A systematic review of published studies showed that breastfeeding is associated with higher concentrations of total Cholesterol and LDL Cholesterol in infancy but lower concentrations in adult life. The reduction of cholesterol concentrations in adults is modest (0.18 mmol/L for TC) but might be associated with a reduction in coronary risk of about 10%.
Term infants who are breast-fed have lower BP at age 7 (Circulation, 2004).
Breast feeding appears to improve chances of upward social ability, independenly of other socio-economic factors! (ArchDis Childhood February 14 2007)
RCT of cup or dummy in prems - dummys do not affect breast feeding, cup feeding improves chance of going home fully breast fed but delays discharge (why?) and no effect on partial breast feeding. Other studies - tube feeding helped in one study, no difference between cup and bottle in another. NB poor compliance with allocated method! (BMJ 2004;329, Adelaide)
Neonates will generally lose weight over the first few days of life. Breast fed babies lose a median of 6.6% of birth weight, formula fed 3.5%. The 97.5th centile is 12.8% for breast fed, 9.5% for formula. Breast fed babies then take a median of 8.3 days to regain their birth weight cf 6.5 for formula fed. The 97.5th centile is 21 and 16.7 days respectively. Mild hypernatraemia (145-150) is seen at all degrees of weight loss, but 80% of those above the 97.5th centile have severe (>150) hypernatraemia. So these cut-offs are a good safety net for feeding problems, although intervention eg breast feeding support should be triggered before then. (Peter Macdonald, Arch 2003 PMID 14602693) A Dutch team have published centile charts for weight loss and recommend a cut off of 2.5 SDs; on their chart 12.5% loss is on the cut off for day 3, and the 10% rule of thumb is on the cut off for day 7.(Arch 2007 PMID 16880225)
Weighing programs do not appear to impinge on breast feeding rates (Arch Dis Child 06, Alison McKie PMID 16239247).
Breast feeding rates in UK up to 76% for initiating, but long term rates remain low. Comparison of video and lactation consultants showed both work, doubling rates at all time points up to 6 months. But systematic review showed conflicting results for antenatal/postnatal interventions. Baby friendly hospitals do not manage to increase duration of breast feeding…
NZ Dunedin cohort used to examine breast feeding and intelligence. Meta-analysis in 2006 showed no effect once other factors eg maternal IQ had been corrected for. More recent study looked at a specific gene that appeared to mediate for IQ benefits after correcting for maternal IQ but not other confounders. (Proceedings of the National Academy of Sciences)
The standard volumes required for growth provide adequate hydration in all but the hottest climates. In very hot weather, breast fed babies should simply be offered more breast feeds! Formula fed babies on the other hand should be offered alternative fluids: cool, boiled water is preferred, else extremely dilute fruit juice.
UNICEF programme to certify hospitals. The main obstacles to successful breast feeding are:
The most common time for mothers to stop breastfeeding is in the first 72 hours. So helpful things to do are:
In Scotland an increase in prevalence of breast feeding has been seen at birth but the proportion still breastfeeding at six weeks and six months fell in 2005. 38% of mothers who breastfed initially had stopped breastfeeding at six weeks.
Babies spending a few days in special care after the birth were less likely than average to be successfully breastfed. Long-term admissions did better.
A third of breastfed babies received additional feeds while in hospital, mostly low birth weight babies and those in special care. But in about a third of cases, additional feeds had been given because the mother wanted them, not because this had been advised.
Problems in the very early days were mainly centered on problems with attachment or failure to feed followed by breast or nipple discomfort.
Protein - Primine has higher conc than vaminolact, profile based on cord blood (cf breast milk).
Intralipid not ideal balance of ffa's, but no alternative.
peditrace=minerals (reduces stability so only added if bag to be used same day)
sodium free allows contraction of extracellular fluid compartment in first 24hrs.
TPN is contraindicated in acidosis, renal failure, unstable glucose.
165ml/kg gives 2.8 g/kg protein, calc 1.1 mmol/kg.
Vitlipid contains 10% intralipid, so adding it makes calculations complicated! Lipid displaces bound bilirubin hence relative contrainidication in jaundice.
