what’s new in infant nutritioncme.uthscsa.edu/presentations/peds2011/friday/4...this presentation...
TRANSCRIPT
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
What’s new in Infant NutritionVitamin D, Calcium, Iron and New Formulas
Ivor D. Hill, MB, ChB, MD.
Wake Forest University School of Medicine.
I have the following financial relationship to disclose:
Astra-Zeneca - Consultant
No products or services produced by this company is relevant to my presentation.
Disclosure Statement
Infant Nutrition
Formula Marketing
“Enfapro iron-fortified is a nutritionally balanced milk supplement for babies 6 months and above. It contains essential fatty acids, alpha-linolenic acid and linoleic acid (DHA and ARA precursors) which help promote nourishment of the baby’s brain”
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
Now present in nearly every brand name of formula
Wholesale price is approximately 15-25% higher than standard formula
WIC spent an extra $91 M in 2009 due to DHA/ARA additives
Infant Nutrition
Objectives
DHA and ARA
What are they?
Are they beneficial?
Vitamin D
What does it do?
Who needs it and how much?
Calcium and Iron
New dietary recommendations
Infant Nutrition
What are DHA and ARA?
LCPUFA’s
Linoleic acid (C18:2 n-6) Linolenic acid (C18:3 n-3)
Desaturation and elongation
Arachidonic acid (ARA) Docosahexanoic acid (DHA)(C 20:4 n-6) (C 22:6 n-3)
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
DHA & ARA factoids!
Major component of neural tissue & photoreceptor membrane
Accumulate in 3rd trimester and first 2 years of life
Plasma and RBC content higher in breast fed infants
Plasma and RBC content higher in formula supplemented with DHA and ARA
Infant Nutrition
Theory of benefits!
Cognitive/behavioral function
Breast > formula fed
Visual acuity in infants
Breast > formula fed
Differences presumed related to DHA and ARA in breast milk
Infant Nutrition
DHA and ARA – the facts
Availability
Term infant formula – 2002
Preterm infant formula – 2003
Early concerns - safety
Effect on growth Negative effect in preterm with DHA alone
Oxidant effect
Bronchopulmonary dysplasia, sepsis, NEC
DHA + ARA considered safe!
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
DHA & ARA – facts
Growth in term infants
Cochrane review
20 randomized studies
No benefit or harm
Auestad N et al. Pediatrics 2001; 108:372-81.
Infant Nutrition
DHA & ARA – facts
Growth in pre-term infants
Cochrane review
11 studies included
Mild decrease in Wt. & Lt. at 18 mths x 1
Increase in Wt. & Lt. at 2 months x 5 – not sustained
Conclusion?
Fewtrell et al. J Pediatr 2004;144:471-9.Increased Wt. & Lt in boys at 9-18 mths
Infant Nutrition
DHA & ARA – facts
Neurodevelopmental outcomes – term infants
Cochrane review
14 studies – 1719 term infants
Bayley Scales used in most
Pooled data – no significant benefit on mental or psychomotor development
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
DHA & ARA – facts
Neurodevelopmental outcomes – pre-term
Cochrane review
7 studies included
Meta-analysis at 12 & 18 months – no significant effect
Infant Nutrition
Controls –term, breast fed
* p < .05 vs. control
+ p = .056 vs. control
p < 0.5
$ p < 0.5
Clandinin et al. J Pediatr 2005;146:461-8Pre-term infants. Bayley Scores at 18 mths. Control MDI: 77.2 PDI: 83Supplemented MDI: 85.1 PDI: 90.7
Infant Nutrition
DHA & ARA – facts
Visual acuity – term infants
Cochrane review
9 studies evaluated
VER used in 5 studies
Teller cards in 4 studies
Results
Beneficial x 3
No benefit x 6
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
DHA & ARA – facts
Visual acuity – term infants
Auestad N et al. Pediatrics 2001; 108:372-81.
Breastvs.
ControlVs.
SupplementP > .05
Infant Nutrition
DHA & ARA – facts
Visual acuity – pre-term infants
Cochrane review
14 studies evaluated
VER used in 6 studies
Teller cards in 8 studies
Results
? Benefit at 2 & 4 mths
Overall no benefit
Infant Nutrition
DHA and ARA – role in allergic disease?
