Nutrition Module Notes

Pediatric I – Second Year

 Compiled By:

Rebecca Abiog-Castro, M.D.

Pediatric Gastroenterology &
Nutrition
Faculty of Medicine & Surgery, UST
 Objectives of the Course

At the end of the course a Second Year Medical Student

should be able:

4) To explain the benefits and advantages of

breastfeeding;

6) To Identify the anatomical structures of the breast;

8) To discuss the physiology of lactation (endocrine &

autocrine factors);

10) Discuss the factors involved for the successful

maintenance of breastmilk supply;
 Objectives of the Course

5) To discuss the manifestations of an adequate

breastmilk supply;

6) To discuss the correct breastfeeding techniques;

7) To compare the composition of breast milk & cow

milk;

8) To define complementary feeding;

 Objectives of the Course

9) To discuss the art of introduction of

complementary food;

10) To prescribe appropriate diet at various

age group using the dietary prescription.
 Nutrient Sources for Infants

1) HUMAN MILK:
 Preferred feed for all infants
 Sufficient to provide nutrient needs until 6
months of life
 Continued until two years and beyond
supplemented w/ complementary foods
 Serves as standard for all breastmilk
substitutes

2) Breastmilk Substitute (Infant formula)

 Advantages of Breast milk over Formula
– Antibodies
– Less sugar than infant formulas
– Contains Amino Acids, Fatty Acids,
Cholesterol not found in formulas
– Growth factors (epidermal growth factor,
etc.)
– GnRH
– Delta sleep inducing peptide

 Disadvantages of Breast milk:

– harmful substances ingested by
mother can pass to baby
 Protection Against Infection
 Reduces risk & severity of infectious illness
among infants
– Diarrhea
– Otitis Media
– Lower Respiratory Infections
– Bacteremia
– Bacterial Meningitis
– Necrotizing Enterocolitis
– Infant Botulism
– Urinary Tract Disease
– Sudden Infant Death Syndrome (SIDS)
– Colic
– Wheezing
 Anti-infective Properties
 Bifidus factor: stimulates bifidobacteria,
which fight against pathogenic bacteria

 IgA, IgM, IgG: immunoglobulins that guard

the gut against infective bacteria

 Lactoferrin: binds iron away from bacteria

 Macrophages: phagocytosis of infective

bacteria

 B12 binding protein: removes B12 from

bacteria
 PREMATURE INFANT
 Breastfeeding and premature infants:

 Premature infants fed their mother's milk were

found to
– Decreased Incidences
1. Sepsis
2. Meningitis
3. Necrotizing enterocolitis
 Breastmilk

Variations of Breastmilk

– Colostrum (1st 3-5 days of life)

– Term breastmilk (mother’s own: 7 - 10 – 28 days)

– Pre-term Milk (7- 28 days)

– Mature breastmilk (>30 days)

– Drip breastmilk (30-90 days postpartum)

Type of Volume Energy Protein CHO FAT NA
Milk ml/d Kcal/100 ml G/100mL G/100 ml G/100 ml mmol/100ML

Colostrum 100 0.67 2.3 5.3 2.9 1.7

(1-5 d)

Term

D7 558 0.73 1.95 6.72 3.52 0.97

D 14 591 0.67 1.62 6.97 3.88 1.27

Breastmilk 750 0.69 1.1 7.4 4.2 0.70

(Mature>30 d)
Type of Volume ENERGY PROTEIN CHO FAT NA
Milk (ml/d ) KCAL/ml G/100 ml G/100 ml G/100 ml mmol/100 ml

Preterm

D7 461 0.647 2.59 6.23 4.02 2.45

D14 413 0.68 2.29 6.21 4.71 2.2

D28 452 0.652 1.91 6.39 4.33 1.51

Drip
BM(mature) 0.54 1.35 7.1 2.2 0.5

Cow 0.67 3.4 4.6 3.9 2.3

 Colostrum
 1st postpartum week’s mammary secretion consisting of
Yellowish (beta carotene) thick fluid;
– Higher protein
– Lower fat and lactose
– Rich in
» Vitamin A (3x > BM)
» Vitamin E (3x)
» Carotenoid (10x)

