Early Infancy Nutrition: Challenges and Solutions

Jessy El Hayek Fares

Sunday Oct 1st, 2017 Care of the Elderly: Simplifying

Complexity Metropolitan Hilton

Outline 1. Introduction

2. Challenges & Solutions

A. Does Early Support of Breastfeeding Increases Duration of Exclusive Breastfeeding?

B. Does Early Initiation of Breastfeeding Affect Breastfeeding Duration?

C. Does Early Skin to Skin Contact (SSC) Improve Breastfeeding Duration?

D. Scheduled Feedings or Breastfeeding on Demand?

E. Does the Use of Supplementary Feeds Negatively Affect Breastfeeding Duration?

F. Does the Use of Pacifiers Affect Establishing Breastfeeding?

G. Are Herbal Teas Safe for Infants?

H. Are Vitamin D Supplements Recommended for Mixed Fed Children?

I. Are Probiotics Recommended to Treat Infantile Colic?

J. Are Probiotics Recommended to Treat Infantile Constipation?

K. When is the Best Time to Introduce Allergens to Infants?

L. Cow’s Milk or Growing Up Milk at 1 Year?

M. Is it Acceptable to Give Fruit Juice for Infants?

3. Conclusion

Introduction

• Gestation and the first two years of life

represent a sensitive period or “window of

opportunity” for humans to learn to eat

healthy and nutritious diets.

Escamilla, et al. 2017

Introduction

Infant Feeding: WHO

Recommendation

• Infants should be exclusively breastfed for

the first 6 months after birth to achieve

optimal growth, development, and health.

• After the first 6 months, infants should

receive nutritionally adequate and safe

complementary foods while breastfeeding

continues for up to 2 years of age or

beyond.

World Health Organization, 2001

Infant Feeding:

Recommendations from

Different Countries

Country Institution, year 0-6 months > 6 months

United States American Academy of Pediatrics, 2012

Exclusive breastfeeding the first 6 months

Breastfeeding + solid foods until 1 year After 1 year, breastfeeding can be continued if mutually desired by the mother and her infant

Australia National Health and Medical Research Council, 2012

Exclusive breastfeeding of infants to around six months

Breastfeeding + solid foods until the age of 1 year and beyond, if both mother and infant wish

Canada Canadian Pediatric Society, 2014

Exclusive breastfeeding for the first 6 months

Breastfeeding + solid foods until the child is 2 years of age and beyond

United Kingdom

National Health Services, 2003

Exclusive breastfeeding is recommended for around the first six months

Breastfeeding + solid foods beyond 6 months

France Programme national nutrition – santé, 2004

Allaitement maternel exclusif pendant six mois, au moins jusqu’à 4 mois. Même de plus courte durée, l’allaitement reste toujours recommandé

N/A

Does Early Support of

Breastfeeding Increases

Duration of Exclusive

Breastfeeding? • Breastfeeding support increases duration of exclusive

breastfeeding in the immediate postnatal period and at 6

months (Evidence Grade B).

– A Cochrane Review (n=83,246 mother-infant pairs from 73

studies) reported that professional support increased the rate

of intermediate duration of breastfeeding (up to 4 months) and

had a beneficial effect on exclusive breastfeeding, particularly in

the first 3 months.

– Without fathers’ support, duration of breastfeeding is likely to

be shorter (Evidence Grade B).

McFadden et al., 2017

Does Early Initiation of

Breastfeeding Affect

Breastfeeding Duration? • Breastfeeding within the first hour or so of birth is good for

both mother and infant and for continued breastfeeding

(Evidence Grade C).

