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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.

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Presentation Transcript
how did we get here
HOW DID WE GET HERE?
  • MUST DEVELOP EXPERTISE
  • TIME
  • HISTORY
evolution
EVOLUTION
  • BM – BEST FOR HUMAN BABIES
  • ? IDEAL
  • CHANGES IN DIET/HYGEINE
  • AFFECTED VIT.K, D, Fe
wet nurse an alternative
WET NURSE—AN ALTERNATIVE
  • 4th century B.C.
  • 13th century…highly organized
    • State controlled practice
    • Transmit traits
vessels to feed milk
VESSELS TO FEED MILK
  • BOVINE HORNS
  • ANIMAL HIDE
  • 1800 GLASS FEEDING BOTTLE
middle ages
MIDDLE AGES
  • INFANTS TO SUCKLE FROM ANIMALS
    • GOAT
    • SHEEP
age of weaning
AGE OF WEANING
  • HAS DECREASED FROM AGE 3 YEARS TO THE PRESENT 12 MONTHS.
  • NEVER WEANED IN JULY,AUGUST,SEPTEMBER
animal milk
ANIMAL MILK
  • REPLACED WET NURSES IN 18 CENTURY
  • COW, ASS, GOAT
  • 50-100% MORTALITY RATE IN EARLY 19 CENTURY
slide14
WHY?
  • POOR SANITATION
  • ADULTERATION
  • NO ICE BOX
important events
IMPORTANT EVENTS
  • GERM THEORY DISCOVERED
  • KNOWLEDGE OF MILK COMPOSITION
  • BORDEN-CONDENSED MILK
important events1
IMPORTANT EVENTS
  • PASTUERIZATION
  • RUBBER NIPPLES-CLEAN
  • 1910 ICE BOXES
  • DEVELOPMENT OF FORMULAS
today
TODAY
  • BREAST FEEDING
  • FORMULA
  • BOTH
  • MUCH IS TAKEN FOR GRANTED
objective
OBJECTIVE
  • PROVIDE NUTRIENTS TO SUPPORT OPTIMUM GROWTH
  • DEVELOP OROMOTOR SKILLS
  • APPROPRIATE EATING BEHAVIORS
how much energy is needed
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
slide20

COST OF DEPOSITING FAT

    • 10.8KCAL/GM.

