Infant Feeds

Question 1

Why is Nutrition Important?

Answer 1

• Fundamental aspect of life
• First 1000 days of life – provide best start to life
• Growth not just about increasing size but change in brain and body structure, composition and function
• Good nutrition prevents disease

Question 2

what are the recognised phases of childhood?

Answer 2

• Neonate (<4w)
• Infant (<12m/1y)
• Toddler (~1-2y)
• Pre-school (~2-5y)
• School age
• Teenager/ Adolescent

Question 3

Phases of Growth:

• Infant – _________ led
• Child – _______ _________ led
• Pubertal – ___ ________ led

Answer 3

nutrition

growth hormone

sex steroid

Question 4

Birth size and weight depends on what things?

Answer 4

• Maternal size (Small mother wouldn’t really have a really big baby)
• Placental function (Problem with placenta function in utero = not as big as a baby)
• Gestation (preterm = smaller)
• More than genetic make up
• Average term infant 3.3 kg

Mother diabetic = bigger baby born

Question 5

Nutritional Requirements - why?

Answer 5

• Energy is needed for: Physical activity, Thermogenesis, Tissue maintenance (repair of any damage), Growth
• Energy requirement = energy expended + energy deposited in new tissue
• Growth demands - about 35% of energy intake in infants but falls for rest of childhood

Question 6

Infant Nutrition:

•Characteristic feature is the need to fuel both rapid growth and maintenance

what risks are there?

Answer 6

Infants can rapidly become malnourished.

Dependent on carer

High demands for growth and maintenance

• infants 100kcal and 2g protein/kg/day
• adults 35kcal and 1g protein/kg/day

Low stores (Fat and protein)

Frequent illness (if unwell then they don’t want to feed and can then lose weight and can impact on growth)

Question 7

what is average weight gain?

Answer 7

• 0-3months 200g
• 3-6 months 150g
• 6-9 months 100g
• 9-12 months 75-50g
• Double weight by 6 months and triple by 1 year
• After 1 year approx 2kg and 5cm/year until puberty
• 4kg baby with 4 weeks of static weight ,20% underweight, like an adult losing 20kg.

Growth charts, plot and interpret

Question 8

Why is Breast best?

Answer 8

•Nutritionally complete feed for full term babies

• Well tolerated
• Less allergenic
• Low renal solute load
• Ca:PO4, Iron, LCP FAs
• Improves cognitive development
• Reduces risk of infection

Best nutrition

Question 9

Breast milk vs. Formula

Answer 9

Question 10

what age should breastfeeding be done?

Answer 10

• Recommended to exclusively breast feed to around 6 months of age
• From 6 months, complementary breast feeding alongside solids is supported

Question 11

If Breast Feeding is not possible what should be done?

Answer 11

• Families who formula feed should be supported to do so as safely as possible
• Standard formula are cows milk based
• Various brands available - No significant difference, Use whey dominant “first milks”
• Powder or ready to feed
• Various compositions based on age

Question 12

• Milk is the exclusive feed for 4-6 months (breast milk or formula)
• Breast is Best- WHO recommendation

What are the Types of Milk for Infants?

Answer 12

• Standard formula (Cows milk based)
• Specialised - for cows milk protein allergy, nutrient dense, disease specific
• Cows milk not as main drink until 1 year - Contains no iron (runs risk of iron deficiency anaemia)

Other formulae - Pre-term formulae, Nutrient dense formulae, Cows milk protein allergy, Disease specific

Question 13

Normal feeding patterns - how does the number of feeds per day change with age?

Answer 13

decreases

Question 14

What is used if there is Cows milk protein allergy?

Answer 14

•First line feed choice (top photo)

• Extensively hydrolysed protein feeds
• 90% should respond (10% react)
• Palatability a problem in older babies

•Second line feeds (bottom photo)

• Amino acid based feeds
• Babies with severe colitis/enteropathy/symptoms on breast milk

Question 15

what is the milk ladder?

Answer 15

1 year – increasing small amounts of dairy in diet

Start with biscuit with small amount of milk powder in it as you tend to tolerance a milk derivative that has been cooked well

Heat processing will denature the protein so you tend to tolerate that better

Moves up to a less processed and bigger dose of dairy

Ultimate goal is to reach milk as cows milk at the top of the ladder

Question 16

Lactose Free Milks - what is lactose intolerance?