 Protein content is rich in

– sIgA
– Mononuclear cells [immunologically competent]
 Contains Antioxidants which trap neutrophil-generated Oxygen
radicals
 Comparison
of
Human Milk vs Cow’s Milk
 Osmolality & Renal Solute Load

Type of milk Osmolality Renal Solute Load

mosmol/100kcal
Human milk LOW, less than 300 13
mosmolar, gut can
easily handle

Cow’s milk HIGHer osmolality 46

Cow’s milk 86
SKIM MILK w/ milk
solids added
Infant formulas: 18-25
 Proteins
Whey or Soluble proteins:
– form very LIGHT CURDS & EASY TO DIGEST

– Whey proteins in human milk high in anti-infective

proteins
» (mainly IgA)

– These Antibodies Coat the surface of the small intestine,

blocking binding sites from bacteria and allergens

Casein:
– forms very THICK CURDS & DIFFICULT TO
DIGEST
– Incidence of colic or pain in abdomen is generally higher
in
babies fed on cow’s milk because of thick curds that are
formed from high amount of casein
Proteins …
 Lipids
* Provide 50% of calorie content, thus, major
source of calories
* Composition:
 Palmitic acid
 Oleic acid
 Phospholipids
 Essential Fatty acids: Linoleic & Linolenic
Acids
 PUFA: DHA, Arachidonic acid
 Cholesterol
 Bile-salt stimulated lipase
 Fats
 Breast milk contains
1. Essential fatty acids
2. Linoleic and linolenic acid
3. Essential for development of BRAIN & EYES

 Also contains
– Bile salt stimulated lipase

 Fats in breast milk bind less calcium as

compared to other milks
 Carbohydrates
 LACTOSE:
– Not all Lactose in breast milk is absorbed
– Some Fermented  Lactic Acid
» Helps make pH of Lower Gut Acidic
» Acidic pH  Inhibits Growth of pathogenic
bacteria  reducing the chances of Diarrhea
» Acidic pH  helps Keep iron in FERROUS
form  Promoting IRON ABSORPTION
 GALACTOSE:
– Used during MYELINIZATION of Nervous
System
Vitamins
Iron
 Calcium
– Breast milk contains only about 1/3 of the Calcium
compared to cow’s milk

– Absorption of calcium from breast milk is

much better due to low level of phosphates

– High levels of lactose also promote absorption of

calcium

– Less binding of calcium by fats in the BREAST MILK

also helps in promoting better calcium absorption
 Benefits of Breastmilk
 Baby:
– Protection against infection
– Higher Intelligence Quotient
– Bonding
– DHA content

 Mother
– Protection against several illnesses
 Health Benefits for Infant

 Enhanced immune response to immunizations

1. Polio
2. Tetanus
3. Diptheria
4. Haemophilus influenza
 Other Breastfeeding Benefits for
Baby
 Promotes Cognitive development
 Better Teeth & Jaw development
 Promotes Facial & Muscular Develpmnt
 Promotes Normal Weight Gain
 Promotes Strong Bond
 Less Spitting up
 Longer-term Health Outcomes
Maternal benefits

 Reduces risk of chronic illness in

childhood
– Some food allergies
– Type-1 insulin dependent diabetes
– Lymphoma
– Asthma
– Obesity
 Health Benefits for the Mother

 Promotes more rapid return to pre-

pregnancy weight
 Reduces risk for certain cancers (lower
estrogen)
– Breast cancer
– Uterine, ovarian, and endometrial
cancers
 Reduces post-partum hemorrhage
 Promotes maternal attachment to baby
• Reduces risk of osteoporosis
• Saves money (~$1200/year)
 Excerpts from the American Academy of
Pediatrics Policy Statement (Dec. 1997)

