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Infant nutrient needs. Basis/Approach Public health vs individual recommendations, guidelines, education Specific nutrients water energy protein fatty acids vitamin K Vitamin D Iron Fluoride. Growth and development Physiology GI Renal Programming

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Infant nutrient needs
Infantnutrient needs

Basis/Approach

Public health vs individual

recommendations, guidelines, education

Specific nutrients

water

energy

protein

fatty acids

vitamin K

Vitamin D

Iron

Fluoride


Basis of recommendations

Growth and development

Physiology

GI

Renal

Programming

Public health vs individual

Optimize growth and development

Prevent deficiencies

Safety

Prevention of chronic illness and optimize health through life cycle

Basis of recommendations


Approaches to estimating nutrient requirements
Approaches to Estimating Nutrient Requirements

  • Direct experimental evidence (ie protein and amino acids)

  • Extrapolation from experimental evidence relating to human subjects of other age groups or animal models

    • ie thiamin--related to energy intake .3-.5 mg/1000 kcal

  • Breast milk as gold standard (average [] X usual intake)

  • Metabolic balance studies (ie protein, minerals)

  • Clinical Observation (eg: manufacturing errors B6, Cl)

  • Factorial approach

  • Population studies


Challenges
Challenges

  • Strength of Evidence

  • Individual vs population

    • Public health approach

    • Individual genetics

    • Maternal-infant dyad

      • In utero endowment

      • Beliefs, values, choices

      • Relationship/nurture

    • Environmental factors


Public health vs individual
Public health vs individual

  • Prevalence of nutrient deficiencies

  • Balance incidence, burden, and treatment

    • Eg: Vitamin K and hemorrhagic disease of newborn

  • Prevalence and evidence of chronic conditions associated with dietary practices

  • Etiology of nutrient deficiencies and/or chronic conditions

    • Eg: allergy, obesity, anemia, dental caries,…


Individual requirements
Individual Requirements

  • Genetics

  • Adaptation

  • Environment

  • Behavior/activity

  • Choices, access, resources

  • other


1940 s
1940’s

  • Rickets (D)

  • Pellagra (Niacin)

  • Scurvy (C)

  • Beriberi (Thiamin)

  • Xeropthalmia (A)

  • Goiter (Iodine)


United nations 5 th report on world nutrition march 2004
United Nations 5th report on World Nutrition: March 2004


United nations 5 th report on world nutrition march 20041
United Nations 5th report on World Nutrition: March 2004

  • Vitamin A deficiency

    • 140 million preschoolers

    • 7 million pregnant women

  • Iron Deficiency

    • One of most prevalent

    • 4-5 billion affected



Causes
Causes

Nutrition - Disease

Access

Food

Health Care

Environment

Economics

Education


Programming by early diet

Nutrient composition in early diet may have long term effects on GI function metabolism and health

Animal models show that glucose and amino acid transport activities are programmed by composition of early diet

Animals weaned onto high CHO diet have higher rates of glucose absorption as adults compared to those weaned on high protein diet

Barker Hypothesis:

Association between BMI and chronic disease: HTN and cardiovascular, SGA/IUGR

Other examples: early diet associations with allergy, obesity, diabetes

Programming by Early Diet


Allergies prevention by avoidance zeigler pediatr allergy immunol 1994
Allergies: Prevention by Avoidance effects on GI function metabolism and health(Zeigler, Pediatr Allergy Immunol. 1994)

  • High risk infants from atopic families, intervention group n=103, control n=185

  • Restricted diet in pregnancy, lactation, Nutramagen when weaned, delayed solids for 6 months, avoided highly allergenic foods

  • Results: reduced age of onset of allergies


Allergies prevention by avoidance zeigler pediatr allergy immunol 19941
Allergies: Prevention by Avoidance effects on GI function metabolism and health(Zeigler, Pediatr Allergy Immunol. 1994)


Allergies early introduction of foods fergussson et al pediatrics 1990
Allergies: effects on GI function metabolism and healthEarly Introduction of Foods(Fergussson et al, Pediatrics, 1990)

  • 10 year prospective study of 1265 children in NZ

  • Outcome = chronic eczema

  • Controlled for: family hx, HM, SES, ethnicity, birth order

  • Rate of eczema with exposure to early solids was 10% Vs 5% without exposure

  • Early exposure to antigens may lead to inappropriate antibody formation in susceptible children.


Early introduction of foods fergussson et al pediatrics 1990
Early Introduction of Foods effects on GI function metabolism and health(Fergussson et al, Pediatrics, 1990)


Allergies prevention by avoidance marini 1996
Allergies: Prevention by Avoidance effects on GI function metabolism and health(Marini, 1996)

  • 359 infants with high atopic risk

  • 279 in intervention group

  • Intervention: breastfeeding strongly encouraged, no cow’s milk before one year, no solids before 5/6 months, highly allergenic foods avoided in infant and lactating mother


Allergies prevention by avoidance marini 19961
Allergies: Prevention by Avoidance effects on GI function metabolism and health(Marini, 1996)


Cochrane review
Cochrane Review effects on GI function metabolism and health

  • Osborn et al: Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants 2006;18

  • Concluded that use of hydrolysed formula in non breastfed infants at risk for allergy (atopic dermatitis) for at least 4 months reduces the incidence of allergy.


