Introduction to Infant Nutrition

Introduction to Infant Nutrition

Basis
Goals and objectives
Policy development
History
Individual v.s. population

 The Basis for Feeding Recommendations

Growth in infancy
Physiology of infancy
GI
Renal

Infant Development
Nutrient requirements

The recommendations
Milk based feedings/Infant formulas
Timing of complementary foods
What are families actually doing?

Specific issues of safety and oral health

Basis
Typical growth and
changes in body
composition
Development
Metabolic
Physiologic
neurologic

Goals and Objectives

Optimal growth and development

Individual health
Population Health
Prevention and Chronic illness
Safety

Policy Making
Focus
target
prevalence
implication

Evidence
Cost v.s. Benefit
Stakeholders
Implementation/application
population
target group
individual

 Prevalence of
nutritional deficiencies
Prevalence of nutrient
related health issues
Significance of
nutrient related issue

United Nations 5th report on

World Nutrition: March 2004
Prevalence (%)

1990

2005

underweight

35.2

26.5

Iodine deficiency

35.2

WHO Health Statistics 2005

Preschool or <5 years of age
Undernutrition:

27% 1990
20% 2005
112 million children are underweight
Underlying cause of more than 1/3 child deaths

Vitamin A Deficiency
33.3% global prevalence

Anemia
47.4 % global prevalence

United Nations 5th report on

World Nutrition: March 2004
Vitamin A deficiency
140 million preschoolers
7 million pregnant women

Iron Deficiency
One of most prevalent
4-5 billion affected

Untreated Dental Caries

in 2-5 year olds
1971-1974 1988-1994

20012004

total

25

19.1

19.5

White

23.7

13.8

14.5

Black or African American

29

24.7

24.2

34.9

29.2

Mexican
< 100% poverty level

32

30.2

26.1

100-200% poverty level

29.9

24.3

25.4

>200% poverty level

17.8

9.4

12.1

 Reports in US of PEM, Rickets, Zinc

deficiencies
Vitamin D?
Obesity?

 Biology
Genetics, physiology,
Programming
adaptation

Behavior
Interaction between
individual and environment
Influenced by genetics,
neurophysiology, and
temperament

Adaptation
Interaction between
individual and environment
Influenced by genetics and
physiology

Factors to Consider
Nutrition - Disease
Access
Food
Health Care
Environment
Economics
Education

Infant Feeding: Historical

Perspective
Science, Medicine
and Industry
Breast feeding
Human Milk
Substitutes

Science, Medicine, and Industry

Growth of child
Health and
welfare in early
20th century

Human Milk Substitutes

Wet nurses
Other mammalian milk (cow, goat, donkey,
camel)
Pablum: bread/flour, mixed with water
bread, water, flour, sugar and castille soap to
aid digestion

Science, Medicine, and Industry

Infant Morbidity and
Mortality
Recognition of
association with human
milk substitutes, and
infection
Industrial development
Storage
Safety
Food industry

Historical timeline
1900
Pasteurization of milk
in US
Association between
bacteria and diarrhea
1912
U.S Childrens Bureau
Public Health and
Pediatricians efforts to
improve infant/child
health and decrease
mortality

1920
Intro evaporated milk
Cod liver oil prevents
rickets
Curd tension of milk
altered
Increased availability of
refrigeration
Vitamin C isolated
Vitamin D prepared in
pure form
Improved sanitation

History: MCHB Timeline

http://www.mchb.hrsa.gov/timeline/text-only.html
1855

1st childrens hospital in Philadelphia.

1860

1st Childrens Clinic. Recognition of pediatrics as distinct discipline through work of Dr. Abraham
Jacobi

1872

American Public Health Association established by Stephen Smith

1874

Case for Mary Ellen Wilson: trial based on laws against cruelty to animals. 1 st organized attempt to
prevent cruelty to children

1881

Movement toward abolition of child labor

1893

First Milk Stations

1907

1st Bureau of Child Hygiene: Liscensure of Midwives, Silver Nitrate to NB to prevent GC blindness, NB
formula with made from cows milk

1909

American Association for prevention of infant mortality. Tracking system

1914

Pamphlet on Infant Care> Result of Data on tracking of infant mortality. Addressed Hygiene and infant
feeding. Support of Breastfeeding

