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INFANT NUTRITION

Sinad Feehan
Department of Nutrition & Dietetics A.M.N.C.H.
August 2009

Overview

Assessing growth
Requirements
Breastfeeding
Formula Feeding
Introducing Solid Foods
Iron & Vitamin D

Normal Growth: Weight

Normal birth weight 3.5kg


Regain birth weight by 2 weeks
Expected gain

200g per week for 1st 3 months


150g per week for 2nd 3 months
100g per week for 3rd 3 months
50-75g per week for 4th 3 months

NB standardisation of measurements

Normal Growth : Length

Normal birth length 50cm


Expected growth

1st year 25cm


2nd year 12cm
3rd year onwards 10-6cm per year
until puberty

Supine length until age 2

Normal Growth: OFC

Normal head circ at birth 35cm


>0.5cm per week (48cm by 1 yr)
Reflects brain growth
Above eyes, upright, looking
straight ahead

Centile Charts

Various charts available


Calculate age in weeks
<37/40: correct until 2 years
Weight at 4-8 weeks predictive
View growth in relation to normal
population

Reference Nutrient
Intakes
Age
(months)

Weight Fluid
(kg)
(mls)

Energy
(kcals/kg)

Protein
(g/kg)

0-3

4.4

150

115 110

2.8

4-6

7.2

130

95

1.8

7-9

9.0

120

95

1.5

10 12

10.0

110

95

1.5

WHO RECOMMENDATION

Exclusively Breastfeed for 6 months


Continue to breastfeed after that,
in combination with appropriate
complementary foods, until the age
of 2 years or beyond
WHO guidelines have
been accepted and
endorsed by the DOHC

Breastfeeding Benefits

Immunological:
Breastfed babies are at lower risk of
infection.
Nutritional:
Easy to digest, optimal blend of nutrients,
low risk of contamination.
Psycho/social:
Bonding, pain relief, maternal confidence &
empowerment.
Financial:
Milk is always available: shorter hospital
stay.

Benefits

Optimal nutrition for human infant

Correct nutrient composition macro/micronutrients

Nutritionally complete until 6 mths

Immunological advantages

Macrophages: lysozymes and lactoferrin

Lymphocytes: interferon and IgA

Bifidus factor

Antibodies

Anti-trypsin factor

Possible Contraindications

Medications

IV Drug Abuse

HIV

Galactosaemia, Alactasia

Note: Very low birth weight/premature,


can be
fed expressed breast milk

Colostrum

Protein rich Arginine & Tryptophan

Essential fatty acids

Vitamins

Frequent suckling increases hormone


production (Prolactin & Oxytocin) which
increases milk production

(A, D & B12)

and minerals

Mature Breast Milk

Fore milk & hind milk

Less protein, more fat and energy

Antibodies & anti-infective agents

Digestive enzymes lipase and amylase

Vitamins, minerals and trace elements

High bioavailability of nutrients

67 -70 kcals/100mls

Formula Feeding

Approved formulae nutritionally complete

No immunological/enzymic properties

Cows milk based, modified to mimic the


nutrient profile of mature breast milk

Provide 65-69 Kcals / 100mls

Demand feed: 150 200mls/kg/day

I n f a n t F o r m u la
W hey Based

C a s e in B a s e d

Standard Products

Whey based/ first milks

Cow & Gate First Infant Milk


Farleys First Milk
Milupa Aptamil First Infant Milk
SMA First Infant Milk

Caesin based/ milk for hungrier babies

Cow & Gate Second Infant Milk


Farleys Second Milk
Milupa Aptamil Extra Hungry
SMA Extra Hungry

Follow-on Formulae

Follow-on milks
Cow & Gate Follow-on Milk
Farleys Follow-on Milk
Milupa Aptamil Follow-on Milk

SMA Follow-on Milk

Marketed for babies > 6 months


Higher Energy, Iron & Vitamin D than
term formulae

Specialised Formula (Non-Px)

Anti-regurgitation Formula

Enfamil AR
SMA Staydown

Not effective with ant-acid medications

Lactose-free Formula

Enfamil 0-Lac
SMA LF

Glucose syrup instead of lactose


Lactose intolerance usually transient - avoid
prolonged use

Special Formula (Non-Px)

Soya milks

Farleys Soya Formula


SMA Wysoy

Lower biological value


Limited clinical indications Galactosaemia
Not indicated in colic, lactose intolerance,
CMPI
Contra-indicated under 6 months (BDA)