DRI effects on GI function metabolism and health

  • Nutrition Recommendations from the Institute of Medicine (IOM) of the U.S> National Academy of Sciences for general public and health professionals.

  • Hx: WWII, to investigate issues that might “affect national defense”

  • Population/institutional guidelines

  • Application to individuals.


DRI effects on GI function metabolism and health

  • Estimated Average Requirement (EAR): expected to satisfy the needs of 50% of the people in that age group based on review of scientific literature.

  • Recommended Dietary Allowance (RDA): Daily dietary intake level considered sufficient by the FNB to meet the requirement of nearly all (97-98%) healthy individuals. Calculated from EAR and is usually 20% higher

  • Adequate intake (AI): where no RDA has been established.

  • Tolerable upper limit (UL): Caution agains’t excess


Dri s for infants
DRI’s for infants effects on GI function metabolism and health

  • Macronutrients based on average intake of breast milk

  • Protein less than earlier RDA

  • Energy: EER


Dri s for infants1
DRI’s for infants effects on GI function metabolism and health

  • Macronutrients based on average intake of breast milk

  • Protein less than earlier RDA

  • AAP Recommendations

    • Vitamin D: 200 IU supplement for breastfed infants and infants taking <500 cc infant formula

    • Iron: Iron fortified formula (4-12 mg/L), Breastfed Infants supplemented 1mg/kg/d by 4-6 months


Feeding guidelines and recommendations
Feeding Guidelines and Recommendations effects on GI function metabolism and health

  • Public health policy

  • Health promotion

  • Prevention


Recommendations guidelines
Recommendations/guidelines effects on GI function metabolism and health

  • DRI: Dietary Reference Intakes

    • AI

    • UL

    • EER

  • AAP

  • Bright Futures

  • Start Healthy feeding guidelines


Comparison of individual intake data to a reference or estimate of nutrient needs
Comparison of individual intake data to a reference or estimate of nutrient needs

  • DRI: Dietary Reference Intakes

    • periodically revised recommendations (or guidelines) of the National Academy of Sciences

    • quantitative estimates of nutrient intakes for planning and assessing diets for healthy people

AI: Adequate Intake

UL: Tolerable Upper Intake Level

EER: Estimated Energy Requirement


Dri s for infants2
DRI’s for infants estimate of nutrient needs

  • Macronutrients based on average intake of breast milk

    • Protein less than earlier RDA

    • Factors to consider: fetal endowment, individual variability, impact of diet on bioavailability and need



Bright futures
Bright Futures Toddlers (JADA, 2004)

AAP/HRSA/MCHB

http://www.brightfutures.org

“Bright Futures is a practical development approach to providing health supervision for children of all ages from birth through adolescence.”


Examples
Examples Toddlers (JADA, 2004)

  • Transition

  • Supplements to breastmilk

  • Safety

  • Allergy prevention

  • Dental health

  • other


Water

Water Toddlers (JADA, 2004)


Water1
Water Toddlers (JADA, 2004)

  • Water requirement is determined by:

    • water loss

      • evaporation through the skin and respiratory tract (insensible water loss)

      • perspiration when the environmental temperature is elevated

      • elimination in urine and feces.

    • water required for growth

    • solutes derived from the diet


Water2
Water Toddlers (JADA, 2004)

  • Water lost by evaporation in infancy and early childhood accounts for more than 60% of that needed to maintain homeostasis, as compared to 40% to 50% later in life

  • NAS recommends 1.5 ml water per kcal in infancy.


Renal

Limited ability to concentrate urine in first year due to immaturities of nephron and pituitary

Potential Renal solute load determined by nitrogenous end products of protein metabolism, sodium, potassium, phosphorus, and chloride.

Renal


Ur ine concentrations

Most normal adults are able to achieve urine concentrations of 1300 to 1400 mOsm/l

Healthy newborns may be able to concentrate to 900-1100 mOsm/l, but isotonic urine of 280-310 mOsm/l is the goal

In most cases this is not a concern, but may become one if infant has fever, high environmental temperatures, or diarrhea

Urine Concentrations


Renal solute load
Renal solute load of 1300 to 1400 mOsm/l

  • Samuel Foman J Pediatrics Jan 1999 134 # 1 (11-14)

  • RSL is important consideration in maintaining water balance:

    • In acute febrile illness

    • Feeding energy dense formulas

    • Altered renal concentrating ability

    • Limited fluid intake


Water needs
Water Needs of 1300 to 1400 mOsm/l


Water3
Water of 1300 to 1400 mOsm/l

  • Individual needs

  • Renal concentrating ability

  • Solute in diet

  • Health

  • environment


  • Water vs fluid of 1300 to 1400 mOsm/l

  • Concentrating formula decreases free water and increases RSL

  • What is the % water in 20 kcal/oz infant formula?

    • 90%

    • To achieve 100 ml/kg/d needs to consume at least 110 cc/kg/d


Energy requirements
Energy Requirements of 1300 to 1400 mOsm/l

  • Higher than at any other time per unit of body weight

  • Highest in first month and then declines

  • High variability - SD in first months is about 15 kcal/kg/d

  • Breastfed infants many have slighly lower energy needs

  • RDA represents average for each half of first year


Energy requirements cont
Energy Requirements, cont. of 1300 to 1400 mOsm/l

  • RDA represents additional 5% over actual needs and is likely to be above what most infants need.

