INFANT NUTRITION

RICHARD L. MONES MD

HARLEM HOSPITAL

HOW DID WE GET HERE?

MUST DEVELOP EXPERTISE

TIME

HISTORY

EVOLUTION

BM – BEST FOR HUMAN BABIES

? IDEAL

CHANGES IN DIET/HYGEINE

AFFECTED VIT.K, D, Fe

NO BREAST MILK MEANT CERTAIN DEATH

WET NURSE—AN ALTERNATIVE

4th century B.C.

13th century…highly organized State controlled practice Transmit traits

LOUIS XIV AND WET NURSE

VESSELS TO FEED MILK

BOVINE HORNS

ANIMAL HIDE

1800 GLASS FEEDING BOTTLE

MIDDLE AGES

INFANTS TO SUCKLE FROM ANIMALS

GOAT SHEEP

AGE OF WEANING

HAS DECREASED FROM AGE 3 YEARS TO THE PRESENT 12 MONTHS.

NEVER WEANED IN JULY,AUGUST,SEPTEMBER

ANIMAL MILK

REPLACED WET NURSES IN 18 CENTURY

COW, ASS, GOAT

50-100% MORTALITY RATE IN EARLY 19 CENTURY

WHY?

POOR SANITATION

ADULTERATION

NO ICE BOX

IMPORTANT EVENTS

GERM THEORY DISCOVERED

KNOWLEDGE OF MILK COMPOSITION

BORDEN-CONDENSED MILK

IMPORTANT EVENTS

PASTUERIZATION

RUBBER NIPPLES-CLEAN

1910 ICE BOXES

DEVELOPMENT OF FORMULAS

TODAY

BREAST FEEDING

FORMULA

BOTH

MUCH IS TAKEN FOR GRANTED

OBJECTIVE

PROVIDE NUTRIENTS TO SUPPORT OPTIMUM GROWTH

DEVELOP OROMOTOR SKILLS

APPROPRIATE EATING BEHAVIORS

HOW MUCH ENERGY IS NEEDED?

ENERGY BALANCE E(INTAKE)=E(EXCRETED)+E(EXPENDED)+E(STORED)

POSITIVE IN INFANTS AND CHILDREN

EXPENDITURE- BASAL FUNCTIONS + ACTIVITY

EXCRETION- STOOL FAT STORED- IN MOLECULES OF FAT AND

PROTEIN ENERGY COST OF GROWTH

COST OF DEPOSITING FAT 10.8KCAL/GM.

COST OF DEPOSITING PROTEIN13.4 KCAL/GM.

HOW MUCH DOES IT TAKE?

DOUBLE BW IN 4 MONTHS

TRIPLE BW IN LESS THAN 12 MONTHS

FACTORS INFLUENCING FOOD INTAKE

DENSITY

DIGESTIBILITY

TASTE PREFERENCES

PARENTAL ATTITUDES

BREAST VS. BOTTLE

NEEDS

0-2MOS……90-120 KCAL/KG/DAY

3-5 MOS……80-100 KCAL/KG/DAY

6-8 MOS…….80-100 KCAL/KG/DAY

9-11 MOS……90-100 KCAL/KG/DAY

HOW DO YOU KNOW?

GROWTH NAKED WEIGHT LENGTH BOARD PLOT WT./HT. SHOW GC TO PARENTS

EXPECTATIONS

GROWTH CURVES DIFFICULT DURING FIRST 1-2 MONTHS LOW RESOLUTION

REFLECT INTRA-UTERINE NUTRITION

WHAT ELSE CAN YOU DO?