 Human milk is uniquely superior for infant

feeding
 Human milk is the preferred feeding for all
infants, including premature and sick newborns
 When direct breastfeeding is not possible,
expressed human milk, fortified when necessary
for the premature infant, should be provided
 Exclusive breastfeeding for approximately 6
months
 Continuation of breastfeeding for at least 12
months and thereafter for as long as mutually
desired (WHO says 2 yrs. of age or beyond)
Neonatal Reflexes in Breast Feeding
Palate
Teat

Tongue
Anatomy of the Breast
 Physiology of lactation
Endocrine control

Three main phases of lactation under hormonal control

(Endocrine):

1) Mammogenesis or mammary growth

2) Lactogenesis or initiation of milk secretion:

Stage I: 12 wks before parturition

Stage II: 2-3 days postpartum
Stage III of Lactogenesis or maintenance of milk
secretion: 14-30 days
 Endocrine Control of Lactation

 Milk Production Reflex:

Prolactin is a key lactogenic hormone,
stimulating initial alveolar milk production

 Milk Ejection Reflex:

Oxytocin contracts the myoepithelial; cells,
forcing milk from the alveoli into the ducts and
sinuses where it is removed by the infant
 Physiology of Lactation
Endocrine Control

 Support Lactation
1. Cortisol
2. Insulin
3. Thyroid Hormone
4. Parathyroid Hormone
5. Growth Hormone
Endocrine Control of Lactation
Endocrine Control of Lactation
 Autocrine Control of Lactation

Influence of of Local Factors Acting on the Breasts

 It is not just the level of maternal hormones, but the efficiency

of milk removal that governs the volume product in each
breast

 A protein factor called feedback inhibitor of lactation (FIL) is

secreted with other milk components into the alveolar lumen
 Autocrine Control of Lactation

 If milk is not removed, breasts remain full of milk;

 FIL, the chemical inhibitor present, interacts with

the alveolar cells of the breast  insensitive to
prolactin  ↓ breast milk secretion
Autocrine Control of Lactation

FIL
FIL
FIL
 Breast Milk

ADVANTAGES OF HUMAN MILK:

• Infant Nutrition

• GIT Function

• Host Defense

• Psychological Well-being

• Economic benefits
 Nutritional Aspect

Carbohydrate:
Composition
 Lactose

 Monosaccharides

 Neutral and acid oligosaccharides

 Peptide- and protein-bound CHO

 Fucose
All these CHO possess bifidus factor activity
 Nutritional Aspects

CARBOHYDRATE:

LACTOSE (milk sugar):

 Predominant CHO: disaccharide (Glu/Gal)

 Enhances growth of L. bifidus as gut flora  more non-

pathogenic fecal flora

 Provides ready source of galactose  galactolipids 

essential to CNS development

 Plays important role for NB’s growth  Improves

absorption of Ca and P  critical in the prevention of
rickets among BF babies
 Nutritional Aspects
Whey protein
 α -Lactalbumin:
 one of the chief fractions in BM

 Lactoferrin:
Iron-binding protein  inhibits growth of iron-
dependent bacteria in the gut  protection against
GIT infection

 Immunoglobulins:
 Consists principally of Secretory IgA found high during
the first few days then decline rapidly

 Lysozyme:
 bacteriolytic against enterobacteriaceae and Gram (+)
bacteria
 Nutritional Aspects

LIPIDS:
PUFA:
* Arachidonic: derived from Linoleic Acid

* Docosahexanoic ( DHA): derived from Linolenic Acid

* Both fatty acids are associated w/ cognition &

vision

* Only found in Human milk!!