  • Energy expended for growth declines from approximately 32.8% of intake during the first 4 months to 7.4% of intake from 4 to 12 months




2002 Energy DRI of 1300 to 1400 mOsm/l


EER of 1300 to 1400 mOsm/l

  • 0-3 months (89 x wt -100) + 175

  • 4-6 months (89 x wt -100) + 56

  • 7-12 months (89 x wt -100) + 22

  • 13-35 months (89 x wt -100) + 20

  • Equations for older children factor in weight, height and physical activity level (PAL)


Examples of eer by age and weight
Examples of EER by age and weight of 1300 to 1400 mOsm/l


Energy
Energy of 1300 to 1400 mOsm/l

Correlate individual intake with growth


2002 Carbohydrate DRI of 1300 to 1400 mOsm/l


Protein
Protein of 1300 to 1400 mOsm/l

  • Increases in body protein are estimated to average about 3.5 g/day for the first 4 months, and 3.1 g/day for the next 8 months.

  • The body content of protein increases from about 11.0% to 15.0% over the first year


2002 Protein DRI of 1300 to 1400 mOsm/l


2002 Fat DRI of 1300 to 1400 mOsm/l


Essential fatty acids
Essential Fatty Acids of 1300 to 1400 mOsm/l

  • The American Academy of Pediatrics and the Food and Drug Administration specify that infant formula should contain at least 300 mg of linoleate per 100 kilocalories or 2.7% of total kilocalories as linoleate.


Lcpufa

LCPUFA of 1300 to 1400 mOsm/l

DHA and ARA


Lcpufa background
LCPUFA: Background of 1300 to 1400 mOsm/l


Lcpufa background1
LCPUFA: Background of 1300 to 1400 mOsm/l

  • Ability to synthesize 20 C FA from 18 C FA is limited.

  • n-3 and n-6 fatty acids compete for enzymes required for elongation and desaturation

  • Human milk reflects maternal diet, provides AA, EPA and DHA

  • n-3 important for neurodevelopment, high levels of DHA in neurological tissues

  • n-6 associated with growth & skin integrity



Formula supplementation with long-chain polyunsaturated fatty acids: are there developmental benefits? Scott et al. Pediatrics, Nov. 1998.

  • RCT, 274 healthy full term infants

  • Three groups:

    • standard formula

    • standard formula with DHA (from fish oil)

    • formula with DHA and AA (from egg)

  • Comparison group of BF


Outcomes at 12 and 14 months
Outcomes at 12 and 14 months fatty acids: are there developmental benefits? Scott et al. Pediatrics, Nov. 1998.

  • No significant differences in Bayley, Mental or Psychomotor Development Index

  • Differences in vocabulary comprehension across all categories and between formula groups for vocabulary production.


Conclusion
Conclusion fatty acids: are there developmental benefits? Scott et al. Pediatrics, Nov. 1998.

“We believe that additional research should be undertaken before the introduction of these supplements into standard infant formulas.”


PUFA Status and Neurodevelopment: A summary and critical analysis of the literature(Carlson and Neuringer, Lipids, 1999)

  • In animal studies use deficient diets through generations - effects on newborn development may be through mothering abilities.

  • Behaviors of n-3 fatty acid deficient monkeys: higher frequency of stereotyped behavior, locomotor activity and behavioral reactivity


Efficacy and safety of docosahexaenoic acid and arachidonic acid addition to infant formulas: can one buy better vision and intelligence?(Koo. J Am Coll Nutr. 2003 Apr;22(2):101-7)

  • “Functional benefits in particular visual or neural development from IF containing LCPUFA remains controversial.”

  • “Potential for excessive and/or imbalanced intake of n-6 and n-3 fatty acids exists with increasing fortification of LCPUFA to infant foods other than IF.”


Formula supplemented with dha ara a critical review of the research wright et al 2006
Formula Supplemented with DHA & ARA: A Critical Review of the Research(Wright et al, 2006)

  • 10 RCTs from 1997-2003 of variable quality

  • Considered the strength of each study by looking at indices of research quality.


Wright et al cont
Wright et al, cont. the Research

  • Growth (7 studies)

    • no differences in weight, length, OFC

  • FA in blood (7 studies)

    • DHA & ARA higher with supplementation

    • those supplemented with only DHA had lower levels of ARA than those on standard formula

    • Supplementation with LCPUFA for only 17 weeks lead to higher EFA levels at 1 year of age


Wright et al cont1
Wright et al, cont. the Research

  • Vision (6 trials)

    • 2 found better visual function with LCPUFA , 4 did not

  • Neurodevelopment

    • 1 of 4 found positive results on Bayley Scales of Infant Development II

    • 2 of 5 found positive information processing/IQ/cognitive effects


Wright et al cont2
Wright et al, cont the Research

  • Conclusions

    • No detrimental effects found

    • Possibly a small improvement in visual acuity, but significance of this small effect in global development is questionable

    • “thoughtful consideration is advised before recommending more expensive formula for term infants.”


Longchain polyunsaturated fatty acid supplementation in infants born at term cochrane 2001
Longchain polyunsaturated fatty acid supplementation in infants born at term(Cochrane, 2001).

