Breastfed and Formula-Fed Infants: Need of a Different Complementary Feeding Model?

Suboptimal nutrient quality/quantity during complementary feeding (CF) can impact negatively on infants’ healthy growth, even with adequate energy intake. CF must supplement at best human milk (HM) or formulas, which show nutritional differences. Considering this, a differentiated CF is probably advisable to correctly satisfy the different nutritional needs. To assess whether current needs at 6–24 months of age can still be met by one single CF scheme or different schemes are needed for breastfed vs. formula/cow’s milk (CM) fed infants, protein, iron and calcium intakes were assessed from daily menus using the same type and amount of solid food, leaving same amounts of HM and follow-up formula at 9 and again 18 months of age, when unmodified CM was added. Depending on the child’s age, calcium- and iron-fortified cereals or common retail foods were used. The single feeding scheme keeps protein intake low but higher than recommended, in HM-fed children while in formula/CM-fed ones, it achieves much higher protein intakes. Iron Population Recommended Intake (PRI) and calcium Adequate Intakes (AI) are met at the two ages only when a formula is used; otherwise, calcium-fortified cereals are needed. ESPGHAN statements on the futility of proposing different CF schemes according to the milk type fed do not allow to fully meet the nutritional recommendations issued by major Agencies/Organizations/Societies for all children of these age groups.

Type, Timing, and Diversity of Complementary Foods Among Native Hawaiian, Pacific Islander, and Filipino Infants

Prevention is the recommended strategy for addressing childhood obesity and may be particularly important for minority groups such as Native Hawaiians, Pacific Islanders, and Filipinos (NHPIF) who display poorer health outcomes than other race/ethnic groups. Complementary feeding is a critical milestone in the first 1,000 days of life and plays a critical role in growth and eating habit formation. This cross-sectional study recruited NHPIF infants between 3 - 12 months of age residing on O'ahu, Hawai'i to examine timing and types of complementary foods introduced first as well as the dietary diversity of those infants 6 - 12 months of age. Basic demographic information and early feeding practices were assessed via online questionnaire. Diet was evaluated using the image-based mobile food record completed over 4-days. Images were evaluated to derive the World Health Organization's minimum dietary diversity (MDD) score. Data were analyzed using descriptive statistics and linear regressions. Seventy participants completed the study with a majority being between the ages of 6 - 12 months (n=56). About half of the participants were provided a complementary food prior to 6 months of age with the most common first complementary food being poi (steamed, mashed taro). Grains were the most commonly reported food group while the high protein food groups was the least commonly reported. Approximately 25% of infants 6 - 12 months of age met MDD all four days. Meeting MDD was significantly associated with age. Findings illuminate opportunities for improvement (eg, delayed introduction) and for promotion (eg, cultural foods) in NHPIF complementary feeding.

The Impact of Following Solid Food Feeding Guides on BMI Among Infants: A Simulation Study

INTRODUCTION

There are several recommendations advising caregivers when and how to introduce solid food to infants. These complementary feeding guides vary in terms of the recommendations for timing and portions. The objective of this study is to determine the impact of following different guidelines on weight trajectories of infants.

METHODS

In 2018, the study team developed a computational simulation model to capture feeding behaviors, activity levels, metabolism, and body size of infants from 6 months to 1 year. Daily food intake of virtual infants based on feeding recommendations translated to changes in body weight. Next, simulations tested the impact of the following complementary feeding recommendations that provided amount, type, and timing of foods: Children's Hospital of Philadelphia, Johns Hopkins Medicine, Enfamil, and Similac.

RESULTS

When virtual caregivers fed infants according to the four different guides, none of the simulated situations resulted in normal weight at 12 months when infants were also being breastfed along average observed patterns. Reducing breast milk portions in half while caregivers fed infants according to complementary feeding guidelines resulted in overweight BMIs between 9 and 11 months for Children's Hospital of Philadelphia, Johns Hopkins Medicine, and Enfamil guidelines. Cutting breast milk portions in half also led to infants reaching unhealthy underweight BMI percentiles between 7 and 11 months for female and male infants when caregivers followed Children's Hospital of Philadelphia, Johns Hopkins Medicine, and Similac guidelines.

CONCLUSIONS

This study identified situations in which infants could reach unhealthy weights, even while following complementary feeding guidelines, suggesting that current recommended portion sizes should be tightened.

Magnitude and Factors Associated with Optimal Complementary Feeding Practices among Children Aged 6-23 Months in Bensa District, Sidama Zone, South Ethiopia

BACKGROUND

Prevalence of optimal complementary feeding practices are lower than expected. Undernutrition contributes 35% of children mortality. Our study was aimed to assess magnitude and factors associated with optimal complementary feeding practices among children 6-23 months in Bensa Dstrict, Sidama Zone, South Ethiopia, 2016.

METHODS

A community based cross sectional study was conducted from January to February 2016 in (8) randomly selected kebles found in Bensa District. Respondents were selected by using simple random sampling technique after sampling frame was prepared from rapid survey. Pre-tested questionnaire was used to collect information. Then, data were entered into SPSS version 20, Then, crude odds ratio (COR) and adjusted odds ratio (AOR) with 95% confidence interval were computed to examine statistical significance.