• A successful first breastfeed has a number of positive effects:

– it builds the mother’s confidence in her ability to breastfeed

– the infant starts to receive the immunological benefits of colostrum

– the infant’s digestion and bowel function are stimulated

– correct sucking at the breast at this stage may avert later sucking difficulties

– bonding and attachment between mother and infant are enhanced

• A cochrane review of 3 randomized and quasi-randomized trials

(n=209 women) found no differences between early and delayed

contact in regard to breastfeeding duration

Candel et. al;. 2017; Renfrew et al., 2000

Does Early Skin to Skin Contact

(SSC) Improve Breastfeeding

Duration?

• Early SSC increases breastfeeding duration

(Evidence Grade B)

• A cochrane review of 38 studies (n=3472

women) found that:

– More women who had SSC with their babies were still

breastfeeding at one to four months after giving birth

(moderate-quality evidence)

– Mothers who had SSC breast fed their infants longer,

on average over 60 days longer (low-quality evidence)

Vila-Cadel et. al., 2017; Sharma, 2016; Moore et. al., 2016, Agudelo et al., 2016

Scheduled Feedings or

Breastfeeding on Demand?

• Breastfeeding: supply and demand

• The goal in infant-led feeding is for the mother to recognize and

respond to the infant's appetite, hunger, and fullness cues.

• Infant-led breastfeeding, as opposed to bottle-feeding,

encourages self-regulation.

• Data from the Avon Longitudinal study (n=10,419) have

examined the long term benefit of breastfeeding on demand

found that breastfeeding on demand improved children’s

cognitive and academic outcomes however decreased maternal

well-being

Ken et. al., 2006; Lacovou& Sevilla, 2013; Li, Fein, & Grummer-Strawn, 2010

Does the Use of Supplementary

Feeds Negatively Affect

Breastfeeding Duration? • The use of supplementary feeds negatively affects

breastfeeding duration (Evidence Grade C)

• Observational studies have found associations between early

additional foods and fluids and shorter duration of breastfeeding

• The effect of early additional foods and fluids on reducing

breastfeeding duration may include:

– Decreased milk production due to reduced removal of milk from the

breast

– Difficulties in developing effective breastfeeding skills when the newborn

infant is also feeding from a bottle

– Reduced maternal confidence in the ability to successfully breastfeed

and the reinforcement of a negative belief that human milk is insufficient

for an infant.

Smith & Becker, 2015; Blomquist 1994; Chantry 2014; Giovannini 2005; Hornell 2001; Kurinij 1991

Does the Use of Pacifiers Affect

Establishing Breastfeeding?

• The use of a pacifier before 4 weeks is associated with reduced duration of

breastfeeding (Evidence Grade C)

• Pacifier use in healthy term breastfeeding infants, started from birth or after

lactation is established, did not significantly affect the prevalence or duration of

exclusive and partial breastfeeding up to four months of age

• Meta-analysis of two combined studies (n=1302 healthy full-term breastfed

infants) showed that pacifier use in healthy breastfeeding infants had no

significant effect on the proportion of infants exclusively breastfed at three

months and at four months of age

• Dipping pacifiers in sugar, jam, honey or any other sugary substance may lead

to dental caries or botulism

• A number of studies have confirmed a probable association between the use of

pacifiers during sleep and a decrease in the risk of SIDS (Evidence Grade

B)

Jaafar, et., al., 2016; Jenik et. al., 2009

Are Herbal Teas Safe for

Infants?

• Insufficient evidence on efficacy and safety of herbal

teas to warrant their use during infancy

• The use of these products is not without risk:

– They may have pharmacologic actions

– They frequently contain sugar and may interfere with

breastfeeding

– The composition of herbal teas varies considerably among

products

– Microbiologic contamination

– Adverse effects been reported: seizures in previously healthy

infants and death

Zhang et. al., 2011, Volker, 2011

Are Vitamin D Supplements

Recommended for Mixed Fed

Children?

• Non-breastfed infants do not require a vitamin D

supplement because the infant formula contains

vitamin D

• Infants who are partially breastfed should receive a

vitamin D supplement of 10 µg (400 IU)

– They should get this amount regardless of their average

formula intake

– Their total intake from supplement and formula is not likely to

exceed the upper level of 25 µg (1000 IU) per day

CPS, 2014

Are Probiotics Recommended to

Treat Infantile Colic?