  • At present there is little evidence from randomised trials of LCPUFA supplementation to support the hypothesis that LCPUFA supplementation confers a benefit for visual or general development of term infants.

  • A beneficial effect on information processing is possible but larger studies over longer periods are required to conclude that LCPUFA supplementation provides a benefit when compared with standard formula.

  • Data from randomised trials do not suggest that LCPUFA supplements influence the growth of term infants


Omega-3 FA and Neural Development to 2 years of Age: Do we Know enough for Dietary Recommendations: Innis JPGN 48:S16-24:2009

  • Estimated requirement and variability among individuals necessary to set DRI

  • Dietary recommendations affect food supply and supplements and are used in labeling

  • When scientific information is incomplete, consideration must be given to implications of recommendations


Omega-3 FA and Neural Development to 2 years of Age: Do we Know enough for Dietary Recommendations: Innis JPGN 48:S16-24:2009

  • “ While there is no doubt that DHA is critical for the developing brain, western diets poor in w-3 FA and rich in w-6 FA are becoming increasingly implicated in contributing to risk of poor neurodevelopment and function…..The w-3 FAs are clearly essential nutrients, suggesting that dietary recommendations, such as AI, to minimize risk of poor CNS development can be justified, and are consistent with a philosophy of dietary advice that promotes optimal child development and health. However, because dietary recommendations often promulgate changes in the food supply and supplement use…..premature recommendations based on incomplete science that focus on individual nutrients rather than dietary practices such as breastfeeding and foods such as fish rich in DHA are not necessarily in the best public interest”


Vitamin k
Vitamin K Know enough for Dietary Recommendations: Innis JPGN 48:S16-24:2009


Vitamin k1
Vitamin K Know enough for Dietary Recommendations: Innis JPGN 48:S16-24:2009

  • 2 forms: K1 or phylloquinone (plant form) and K2 (synthesized by bacteria)

  • Function: cofactor inmetabolic conversion of precursors of Vitamin K dependent proteins to active form ( eg: prothrombins, osteocalcin)


Vitamin k2
Vitamin K Know enough for Dietary Recommendations: Innis JPGN 48:S16-24:2009

  • Lack of specific information regarding an infant’s requirement

  • Vitamin K concentration of breastmilk is low and for the breastfeeding infant a deficiency state has been described

  • No “gold standard” available


Vitamin k3
Vitamin K Know enough for Dietary Recommendations: Innis JPGN 48:S16-24:2009

  • DRI for infants 2-2.5 ug/day

  • Formula provides 7-9 ug/kg/d

  • BM contains < 10 ug/L

  • Hemorrhagic disease of the Newborn…Vitamin K deficiency

  • Prophylaxis: 1 mg Vitamin K IM for all newborn infants


Vitamin k controversy
Vitamin K Controversy Know enough for Dietary Recommendations: Innis JPGN 48:S16-24:2009

  • Adequacy of BM

  • Maternal Diet and Vitamin A content of BM

  • ? Significance/prevalence of hemorrhagic disease of newborn

  • IM injections of all newborns



Vitamin k deficiency definitions aap 2003
Vitamin K Deficiency- definitions – AAP, 2003 Policy Statement, 2003

* Formerly known as classic hemorrhagic disease of the newborn


Incidence of vkdb
Incidence of VKDB Policy Statement, 2003

  • Early: 0.25%–1.7% incidence

  • Late:

    • No vitamin K prophylaxis: 4.4 to 7.2 per 100,000 births

    • Single oral vitamin K prophylaxis:1.4 to 6.4 per 100 000 births

    • IM vitamin K prophylaxis: 0

  • Oral vitamin K has effect similar to IM in preventing early VKDB, but not in preventing late VKDB


Danielson et al arch dis child 2004 89 f546 550
Danielson et al Arch Dis Child 2004 89:F546-550 Policy Statement, 2003

  • Late onset vitamin K deficient bleeding in infants who did not receive prophylactic vitamin K at birth in Hanoi province

    • Incidence: 116 per 100,000 births

    • Higher in rural areas

    • 9% mortality

    • 42% impaired neurodevelopmental status at discharge in survivors


Incidence
Incidence Policy Statement, 2003

  • Netherlands 2005: 3.2 per 100,000 births

  • Canada 2004: 0.45 per 100,000 births

    • Conclude low incidence associated with current practice of prophylactic Vitamin K at birth


Closing the loophole midwives and the administration of vitamin k in the neonate
Closing the Loophole:Midwives and the Administration of Vitamin K in the Neonate

Adame and Carpenter J Pediatr 2009 154:769-771

Case Report of a previously healthy, exclusively breastfed 6 week old infant delivered by a midwife on the south Texas border. Did not receive Vitamin K at birth. Admitted with severe intracranial hemorrhage, cooagulopathy, and seizures, unresponsive, pupils fixed and dialated


Cochran prophylactic vitamin k for preventing haemorrhagic disease in newborn infants
Cochran Prophylactic Vitamin K for preventing haemorrhagic disease in newborn infants

Vitamin K deficiency can cause bleeding in an infant in the first weeks of life. This is known as Haemorrhagic Disease of the Newborn (HDN) or Vitamin K Deficiency Bleeding (VKDB).