 Host Resistance Factors in BM

 Immunoglobulin:
– sIgA, IgM, IgG
– Cellular components:
» Macrophages
» Polymorphonuclear
» Lymphocytes

 Non-immunoglobulin components:
– Oligosaccharides
– Mucin
– Fatty acids
 Host Resistance Factors in BM

Non-immunoglobulin components:
- Non-specific factors:
» Bifidus factor
» Resistance factor (Anti-staphylococcal factor)
» Anti-viral factor
» Anti-protozoal factors (Bile-salt stimulated lipase)

– Enzymes: Lysozyme, lipoprotein lipase

 Host Resistance Factors in BM

Antiviral Factors:
 sIgA: Active against
– Enteroviruses (Polio, Coxackie, Echov.)
– Herpes virus (CMV. H. simplex)
– Respiratory Syncitial Virus
– Rubella
– Reovirus
– Rotavirus
 IgM, IgG: Active against
– CMV, RSV, Rubella
 Host Resistance Factors in BM
 Anti-inflammatory properties:
– Poor initiators & mediators of
inflammation
» Complement system
» Fibrinolytic
» Coagulation system
– Rich in anti-inflammatory agents
» sIGA
» Lysozyme
 Provides good mucosal barrier
– (growth factors)  prevents attachment
of bacteria & antigen
 Breastmilk

GIT FUNCTION:

• Gastric emptying time is FASTER

• Large gastric residual volumes are
LESS
• Many factors Stimulate GIT growth and
motility
• Enhances GUT Maturity
 Breastmilk

PSYCHOLOGICAL EFFECTS:

• Maternal-infant BONDING
enhanced

• Long term Cognitive & Motor

abilities developed
Infant Milk Formulas
 TYPES OF INFANT FORMULA

• Pre-term Formula
• Catch-up Growth Formula
• Standard Infant Formula
Whey Dominant ( 60%)
Casein Dominant ( 60%)
• Follow-on (up) Formula
• Growing-up Formula
• Whole cow’s Milk
• Evaporated Milk
 Types of Infant Formulas

 SPECIAL Formulas:

– Hydrolysates:
»Partial Hydrolysates
»Complete Hydrolysates

– Goats milk
 Nutrient Sources:
FOR INFANTS LESS THAN 2 YEARS

3 Indications for Use of Infant

Formulas
 Substitute (or supplement) for human
milk in infants whose mother choose not
to breastfeed

 Substitute for human milk in infants for

whom breastfeeding is medically
contraindicated

 Supplement for infants who do not gain

weight appropriately
 Nutrient Sources:
< 2 Years of Age
 PRETERM FORMULA:

Prescribed for premature until 35-36

weeks of gestation or gained 2
kilograms.

 When given beyond recommended age

may cause hypercalcemia

Special Features:
• Protein: Whey predominant formula
at a level higher than breast milk &
standard infant formula (2.0
2.5g/100ml.)
 PRETERM FORMULA

 Pre-Aptamil (Milupa): 1:1 dilution

 Enfalac Premature: 1:1 dilution

 Pre-Nan: 1:1 dilution

 S-26 LBW: 1:2 dilution

 STANDARD INFANT FORMULA
 Recommended during  Example:
first 6 –12 months of
life 1. S-26
2. Enfalac
 Extensively modified
from what was
3. Nan
originally produced by 4. Similac
the cow;
5. Mylac
 Very little difference 6. Aptamil
between brands
7. Bonna
8. Nestogen
 FOLLOW-UP FORMULA
 Liquid part of the weaning
diet for infants & children  Example:
12 mos - 3 years
of age 1. Promil
 Distribution of calories &
nutrients is in between 2. Nan 2
standard infant formula &
whole cow’s milk 3. Gain
 Protein is higher w/ the
ratio
4. Milumil
– 20% Whey
– 80% Casein
 COMPOSITION OF VARIOUS NUTRIENT SOURCES

