Pediatric Nutrition IPediatric Nutrition I

Nutrition of Neonates and InfantsNutrition of Neonates and Infants– Prior to 1 year of agePrior to 1 year of age– Growth Rates and Nutritional GoalsGrowth Rates and Nutritional Goals– Nutrient RequirementsNutrient Requirements

Energy, Protein, Minerals, VitaminsEnergy, Protein, Minerals, Vitamins Absorptive/Digestive ImmaturityAbsorptive/Digestive Immaturity

– Human MilkHuman Milk– Infant FormulasInfant Formulas

Growth rates are most rapid in the first six Growth rates are most rapid in the first six months of human lifemonths of human life

Nutrient requirements on a weight basis are Nutrient requirements on a weight basis are highest during the first six monthshighest during the first six months

Rapid organ growth and development occurs Rapid organ growth and development occurs during the last trimester and first six monthsduring the last trimester and first six months

The detrimental effects of nutritional The detrimental effects of nutritional insufficiencies are magnified during periods of insufficiencies are magnified during periods of rapid organ growth (I.e., vulnerable periods for rapid organ growth (I.e., vulnerable periods for brain growth)brain growth)

Provide sufficient macro- and micronutrient Provide sufficient macro- and micronutrient delivery to promote normal growth rate and body delivery to promote normal growth rate and body composition, as assessed by curves which are composition, as assessed by curves which are generated from the population generated from the population

Curves exist for:Curves exist for:– Standard anthropometrics: weight, length, OFCStandard anthropometrics: weight, length, OFC– Special anthropometrics: arm circumference, skinfold Special anthropometrics: arm circumference, skinfold

thicknessthickness– Body proportionality: weight/length, mid-arm Body proportionality: weight/length, mid-arm

circumference: head circumference ratiocircumference: head circumference ratio Body composition measurements (e.g. DEXA, Body composition measurements (e.g. DEXA,

PeaPod) are not standardized yetPeaPod) are not standardized yet

GIRLSBirth to 36 mo

BOYSBirth to 36 mo

Term infants require 85-90 Kcal/kg/d if Term infants require 85-90 Kcal/kg/d if breast-fed, 100-105 Kcal//kg/d if breast-fed, 100-105 Kcal//kg/d if formulaformula

Differences are due to increased Differences are due to increased digestibility and absorbability of digestibility and absorbability of breast milkbreast milk– Presence of compensatory enzymes Presence of compensatory enzymes

(lipases)(lipases)

(Continued)(Continued)

Energy requirements are 20% higher Energy requirements are 20% higher in premature infants due to:in premature infants due to:– Higher basal metabolic rateHigher basal metabolic rate– Lower coefficient of absorption for fat Lower coefficient of absorption for fat

and carbohydratesand carbohydrates

Energy requirements decrease to 75 Energy requirements decrease to 75 Kcal/kg/dKcal/kg/d between 5-12 monthsbetween 5-12 months

GrossGross

EnergyEnergy

IntakeIntake

MetabolizableMetabolizable

EnergyEnergy

IntakeIntake

Basal MetabolismBasal Metabolism

Thermic Effect of FeedingThermic Effect of Feeding

ActivityActivity

Energy Stored “growth”Energy Stored “growth”

Tissue SynthesisTissue Synthesis

Energy ExcretionEnergy Excretion

Diseases of infancy that increase BMR Diseases of infancy that increase BMR (cardiac, neurologic, respiratory) affect (cardiac, neurologic, respiratory) affect energy requirementsenergy requirements

Diseases that increase nutrient losses Diseases that increase nutrient losses (malabsorption due to cystic fibrosis, (malabsorption due to cystic fibrosis, celiac disease, short bowel syndrome) celiac disease, short bowel syndrome) increase the need for energy delivery, increase the need for energy delivery, although the BMR is normalalthough the BMR is normal

Late gestation and infancy is the time of Late gestation and infancy is the time of highest protein accretion in human lifehighest protein accretion in human life

Protein requirements range from 1.5 g/kg/d Protein requirements range from 1.5 g/kg/d (healthy breast-fed infant) to 3.5 g/kg/d (healthy breast-fed infant) to 3.5 g/kg/d (septic, preterm infant)(septic, preterm infant)

Amino acid synthesis is incomplete in the Amino acid synthesis is incomplete in the premature; taurine and cysteine are premature; taurine and cysteine are additional essential amino acids because of additional essential amino acids because of immaturity of enzyme systemsimmaturity of enzyme systems