Answer 16

Not allergy.

Reduced levels of the enzyme (lactase)

Seen to minor degree in some breast fed babies

Post gastro enteritis (Transient and self resolving)

Also in certain ethnic groups post weaning

Question 17

Lactose Free Milks can also be used For secondary lactose intolerance, what is it?

Answer 17

Short lived condition eg post gastro-enteritis

Confused with cow’s milk protein intolerance

Lactose free/ “Comfort” milks are not CMP free

Question 18

what are soya milks?

Answer 18

• Phytoestrogens - Most concern in under 6 months
• Cross reactivity with cows milk (1/3 with CMP intolerance also have soya intolerance)
• Soya indications
• Milk allergy when hydrolysed formulae refused
• Vegan families, if not breast fed
• Consider for children>1 year still on milk free diet

Question 19

Over 1 year can introduce non formula milks such as what?

Answer 19

• Rice Milk - Not advised for children under 5 years
• Goats’ and Sheep’s milk* - Not suitable for under 1’s. Many children will react
• Oat and nut milks - Organic versions are not calcium fortified

Question 20

Calories and calcium - what is required?

Answer 20

Full fat cows milk - 65kcal/100ml and 120 mg calcium/100ml. Organic/unsweetened milk substitutes low in calories and Organic milks are no calcium supplemented

• Need 400-500ml of a calcium fortified “milk” to meet calcium requirements
• Supplement if <500ml calcium fortified substitute

Question 21

Solids - What and Why?

Answer 21

• Complementary feeding
• Transition from milk to a mixed diet - nutritional and developmental changes
• Developmentally ready to actively accept foods. Starts around 6 months of age (17-26 weeks) - Look for signs of readiness such as head control, interest in food

Wouldn’t get all nutrition form beast milk as they get older

Question 22

Why introduce solids?

Answer 22

•Milk alone inadequate

• Variety of solids provide a source of protein, energy, vitamins, minerals and trace elements
• Encourage tongue and jaw movements in preparation for speech and social interaction

Question 23

what is Neophobia?

Answer 23

Normal part of child development

To reject novel or unknown foods in childhood

Associated with maternal neophobia

Increase acceptance by repeatedly offering a variety of foods

Question 24

what is weaning?

Answer 24

Introducing your baby to solid foods, also referred to as weaning or complementary feeding, starts when your baby is around 6 months old. Your baby should be introduced to a varied diet, alongside their usual breast milk or first infant formula

Individual to baby

Can manage solids and good head control

Question 25

Stages of developmental progression - Liquid

Answer 25

Stages of developmental progression - Solid

Question 26

What about vitamins - what vitamin are we often lacking?

Answer 26

•Vitamin D - Dark skinned children not on vitamin drops at risk * Prolonged breast feeding and mum not on Vit D * Poor vitamin D status amongst Scots - Higher risk of poor musculoskeletal health such as rickets and poor muscle strength - Cannot synthesise Vit D from September to April - Diet is a poor source

Question 27

what supplements should children use?

Answer 27

All babies from birth to one year of age - 8.5-10 ug Vitamin D, Not required if infant formula \>500ml Everyone over one year of age - 10 ug Vitamin D Healthy start vitamins (\>1 month)

Question 28

Those sicky babies - what is GOR and what is GORD?

Answer 28

* GOR - effortless passage of gastric contents into oesophagus with or without regurgitation and vomiting * GORD - when the reflux of gastric contents causes troublesome symptoms and/or complications

Question 29

what is GOR?

Answer 29

* Vomiting is common in babies, “Normal” physiological phenomenon, Effortless vomiting with no discomfort * Does not need special tests or affect growth * 40-70% of all babies regurgitate 1-4 times daily or more - Peaks at 3-4 months Reassurance over natural course Advice on feeding. Overfed? Improving from 6 months with solids and sitting up Need no specific treatment •Thickened formula/thickener or if no improvement consider 2-4 week trial of milk free diet

Question 30

what htickners can be used?