Reasoning
Precursors of eicosanoids
Breast fed infants have less allergies at 18 mths.
DHA + ARA associated with decreased URI’s and common allergies in first 3 years of life*
No RCT’s to date
* Birch et al. J Pediatr 2010;156:902-6
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
Vitamin D – what does it do?
Skeletal health - rickets
Skeletal heath – other- in utero effects
Non skeletal health effects
Infant Nutrition
Vitamin D – what does it do?
Factoids
most tissues have vit D receptors
1,25 (OH)2 D controls > 200 genes
regulates cell differentiation & apoptosis
decreases normal and cancer cell proliferation
Vit D receptors
Infant Nutrition
Vitamin D – what does it do?
Potent immune modulatorMonocytes & macrophages
- lipopolysaccharides - mycobacterium TB
- receptor upregulation
- cathelicidin synthesisEffect abolished with 25 (OH) D levels < 20 ng/ml
OTHER RTI’s (influenza, pneumonia, viral) – increased in children with low 25 (OH) D3 levels & more frequent in winter.J Pediatr 2010;156:698-703.
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
Vitamin D – what does it do?
Role in cancer prevention?
30%-50% increase risk for colon, breast and prostate cancer with 25 (OH) D levels below 20 ng/ml!
Mortality in these cases was also higher!
Infant Nutrition
Vitamin D – what does it do?
Role in autoimmune disease?
Prevalence of type 1 diabetes, rheumatoid arthritis, Crohn’s disease and multiple sclerosis lower in:-
Lower latitudes
Higher levels of 25 (OH) D3
Those on supplements of D3
Hypponen E et al. Lancet 2001;358:1500-3.Children supplemented with D3 in the first year of life had an 80% decreased risk for T-1-D over 30 yrs
Infant Nutrition
Vitamin D – who needs it? Definitions
Deficient [Def] 25 (OH) D < 20 ng/ml
Insufficient [Ins] 25 (OH) D < 30 ng/ml
Def - 29%Ins – 56% *
•*Pediatrics 2010;125:1104-1111.•+Pediatrics 2009;124:e362-e370.•! Pediatrics 2010;125:640-647.
NHANES +
9757 childrenDef – 9%(7.6 million)Ins – 61%(50.8 million)
Infant/motherInfants!- Def - 58%
Mothers- Def – 36%
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
Factors affecting Vit D status
Latitude Season
Girls < boys Pigmentation
Infant Nutrition
Vitamin D recommendations
Sources of vitamin D
Sunshine!
7 dehydrocholesterol D3
Dietary
Fish (salmon, tuna, cod liver)
Mushrooms, eggs
Fortified foods (milk, cheese)
Supplements
Infant Nutrition
Vitamin D recommendations
Historical
2003 AAP endorses IOM recs for 200 IU/day*
2008 AAP advises increase to 400 IU/day+
Current state of affairs
Infants meeting recs in first year of life!
2003 recs – 44% - 58%
2008 recs – 11% - 25%
Breast fed << Formula fed
*Pediatrics 2003;111:908-910+Pediatrics 2008;122:1142-1152!Pediatrics 2010;125:627-632
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
Vitamin D recommendations
Who should get it?
Pregnancy – larger babies & greater bone mass with supplements
Breast fed infants – breast milk contains 25 – 78 IU/L vitamin D
Formula fed infants – if taking less than 1 L per day
Children and adolescents –universal!
Amount? – 400 IU/day (? more)Pediatrics 2008;122:1142-1152NEJM 2007;357:266-281
Infant Nutrition
Calcium – factoids!
99% of total body calcium is in bone
Homeostasis controlled by vitamin D, parathormone & calcitonin
40 % of lifetime calcium acquired between 11-15 years
In children lower Ca intake associated with more fractures
Infant Nutrition
Calcium – factoids!
Other factors affecting calcium retention
Dietary
alcohol, caffeine, oxolates, phytates
Weight bearing exercise
Non sedentary lifestyle
BMI
High BMI associated with lower bone mass
X√
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition Calcium intake – how much?
Age Calcium mg/day
0-6 months 210
7-12 months 270
1-3 years 500
4-8 years 800
9-18 years 1300
19-50 years 1000
50 years + 1200
Pediatrics 2006;117:578-585
Infant Nutrition Calcium intake – how adequate?