1924

Ricketts demonstration Grant> Dr. Martha Elliot. Community Health Center approach to prevention of
rickets

1930

Milk Fortification with Vitamin D to prevent Rickets

MCH PYRAMID
Direct Health Care
Services:
Health Services for
CSHCN
Enabling Services: Examples:
Transportation, Translation, Outreach,
Respite Care, Health Education, Family
Support Services, Case Management
POPULATION-BASED SERVICES
Examples: Newborn Screening, Lead Screening,
Immunization, Sudden Infant Death Syndrome
Counseling, Oral Health, Injury Prevention
Infrastructure Building Services:
Examples: Needs Assessment, Evaluation, Planning, Policy Development,
Coordination, Quality Assurance, Standards Development, Monitoring,
Training, Applied Research, Systems of Care, and Information Systems

Infant Formulas - History

Cows milk is high in protein, low in cho,
results in large initial curd formation in gut
if not heated before feeding
Early Formulas
from 1920-1950 majority of non-breastfed infants
received evaporated milk formulas boiled or
evaporated milk solved curd formation problems
cho provided by corn syrup or other cho to decrease
relative protein kcals

Human Milk Substitutes

1915 Gerstenberger developed
first complete infant formula
marketed as SMA (synthetic
milk adapted)
Base was defatted and diluted cows
milk with beef tallow added to mimic
the fat content of human milk

Soy Formulas
First developed in 1930s with soy flour
Early formulas produced diarrhea and
excessive gas
Now use soy protein isolate with added
methionine

1940s

Rickets (D)
Pellagra (Niacin)
Scurvy (C)
Beriberi (Thiamin)
Xeropthalmia (A)
Goiter (Iodine)

Infant Formula - History, cont.

50s and 60s commercial formulas replaced
home preparation
1959: iron fortification introduced, but in 1971
only 25% of infants were fed Fe fortified formula
Cows milk feedings started in middle of first
year between 1950-1970s. In 1970 almost 70%
of infants were receiving cows milk.

Formula Regulation
Regulation is by the Infant Formula Act of 1980,
under FDA authority
Nutrient composition guidelines for 29 nutrients
established by AAP Committee on Nutrition and
adopted as regs by FDA
Nutrient Requirements for Infant Formulas.
Federal Register 36, 23553-23556. 1985. 21
CFR Part 107.

Regulation of Infant Formulas

Infant Formula Act: The purpose of the infant formula act
(1980) is to ensure the safety and nutrition of infant
formulas including minimum and in some cases
maximum levels of specified nutrients. The act
authorizes the FDA to establish appropriate regulations
for 1) new formulas, 2) formulas entering the U.S.
market, 3) major changes, revisions, or substitutions of
macronutrients 4) formulas manufactured in new plants
or processing lines, 5) addition of new constituents 6)
use of new equipment or technology 7) packaging
changes

Regulation of Infant Formulas

Infant Formula Act:
Manufacturing regulations
Quality control
Non specific testing requirements, case by case basis,
growth outcomes

Recall Proceedures
Nutrient content and labeling
Panel convened 1998 and 2002 (recommended
revisions including exemptions)

Regulation of Infant Formula

FDA
Infant Formula Act
Manufacturers
Voluntary monitoring
AAP, National Academy of Sciences, other
professional organizations
Guidelines for composition and intake:
(e.g. DRIs)
Guidelines for preparation and handling
of formula/human milk in health care
facilities

Infant Feeding and later health

Epigenetics is
emerging as the
hidden link between
early life exposure
and late life events
Implications?
Prediction
Prevention
treatment

Infant Feeding Health,and Chronic

Illness
Microbiome and
intestinal health
Obesity
Allergy
Diabetes

Infant Feeding and Microbiome

Role of Intestinal
Microbiota on Health
and disease

Infant Feeding and Microbiome

Health

Growth of epithelial barrier

Nutrition: biotin, folate, vitamin K
Metabolic support
Promotion of immune function

Disease

NEC
Atopic and allergic disease
Obesity
Inflammatory bowel disease
Diarhea
Colitis
Transcription and translocation