Answer 30

* Infant Gaviscon sachets (NOT an antacid) * Carobel * Use large hole or variable flow teat * Pre-thickened feeds, not normally recommended * Ask for help from colleagues or refer to specialist for advice

Question 31

what are red flag signs?

Answer 31

* Weight loss or poor weight gain * Recurrent or bilious vomiting * GI bleeding * Persisting diarrhoea * Dysphagia * Stridor/cough/hoarseness * High risk groups - Preterm babies, neurological impairment, chronic respiratory illness, anatomical, some genetic disorders e.g. Down’s syndrome * More severe cases, likely under specialist teams

Question 32

what are GORD treatments?

Answer 32

* Medical referral * Require acid supression - Reduced gastric acid may increase risk of pneumonia, gastroenteritis and candidiasis * Trial of milk free diet (increase this is cause) * Continuous NG/jejunal feeds * Consideration of anti reflux surgery * Drug therapy

Question 33

what drug therapy can you use for GORD?

Answer 33

* Gaviscon Liquid - Not advised\<1 year * H2 receptor * PPIs decrease the acidity * Pro-kinetics: * Domperidone promote gastric emptying - From April 2014 use restricted to short term only for nausea/vomiting not long term use in GORD * Low dose erythromycin * Alimemazine (anti histamine)

Question 34

Feeding Problems: * Refusal to feed and excessive crying in a well baby is not always \_\_\_\_\_\_ * Babies cry !! - Mean of 110-118 mins /day 0-6 weeks - Reducing to 72 mins /day by 10-12 weeks

Answer 34

reflux

Question 35

what is Colic?

Answer 35

* Diagnosis of exclusion * Inconsolable crying in a baby - \<3 months of age, \>3hours/day, \>3 days/week * For at least a week * No red flag symptoms

Question 36

how do you manage colic?

Answer 36

Explanation and reassurance Probiotics Trial of cows milk protein avoidance Lactase drops Anti spasmodics

Question 37

whata re some other potential feeding problems?

Answer 37

•Breast fed baby - Functional lactose overdose •All babies - Consider cow’s milk protein allergy - Psychosocial issues - Maternal mental health

Question 38

what is important to know in regards to iron?

Answer 38

* Most common nutritional deficiency in the world * Iron status at birth is the most important determinant of iron status throughout infancy * Breast fed/Pre term * Cow’s milk - Introducing cow’s milk as a drink before 1 year of age. No more than 500ml to drink after 1 year of age * Too much juice - Drink after meals and with snacks. Only milk and water are tooth friendly Factors associated with lower iron status at birth include low infant birthweight, and maternal iron deficiency anaemia, obesity, smoking status and gestational hypertension * No structure to meals/snacks & offering choices ++ * ? Constipated

Question 39

what is norml bowel function?

Answer 39

Normal to open bowels from 3 times a day to 3 times a week Aim for type 4 stools ERIC – The children’s bowel and bladder charity Constipation can occur at any age and is prevalent in 5-30% children (can affect oral intake aswell)

Question 40

what is constipation?

Answer 40

* No bowel movement for three or more days * Passing lots of small hard stools * Holding on to stools: - pushing with signs of or her face becoming red - using avoidance techniques - soiling, loose stools that leak into pants, pyjamas and bedclothes. This happens when the bowel is full

Question 41

how do you manage constipation?

Answer 41

•Laxatives ## Footnote - Lactulose in infants - Movicol/Laxido in older children * Adequate fluid intake encouraged * Fruit, vegetable and wholegrains intake encouraged * Constant routine – sitting on potty or toilet after meals * Give praise and encouragement

Question 42

Nutrition issues beyond infancy… what are nutrition issue in toddlers and pre-school?

Answer 42

- Learning to feed self and find food - Picky eaters/excess milk - Dependent on carer - Frequent illness

Question 43

Nutrition issues beyond infancy… what are nutrition issue in school age?

Answer 43

- Learning to be independent - Chronic disease - Obesity •12 % of Aberdeen primary 1’s are overweight and 10% obese

Question 44

Nutrition issues beyond infancy… what are nutrition issue in adolescents?

Answer 44

Independent, puberty ,eating disorders