Fat
50%
45-50%
50%
CHO
40-45%
41-43%
30%
Transition to Cow’s Milk
• pasteurized whole cow’s milk may be introduced between
9-12 months of age and continued throughout the second
year of life
• partly skimmed milk (1% and 2%) is not routinely
recommended in the first 2 years of life
• skim milk is inappropriate in the first 2 years of life
Transition to Solid Foods
• infants between 4 and 6 months of age are physiologically
and developmentally ready for new foods, textures and
modes of feeding
• infants intestinal track is relatively permeable and may
predispose the infant to absorb foreign proteins resulting in
an allergic reaction
• introduction of single foods makes it easier to identify
allergen
Transition to Solid Foods
• single grains such as rice, barley and oat cereals offered
first before mixed cereals
• little nutritional or developmental benefit associated with
practice of adding infants cereals or other pureed foods to
bottles containing formula
• introducing solids should support developmental readiness
to progress from sucking to spoon feeding
Transition to Solid Foods
• critical learning period where texture should be introduced
(6-10 months) or it becomes more difficult with increasing
age
• important to encourage transition from pureed foods to
finger foods and table foods
• by 1 year, a variety of foods should be consumed with less
dependency on milk as major source of nutrition
Other Highlights
• iron-containing foods such as iron-fortified cereals are
recommended as the first foods
• fruit juice intake should be limited to avoid interfering with
the intake of nutrient containing foods and fluids
• soy (except soy formula), rice or other vegetarian
beverages, whether or not they are fortified, are
inappropriate alternatives to human milk, formula or
pasteurized whole cow’s milk in the first two years
Other Highlights
• dietary fat restriction during the first 2 years of life is not
recommended as it may compromise the intake of energy
and EFA and affect growth and development
• to prevent infant botulism, honey should not be used in
infants under 1 year
• to prevent nursing bottle syndrome, infants should not be
fed using a “propped” bottle
Gastroenteritis
• mild to moderate dehydration may be managed with an
oral electrolyte solution and early refeeding
• for infants who are breastfed, continue breastfeeding while
supplementing fluid intake with an oral electrolyte solution
• there is no justification to recommend a lactose free
formula for routine feeding after a bout of gastroenteritis
Constipation
• parents should be educated about the wide variation in
normal bowel function in infants and toddlers
• no evidence to support infants on iron-fortified formula are
more constipated
• often seen with transition to whole cow’s milk when done
too quickly
– transition with half formula/human milk feedings and
half whole cow’s milk minimizes complications