Allergies: Areas of Recent

Interest
Early introduction of dietary allergens and
atopic response
atopy is allergic reaction/especially associated
with IgE antibody
examples: atopic dermatitis (eczema),
recurrent wheezing, food allergy, urticaria
(hives) , rhinitis

Prevention of adverse reactions in high

risk children

Allergies: Infancy
Increased risk of sensitization as antigens
penetrate mucosa, react with antibodies or
cells, provoking cellular response and
release of mediators
Immaturities that increase risk:
gastric acid, enzymes
microvillus membranes
lysosomal functions of mucosal cells
immune system, less sIgA in lumen

Allergies: Breastmilk
May be protective due to sIgA and
mucosal growth factors
Maternal avoidance diets in lactation
remain speculative. May be useful for
some highly motivated families with
attention to maternal nutrient adequacy.

Allergies: Breastmilk (Saarinen, 1995)

235 Helsinki infants born in 1995
Categorized by duration of breastfeeding,
> 6 months, 1-6 months, no or short
breastfeeding
Incidence of food and respiratory allergy
was greatest in short or no breastfeeding
group
Differences persisted at 17 years of age

Allergies: Prevention by
Avoidance (Marini, 1996)
359 infants with high atopic risk
279 in intervention group
Intervention: breastfeeding strongly
encouraged, no cows milk before one
year, no solids before 5/6 months, highly
allergenic foods avoided in infant and
lactating mother

Allergies: Prevention by
Avoidance (Marini, 1996)

Allergies: Early Introduction of

Foods
(Fergussson et al, Pediatrics, 1990)
10 year prospective study of 1265 children in NZ
Outcome = chronic eczema
Controlled for: family hx, HM, SES, ethnicity,
birth order
Rate of eczema with exposure to early solids
was 10% Vs 5% without exposure
Early exposure to antigens may lead to
inappropriate antibody formation in susceptible
children.

Allergies: Prevention by Avoidance

(Zeigler, Pediatr Allergy Immunol. 1994)

Definite or Probable Food Allergy

Age

Intervention Control

12 mo

5%

16%

0.007

24 mo

7%

20%

0.005

48 mo

4%

6%

ns

Early Introduction of Foods

(Fergussson et al, Pediatrics, 1990)

Proportional Hazard Coefficient (p<0.01)

For Risk of Chronic Eczema

No solid Food before 1.00

4 months
1-3 types of food
before 4 months

1.69

4+ types of foods
before 4 months

2.87

Allergies: Prevention by
Avoidance (Zeigler, Pediatr Allergy Immunol. 1994)
High risk infants from atopic families,
intervention group n=103, control n=185
Restricted diet in pregnancy, lactation,
Nutramagen when weaned, delayed solids
for 6 months, avoided highly allergenic
foods
Results: reduced age of onset of allergies

Allergies: IDDM
Theory: sensitization and development of
immune memory to food allergens may
contribute to pathogenesis of IDDM in
genetically susceptible individuals.
Milk, wheat, soy have been implicated.
Breastfeeding and delay in non-milk feedings
may be beneficial.
There is little firm evidence of the significance of
nutritional factors in the etiology of type 1
diabetes. (Virtanen SM, Knip M. Am J Clin Nutr , 2003)

Cows milk protein avoidance and development of

childhood wheeze in children with a family history of atopy
(Cochrane, 2003)

Breast-milk should remain the feed of choice for

all babies.
In infants with at least one first degree relative
with atopy, hydrolysed formula for a minimum of
four months combined with dietary restrictions
and environment measures may reduce the risk
of developing asthma or wheeze in the first year
of life.
There is insufficient evidence to suggest that
soya-based milk formula has any benefit.

Soy formula for prevention of allergy and

food intolerance in infants (Cochrane, 2006)
Feeding with a soy formula cannot be
recommended for prevention of allergy or food
intolerance in infants at high risk of allergy or
food intolerance. Further research may be
warranted to determine the role of soy formulas
for prevention of allergy or food intolerance in
infants unable to be breast fed with a strong
family history of allergy or cow's milk protein
intolerance.