Cochran
Cochran disease in newborn infants

  • The risk of developing vitamin K deficiency is higher for the breastfed infant because breast milk contains lower amounts of vitamin K than formula milk or cow's milk


Cochran1
Cochran disease in newborn infants

  • In different parts of the world, different methods of vitamin K prophylaxis are practiced.


Cochran2
Cochran disease in newborn infants

  • Oral Doses:

  • The main disadvantages are that the absorption is not certain and can be adversely affected by vomiting or regurgitation. If multiple doses are prescribed the compliance can be a problem


Cochran3
Cochran disease in newborn infants

  • I.M. prophylaxis is more invasive than oral prophylaxis and can cause a muscular haematoma. Since Golding et al reported an increased risk of developing childhood cancer after parenteral vitamin K prophylaxis (Golding 1990 and 1992) this has been a reason for concern .


Cochrane conclusions 2000
Cochrane Conclusions, 2000 disease in newborn infants

  • A single dose (1.0 mg) of intramuscular vitamin K after birth is effective in the prevention of classic HDN.

  • Either intramuscular or oral (1.0 mg) vitamin K prophylaxis improves biochemical indices of coagulation status at 1-7 days.

  • Neither intramuscular nor oral vitamin K has been tested in randomized trials with respect to effect on late HDN.

  • Oral vitamin K, either single or multiple dose, has not been tested in randomized trials for its effect on either classic or late HDN.


Brousson and Klien, Controversies surrounding the administration of vitamin K to newborns; a review. CMAJ. 154(3):307-315, February 1, 1996.

  • Study selection: Six controlled trials met the selection criteria: a minimum 4-week follow-up period, a minimum of 60 subjects and a comparison of oral and intramuscular administration or of regimens of single and multiple doses taken orally. All retrospective case reviews were evaluated. Because of its thoroughness, the authors selected a meta-analysis of almost all cases involving patients more than 7 days old published from 1967 to 1992. Only five studies that concerned safety were found, and all of these were reviewed


Brousson and Klien, Controversies surrounding the administration of vitamin K to newborns; a review. CMAJ. 154(3):307-315, February 1, 1996.

  • Data synthesis: Vitamin K (1 mg, administered intramuscularly) is currently the most effective method of preventing HDNB. The previously reported relation between intramuscular administration of vitamin K and childhood cancer has not been substantiated. An oral regimen (three doses of 1 to 2 mg, the first given at the first feeding, the second at 2 to 4 weeks and the third at 8 weeks) may be an acceptable alternative but needs further testing in largeclinical trials.


Brousson and Klien, Controversies surrounding the administration of vitamin K to newborns; a review. CMAJ. 154(3):307-315, February 1, 1996

  • Conclusion: There is no compelling evidence to alter the current practice of administering vitamin K intramuscularly to newborns.


Aap recommendations pediatrics vol112 1 july 2003
AAP Recommendations: Pediatrics:Vol112#1 July 2003 administration of vitamin K to newborns; a review.

1. Vitamin K1 should be given to all newborns as a single, intramuscular dose of 0.5 to 1 mg.

2. Further research on the efficacy, safety, and bioavailability of oral formulations of vitamin K is warranted.


Aap recommendations
AAP Recommendations administration of vitamin K to newborns; a review.

3. Health care professionals should promote awareness among families of the risks of late VKDB associated with inadequate vitamin K prophylaxis from current oral dosage regimens, particularly for newborns who are breastfed exclusively

4. Earlier concern regarding a possible causal association between IM vitamin K and childhood cancer has not been substantiated



Vitamin d
Vitamin D Japan


Vitamin d1
Vitamin D Japan

  • Role

  • Source

    • Dietary

    • sunlight

  • Deficiency

    • Rickets


Role Japan

  • Enhances intestinal absorption of Ca

  • Increase tubular resorption of Ph

  • Mediation of recycling of Ca and Ph for bone growth and remodeling

  • Sterol hormone

    • Deficiency: Rickets


Role Japan

  • Extraskeletal effects of Vitamin D

    • Modulates B and T Lymphocyte fx and deficiency may be associated with autoimmune diseases (diabetes, MS associations)

    • Regulation of cell growth (assoc with breast, prostrate, and colon cancer)


Prevalence
Prevalence Japan

  • Thought to be disease of past (prior to 1960’s)

    • Disappeared secondary to recognition of role of sunlight, fortification of milk, use of multivitamins, AAPCON recommendation for 400 IU supplementation of infants


Prevalence1
Prevalence Japan

  • Increased incidence and case reports 1970’2

  • No national data in US

    • Georgia 1997-99: 9 per million hospitalized children

    • National Hospital Discharge Survey: 9 per million

    • Pediatric Research in Office Setting (AAP):23-32 hospitalized cases reported 1999-2000


Prevalence2
Prevalence Japan

  • Literature Review

    • 13 articles published between 1996-2001

    • 122 case reports


Prevention of rickets and vitamin d deficiency new guidelines for vitamin d intake

Prevention of Rickets and Vitamin D Deficiency: New Guidelines for Vitamin D Intake

PEDIATRICS Vol. 111 No. 4 April 2003, pp. 908-910


Vitamin d and sunlight
Vitamin D and Sunlight Guidelines for Vitamin D Intake

  • Vitamin D requirements are dependenton the amount of exposure to sunlight.