COST OF DEPOSITING PROTEIN

13.4 KCAL/GM.

how much does it take
HOW MUCH DOES IT TAKE?
  • DOUBLE BW IN 4 MONTHS
  • TRIPLE BW IN LESS THAN 12 MONTHS
factors influencing food intake
FACTORS INFLUENCING FOOD INTAKE
  • DENSITY
  • DIGESTIBILITY
  • TASTE PREFERENCES
  • PARENTAL ATTITUDES
  • BREAST VS. BOTTLE
needs
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
HOW DO YOU KNOW?
  • GROWTH
    • NAKED WEIGHT
    • LENGTH BOARD
    • PLOT WT./HT.
    • SHOW GC TO PARENTS
expectations
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
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
POSSIBLE EXCEPTIONS
  • CATCH UP GROWTH
  • CATCH DOWN GROWTH
breast milk
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
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 milk1
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 milk2
BREAST MILK
  • ADVANTAGES OTHER THAN NUTRITIONAL
  • CLEAN MILK
  • PROTECT AGAINST INFECTION
    • MACROPHAGES
    • LYMPHOCYTES
    • LACTOFERRIN
    • LYSOZYMES
    • IgA
slide32
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 milk3
BREAST MILK
  • WHAT WOULD YOU DO?
breast milk4
BREAST MILK
  • GAIN ABOUT 11 GMS./DAY
  • NORMAL OR NOT?
  • ?LABS-----HYPERNATREMIA
  • REMIAFORMULA FEED?
  • LIFESTYLE CHANGES?
insufficient breast milk syndrome
INSUFFICIENT BREAST MILK SYNDROME
  • STRESS STRESS STRESS STRESS
  • CHICKENS LAY FEWER EGGS
  • COWS PRODUCE LESS MILK
  • SO DO HUMANS
formula
FORMULA
  • CONVENIENCE
  • NECESSITY
  • CULTURAL
  • SUPPLEMENTAL
numerous formulas
NUMEROUS FORMULAS
  • SOY
  • COLIC
  • REFLUX
  • ALLERGY
  • GI ABNORMALITES (SHORT GUT, post-infectious gastroenteritis)
  • INBORN ERRORS OF METABOLISM
how do you choose
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
SOY FORMULAS
  • 20 CAL/OZ.
  • SOY PROTEIN
  • FAT- MIXTURE OF VEGETABLE OILS ( PALM,SOY,COCNUT,SFFLOWER,SUNFLOWER)
  • CHO- SUCROSE AND CORN SYRUP
soy formula
SOY FORMULA
  • VEGETARIAN
  • WILL SUPPORT NORMAL GROWTH
  • COLIC?
  • MILK PROTEIN ALLERGY
    • 40% CROSS REACTIVITY
    • NOT IgE
protein hydrolysate
PROTEIN HYDROLYSATE
  • ALIMENTUM
  • NUTRAMIGEN
  • PREGESTIMIL
hydrolyste
HYDROLYSTE
  • HYDROLIZED CASEIN
  • CHO-CORN SYRUP SOLIDS AND MALDEXTRINS
  • FAT-VEGETABLE OIL
  • SOME WITH MCT ( PREGESTIMIL)
hydrolysate
HYDROLYSATE
  • COW MILK PROTEIN ALLERGY
    • STILL POSSIBLE
  • “SEMI-ELEMENTAL” FORMULAS
  • POST INFECTIOUS GASTROENTERITIS
  • COLIC
  • CHOLESTASIS
  • SHORT GUT
elemental formula
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
ELEMENTAL FORMULAE
  • NEOCATE
  • ELECARE
  • NUTRAMIGEN AA
elemental formulae1
ELEMENTAL FORMULAE
  • SHORT GUT SYNDROME
  • COW PROTEIN/SOY PROTEIN ALLERGY
  • COLIC
  • PATIENT DEMAND
  • EXTREMELY EXPENSIVE
  • NOT COVERED BY INSURANCE
follow the money
FOLLOW THE MONEY
  • PRESSURE BY COMPANY REPS
  • SPONSORSHIP OF MEETINGS,LUNCHES ETC.
  • MILLIONS IN COSTS FOR ADVERTISING
  • ENFAMIL AR
key points about formulae
KEY POINTS ABOUT FORMULAE
  • COMMUNICATE REALISTIC EXPECTATIONS TO PARENTS
  • MOST OFTEN SYMPTOMS ARE NOT RELATED TO FORMULA
  • THEREFORE YOU WILL FAIL !
beikost
BEIKOST
  • COMPLIMRNTARY OR WEANING FOODS
beikost1
BEIKOST
  • INTRODUCED BETWEEN 4-6 MOS.
  • GRADUALLY SUPPLIES INCREASING FRACTION OF ENERGY
  • BY 12 MOS. MAY BE 50%
beikost when
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
beikost2
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
beikost3
BEIKOST
  • MONES METHOD
  • AT 4 MOS. INTODUCE CEREALS
  • ONE KIND AT A TIME
  • FOR 1 WEEK
  • HAS VARIETY OF CEREALS
  • IN ONE MONTH
beikost4
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

beikost5
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
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
vitamins1
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
slide62
TIPS
  • FEED ON DEMAND !!

WHEN THE BABY SHOWS CUES OF HUNGER

    • SUCK ON HAND
    • MOVE LIPS
    • FUSS/CRY
    • NO “SCHEDULE”
slide63
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.
slide64
TIPS
  • STOP WHEN FULL
    • TURN AWAY,
    • CLOSE LIPS,
    • SLOW DOWN SUCKING,
    • SPIT OUT NIPPLE