WHO recommends 6 months exclusive breast feeding. AAP says this is appropriate in developing countries, but in developed countries weaning from 4 months is probably acceptable (no good evidence from developed world). Some evidence to suggest cow's milk as trigger for IDDM. Exclusive breast feeding for 6/12 appears to be safe, although this depends on what centiles you use: in the UK new WHO based growth charts based on the weight gain of exclusively breast fed infants. These centiles are a third of a centile band lower than standard centiles, which would includ predominantly bottle fed infants. Some vitamins may become marginal after 4/12 eg Vit D, zinc, iron, B12 and riboflavin. Zinc found in meat, pulses, dairy products, wheat, and rice.
The results of a study from Dundee showed no increase in gastrointestinal illness among those weaned before 12 weeks compared to those weaned later, when appropriate adjustments for maternal age and social class were made. However, these infants experienced more respiratory illness at 14-26 weeks. A later examination of the same cohort revealed an increase in wheezing illness, weight, and body fat among 6-10 year old children who had received solids early, though it is not clear whether the early weaning caused the increase in weight and body fat or if bigger babies demand solids sooner.
In the baby friendly initiative carried out in Belarus, the intervention increased the duration and degree (exclusivity) of breast feeding and decreased the risk of gastrointestinal tract infection (9.1% versus 13.2%; adjusted OR 0.6; 95% CI 0.40 to 0.91).
Less wheezing where exclusive breast feeding for 4/12 (Australia). Relationship of early weaning to asthma (rather than wheezing) is unclear. 2 large studies of general population found an assocation between breast feeding and asthma. See also Atopy, below.
Arch review 2003 PMID 12765913
Infants weaned early tend to be perceived as hungry, have more rapid weight growth, be bottlefed and from lower SE classes. No difference in later wt gain, more diarrhoea though. (Charlotte Wright, Arch 2004;89
The speed of weaning depends on the time of introduction. If solids introduced early, then a more gradual approach can be taken. At 6 months, purees may only be appropriate for a few days! Start with:
If family history of allergy, avoidance of high risk foods sensible - see Atopy, below. Introduce different textures eg mash, soft finger food and stronger flavours gradually. Avoid honey below 1yr as associated with infant botulism. Aim for 3 meals a day by 9 months.
See also Allergy. exclusively did not change allergy prevalence at 6yrs in Belarus study. But low prevalence anyway. (BMJ2007) Maternal atopy is a major risk factor for childhood atopy cf paternal atopy. Allergy promoting environment for fetus and young baby? Perhaps logical if considered protection vs environmental parasites. However, IgG from the placenta seems to downregulate IgE responses in the baby: eg rye grass immunotherapy during pregnancy protects the infant from sensitization. Retinoids in the diet inhibit IgE production, perhaps relevant antenatally, also diets rich in linolenic acid eg fish oil (cf cow milk fat intake at 2 yrs, a known protective factor).
RCT of breast feeding vs formula, duration of feeding etc is never going to happen! Very difficult then to extract risk factors from complex non-randomized cohorts.
Weaning prior to 4/12 is associated with persistent eczema, and there is 1 cohort study linking early weaning with pollen allergy, but most studies retrospective, uncontrolled, do not allow for important confounders eg atopic history and do not gauge quantity (ie dose). (Arch Ped Adol Med 160(5), 2006: 502-507)
Exclusive breast feeding? Reviews have suggested that 4/12 exclusive breast feeding is protective vs cow's milk allergy, eczema and episodes of asthma (but at least 4 studies have shown no evidence for benefit vs food allergies, although none prospective).
European Academy of Allergology and Clinical Immunology (EAACI) recommends for infants at increased risk of allergic disease, defined as at least one first-degree relative, extensively hydrolysed rather than normal formula for first 4 months of life.