  • Dermatologists recommend caution with sun exposure.

    • Sunscreens markedly decrease vitamin D production in the skin

    • Decreased sunlight exposure occurs during the winter and other seasons and when sunlight is attenuated by clouds, air pollution, or the environment

    • AAP recommends against exposing infants < 6 months to direct sun


Breastfeeding and vitamin d
Breastfeeding and Vitamin D Guidelines for Vitamin D Intake

  • Breastmilk has < 25 IU/L Recommended adequate intake can not be met with breastmilk alone

  • Formerly stated that needs could be met with sun exposure, but now, due to cancer concerns recommend against this


Vitamin d recommendations
Vitamin D Recommendations Guidelines for Vitamin D Intake

  • Before 2003 AAP recommended 10 mg (400 IU) per day for breastfeed infants

  • 2003: American Academy of Pediatrics recommends supplements of 5 mg (200 IU) per day for all infants as recommended in DRIs.

  • 10/14/2008: AAP updates guidelines vor vitamin D intake for infants, children, and teens to be published in Nov 5th ed Pediatrics

    • 400 IU per day intake of vitamin D beginning in first few days of life


Formulas
Formulas Guidelines for Vitamin D Intake

  • if an infant is ingesting at least 500 mL per day of formula (vitamin D concentration of 400 IU/L), he or she will receive the recommended vitamin D intake of 200 IU per day.

  • If intake is less than 500 ml recommend additional supplement of vitamin D


Summary of aap recommendations 2003
Summary of AAP Recommendations, 2003 Guidelines for Vitamin D Intake

  • All breastfed infants unless they are weaned to at least 500 mL per day of vitamin D-fortified formula or milk.

  • All nonbreastfed infants who are ingesting less than 500 mL per day of vitamin D-fortified formula or milk.

  • Children and adolescents who do not get regular sunlight exposure, do not ingest at least 500 mL per day of vitamin D-fortified milk, or do not take a daily multivitamin supplement containing at least 200 IU of vitamin D.


Aap recommendations for vitamin d
AAP Recommendations for Vitamin D Guidelines for Vitamin D Intake

  • 2008

    • Intake of 400 IU beginning in first few days of life

      • Supplement breastfed, partially breastfed, infants and children consuming less than 1 liter formula or vitamin D fortified whole milk

      • Wagner et al: Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents: Pediatrics 2008;122;1142-1152


Vitamin d2
Vitamin D Guidelines for Vitamin D Intake

  • DRI: B-6 months 200 IU, 7-12 months 250 IU

  • UL: 1000 IU


Iron Guidelines for Vitamin D Intake


Iron Guidelines for Vitamin D Intake

  • Function

  • Source

    • Formula, breast milk, other foods

    • Bioavailability:

      • Breast milk

      • Soy formula

  • Deficiency

    • Anemia


Anemia
Anemia Guidelines for Vitamin D Intake

  • Anemia (low Hct, Hgb: not specific for iron deficiency)

    Causes:

    • Inadequate iron in diet

    • Loss

      • GI bleeding, cows milk proteins, infectious agents

  • Other

    • Genetics

    • Lead

    • Other nutrients


Iron Guidelines for Vitamin D Intake

  • Biological function

    • Oxygen transport primarily in hemoglobin

    • Component of other proteins including cytochrome a, b, c, and cytochrome oxidase essential for electron transport and cellular energetics


Iron deficiency id and ida
Iron deficiency (ID and IDA) Guidelines for Vitamin D Intake

  • Anemia: Hgb <11 g/dl 12-36 months

  • Iron deficiency Anemia (IDA): anemia due to iron deficiency

  • Iron deficiency: Insufficient iron to maintain normal physiologic functions leading to decrease in iron stores as measured by serum ferritin with or without IDA



Iron deficiency anemia
Iron Deficiency Anemia development

  • Impact on social, neurobehavioral and sleep

    • Peirano et al: Sleep and Neurofunction Throughout Child development: Lasting Effects of Early Iron Deficiency J Ped Gastroenterology and Nutr 2009 48:S8-S15

    • Lozoff et al: Dose-Response Relationships between Iron deficiency with or without anemia and Infant Social-emotional Behavior J Pediatr 2008 152:696-702


Peirano
Peirano development

Slower neurotransmission in auditory and visual systems

Different motor activity patterning sleep-waking and sleep state organization

Alterations in behavioral and cognitive function


Lozoff
Lozoff development

  • N=77

  • “Infant social-emotional behavior appears to be adversely affected by iron deficiency with or without anemia”

    • Shyness, orientation engagement, soothability


Carter et al iron deficiency anemia and cognitive function in infancy pediatrics 2010 126 2427 e434
Carter et al: Iron Deficiency Anemia and Cognitive Function in Infancy: Pediatrics 2010 126;2427-e434

  • N= 87 (28 IDA, 49 no anemia)

  • Methods: at 9 and 12 months series of cognitive, intellegent and behavioral tests administered (Fagan test of infant intellegence (FTII), Emotionality, Activity and Sociability Temperment Survey, and Behavior Rating Scale (BRS))


Carter et al iron deficiency anemia and cognitive function in infancy pediatrics 2010 126 2427 e4341
Carter et al: Iron Deficiency Anemia and Cognitive Function in Infancy: Pediatrics 2010 126;2427-e434

