NASPGHAN Slide Set - Infant Nutrition - For Residents (1)(1)_0.ppt

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1. 2013
Resident Education Series
Infant Nutrition
Ala K. Shaikhkhali, MD
Maria Mascarenhas, MD
The Children’s Hospital of Philadelphia
Reviewed by Sandeep Gupta, MD of the Professional Education Committee

2. Objectives
•Normal growth patterns in infancy
•Nutritional requirements of healthy term
infants
*
–Macronutrients
–Micronutrients
•Benefits of human-milk
•Practical guidelines for complementary feeding
•Summary

3. Case Presentation
•A mother brings in her 2 month old healthy term
infant who is exclusively breast fed for a well visit
How would you answer these nutritional questions:
Can she eat cereal now?
Mom heard that human-milk has less iron than
formula, should the baby be on an iron
supplement?
What about other supplements?
How fast should she be growing?
When will she double, triple her birth weight?

4. GROWTH PATTERNS IN INFANCY

5. Growth Patterns in Infancy
•The first year of life is a period of very rapid growth
- Healthy 1 month old gains~ 1 cm/week and 20-30 g/day
- By 12 months of age gains 0.5 cm/week and 10 g/day
•Average newborn weight is 3.5 kg, weight is
doubled by 4-6 months and tripled by 12 months
•Nutrition during infancy can influence risk factors
for disease in adult life
Fun Fact: If a person who was born 8 lbs. and 20 in. at birth
continued growing at the same rate as he does the first year, by
the time he reached 20, he’d be 25 ft. tall and weigh nearly 315
lbs!

6. Growth Charts
•April 2006 WHO international growth charts**
–Growth standard – describe growth of healthy children in optimal
conditions (e.g. exclusive breastfeeding for 4 mo, continued to 12
mo)
–Includes children 0-20 yrs
–AAP recommends using WHO growth charts between 0-24 mo
•May 2000 Chronic Disease Prevention and Health Promotion
and Center for Disease Control*
–Growth reference –how children grew in a particular place and time
–Includes children 0 to 20 years of age
–AAP recommend susing CDC growth charts between 2 and 20 yrs
•Both growth charts include
–Weight, length/height, head circumference, body mass index for age
Normal growth reflects nutritional status and overall
wellbeing; poor growth is always a cause for concern
and should be evaluated promptly

7. Development of Feeding Abilities
•Neonates have instinctive
sucking reflexes
•Things touching the infant’s
palate (nipple or finger) will
trigger the sucking reflex
•At one year, infants can
chew soft foods and
swallow easily
WHO recommends exclusive breast feeding for children
until 6 months of age, followed by introduction of soft
complementary foods with continued breast feeding

8. Development of Renal Capacity
•Early in infancy, high protein load will cause renal
overload and osmotic diuresis leading to dehydration
•The kidneys of a healthy term infant can excrete urea,
sodium, and other solutes load that is present in
human-milk or infant formula
Renal Solute Load per 100 kcal
human-milk 14 mOsm
Infant formula 20 mOsm
Cow’s milk 46 mOsm

9. Summary
•The first year of life is a period of very rapid growth
•Suboptimal growth is always a cause of concern
•Infants have limited gastrointestinal and renal capacities
•human-milk or iron-fortified formula should be the sole
source of nutrition during the first 4-6 months of life
•Physiological changes in the gut enable the infant to
progress from digesting only milk to digesting complex
foods by one year

10. BREAST FEEDING
AND
INFANT FORMULA

11. Breast Feeding
• AAP recommends human-milk as the feeding of choice for infants
whenever possible*
•Successful breast feeding require a supportive environment for the
mother
•Nutrient needs of term infants from birth to 6 months of age are met
with human-milk as a source of exclusive nutrition (with few
exceptions)**
•Success of breast feeding is demonstrated when infant has feedings
8-12 times per day, at least 6-8 wet diapers, regular stools, and
growth along established growth curves
•On average human-milk provides 20 calories/oz

12. human-milk vs. Infant Formula
•Benefits of breast feeding over infant
formula are well established:
–Enhanced motility and maturity of the GI tract
–Maternal infant bonding
–Monetary saving
–Facilitated fat, protein, and carbohydrate digestion and
absorption
–Passive immunity
–Improved cognitive development
–Decreased incidence of respiratory and GI disease
–Further potential benefits are decreased risk of overweight,
cardiovascular disease, and ? Type I DM

13. Infant Formula
•When human-milk is not available, iron fortified infant formula
is the appropriate alternative
•There are continued efforts to evolve infant formula to be
closer to composition of human-milk
•Addition of DHA and ARA* is a recent example
–Multiple studies in term and preterm infants showed significantly
lower levels of DHA and ARA in RBC of infants who are formula
fed
–Some studies suggested short term improvement in vision and
cognitive functions

14. Nutritional Requirements of
Healthy Term Infants
• Nutrient requirements for first 6 months are based on
composition of human-milk
• From 6 months to one year of age, RDA assume the
composition of infant formula and increasing amounts of solid
food

15. Macronutrients
• Energy
• Fluid
• Carbohydrate
• Fat
• Protein

16. Energy Requirements
•Expressed per unit of body weight, estimated energy
requirements of a normal newborn is more than a normal
adult
–80-110 kcal/kg/day vs. 20-35 kcal/kg/day in adults
–Reflection of higher metabolic rate and energy needs for
growth and development
•Studies show that infants consume markedly higher
energy intakes during the early months of life
–Data also show that formula-fed infants consume more
energy than breast-fed infants*
–Gender differences are small but consistently present

17. Fluid Requirements
•Necessary to replace losses (skin, lungs,
feces, and urine) and for growth
•human-milk and infant formula
*
provide ~
89 ml of water in each 100 ml
•Fluid needs:
–1 to 10 kg: 100 mL/kg/day