GUIDE TO WEIGHT GAIN FIRST TWO MONTHS

50th %ile= 30 GMS./DAY

95th %ile=45 GMS./DAY

5th %ile=15 GMS./day

LESS THAN 15 GM./DAY IS INADEQUATE

POSSIBLE EXCEPTIONS

CATCH UP GROWTH

CATCH DOWN GROWTH

BREAST MILK

MILK COMPOSITION VARIES AND IS DYNAMIC

WOMAN TO WOMAN

OVER TIME- DAY TO DAY, MONTH TO MONTH

DURING A FEED FOREMILK VS. HINDMILK

BREAT MILK

WELL NOURISHED WOMAN WILL MEET ALL NUTRITIONAL NEEDS FOR FIRST 6 MOS. OF LIFE

EVENTUALLY, EXCLUSIVE BF WILL NOT MATCH NEED OF THE INFANT

SUBOPTIMAL GROWTH

BREAST MILK

INFANT WITH GROWTH RATE AT 95%ILE BUT

MOTHER’S MILK PRODUCTION IS ON THE 5%ILE

WEIGHT GAIN <5%ILE = RED FLAG FOR UNDERNUTTION

MISMATCH IN MACRO AND MICRO NUTRIENTS

BREAST MILK

ADVANTAGES OTHER THAN NUTRITIONAL

CLEAN MILK

PROTECT AGAINST INFECTION MACROPHAGES LYMPHOCYTES LACTOFERRIN LYSOZYMES IgA

CASE 34 YO G1P0 MOM BRINGS HER BABY IN WITH A

CC: IRRITABITLIY, POOR SLEEPING, XS CRYING.

SURGICAL RESIDENT, LIVES ACROSS FROM HOSPITAL. XLUIVELY Breast Feeding

MOM IS QUITE FATIGUED

3 WEEKS OF AGE (21DAYS)

BW=7-4 (3290), D/C 7-0 (3180)CAN TOLERATE UP TO 15% WEIGHT LOSS

IN FIRST 24-72 HOURS. (DIURESIS)

TODAY= 7-8(3410)

BREAST MILK

WHAT WOULD YOU DO?

BREAST MILK

GAIN ABOUT 11 GMS./DAY

NORMAL OR NOT?

?LABS-----HYPERNATREMIA

REMIAFORMULA FEED?

LIFESTYLE CHANGES?

INSUFFICIENT BREAST MILK SYNDROME

STRESS STRESS STRESS STRESS

CHICKENS LAY FEWER EGGS

COWS PRODUCE LESS MILK

SO DO HUMANS

BREAST VS. FORMULA * G/100ML

CAL/30ML PRO FAT CHO OSM

BREAST 20 0.9 3.9 6.7 260-300

FORMLA 20 1.45 3.6 7.3 300

BREAST VS. FORMULA

CHO FAT PRO

HUMAN LACTOSE HUMAN MILK FAT

HUMAN W:C=60:40

FRMLA LACTOSE VEGETABLE OILS

COW W:C=40:60

FORMULA

CONVENIENCE

NECESSITY

CULTURAL

SUPPLEMENTAL

convenience

NUMEROUS FORMULAS

SOY

COLIC

REFLUX

ALLERGY

GI ABNORMALITES (SHORT GUT, post-infectious gastroenteritis)

INBORN ERRORS OF METABOLISM

HOW DO YOU CHOOSE ?

FIRST DECIDE WHAT YOUR GOAL IS !!!!

IS THERE EVIDENCE TO SUPPORT THAT GOAL?

SET REALISTIC EXPECTATIONS FOR THE PARENTS

CONSIDER COST AND AVAILABILITY

KNOW ONE FORMULA IN EACH CATEGORY

SOY FORMULAS

20 CAL/OZ.

SOY PROTEIN

FAT- MIXTURE OF VEGETABLE OILS ( PALM,SOY,COCNUT,SFFLOWER,SUNFLOWER)

CHO- SUCROSE AND CORN SYRUP

SOY FORMULA

VEGETARIAN

WILL SUPPORT NORMAL GROWTH

COLIC?

MILK PROTEIN ALLERGY 40% CROSS REACTIVITY NOT IgE

PROTEIN HYDROLYSATE

ALIMENTUM NUTRAMIGEN PREGESTIMIL

HYDROLYSTE

HYDROLIZED CASEIN

CHO-CORN SYRUP SOLIDS AND MALDEXTRINS

FAT-VEGETABLE OIL

SOME WITH MCT ( PREGESTIMIL)

HYDROLYSATE

COW MILK PROTEIN ALLERGY STILL POSSIBLE

“SEMI-ELEMENTAL” FORMULAS

POST INFECTIOUS GASTROENTERITIS

COLIC

CHOLESTASIS

SHORT GUT

ELEMENTAL FORMULA

MACRONUTRIENTS IN MOST BASIC FORM

PROTEIN = FREE AMINO ACIDS

CHO=POLYCOSE AND GLUCOSE

FAT= MIXTURE OF MCT AND LCT

HIGH OSMOLARITY

ELEMENTAL FORMULAE

NEOCATE ELECARE NUTRAMIGEN AA

ELEMENTAL FORMULAE

SHORT GUT SYNDROME

COW PROTEIN/SOY PROTEIN ALLERGY

COLIC

PATIENT DEMAND

EXTREMELY EXPENSIVE

NOT COVERED BY INSURANCE

FOLLOW THE MONEY

PRESSURE BY COMPANY REPS

SPONSORSHIP OF MEETINGS,LUNCHES ETC.