On the other hand, no obvious benefit of extending the exclusive breast feeding for longer than 6 months, indeed some suggestion that it might increase risk. 4 cohorts reported since 2004: no study found any benefit on allergic outcome by delaying the introduction of solids and two found an association between the delayed introduction of milk/egg and increased incidence of eczema and atopic sensitisation. More recently one study suggested that exposure to cereals before 6/12 (vs after 6/12) are protected from development of wheat-specific IgE. (KOALA Birth Cohort Study (Netherlands). Pediatrics 2008;122:e115-e122 ) As usual, all these studies were retrospective. (Allergy 64(10) 2009 :1407-1416)
Bizarrely, many countries recommend prolonged allergen avoidance despite these very limited data eg avoid nuts for 5yrs, egg for 1yr.
So probably reasonable to limit allergen exposure in the high risk, but not to be excessive about it, given the poor evidence of long term benefit and the risk of restricting an infant nutritionally.
Usual suspects are:
Source?
For prems, same rules about weaning apply, using chronological age - early introduction of milk stimulates gut development so appropriate to not to correct for prematurity. There is a higher prevalence of behavioural feeding problems, and this is probably due to the delayed introduction of solids esp lumps beyond 7 months.
Preterm and low birth weight babies have additional requirements that may not be met by breast feeding; one study found better linear growth and iron status when weaned at 3 months postnatal age and continued on preterm formula.
Ethnic minorities in the UK tend to wean later.
Lactose Free - Nutramigen 1 (or 2 if over 6 months, has more calcium), SMA LF, Enfamil O-Lac.
Soya formula - do not use over the counter soya milk! Avoid in under 6 months, as theoretical evidence of phyto-oestrogen effects. But a few cases where benefits outweight risks (BDA paediatric group statement):
Dental hygiene important, as glucose rather than lactose based. Can be prescribed or bought over the counter.
Different Hypoallergenic formulas have different compositions and different allergenicity. Some are pure amino acids, others are variably hydrolysed (eg Peptijunior), more to aid absorption. Also Pregestamil, Nutramigen.
Nutramigen AA and Neocate are amino acid based, so minimally allergenic. Nutramigen is better suited to preterms, has lower osmolality (and therefore is better tolerated), has more long chain and medium chain FAs (some evidence to suggest relationship with visual development) and is cheaper.
PUFA (ie arachidonic and docosahexachoic) supplementation improves neurodevelopment in prems (Canada), mental development index in term (Dallas). Long Chain Triglycerides (LCTs) - have trophic effect (ie provide direct cellular nutrition for enterocytes +/- encourage normal bowel endocrine patterns) plus they are essential FAs but need bile salts to be absorbed.
Because the central nervous system continues to develop throughout the first year of life, could PUFA supplementation be beneficial after weaning? 2 studies, conflicting results, but most formulas now contain them anyway (Curr Op Ped).
Nutrient enhanced formula for prems makes them heavier at discharge ?better motor cf standard/breast. Nutriprem, SMA LBW, Osterprem, Preaptamil. Unsuitable for term infants even where faltering growth - only for neonatal unit use. Nutriprem not as high calorie as SMA LBW but prescribable. There are follow-on milks for prems viz Premcare, Nutriprem2 for use prior to going on to standard formula at 6 months corrected age.
To boost calorie content - concentrating feeds is probably better than adding Maxijul or Duocal (because preserves protein:calorie ratio). SMA High Energy, Infatrini.
Second stage milks - SMA White (cf Gold, which is standard), Cow&Gate step 2 Plus, these are usually casein based, which is less comparable to breast milk, and it is suggested that it may be more "satisfying%quot;. [Milumil is also casein based]. There is no scientific basis for this. If a baby appears hungry, increased volumes should be given. Changing formula is preferable however to premature introduction of solids.
Follow on milks - more protein, more iron, more vitamin D. However, no evidence that they are actually better for preventing iron deficiency if standard weaning advice followed. May be useful for where there is a poor weaning diet or there is inadequate formula intake.
Comfort formulas - SMA Staydown, Omneo Comfort, Enfamil AR. Reported to aid reflux as well as constipation. Some promising early data.
Modular feed is last resort - can make up any ratio of LCT:MCT, choice of glucose, sucrose, fructose. But slow to build up to full strength, and not suitable for home use (potential for error).