18. Carbohydrates
•Comprise 35 to 65% of total energy intake of term infants
•Usually as disaccharides or glucose polymers
•Glucose is the principal nutrient the neonatal brain
utilizes
•Inadequate carbohydrate intake can lead to
hypoglycemia, ketosis, and excessive protein catabolism

19. Fat
• American Academy of Pediatrics recommends 30-55%
of total energy be from fat and 2.7% be of linoleic acid
–Adults should consume ~20-35% of energy
from fat
•Fat serves many roles:
–A concentrated source of energy
–Carries fat- soluble vitamins
–Provides essential fatty acids
–Important for brain and organ growth
•Essential fatty acids are precursors for synthesis of
prostaglandins and have other essential functions

20. Protein
•AAP recommends that 7-16% of total energy be from protein
or 1.6-2.2 g/kg/day
•Protein provides nitrogen and amino acids
–Synthesis of tissues, enzymes, hormones, and
antibodies that regulate and perform physiologic
and metabolic functions
•Excess dietary proteins are metabolized for energy
–Producing urea that increases the renal solute
load, water requirements, and the risk of
dehydration
•Healthy term infants may grow well with a protein intake (from
human-milk) slightly below 1.6 g/kg/day

21. Protein
•Protein in most commercial infant formulas
typically comes from cow milk
–Cow’s milk based infant formula whey/casein
ration of 20:80
–human-milk whey/casein ration is ~70:30
–Some recently developed formulas have a ratio
60:40
•The curd formed from whey in an acidic
stomach is soft, easily digestible, and
emptied quickly

22. Protein
•Other protein sources in infant formula
include
–Soy protein
–Protein hydrolysates
–Free amino acid formulas are also available
for infants with cow’s milk protein allergy who
are unable to tolerate protein hydrolysates

23. Micronutrients
•In this section, we will discuss select
vitamins and minerals that are pertinent to
infant nutrition in board review related
conditions
•Others are beyond the scope of this talk

24. Iron
•Unless mother has iron deficiency, term infants are
usually born with iron stores enough for the first 6
months
•human-milk contains less iron than formula, but that iron
is more bioavailable- so breast fed infants should not
need iron supplementation routinely
•After the age of six months, iron content in human-milk is
no longer enough and complementary foods should
include iron (fortified cereal, meat)

25. Vitamin D
•Human-milk vitamin D content is low, breast fed infants
should receive vitamin D supplementation at 400 IU daily
•Formula fed infants who receive a minimum of 1000 ml
daily do not need vitamin D supplementation
•Risk factors for vitamin D deficiency: dark skin color,
maternal vitamin D deficiency, and recommended lack of
direct sun exposure <6 months of age
•Vitamin D deficiency can result in metabolic
abnormalities and rickets

26. Fluoride
•From birth to 6 months, infants need very little fluoride
and are at risk of fluorosis with excessive intake
•Human-milk contains very little fluoride and there is no
risk of fluorosis
•In formula fed infants, it is recommended to use ready to
feed formula or water with low mineral content (purified,
distilled, etc)
•Infants above 6 months of age should receive fluoride
supplementation only if they live in areas with non-
fluoridated water

27. Folate/Vitamin B12 & Vitamin K
•Infants of vegan mothers who are breast fed should be
monitored for vitamin B12 deficiency
•Folate deficiency is a risk in infants receiving large
amounts of goat milk or powdered milk
•The sterile digestive tract of newborn infants does not
contain vitamin K-producing bacteria and they require a
dose of vitamin K at birth
• A newborn has a limited capacity for nutrient
interconversion, which makes some nutrients
conditionally essential

28. Complementary Feeding
•Complementary food provides micronutrients that infants
beyond 6 months of age need
•Assess physical and psychological readiness for adding food
•Introduce one new food every three days
•Rice cereal is often introduced as the first feeding
•Introducing meat early provides a rich source of iron and zinc
•Repeated exposure may be necessary before acceptance

29. Complementary Feeding
•By 9 months can add finely chopped and
finger foods
•12 months infants can chew and progress
to table food
•Avoid choking hazards*
•Frequency of meals
–6-8 months: two-three daily
–9-12 months: three-four daily
–One or two snacks be added
•Juice is not a necessary component of diet
and should be limited

30. Summary
•Breastfeeding is the normal and by far the
preferred method of feeding infants
•Exclusive breastfeeding is recommended for the
first 6 months of life
•Supplemental vitamin D is recommended for
breastfed infants (400 IU daily)
•When a mother is unable to breastfeed, iron
fortified infant formula is the only acceptable
alternative
•First complementary foods should be iron-rich.
•Routine growth monitoring is important to assess
infant health and nutrition

31. Back to Our Case
A mother brings in her 2 month old healthy term infant
who is being exclusively breast fed for a well visit
How would you answer these nutritional questions:
Can she eat cereal now?
Mom heard that human-milk has less iron than
formula, should the baby be on an iron
supplement?
What about other supplements?
How fast should she be growing?
When will she double, triple her birth weight?

32. References
•AAP Pediatric Nutrition Handbook
•Conn’s Current Therapy
•Nutrition in Medicine http://www.nutritioninmedicine.net/portal/
•Heinberger Handbook of Clinical Nutrition
•Use of World Health Organization and CDC Growth Charts for
Children Aged 0--59 Months in the United States
•FROM THE AMERICAN ACADEMY OF PEDIATRICS Prevention of
Rickets and Vitamin D Deficiency in Infants, Children, and
Adolescents
•Nutrition for Healthy Term Infants: Recommendations from Birth to
Six Months A joint statement of Health Canada, Canadian Pediatric
Society