What were the millenium developmental goals?
UN Initiative 2000-2015
When do we use WHO vs CDC growth charts?
WHO <24 months
CDC >24 months
Why use the WHO growth charts?
- for <24mo
- Growth of BF infant is standard
- Better description of physiological growth in infancy
- Based on high quality study aimed at developing growth charts
What is stunting?
Low height for age (2 SD)
When does stunting start?
•before birth ( poor maternal nutrition)
Why does stunting occur?
- Before birth: poor maternal nutrition
- Poor feeding practices
- Poor food quality
- Frequent infection (--> slowed growth)
What is wasting?
Low Weight for Height
by 2 SD
Definition of underweight
Low Weight for Age
Major contributor to under-five deaths?
Interventions to prevent undernutrition?
•Breast feeding within one hour of birth
•Exclusive breast feeding through 6 mos
•Adequate complementary feeding
Why is breastfeeding recommended?
•Different effects on metabolism
•More open to variety of tastes (formula always tastes the same, BM flavor varies w/mom's diet)
Why is formula used?
As a substitute for human milk
How is formula regulated in the U.S.?
- •Carefully controlled by FDA
- –Nutrients (sugar, fat and protein)
- –Nutrients (sugar, fat and protein)
Preparations of formula on the market
Ready to feed
make sure you ask how they prepare their formula - ensure doing correctly
Why is iron fortification recommended in formula?
–Meet hgb needs after maternal stores depleted (RBCs last 120 days - after 4 months needs restoring)
–Increase stores prior to whole cow's milk: Prevent IDA
–Improve alertness, ability to interact and learn
Iron absorption from breast milk vs formula?
•50% of iron absorbed from breast milk
•12% of iron absorbed from formula
How much iron in iron fortified formulas?
•Iron fortified formulas contain 10-12 mg/l
•Low iron formulas discontinued (were used for fussy babies - no evidence and deprives of needed Fe)
Formula recommendations for non-breast fed term healthy babies?
–Start on CM formula at 20cal/oz
What is DHA/ARA and why is it being added to formulas?
•DHA(Omega-3)/ARA (Arachidonic acid)
–Structural fats found in brain and retina
–Better cognitive and visual development (until 18 months)
–Now all formulas fortified
Why are prebiotics being added to formula?
to help develop the immune system
Rationale for avoiding palm oil in formula?
Improved calcium absorption w/o palm oil
What are the various types of formula on the market?
Contents of Cow's Milk Formulas
•Sugar – lactose
•Protein– cow’s milk
•Minor differences in whey/casein ratios
•Non-nursing babies started on CM formula
Brands of Cow's Milk Formula available? Position of AAP?
•Similac, Enfamil, Good Start, store brands
•AAP – no statement supporting brand
What is different about Similac Organic formula?
•Meets USDA criteria: 95% free
How is does Similac organic compare to non-organic similac?
•Same nutrition as other Similac
•DHA, ARA supplements
•AAP – no benefit to organic BUT:
–Lower exposure to pesticides
–Meats not treated with antibiotics
2012 Position of AAP on organic foods?
•no benefit to organic BUT:
–Lower exposure to pesticides
–Meats not treated with antibiotics ( resistance)
–No large studies to prove better
–Higher costs to families
What age group os Similac Newborn intended for?
Birth to 3 months
Benefits of Similac Newborn?
–27 oz. provides all Vit D (vs 32 oz)
• no need for supplement
–Whey-casein (60-40) ratio more similar to BM in first 6 mos
When and why was soy-based formula introduced?
•1929- intolerance to CM formula
Brands of soy-based formula?
•All brands equivalent
Is soy formula iron fortified?
Calories /nutrition in soy based formula vs cow's milk formula?
BUT recent studies call into question nutritional adequacy and safety
Composition of soy'based formula?
–Corn syrup solids
•Fats from vegetable oil
•Iron fortified, zinc fortified
•Meet vitamin, mineral, -lyte specs
What are phytoestrogens?
•Non-steroidal estrogens (isoflavones)
found in soy
What are potential negative effects for kids of phytoestrogens?
–Sexual development and reproduction
–Immune and thyroid function
•No conclusive data re kids or adults
What are potential benefits of phytoestrogens to adults?
–Coronary artery disease
•No conclusive data re kids or adults
Why was soy based formula previously used in diarrhea?