Multicomponent fortifier can be added to breast milk - in infants under 32 weeks, there is better short-term weight gain, linear growth, head growth and bone mineralization. Does not appear to be increase risk of necrotizing enterocolitis, although data is poor. Also, in the largest trial undertaken there was a significant increase in the incidence of infection among infants receiving fortifier. Whether a unit uses fortifier is generally decided by individual doctors or units. A balance needs to be struck between the many benefits of breastmilk use and the likelihood of increasing breastfeeding duration without increasing infection rates.
(Shenai) Low stores in VLBW at birth, followed by poor intake. Supplementation led to 30% reduction in BPD in 2 studies, but no benefit in 2 studies (different populations and use of surfactant/steroids). In a US multicentre study, mortality and BPD were reduced (NNT=14). Cochrane concludes that IM injection is effective, but less evidence for IV.
For the prevention of vitamin D deficiency, the newly recommended adequate intake of vitamin D is 200 IU/day for healthy infants, children, and adolescents. The previous recommendation was 400 IU/day (AAP). To meet the new adequate intake for vitamin D, a breast-fed infant would need to consume 8 L breast milk/day. Formula is fine unless the intake of formula is less than 500 mL/day, when it is recommended to provide additional vitamin D supplementation (but see Iron, below).
Cup feeding pre-term infants leads to higher rates of full (exclusive or predominant) breastfeeding, compared with bottle feeding. Also appears to have lower risk of bradycardia or desaturation.
Nasogastric vs orogastric tube feeding - Physiological data show that nasogastric tubes increase airway impedance and the work of breathing in very preterm infants, which is supported by clinical data showing an increased incidence of apnoea and desaturation.
Giving toddlers a bottle makes it easier for them to drink - but encourages dependence on milk/juice. Cups should be encouraged.
Iron deficiency related to poor food intake, early cow's milk and high fruit juice intake. DOH recommends 300 ml milk at 1 year. WHO defines anaemia as Hb under 11 up to 2 yrs, 11.2 under 6 yrs. Use of formula until 18 months is effective but free milk tokens only available up to 1 yr. DOH recommends vitamins from 6 months to 2 years, and until 5 yrs in vulnerable children, especially if not on formula.
Jejunal function can be rescued by ileum, but not the other way round. Adaptation to short bowel takes 2-3 years once established on oral feeds. Ileum responsible for:
So loss of bile salts reduces bile acid pool. Ileocaecal valve slows transit & prevents bacterial spread into small bowel (hence overgrowth).
Start enteral feeding as continuous feed, then overnight continuous feed with daytime boluses, remember to include oral stimulation. Check stool for fat & reducing substances (pea size sample). Monitor growth incl mid arm circumference.
Pectin (soluble fibre) promotes gut adaptation in rats (Pectigel). No good evidence for probiotics in short bowel (but what should be the dose?).
Protein is poor marker of nutrition, because albumin is a negative acute phase reactant (leaks out).
Refeeding syndrome - glucose transporter exchanges potassium & phosphate so these drop. Magnesium often drops in diarrhoea; needed to reabsorb potassium in kidney so may fall together. Urinary Na >25 mmol/l needed to grow.
Fatty liver due to high sugar conc in TPN plus lack of enteral hormones driving bile salt secretion, plus bacterial translocation. Oxalate stones occur if excessive bile salts in colon. D-lactate in stool suggests overgrowth. Micronutient & vitamin plasma levels vary inversely with CRP (tissue uptake), no evidence for benefit of supplementation in acute illness except Third World. Remember that normal CRP is <3 so values between 3 & 7 may be associated with low grade inflammation which may drive down plasma levels, making them unreliable. Fat sol vits & Cu/B12 stored for months (year for B12). Check Zn/Se fortnightly.
Cochrane did not find any difference between continuous and intermittent NG feeding; different studies reported opposing findings. See Gastro for more on enteral feeding of preterms.
Simulated Amniotic Fluid has been used to encourage gut adaptation - looks promising!
Pasteurizing milk necessary to remove HIV/CMV (risk of transmlssion in <32/40).
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