BM COW A PREM FF-UP

Energy kcal/100ml 65 67 65 81 65

Protein G/100 ml 1.1 3.5 1.5 2.4 2.8

Whey 60% 60% 20%
Casein 40% 40% 80%

Fat G/100 ml 4.5 3.7 3.6 4.4 2.64

CHO G/100 ml 6.8 4.9 7.2 8.6 8.18

CA mg/100 ml 34 117 44 95(75)

P mg/100 ml 14 92 33 53(40)

NA mmol/100 ml 0.7 2.2 0.64 1.4 1.57

 GROWING –UP FORMULA:

 Product for children above 2 years - 10

years

 Provides nutrient necessary as they

undergo transition from infant  adult
formulation.
• Protein is high (3 g/100 ml) from
Sodium
• Casseinate & Soya protein
 CHO contains a blend of
1. Cornstarch
2. Sucrose
3. Very Minimal Lactose
 GROWING-UP FORMULAS
 NESLAC (Nestle): 1:1 dilution

 ENFAGROW (MJ): 1:1 dilution

 LACTUM (MJ): 1:1 dilution

 GROW (Abbott): 1:2 dilution

 PROGRESS (Wyeth): 1:2 dilution

 Whole Cow’s Milk
 May be given as
 Example:
SUPPLEMENT to a
12
balanced diet from 1.Alaska
months above 2.Bear Brand
 No modification
done to suit the needs of
infants &children
 Protein Hydrolysates

 Definition:
Product of an enzymatic degradation of protein to
proteose, peptone, peptide-AA mix and finally free
AA mix.

 Types:
– Partial Hydrolysate: Degradation of protein to
big, medium size peptides  LESS antigenicity

– Complete Hydrolysate: Degradation of protein

into small peptides and free AA
 Protein Hydrolysates
 Partially Hydrolyzed Formula:
– For prophylaxis on high risk infants:
» FH of atopy, asthma, food allergy
– Preparation:
» Nan-HA
 Extensively Hydrolyzed Formula:
– For treatment of food allergy during
infancy
– Preparations:
» Pregomin (Milupa)
» Pregistimil (MJ)
» Alfare (Nestle)
“Introduction of Complementary Food”
 Complementary Food (CF)

Definition:

It refers to SUPPLEMENTAL foods

(milk & solid foods) given to infants
when breastmilk is no longer
adequate to sustain normal growth
 WHY should CF be given?

Three Infant Feeding Periods:

 Nursing Period (1st6 m of life)
 Transitional Period (6m-10m)
 Modified Adult Period (>10m)
 WHY should CF be given?
Three Infant Feeding Periods:
Nursing Period (1st 6 months of life):

 Breastmilk / standard infant formula is U

to provide nutritional requirements for
normal growth

 MILK should be the ONLY source of

nutrient
 Nursing Period
(1st 6 months of life):

♣ Well developed
♣ Digestive
♣ Mucosal barrier
♣ Renal functions
♣ NOT fully developed
1. Neuro-developmental
 Nursing Period :
(1st 6 months of life)

♣ Addition of solid foods at this time  ↓

breastmilk /milk consumption proportionally 

Growth Failure!!

Stuff et al, J pediatr,1990

 Transitional Period
(6-10 months)

♣ It is the TRANSITION from Nursing period 

Adult Modified period

♣ Milk (Breastmilk / Standard Infant Formula)

♣  NO longer adequate to sustain the

nutritional needs of growing infants
 Transitional Period
(6-10 mos)

♣ Well Developed
♣ Digestive
♣ Renal systems
♣ Taste
♣ Fully developed
1. Skills needed for feeding
 Transitional Period
( 6-10 months)

FAILURE to offer supplemental

foods at this time  difficulty in
accepting them later
 “Critical Learning Period”
6-15 months

♣ 6-15 months
♣ “CRITICAL LEARNING PERIOD” for feeding:
♣ chewing & swallowing coordination is being developed

♣ FAILURE of infants to go through this process 

Feeding Problems

– Dependence to MILK as source of nutrient

– Picky eaters / Neophobic
– Malnutrition (obesity / wasting , anemia)
 Modified Adult Period
(>10 months)

♣ Physiologic Mechanisms 
matured to near adult proficiency

♣ Most of the Nutrients MUST come

from Table Foods w/ Minimal
Alteration(cut into small pieces,
bland)

♣ Taste ability & Preferences have

become established
 Question no 9:

What kind of food would you give?