Formulas containing hydrolysed protein for

prevention of allergy and food intolerance in
infants (2006)
There is no evidence to support feeding with a
hydrolysed formula for the prevention of allergy
compared to exclusive breast feeding. In high risk infants
who are unable to be completely breast fed, there is
limited evidence that prolonged feeding with a
hydrolysed formula compared to a cow's milk formula
reduces infant and childhood allergy and infant cows
milk allergy. In view of methodological concerns and
inconsistency of findings, further large, well designed
trials comparing formulas containing partially hydrolysed
whey, or extensively hydrolysed casein to cow's milk
formulas are needed.

Infant Feeding and Risk of Obesity

Christopher G. Owen et al: Effect of Infant Feeding on the Risk of

Obesity Across the Life Course: A Quantitative Review of Published
Evidence. Pediatrics 2005;115:1367-1377
Meta analysis
28 studies includes (298,900 subjects)
Breastfeeding was associated with reduced incidence of obesity
(OR 0.87, 95% CI 0.33-0.55)
Conclusion: Initial breastfeeding protects against obesity in later
life. However, a further review including large unpublished studies
exploring the effect of confounding factors in more detail is needed.

Breastfeeding in Developed countries: Ip S. et al Evid Rep

Technol Assess 2007 Apr 153:1-186

Reduced risk of
Otitis media, gastroenteritis, lower respiratory
tract infection, atopic dermatitis, asthma,
obesity, type 1 and 2 diabetes, childhood
leukemia, SIDS, and NEC

No or questionable effect on
Cognitive performance, cardiovascular
disease, infant mortality

Breastfeeding and type 2 diabetes

Christopher G. Owen et al: Does breastfeeding influence risk of type

2 diabetes in later life? Am J Clin Nutr 2006:84: 1043-54

Design: Systematic review identified 23 out of 1010 publications

examining relationship between infant feeding and Type 2 diabetes
in later life
Subects who were breastfed had a lower risk of type 2 diabetes
than formula fed infants (7 studies, N- 76,744 ) (OR 0.61, 95%
CI:0.44, 0.85, P=0.003)

Jacknowitz et al
Program participants were less likely to
adhere to AAP recommendations for

Exclusive breastfeeding to 4 months (5.9% decrease

Exclusive breastfeeding >6 months (1.9 % decrease)
Delaying introduction of formula to 6 months (8.5% decrease)
Delay introduction of solids to > 4 months (4.5 decrease

Program participants were more likely to

adhere to AAP recommendations for
Delay introduction of cows milk to 8 months (2.5 % increase)

Ip S et al
A history of breastfeeding is associated with a reduced
risk of many diseases in infants and mothers from
developed countries. Because almost all data in this
review were cathered from observational studies, one
should not infer causality based on these findings. Also,
there is a wide range of quality of the body of evidence
across different health outcomes. For future studies,
clear subject selection criteria and definition of exclusive
breastfeeding, reliable collection of feeding data,
controlling for important confounders including childspecific factors, and blinded assessment of outcomes,
will help..

Population v.s. individual

Population vs individual

AAP Guidelines
DRIs
Bright Futures
Start Healthy Feeding
Guidelines

Bright Futures
AAP/HRSA/MCHB
http://www.brightfutures.org
Bright Futures is a practical development
approach to providing health supervision
for children of all ages from birth through
adolescence.

Recommendations/guidelines

DRI: Dietary Reference Intakes

AI
UL
EER

AAP
Bright Futures
Start Healthy feeding guidelines

 DRI: Dietary
Reference Intakes
periodically revised
recommendations (or
guidelines) of the
National Academy of
Sciences
quantitative estimates
of nutrient intakes for
planning and assessing
diets for healthy people

AI: Adequate Intake

UL: Tolerable Upper
Intake Level
EER: Estimated
Energy Requirement

Infant Feeding Practices Study

II
Fein, Sara B. et al Pediatrics Vol 122
October 2008 (Supplement)
Data from nationally distributed consumer
opinion panel of 500000 households
Mothers of healthy term and late preterm
infants
N= 4902 pregnant women, ~2000 continued
through infants first year

Infant Feeding Practices Study

II
83% of survey respondents initiated
breastfeeding
Declined to 50% at 6 months and 24% at
12 months
52% of breastfed infants received some
formula in the hospital
40% received infant cereal at 4 months