  • N= 87 (28 IDA, 49 no anemia)

  • Methods: at 9 and 12 months series of cognitive, intellegent and behavioral tests administered (Fagan test of infant intellegence (FTII), Emotionality, Activity and Sociability Temperment Survey, and Behavior Rating Scale (BRS))


Carter et al iron deficiency anemia and cognitive function in infancy pediatrics 2010 126 2427 e4342
Carter et al: Iron Deficiency Anemia and Cognitive Function in Infancy: Pediatrics 2010 126;2427-e434

  • Results

    • Sociodemographic background similar between 2 groups

    • IDA infants less likely to exhibit object permanence, less novelty preference on the FTII, lower BRS scores, and decrease engagement/orientation, described as “shyer”


Iron deficiency
Iron Deficiency in Infancy: Pediatrics 2010 126;2427-e434

  • Among children in developing world, iron is the most common single nutrient deficiency

  • No national statistics for prevalence of ID or IDA < 12 months


Iron fortification of formula
Iron Fortification of Formula in Infancy: Pediatrics 2010 126;2427-e434

  • “The increased use of iron-fortified infant formulas from the early 1970s to the late 1980s has been a major public health policy success. During the early 1970s, formulas were fortified with 10 mg/L to 12 mg/L of iron in contrast with nonfortified formulas that contained less than 2 mg/L of iron. The rate of iron-deficiency anemia dropped dramatically during that time from more than 20% to less than 3%.”


Id and ida 12 35 months nhanes 2002
ID and IDA 12-35 Months NHANES 2002 in Infancy: Pediatrics 2010 126;2427-e434


Iron in Infancy: Pediatrics 2010 126;2427-e434

  • Iron absorption from soy formulas is less

  • Greater bioavailabilty of iron in breastmilk


Iron absorption in infancy
Iron Absorption In Infancy in Infancy: Pediatrics 2010 126;2427-e434


Iron deficiency in breastfeeding
Iron Deficiency in Breastfeeding in Infancy: Pediatrics 2010 126;2427-e434

  • At 4 to 5 months prevalence of low iron stores in exclusively breastfed infants is 6 - 20%.

  • A higher rate (20%-30%) of iron deficiency has been reported in breastfed infants who were not exclusively breastfed

  • The effect of iron obtained from formula or beikost supplementation on the iron status of the breastfed infant remains largely unknown and needs further study.


Foman on iron 1998
Foman on Iron - 1998 in Infancy: Pediatrics 2010 126;2427-e434

  • Proposes that breastfed infants should have supplemental iron (7 mg elemental) starting at 2 weeks.

  • Rational:

    • some exclusively breastfed infants will have low iron stores or iron deficiency anemia

    • Iron content of breastmilk falls over time

    • animal models indicate that deficits due to Fe deficiency in infants may not be recovered when deficiency is corrected.


Aap recommendations for dx and prevention of id and ida 2010 pediatrics 2010 126 5
AAP recommendations for Dx and prevention of ID and IDA:2010 in Infancy: Pediatrics 2010 126;2427-e434Pediatrics 2010 126 #5

  • Birth-6 months: 0.27 mg/d

    • Assuming average content Breastmilk 0.35 mg/L and average intake 0.78 L/day

    • Noted variability of iron content of breastmilk, high risk populations (IUGR, LGA associate with maternal IDM, maternal anemia, Preterm birth)


Aap recommendations for dx and prevention of id and ida 2010 pediatrics 2010 126 51
AAP recommendations for Dx and prevention of ID and IDA:2010 in Infancy: Pediatrics 2010 126;2427-e434Pediatrics 2010 126 #5

  • 7-12 months: 11 mg/d

    • Factorial approach: iron loss, iron needed for increased blood volume, tissue mass, and stores

    • Noted that there isn’t a sudden increase in needs from 6 to 7 months.


Aap recommendations for dx and prevention of id and ida 2010 pediatrics 2010 126 52
AAP recommendations for Dx and prevention of ID and IDA:2010 in Infancy: Pediatrics 2010 126;2427-e434Pediatrics 2010 126 #5

  • Diagnosis:

    • Iron status is a continuum with IDA at one end of the spectrum

    • No single measurement is currently available to characterize iron status

    • HgB limitations include specificity and sensitivity. Identifies anemia but not necessarily ID or IDA


Aap recommendations for dx and prevention of id and ida 2010 pediatrics 2010 126 53
AAP recommendations for Dx and prevention of ID and IDA:2010 in Infancy: Pediatrics 2010 126;2427-e434Pediatrics 2010 126 #5

  • Term, healthy infants have sufficient Fe to 4 months.