MILLIONS IN COSTS FOR ADVERTISING

ENFAMIL AR

KEY POINTS ABOUT FORMULAE

COMMUNICATE REALISTIC EXPECTATIONS TO PARENTS

MOST OFTEN SYMPTOMS ARE NOT RELATED TO FORMULA

THEREFORE YOU WILL FAIL !

BEIKOST

COMPLIMRNTARY OR WEANING FOODS

BEIKOST

INTRODUCED BETWEEN 4-6 MOS.

GRADUALLY SUPPLIES INCREASING FRACTION OF ENERGY

BY 12 MOS. MAY BE 50%

BEIKOST-WHEN?

MAY OVERLOOK INDIVIDUAL NEEDS IF ORTHODOX ABOUT AGE

DEVELOPMENTAL SKILLS MORE IMPORTANT INDIVIDUALIZE FEEDING

BABIES ABLE TO SIT, TRUNCAL

SUPPORT, GOOD HEAD CONTROL

BEIKOST

ABILITY TO PROPEL FOOD T0 THE POSTERIOR PHARYNX

EXTINCTION OF THE EXTRUSION REFLEX

ABILITY TO INDICATE DESIRE FOR FOOD. OPEN MOUTH LEAN FORWARD

SIGNS OF SATIETY

BEIKOST

MONES METHOD

AT 4 MOS. INTODUCE CEREALS

ONE KIND AT A TIME

FOR 1 WEEK

HAS VARIETY OF CEREALS

IN ONE MONTH

BEIKOST

ADD ONE FOOD GROUP EACH MONTH FRUITS, VEGGIES,LEAN MEATS

INCREASE REPETOIRE OF FOODS AND MIX AND MATCH

INTRODUCE ONE FOOD EVERY 4 DAYS

PUREED FOODS THIN TO THICK

BEIKOST

ADVANCE TO THICKER PUREES AND SOFT MASHED FOODS

INCREMENTAL INCREASE IN TEXTURE HELPS AQUIRE NORMAL CHEWING AND SWALLOWING SKILLS

A MISMATCH IN TEXTURE AND READINESS IS A DISASTER

VITAMINS VITAMIN K GIVEN IN NB NURSERY TO AVOID

HEM. DIS.NB

D: NEED SUPPLEMENT IN SOME BABIES DEPENDING ON LATITUDE AND SKIN COLOR

Fe: FORMULA FORTIFIED (12MG./L) BREAST :ADEQUATE ABSORPTION FOODS (FORTIFIED CEREAL) WILL

ADD IRON 1 MG./KG/24H FT 2-3 MG./KG/24 PREMIE

VITAMINS

FLOURIDE: KNOW STATUS OF WATER IN COMMUNITY

IF USE READY TO FEED FORMULA, MUST SUPPLEMENT FLOURIDE

B12 RECCOMMENDED FOR BF BABIES OF STRICT VEGETARIAN MOTHERS

NIGHT TIME –NAP TIME BOTTLE SYNDROME

TIPS

FEED ON DEMAND !!

WHEN THE BABY SHOWS CUES OF HUNGER

SUCK ON HAND MOVE LIPS FUSS/CRY NO “SCHEDULE”

TIPS

INTRODUCE SIPPY CUP AT 9 MOS.

WCM, SMALL AMOUNTS, IN CUP

GRADUALLY INCREASE WCM OVER NEXT 3 MOS.

WEAN FROM BOTTLE BY 12-15 MOS.

TIPS

STOP WHEN FULL

TURN AWAY,

CLOSE LIPS,

SLOW DOWN SUCKING,

SPIT OUT NIPPLE

QUESTIONS