Infant Feeding Practices Study

II
Majority of formula feeding mothers did not
receive instruction on formula preparation or
storage from a health professional (73-77%)
30% did not read safe use instrcutions on
package label
55% did not wash hands before bottle prep, 32%
did not wash bottle nipples between use, 35%
heated bottles in microwave, and 6% did not
always discard formula left standing > 2 hours

Infant Feeding Practices Study

II
At 6 months of age 18% of term breastfed
and mixed fed infants had not received
infant cereal or meat in the previous 7
days. 58% received <2 daily servings and
did not receive oral supplements >3X per
week

Breastfeeding rates in the US

Year

19931994

Rate 60
(%)

19951996

19971998

19992000

20012002

20032004

20052006

60

64

67

67

70

77

Special Supplemental Nutrition Program for Women,

Infants, and Children, and Infant Feeding Practices
Jacknowitz Alison et al Pediatrics 119:2, February 2007

Association between participation in WIC and adherence

to 4 AAP recommendations for infant feeding

Exclusive breastfeeding to 6 months

Iron fortified formula
Introduction of solid food 4-6 months
Cows milk > 12 months

Population v.s. individual

Nutrition Services: Stepwise Approach

Screening
Assessment
Intervention
Monitor
Reassessment

Screening: Definition
Process of identifying characteristics
known to be associated with nutrition
problems
ASPEN, Nutri in Clin Practice 1996
(5):217-228
Simplest level of nutritional care (level 1)
Baer et al, J Am Diet Assoc 1997 (10)
S2:107-115

Screening Risks
Weight less than 5th %ile
Weight greater than 90th %ile
Improper or inappropriate food/formula
choices or preparation
Bottle in bed

Assessment
Screening identifies nutritional risk
Nutrition Assessment
Uses information gathered in screening
Adds more in depth, comprehensive data
Interprets data
Develops care plan
Reassess

Goals of Nutrition Assessment

To collect information necessary to
document adequacy of nutritional status or
identify deficits
To develop a nutritional care plan that is
realistic and within family context
To establish an appropriate plan for
monitoring and/or reassessment

Comprehensive Nutrition Assessment

Collection of Nutritional data

interpretation of data
individualized intervention
monitoring outcomes of intervention

Information

Growth
Dietary
Medical history
Feeding and developmental information
psychosocial and environmental
information
Other (anthropometrics, laboratory )

NCP: Nutrition Care Process

Provides a framework for critical thinking
4 Steps
Assessment
Diagnosis
Intervention
Monitoring/Evaluation

NCP
Assessment
Obtain, verify, interpret information
Data used might vary according to setting,
individual case etc
Questions to ask
Is there a problem?
Define the problem?
Is more information needed?

NCP
Diagnosis
Identification or labling of problem that is
within RD practice to treat
Examples:
Inadequate intake
Inadequate growth

NCP:
Diagnosis written as a PES statement
Problem/Etiology/Signs and symptoms
Must be clear and concise. 1 problem
one etiology

NCP: PES Statement

inadequate growth secondary to
inadequate intake as evidenced by
decreased weight from 25th to 5th
percentile.
Why inadequate intake?

NCP:PES statement
Inadequate intake secondary to poor
feeding as evidenced by (? Energy intake
estimated from food record as.or weight
decrease from 25th percentile)
Why poor feeding?
What if has higher energy needs?

NCP:PES statement
Inadequate growth secondary to
inadequate intake due to poor feeding and
altered needs associated with RDS as
evidenced by energy intake of .. and
weight gain less than 20 grams per day.

NCP
Intervention
Etiology drives the intervention

Monitoring and Evaluation

Interpretation
Comparison with
references
established for
children without
special health care
needs

Interpretation
Information
Goals
Expectations
References
Evidenc

Process
The process of nutrition
assessment involves linking
information collected with
goals/expectations/evidenc
e to identify and define
problem, determine
intervention, and establish
plan for follow-up

Carl

Born at Term
Birthweight: 1.8 kg
SGA
Healthy
At 10 months of age weight was 7.8 kg (<
3rd percentile and length was 69 cm (510th percentile)

Carl

Carl
At 10 months is greater than 4x
birthweight
Currently gaining 12-15 g/d
reported to be healthy
reported to like eating
transitioning to solids and table foods
Breastfeeding and transitioning to cup