If diarrhea, gp off formula, use a kind of ORS, then titrate up on soy. Theory had washed lactase out of system w/diarrhea and thus not give lactose. Recent info does not hold this up.
•Similac Soy Expert Care DF: plays on this belief
Should soy based formula be used for recovery from AGE?
•Most infants OK with breast or CM formula during recovery from AGE
Should soy based formula be used in preterm infants?
•Serum phosphorous lower
•Alkaline phosphatase higher
•Degree of osteopenia increased even with Ca and D supplements
Relationship between soy formula and cow's milk sensitivity
•Cross reactivity to soy protein if enterocolitis from CM formulas
Indications for Soy Formula
•Disorders of carbohydrate metabolism
–Galactosemia ( newborn screening)
–Primary lactase deficiency ( very rare)
•Family’s desire to avoid animal products
Benefit of soy formula in colic?
•10-20% of 0-3month old infants with “colic”
•Calming attributed to sucrose and fiber in soy
•Controlled studies – no differences in soy or CM
What formulas are marketed for colic?
•CM protein partially broken down = partially hydrolyzed
–Carnation Good Start
•Marketed for fussiness and gas
Rule of 3s for colic
“3 weeks old, 3 hours a day, 3 months”- normal!
Doesn’t mean they need treatment, have gerd, etc
What percentage of infants have a CM protein allergy?
Types of CM protein allergy reactions
•IgE mediated reactions (antibody-mediated)
•Non IgE mediated (cell- mediated)
Immediate response (IgE) to CM protein allergy?
–Acute flare of eczema
–Severe GI symptoms
•Bloody mucousy stools
Delayed response to CM protein allergy
Diagnosis of CM protein allergy
–Positive skin prick
–Positive serum specific IgE
Prognosis for CM protein allergy
•75% outgrow by 3 yrs
•90% outgrow by 6 yrs
MGMT recommendations for CM protein allergy, BF and non
•Breast feeding encouraged
•Management if symptoms con’t with BF:
–Mom to avoid all milk products
–Try for 2-4 weeks
When to use elemental formulas?
–CM or (?) soy formula tried
–still severe symptoms
Brands of elemental formulas?
–Fat malabsorption and protein allergy
When should you see improvement on elemental formulas?
How long to use elemental formulas
Continue at least until 12 months
What is a super hypoallergenic formula?
–100% free amino acids
–No intact proteins
When to use a super hypoallergenic formula?
•Multiple food protein intolerances
•Soy and protein hydrolysate not helpful
–Previously only available by prescription, now OTC.
What is a lactose free formula?
•Cow’s milk formula
–No lactose – corn syrup solids for CHO
–Promoted for “non-specific formula intolerance”
– Same calories/oz as standard formulas
Why is a lactose free formula questionably necessary?
LI is not usually present at birth
Why do preterm infants need special formulas?
–low body stores of nutrients
–deficient bone mineralization
–accumulated energy deficit
Formulas available for preterm infants?
How many calories per ounce in preterm infant formulas?
How long should preterm infant formulas be used?
–Recommended until 9 months, often stopped earlier
What spit-up formulas are available and why are they used?
•Enfamil A.R. Lipil and Similac Spit Up
• - full-term infants who spit up frequently or who need a thickened formula
can thicken your own formula w/a spoonful of rice cereal
How does spit-up formula compare to other formulas?
–Rice starch for thickening
–Viscosity 10 X routine formula
–Flows through standard nipple
–Milk–based fatty acid pattern similar to breast milk
–Easier preparation than adding rice to formula
–Contains DHA and ARA
What are follow up formulas?
•Marketed for 9 months through toddler
•Increased iron and calcium
–Enfamil Next Step
–Carnation Good Start Supreme 2
•V/M of 2-3 servings of F/V in sippy cup!!!
•NOT needed if good variety of solids
Examples of when specialty formulas may be used
Inborn errors of metabolism:
-Maple syrup urine disease
-Organic acid disorders
Problems with goat milk formula
•Not the best alternative
– Vitamin D
– Vitamin B12
•may lead to IDA or megaloblastic anemia
Recommendations for patients using goat milk formula
•Pasteurized, supplemented with Vitamin D and Folic Acid
•additional carbohydrate, such as sugar or corn syrup.
–Need vitamin supplements with iron
Recommendation for Almond Milk Formula?
can lead to scurvy, FTT, etc
Usefulness of differently shaped bottles
One option to try for fussy babies - before "flipping formulas"
Why is Vit D important to G&D?