Preterm infants:Preterm infants: 15 g/kg/d15 g/kg/d

Toddlers:Toddlers: 6 g/kg/d 6 g/kg/d

Adolescents:Adolescents: 4 g/kg/d 4 g/kg/d

NutrientNutrient Term Term Preterm 5-12 Month Preterm 5-12 Month

Neonate Neonate InfantNeonate Neonate Infant

Na (mEq/kg/d)Na (mEq/kg/d) 2 - 32 - 3 4 - 74 - 7 1 - 21 - 2

KK (mEq/kg/d)(mEq/kg/d) 1 - 2 1 - 2 2 - 4 1 - 2 2 - 4 1 - 2

Ca (mEq/kg/d) Ca (mEq/kg/d) 60 150 40 60 150 40

Iron (mEq/kg/d) Iron (mEq/kg/d) 1 1 2 - 4 2 - 4 0.7 0.7

Zinc (mEq/kg/d) 0.2 - 0.5 0.4 0.3Zinc (mEq/kg/d) 0.2 - 0.5 0.4 0.3

Water-soluble vitaminsWater-soluble vitamins (B, C, folate, etc.) (B, C, folate, etc.) are rarely a problem in newborns and are rarely a problem in newborns and infants; babies are born with adequate infants; babies are born with adequate stores and/or all food sources have stores and/or all food sources have adequate amountsadequate amounts

Fat-soluble vitaminsFat-soluble vitamins (A,E,D,K) may present (A,E,D,K) may present significant problems because of relatively significant problems because of relatively poor fat absorption by newborn infants poor fat absorption by newborn infants (especially premature infants)(especially premature infants)

K: Needs to be given at birth to prevent K: Needs to be given at birth to prevent hemorrhagic disease of newborn; hemorrhagic disease of newborn; adequate thereafter due to synthesis by adequate thereafter due to synthesis by intestinal bacteriaintestinal bacteria

D: Low amounts in breast milk; infants D: Low amounts in breast milk; infants born in winter in north and infants who are born in winter in north and infants who are clothed at all times (minimal sun exposure) clothed at all times (minimal sun exposure) have been identified with ricketshave been identified with rickets AAP now recommends 400 IU/d for all infantsAAP now recommends 400 IU/d for all infants

(Continued)(Continued)

A: Essential for normal structural collagen A: Essential for normal structural collagen synthesis and retinal development synthesis and retinal development deficiency in premature infants contribute deficiency in premature infants contribute to fibrotic chronic lung diseaseto fibrotic chronic lung disease

E: Antioxidant that protects against E: Antioxidant that protects against peroxidation of lipid membranes; preterms peroxidation of lipid membranes; preterms have poor antioxidant defense and are have poor antioxidant defense and are subjected to large amounts of oxidant subjected to large amounts of oxidant stress; vitamin E deficiency causes severe stress; vitamin E deficiency causes severe hemolytic anemiahemolytic anemia

Rapid transit timeRapid transit time

++

Immature digestive capabilitiesImmature digestive capabilities

==

Reduced nutrient retentionReduced nutrient retention

Primary sources of CHO in newborn Primary sources of CHO in newborn and infant diet are disaccharides (esp. and infant diet are disaccharides (esp. lactose)lactose)

Disaccharides must be broken into Disaccharides must be broken into component monosaccharides to be component monosaccharides to be absorbedabsorbed– Lactose = glucose + galactose (lactase)Lactose = glucose + galactose (lactase)– Sucrose = glucose + fructose (sucrase)Sucrose = glucose + fructose (sucrase)– Maltose = glucose + glucose (maltase)Maltose = glucose + glucose (maltase)

Intestinal lactase concentrations are Intestinal lactase concentrations are low at birth and are not induciblelow at birth and are not inducible

Amylase, necessary for breaking Amylase, necessary for breaking down starches, are not adequate down starches, are not adequate until > 4 monthsuntil > 4 months

Sucrase, Maltase, IsomaltaseGlucose Uptake

Gluco-amylase

Salivary AmylaseZymogen Granules in Pancreas

Pancreatic Amylase

Lactose

10 Wks10 Wks

20 Wks20 Wks

24 Wks24 Wks

24 - 28 Wks24 - 28 Wks

22 Wks22 Wks

85 % of ingested protein is absorbed in 85 % of ingested protein is absorbed in spite of functional immaturities:spite of functional immaturities:– Reduces stomach acidityReduces stomach acidity– Low pancreatic peptides levels Low pancreatic peptides levels

(chymotrypsin caroboxypeptidases)(chymotrypsin caroboxypeptidases)

Compensation is by trypsin and brush Compensation is by trypsin and brush border peptidasesborder peptidases

Adult: 95%Adult: 95%

Term infant: 85-95%Term infant: 85-95%

Preterm infant: 50 - 90% Preterm infant: 50 - 90% (dependent on source of fat)(dependent on source of fat)

Low levels of intestinal lipasesLow levels of intestinal lipases

Small bile salt poolSmall bile salt pool

Committee on Nutrition of the AAP Committee on Nutrition of the AAP strongly recommends breastfeeding strongly recommends breastfeeding for infantsfor infants

The rates of breastfeeding have risen The rates of breastfeeding have risen recently, but the attrition rate is highrecently, but the attrition rate is high

The goal of the AAP and NIH Health People The goal of the AAP and NIH Health People 2010 is to have 75% women breastfeed, with a 2010 is to have 75% women breastfeed, with a continuation rate of 50% at 6 monthscontinuation rate of 50% at 6 months

It is necessary to breastfeed for at least 12 It is necessary to breastfeed for at least 12 weeks to achieve the immunologic and weeks to achieve the immunologic and disease preventative benefits of breast milkdisease preventative benefits of breast milk