• 3 of 5 trials concluded probiotics effectively treat colic in breastfed babies

• 1 suggested ineffectiveness in breastfed babies with colic

• 1 suggested possible effectiveness in formula-fed babies with colic

• Meta-analysis of 3 small trials of breastfed infants with colic found that

Lactobacillus reuteri markedly reduced crying time at 21 days (median

difference, −65 minutes/d; 95%CI, −86 to −44).

• Although L reuteri may be effective as treatment for crying in exclusively

breastfed infants with colic, there is still insufficient evidence to support

probiotic use to manage colic, especially in formula-fed infants

• In 2015, a team of Latin American expert reached a consensus:

• L. reuteri is recommended in the treatment of infant colic of breastfed infants (Grade 1A).

Ruggiero et. al., 2016; Cruchet et. al., 2015; Sung et. al;., 2013

Are Probiotics Recommended to

Treat Infantile Constipation? • A double-blind randomized placebo-controlled study in 44 formula-fed infants with a

diagnosis of functional chronic constipation received supplementation with the probiotic L.

reuteri and the other group received a placebo for 8 weeks.

– Infants treated with L. reuteri had a significantly higher defecation frequency than placebo

after 2, 4, and 8 weeks.

• A prospective, multicenter, double-masked, placebo-controlled randomized clinical trial was

performed on term newborns (age <1 week, n=589) at 9 different neonatal units. Infants

were randomly allocated to receive L reuteri or placebo daily for 90 days.

– The mean number of evacuations per day (4.2 vs 3.6; P < .01) for the L reuteri and

placebo groups.

• In their evidence-based guidelines of the management of children with constipation , the

North American and the European Society for Pediatric Gastroenterology, Hepatology and

and Nutrition considered that the evidence does not support the use of probiotics in

the treatment of infant constipation

Tabbers et. al., 2014; Tabbers et. al., 2010; Coccorullo et. al., 2010

When is the Best Time to

Introduce Allergens to

Infants?

• Highly allergenic foods, may be introduced into the

diet of low-risk infants at any time after four to six

months

• Introduction of highly allergenic solid foods is

recommended in high-risk infants (Grade 1B) that

have tolerated a few less-allergenic complementary

foods at four to six months

Abrams & Becker, 2015; Fleischer et. al., 2017; AAP, 2017

When is the Best Time to

Introduce Allergens to

Infants?

• Highly allergenic foods can be gradually and

carefully introduced to asymptomatic high-risk

infants without prior testing. The one exception is

whole cow’s milk (unrelated to allergy)

• Allergy evaluation is advised before introduction

of highly allergenic foods if an infant has had an

immediate allergic reaction to a food or breast milk

or has difficult-to-control moderate-to-severe atopic

dermatitis despite optimal management

Abrams & Becker, 2015; Fleischer et. al., 2017; AAP, 2017

Cow’s Milk or Growing Up

Milk at 1 Year?

• As of 12 months, an older infant or young

child can transition directly to cow’s milk

• The use of milk-based growing-up formula

does not bring additional value to a

balanced diet in meeting the nutritional

requirements of young children (Evidence

Grade C)

Vandenplas et. al., 2014; Przyrembel & Agostoni, 2013, EFSA, 2014, Canadian Pediatric Society, 2013

Is it Acceptable to Give Fruit

Juice for Infants?

• Fruit juice should not be provided

to children <1 year of age

• Maximum daily intakes of 100% juice

products should be 120 mL for

children ages 1-3 years

• Juice should be offered in a cup

AAP, 2017

Conclusion

Conclusion • Healthcare providers should:

– Understand the challenges of parenthood

– Provide support, particularly for new

parents

– Provide contacts of support groups for new

parents

Questions??