Scientific Rationale:
– “Critical Window” for introducing “lumpy” solid
foods: if these are delayed beyond 10 mos 
increased risk of feeding difficulties later on

– Ingestion of the types of foods depend on the

neuromuscular development of infants
 WHEN should CF be given? 6 months

Signals that indicate readiness of the infant for CF:

♣ Birth weight has doubled;

♣ Extrusion reflex has completely disappeared;

♣ Has good head and neck control;

♣ Sits up with support;

 WHEN should CF be started?

Signals that indicate readiness of infant for CF:

♣ Opens mouth if wants food; turns head away when not

interested anymore;

♣ Has good chewing & swallowing coordination;

♣ Consumes about 32 oz of milk and wants more;

♣ Breastfeeds > 10x and wants more

 Art of Introducing Complementary Food

♥ Introduce one new food at time to allow infant to

get use to it; continue same food for 3-4 days
before giving another food;

♥ Give very small amount of any new food at the

beginning, 1-4 tsp;
 Art of Introducing Complementary Food

♣ Use thin puree consistency initially --> shift gradually

to a more viscous calorie-dense food

♣ Mix foods with ones baby likes, to enhance

acceptability and nutrient content

Cereals +BM: Enhanced acceptance of cereal during weaning!

Mennella et al, Pediatr Res, 1997

 Art of Introducing Complementary Food

♣ Once infant can sit with support at about 6 mos ,

give fluid (milk or water) using trainer’s cup;

♣ By 12 months of age milk should be given by the cup

or glass;

♣ BOTTLES should be OUT by this time!

 Art of Introducing Complementary Food

♥ Avoid adding salt and sugar

♥ When baby is able to chew at about 8-10

months, gradually switch to finely chopped foods

♥ DO NOT continue soft smooth foods for too long

♥ Feeding Frequency:
♥ 6-8 months: 2 -3 meals a day
♥ 9-11 months: 3-4 meals; 1-2 snacks
♥ > 12 months: 3-4 meals: 1-2 snacks
 Art of Introducing Complementary foods

♥ By 12 months, most of the nutrient should come from

table food (modified); infants have attained
physiologic maturity of adult proficiency;

♥ Encourage infant to try new flavors

as a variety of foods is important !

* FNRI-DOST, Nutrition Guidelines for Filipinos, 2000

* Pediatric Nutrition Handbook, 4th Edition AAP

 References:

 FNRI Food Guidelines, 2002

 Lawrence, Ruth, 4th Edition, 1994; Breastfeeding

A Guide for the medical profession

 Nelson Textbook of Pediatrics, 16th Edition, W.B.

Saunders Company

 Pediatric Handbook in Nutrition, 4th Edition

American Academy of Pediatrics
 Practice Questions:

 Compute for the Total Caloric and fluid requirements of a 2 year old
boy with a weight of 14 kg; length of 90 cm.

 Breastfeeding:
2.1 How long can you BF exclusively?
2.2 Discuss the advantages of BF.
2.3 Discuss the endocrine and autocrine control of lactation
2.4 Differentiate breastfeeding & breastmilk jaundice

3) Breastmilk substitutes:
3.1 What breastmilk substitute can be given to a 6 months,
10 months old infant if breastmilk is not available?
3.2 What nutrient source do you give infants with
cow’s milk allergy?

4) Complementary Food:
4.1 Why and when do you introduce CF?
4.2 When is the ‘critical learning period’ for feeding?
4.3 Discuss the art of introduction of CF