Physician’s role is to support, counsel and Physician’s role is to support, counsel and trouble-shoottrouble-shoot

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HealthHealth NutritionalNutritional ImmunologicImmunologic NeurodevelopmentalNeurodevelopmental EconomicEconomic EnvironmentalEnvironmental

Studies in developed countriesStudies in developed countries– Reduced prevalence of:Reduced prevalence of:

» DiarrheaDiarrhea» Otitis mediaOtitis media» Lower respiratory infectionLower respiratory infection» UTI UTI » NEC (in preterms)NEC (in preterms)» SIDSSIDS

Protection of infant from chronic Protection of infant from chronic diseases:diseases:– Insulin dependent diabetes mellitusInsulin dependent diabetes mellitus

(OR 0.61)(OR 0.61)

– Inflammatory bowel diseaseInflammatory bowel disease

– Allergic diseaseAllergic disease

– Childhood lymphoma (OR 0.91)Childhood lymphoma (OR 0.91)

– Obesity (OR 0.75-0.87)Obesity (OR 0.75-0.87)

Protection of mother from:Protection of mother from:

– PregnancyPregnancy

– Postpartum hemorrhagePostpartum hemorrhage

– Bone demineralizationBone demineralization

– Ovarian cancerOvarian cancer

Complete human nutrition for 6 monthsComplete human nutrition for 6 months

– Iron at 4 monthsIron at 4 months

– Vitamin D in northern climates, covered Vitamin D in northern climates, covered infants and mothers, vegetarians (vegans)infants and mothers, vegetarians (vegans)

Energy is more accessible than from Energy is more accessible than from formulaformula– Compensatory lipases Compensatory lipases better fat better fat

retentionretention– But, BF babies grow slower tooBut, BF babies grow slower too

Amino acid spectrum matches Amino acid spectrum matches infant need; lower protein and infant need; lower protein and solute loadsolute load

Faster gastric emptying Faster gastric emptying less less refluxreflux

Better visual acuity (early)Better visual acuity (early)— Role of DHA?Role of DHA?

Higher IQ (debatable)Higher IQ (debatable)— Independent of nursingIndependent of nursing

— Components in human milk which Components in human milk which may potentiate the effect:may potentiate the effect:

» DHADHA» Growth factorsGrowth factors

25% reduced risk of obesity if BF25% reduced risk of obesity if BF— Adjusted OR: 0.75-0.89Adjusted OR: 0.75-0.89—Dose response Dose response (Koletzko et al)(Koletzko et al)

—Rate of Adolescent ObesityRate of Adolescent Obesity—12% if BF < 1month12% if BF < 1month—2% if BF 12 months2% if BF 12 months

—““Small” effect compared to OR if Small” effect compared to OR if parents are obese (4.2), low physical parents are obese (4.2), low physical activity (3.5) or TV (1.5)activity (3.5) or TV (1.5)

Reduced cost of feedingReduced cost of feeding— No formula cost (-$855/year)No formula cost (-$855/year)— Increased maternal consumption (<+$400)Increased maternal consumption (<+$400)— Net savings of >$400/childNet savings of >$400/child

Reduced health care costs due to:Reduced health care costs due to:— Lower incidence of childhood illnessLower incidence of childhood illness

Reduced income loss due to:Reduced income loss due to:— Less days lost to cover childhood illnessLess days lost to cover childhood illness

Galactosemia in infantGalactosemia in infant Illicit drug use by motherIllicit drug use by mother Certain maternal infectious diseasesCertain maternal infectious diseases

— Active TBActive TB— HIV (US only)HIV (US only)— Not CMVNot CMV

Certain maternal medicationsCertain maternal medications— Anti-neoplastics, isotopes, etcAnti-neoplastics, isotopes, etc— How about SSRI's?How about SSRI's?

Promotes adequate growth, but not brain and Promotes adequate growth, but not brain and immunologic development compared to human immunologic development compared to human milkmilk New formulas contain LC-PUFAsNew formulas contain LC-PUFAs Soon to be added: prebiotics; probioticsSoon to be added: prebiotics; probiotics

Most are cow-milk based, although soy-protein Most are cow-milk based, although soy-protein based and fully elemental formulas are based and fully elemental formulas are availableavailable

(Continued)(Continued)

Cow’s milk (not formula) is contraindicated in Cow’s milk (not formula) is contraindicated in the first year of lifethe first year of life— High solute load can lead to azotemiaHigh solute load can lead to azotemia

— Inadequate vitamin D and AInadequate vitamin D and A

— Milk fat poorly toleratedMilk fat poorly tolerated

— Low in calcium; can lead to neonatal seizuresLow in calcium; can lead to neonatal seizures

— Gastrointestinal blood loss/sensitization to cow- Gastrointestinal blood loss/sensitization to cow- milk proteinmilk protein

Feed humans human milkFeed humans human milk— It is species specificIt is species specific

If not human milk, CMF or Soy formulas If not human milk, CMF or Soy formulas with iron are indicatedwith iron are indicated

Hypoallergenic formulas are highly Hypoallergenic formulas are highly specialized, expensive and overusedspecialized, expensive and overused