Pediatrics 2006;117:578-585.
Infant Nutrition Calcium intake – sources
Food Serving size Calcium (mg)
Dairy
- milk ~240 ml (8oz) ~ 250
- yoghurt ~180 ml (6oz) ~ 250
- cheese ~ 30 gm (1oz) ~ 200
Non dairy foods
- salmon ~ 90 gm (3 oz) ~ 200
- beans (white/baked) ~ 6-8 oz ~ 150
- collards - ~ 180 gm (6oz) ~ 250
Fortified foods
- orange juice ~ 240 ml (8oz) ~ 300
- cereals ~ 30 gm (1oz) ~ 100
- soy milk ~ 240 ml (8oz) ~ 200-500
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition Calcium intake –assessment?
Serum measurement –
Dietary history -
How many servings per day of:-
Dairy
Greens and beans
Fortified foods
Supplements?
Exercise? Soft drinks?
X
√
Infant Nutrition
Iron – factoids
Most common known nutritional deficiency
Two thirds of body iron in hemoglobin
One third in myoglobin, enzymes and storage proteins
Effects of deficiency
Anemia
Cognitive & motor deficits
Infant Nutrition
Iron deficiency - who is at risk?
Those with an increased need
Pregnant women
Premature and low birth weight
Periods of rapid growth
Those with increased losses
Teenaged girls
Women of child bearing age
Those with malabsorption
Celiac disease, IBD
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
Iron requirements - RDA
AgeMales
(mg/day)Females(mg/day)
Pregnancy(mg/day)
Lactation(mg/day)
7 to 12 months 11 11 N/A N/A
1 to 3 years 7 7 N/A N/A
4 to 8 years 10 10 N/A N/A
9 to 13 years 8 8 N/A N/A
14 to 18 years 11 15 27 10
19 to 50 years 8 18 27 9
51+ years 8 8 N/A N/A
http://ods.od.nih.gov/factsheets/iron.asp
Infant Nutrition
Iron sources – factoids
Heme iron
Meat, poultry and fish
Non heme iron
Natural foods (beans, spinach)
Fortified foods (cereals, oatmeal)
Supplements
Infant Nutrition
Iron deficiency – how is it determined?
CBC – anemia is a late stage of iron deficiency
Anemia is not specific for iron deficiency
Therapeutic response
Serum ferritin - <15ug/L is the most sensitive test for deficiency
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
Iron – who needs it?
Breastfed infants
Preterm – start at 1 month
Term – start at 4-6 months
Use iron fortified foods or supplements
Formula fed infants
Preterm infants – use both iron fortified formula and a supplement
Term infants – fortified formula
Infant Nutrition
Iron – who needs it?
Young children
Under 2 years – 10% risk for deficiency
Monitor diet and supplement those not meeting RDA’s
Screening for deficiency
Universal
Targeted – those at risk
Infant Nutrition
Iron – who needs it?Clinical Report – Diagnosis and Prevention of Iron Deficiency and Iron Deficiency Anemia in Infants and young Children (0-3 Years of Age) Pediatrics 2010;126:1040-1050.
Term infants - breast fed formula fed1 mg/kg at 4 mths iron fortified milk
(until weaned)
Preterm infants- 2 mg/kg at 1 mth 2 mg/kg
Toddlers 1-3 yrs- 7 mg/day (supplements if not from food)
Universal screening at 12 months – consider risk factors
Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center
San Antonio School of Medicine –June 10-12, 2011
This presentation is the intellectual property of the author/presenter. Contact them for permission to
reprint and/or distribute.
Infant Nutrition
SummaryDHA and ARA – is it worth the cost?
Safe
No good evidence of benefit for growth, cognitive development or visual activity
Role in allergy prevention – stay tuned!
Vitamin D
More than just for bones
Significant deficiency/insufficiency exists
400 + IU per day
Infant Nutrition
SummaryCalcium
Significant numbers not meeting requirements
Best identified through diet history
Target at risk groups
Iron
Deficiency under recognized
Significant potential adverse effects
Target at risk groups
Universal screening at 12 months
Nutrition Health Alert
Swallowing gum can be detrimental!