  • Formula fed: Fe needs met by standard infant formula with 12 mg/dl and introduction of complementary foods after 4-6 months. Whole milk shouldn’t be used < 12 months

  • Breastfed: Exclusively breastfed infants are a increasing risk of ID >4 months and should be supplemented with 1 mg/kg/d oral Fe until appropriate complimentary food are introduced


Aap recommendations for dx and prevention of id and ida 2010 pediatrics 2010 126 54
AAP recommendations for Dx and prevention of ID and IDA:2010 in Infancy: Pediatrics 2010 126;2427-e434Pediatrics 2010 126 #5

  • 6-12 months

    • 11 mg/d

    • Use complimentary foods with higher iron content. Liquid supplement may be needed to augment complimentary foods


Aap recommendations for dx and prevention of id and ida 2010 pediatrics 2010 126 55
AAP recommendations for Dx and prevention of ID and IDA:2010 in Infancy: Pediatrics 2010 126;2427-e434Pediatrics 2010 126 #5

  • Univeral screening should be done at 12 months with Hgb and risk determination

  • Additional screening can be preformed at any time if there is a risk of ID/IDA including inadequate intake


Lead and anemia
Lead and Anemia in Infancy: Pediatrics 2010 126;2427-e434


Fluoride
Fluoride in Infancy: Pediatrics 2010 126;2427-e434

  • Fluoride and dental caries

    • At beginning of 20th century dental caries was common with extraction only treatment available

    • Failure to meet minimum standards of 6 opposing teeth was common cause of rejection from military service in WWI and WWII


Fluoride1
Fluoride in Infancy: Pediatrics 2010 126;2427-e434

  • 1901 Dr. Frederick S Mckay noted mottled teeth (fluorosis) in practice in Colo Springs Colo that were resistent to decay

  • 1909 Dr. FC Robertson noted same mottling in his area of practice after a new well dug

    • Believed was due to something in the water


Fluoride2
Fluoride in Infancy: Pediatrics 2010 126;2427-e434

  • 1945 study was conducted in 4 city pairs (Michigan, NY, Illinois, Ontario)

  • Followed 13-15 years

  • 50-60% reduction in dental caries


Fluoride3
Fluoride in Infancy: Pediatrics 2010 126;2427-e434

  • Proposed mode of action

    • Promotes remineralization of areas of cariogenic lesions

    • Increases resistance to acid demineralization

    • Interferes with formation and function of plaque forming microorganisms

    • Improves tooth morphology


Fluoride4
Fluoride in Infancy: Pediatrics 2010 126;2427-e434

  • Concerns

    • Excess

    • Fluorosis

    • Cancer

    • other


Fluoride5
Fluoride in Infancy: Pediatrics 2010 126;2427-e434

  • Fluoride Recommendations were changed in 1994 due to concern about fluorosis.

  • Breast milk has a very low fluoride content.

  • Fluoride content of commercial formulas has been reduced to about 0.2 to 0.3 mg per liter to reflect concern about fluorosis.

  • Formulas mixed with water will reflect the fluoride content of the water supply. Fluorosis is likely to develop with intakes of 0.1 mg/kg or more.


Fluoride cont
Fluoride, cont. in Infancy: Pediatrics 2010 126;2427-e434

  • Fluoride adequacy should be assessed when infants are 6 months old.

  • Dietary fluoride supplements are recommended for those infants who have low fluoride intakes.


Early childhood caries
Early Childhood Caries in Infancy: Pediatrics 2010 126;2427-e434

  • AKA Baby Bottle Tooth Decay

  • Rampant infant caries that develop between one and three years of age


Early childhood caries etiology
Early Childhood Caries: Etiology in Infancy: Pediatrics 2010 126;2427-e434

  • Bacterial fermentation of cho in the mouth produces acids that demineralize tooth structure

  • Infectious and transmissible disease that usually involves mutans streptococci

  • MS is 50% of total flora in dental plaque of infants with caries, 1% in caries free infants


Early childhood caries etiology1
Early Childhood Caries: Etiology in Infancy: Pediatrics 2010 126;2427-e434

  • Sleeping with a bottle enhances colonization and proliferation of MS

  • Mothers are primary source of infection

  • Mothers with high MS usually need extensive dental treatment


Early childhood caries pathogenesis
Early Childhood Caries: Pathogenesis in Infancy: Pediatrics 2010 126;2427-e434

  • Rapid progression

  • Primary maxillary incisors develop white spot lesions

  • Decalcified lesions advance to frank caries within 6 - 12 months because enamel layer on new teeth is thin

  • May progress to upper primary molars


Early childhood caries prevalence
Early Childhood Caries: Prevalence in Infancy: Pediatrics 2010 126;2427-e434

  • US overall - 5%

  • 53% American Indian/Alaska Native children

  • 30% of Mexican American farmworkers children in Washington State

  • Water fluoridation is protective

  • Associated with sleep problems & later weaning


Early childhood caries cost
Early Childhood Caries: Cost in Infancy: Pediatrics 2010 126;2427-e434

  • $1,000 - $3,000 for repair

  • Increased risk of developing new lesions in primary and permanent teeth


Early childhood caries prevention
Early Childhood Caries: Prevention in Infancy: Pediatrics 2010 126;2427-e434

  • Anticipatory Guidance:

    • importance of primary teeth

    • early use of cup

    • bottles in bed

    • use of pacifiers and soft toys as sleep aides


Early childhood caries prevention1
Early Childhood Caries: Prevention in Infancy: Pediatrics 2010 126;2427-e434

  • Chemotheraputic agents: fluoride varnishes and supplements, chlorhexidene mouthwashes for mothers with high MS counts

  • Community education: training health providers and the public for early detection


Infant feeding
Infant Feeding in Infancy: Pediatrics 2010 126;2427-e434

  • Implications

  • Translation into practice

  • Recommendations


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