Prescribable Specialised
Formulae

Nutrient dense

Hydrolysed

Neocate

LBW/ Premature

Pepti-Junior, Pepdite, Nutramigen 1 and 2, Pregestimil,


Nutrilon Pepti, Prejomin, MCT Pepdite

Elemental

SMA High Energy, Infatrini

Nutriprem 1 and 2, SMA Gold Prem, BM Fortifier

Disease specific

Caprilon, Kindergen, Galactomin 17 and 19, Monogen,


Locasol

Volumes

Feed on demand
Initially small frequent feeds
Volumes increase, frequency decreases

Example
4 week old infant weighing 4.3kg
Fluid requirement 150mls/kg = 645mls/day
80mls 3 hourly x 8 or
95mls 3.5 hourly x 7 or
110mls 4 hourly x 6
All suitable, baby dictates, dont restrict hungry
baby

Formulae :
Possible Problems

Over-concentration

Hypernatraemia and dehydration

Inappropriate calorie density

Over-dilution

Excess volume

Vomiting and hyponatraemia

FTT and malnutrition

Hygiene
Safefood: How to prepare your babys bottle
feed

Weaning

Solid food should be introduced at 6 mths


? Not before 4 months:
-milk meets all nutrient requirements
-immature GIT & limited renal capacity
-Poor neuromuscular co-ordination

? by 6 months:
-increasing energy & nutrient needs
-decreased body stores : Fe & Zn
-aids chewing & speech development
-food refusal less likely

Weaning contd

First foods (6mths):


- puree fruit, veg, rice/ gluten-free cereals

- puree meat/chicken/fish
- offer variety of tastes & textures

Next foods:
-introduce wheat, gluten, eggs*,citrus fruit

-dont add salt or sugar


-more lumpier/mashed consistency
-introduce finger foods
- include iron-rich foods

Weaning contd

Cows milk not as drink before 1 year


Potential allergens

Gluten

No evidence to delay introduction


Eggs well cooked after 6 months
Nuts avoid whole until 5 years; fhx avoid for 3 years
Currently > 6 months
Literature 4 7 months, gradual intro while BF

Vegetarian

Ensure 500mls of BM/ formula

Not recommended

Vegan

Suitable Drinks

Breast milk / formula & water only

Unmodified cows, goats, sheeps milk unsuitable


Juice not required but not before 6 mths and not in
quantities > 120-180mls per day. Offer diluted.

Tea, aerated drinks, mineral waters, coffee :


unsuitable

No additions to bottles

Encourage cup from 6 months

Discourage bottle from 1 year

NB dental care

Current Practices:
Tarrant et al 2006

23% of infants weaned to solids <12 weeks


9% <10 weeks
10% at 6 months crisps/choc/biscuits
>4/week
6% add solids to bottles
31% add gravy to weaning foods
16% add sugar to weaning foods
5% add salt to weaning foods

Current Practices:
Tarrant et al 2006 (contd.)

4% have tea/lemonade/cola at 6 months


2% have these drinks regularly
6% have >180ml juice per day at 6
months
4% have sugar water as a drink at 6
months
20% mothers avoid meat in weaning
diets

By 1 year.

Eat family meals


Wide range of textures and tastes
Approx 1 pint cows milk per day
Drinking from cup not bottle

Common feeding
problems

FALTERING GROWTH

IRON DEFICIENCY ANAEMIA

VITAMIN D DEFICIENCY & RICKETTS

Faltering Growth

Downward deviation in weight across 2 or


more centiles from the max centile achieved
at 4-8 weeks for a period of a month or more

Possible Causes:
-inadequate dietary intake
-malabsorption/excessive losses
-increased nutrient requirements
-inability to utilise nutrients, e.g. metabolic
conditions
-psychological problems, e.g. poor parenting skills

Faltering Growth :
Management

Increase feed volume, if


inadequate
Consider Nasogastric feeding
Supplement feeds to increase
energy density
Aim For: 130 - 150 Kcals/Kg

3 - 4.5g protein/Kg

Iron Deficiency
Anaemia
Definition: Hb < 11g/dl, Ferritin < 10microg
Symptoms include - apathy, poor appetite,
poor growth, psychomotor delay
Possible causes are prematurity and
inadequate weaning diet
Inhibitors of iron are tannins, phytic acid,
phosphoproteins
Prevention = Breast milk/Fe fortified formula
Weaning foods rich in haem iron
Adequate vitamin C

Vitamin D

Re-emergance of rickets
Low vitamin D levels in normal population
Risk factors

Latitude, lack of sunlight exposure


Pigmented skin
Poor maternal status
Prolonged breastfeeding, poor weaning diets

FSAI recommend 5g daily for all infants


Await policy.

Infant Nutrition

Breast/Formula feed up to One year


old
Introduce solids from 6 months
Include iron-rich foods in weaning diet
Offer variety of tastes & textures
Encourage drinking from a cup from
6-8 months

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