•Essential for calcium absorption( bones)
•Maintains healthy immune system
•May help prevent
–Type 2 DM
Consequences of inadequate Vit D?
can lead to rickets and low calcium
How much Vit D supplementation is recommended (BF vs FF)
–Breast fed infants: 400 IU
•TVS, PVS, D-VS*
–Formula fed < 32 oz/day: 400 IU
•*Vitamin D-Only: care with administration- risk of toxicity
What are AAP's 2014 fluoride recommendations?
–When teeth emerge ( grain of rice am’t)
–At three years of age ( pea-sized am’t)
–At tooth emergence and every 3-6 mos
•Community water fluoridation – YES
–If drinking water not fluoridated
•Fluoride rinse - ≥ 6 yrs old
Considerations when introducing eggs, nuts, peanuts, shellfish - when and special considerations?
•Previously eggs delayed until 12 months; Nuts, peanuts, shellfish until 2-3 yrs
•Now: Solids held until 4-6* mos; above foods can be given unless
–Positive family history of food allergy (1 first degree relative-parent or sib), then wait until ~ 2 yrs
–Also controversial in literature
Percent of 6 mo olds who are obese?
Overweight 5yo are __x more likey to be obese w/in 9 years
**obesity at 5y is a strong indicator for obesity as an adult
Infant interventions to prevent obesity
•Recognize hunger and satiety cues
•Engage infant in other ways than feeding
•No need to “finish the feeding”
•Variety of foods after (4) 6 months
•May need to introduce new foods (5-10x)
•Avoid “kid foods” with ↑fat/calories
Duration of infant feeding patterns
Last longer than previously thought!
Early taste preferences for F/V, sugary bevs last
According to 2014 pediatrics study, when is the best time to set infant feeding patterns?
10-12 months - start early
Again, patterns last
What is WIC?
Women, Infants, Children
•1970’s - nutrition program for low-income pregnant, breast feeding and non-breast feeding moms, infants and children <5yrs.
Obesity and WIC
Where is WIC available?
•50 state health departments
•34 Indian Tribal Organizations
–Medical ( LBW, anemia)
•Inappropriate feeding habits
•Does not meet current guidelines for Americans
–185% of federal poverty guidelines
•Family size and income ( family of 4; 44,123)
–Medicaid and/or SNAP
•Nutrition risk assessment
•Breast feeding education
•Health, social and welfare referrals
Outcomes associated with WIC services
•Lower Medicaid costs for mom and baby
•Higher birth weights
•Lower infant mortality
How does WIC support breastfeeding?
–If fully breast feeding mom
•More fruits and vegetables
–If fully breast fed baby
•More fruits and vegetable
•More baby meats
Recent revisions to WIC for infants (2009)
–No cereal until 5 months
–Decrease in amount of formula > 6 months
–Baby foods added
Recent revisions to WIC for children (2009)
–Voucher for fruits/vegs @ FM
–Less milk and more calcium substitutions but not yogurt or rice milk in CT
–Whole wheat/grain bread
WIC Foods: Federal vs State decisions
•Feds determine nutritional values
•States determine specific foods
–Some allow organic milk, eggs, cheese
–All allow organic fruits and vegetables
–Food packages adapted to needs of family
•Allergy, intolerance, medical conditions
APRN role in r/t WIC
•Collaborate/communicate with WIC colleagues
•Make both roles more effective in helping children to be healthy weight
•Complete forms with essential information
Immediate risks to obesity
•Low self esteem
•Negative body image
•Lack of friends
•Inability to play
Long term risks to obesity
Obstacles to healthy nutrition
•Lack of knowledge/information from PCPs
•Heavily marketed toddler foods
–Authoritarian: Rigid, controlling--> decreased intake of healthy
–Avoidance of conflict--> poor eating habits
–Flexible yet firm--> healthy eating habits
High risk populations for obesity
•Southern region of US
•Difficult to separate SES and racial/cultural factors
Challenge of feeding with Toddlers?
Developmentally: exploring, saying no
Erickson’s stages: independence. --> picky eating
Tricky to give healthy food!
Approaches with Toddlers/Preschoolers
•Healthy choices and reasonable quantities
•Limit milk ( 20-24 oz/day)
–WCM 12-24 months; Low fat or skim >24 months
–If significant family history – low fat milk @ 12 mos
•Do not force to eat if not hungry or food averse
•Avoid juices, sweetened drinks, cereals, candy, fast food