RESULT

This study revealed that only 8.6% (95%CI: 6.4, 10.7%) of 6-23 months children had optimal complementary feeding practices. Mother's knowledge on optimal complementary feeding (AOR=5.4, 95%CI: 2.7, 11), postnatal care service utilization (AOR=3.4, 95%CI: 1.7, 7), and household food security (AOR=5, 95%CI: 2.5, 10.5) were positively associated with optimal complementary feeding practices.

CONCLUSION

Mother's knowledge, postnatal care utilization and household food security positively affected optimal complementary feeding practices. Thus, Bensa District Health Office, Sidama Zone Health Departiment and other respective stakeholders should cooperatively work to enhance knowledge of mothers/care takers on optimal complementary feeding practices, household food security and on advantages of postnatal care service utilization.

Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial

BACKGROUND

Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe.

METHODS

We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940.

FINDINGS

Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported.

INTERPRETATION

Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone.

FUNDING

Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.

An update on complementary feeding

Complementary feeding is an important developmental milestone in children and occurs at a formative time for the development of healthy eating habits that can continue into later childhood and beyond. The timing of weaning has been a controversial subject and recommendations in the UK differ from those in Europe. In the UK and New Zealand, baby-led weaning is becoming increasingly popular. The importance of responsive feeding is highlighted to make parents aware of a baby's cues indicating hunger or fullness. There have also been advances in the science of immunology that deem the early introduction of allergens to be a preventive strategy for food allergies. This article discusses the nutritional requirements for infants and reviews the foods that should be introduced and avoided. Guidelines are changing all the time, so nurses must keep up to date with current research to be able to offer advice to parents of infants.

Use of pasteurised human donor milk across neonatal networks in England

OBJECTIVES

To describe the use of pasteurised human donor milk (pHDM) in England and the influence of a human milk bank in the network.

DESIGN

Prospective observational study SETTING: All 163 neonatal units (23 networks) in England 2012-2013.

PATIENTS

Preterm infants born at <32 weeks gestational age (GA).

MAIN OUTCOME MEASURES

Proportion of infants and care-days fed pHDM during the first 30 postnatal days by network METHODS: We extracted daily patient-level data from the National Neonatal Research Database (NNRD). We fitted a logistic regression of pHDM exposure on the presence of a pHDM bank within the network, with GA, BW z score and network as covariates. Significance was assessed by the likelihood ratio (chi-squared) test.

RESULTS

Data for 13,463 infants were included in the study. Across the networks, the proportion (95%CI) of infants ranged from 2.0% (1.0, 3.0) to 61.0% (57.4%, 64.6%), and the proportion of care-days in which pHDM was fed from 0.08% (0.04%, 0.10%) to 21.9% (19.9%, 24.0%). In three networks <5%, and in seven networks >30% of infants received any pHDM. Variation in the use of pHDM across networks remained significant after adjustment for presence of a human milk bank within the network and all covariates (p < 0.001).

CONCLUSIONS

Wide variation of pHDM use in England is not fully explained by presence of a pHDM bank or patient characteristics. This suggests clinical uncertainty about the use of pHDM.

Nutritive support for newborns in critical conditions: semi-elemental formilas as a means of enteral nutrition

OBJECTIVE

Introduction: The goal is to increase the efficiency of nutritional support in intensive care of newborns by substantiating the choice of the enteral blend.

PATIENTS AND METHODS

Materials and methods: A prospective cohort study was conducted, which included 173 newborns. The main group consisted of 143 patients of intensive care units. The comparison group - 30 virtually healthy newborns. Physical parameters, changes in protein metabolism, serum immunoglobulins, functioning of the gastrointestinal tract and hepatobiliary system in the development of critical conditions and depending on the type of enteric urine formula were determined.

RESULTS

Results: At the beginning of newborn enteral nutrition in the main group, (46.15% of cases), there were signs of gastrointestinal malformation, distributions were detected in protein metabolism, decreased serum immunoglobulin fractions, gastroduodenal cytoprotection, increased alkaline phosphatase activity. Against the background of the use of semi-elemental hydrolysable formulas a greater frequency of excretions was observed, the assimilation orientation of protein metabolism, increased levels of serum immunoglobulin fractions, reduction of gastroduodenal cytoprotection, reduction of laboratory characteristics cholestasis and damage to hepatocytes.

CONCLUSION

Conclusions: In newborns in critical conditions, adaptation to the onset of enteral nutrition is accompanied by a catabolic direction of metabolism. The use of semi-elemental formulas increases the efficiency nutritional support in the intensive care of newborns.

Transition in Infant and Young Child Feeding Practices in India

INTRODUCTION

Optimal infant and young child feeding, which includes initiation of breastfeeding within one hour of birth, exclusive breastfeeding for first six months, age appropriate complementary feeding after six months along with continued breastfeeding for 2 years and beyond, is a public health intervention to prevent child morbidity, mortality and malnutrition [1]. In India, even though institutional delivery rates are increasing, only 44% women are able to breastfeed their babies within one hour of delivery. While 65% children are exclusively breast fed for the first six months, the median duration of breastfeeding is 24.4 months and complementary feeding rates are 50%. To achieve optimal IYCF practices, each woman should have access to a community based IYCF counseling support system. Efforts are therefore needed to upgrade skill based training of health workers and revive and update the Baby Friendly Hospital Initiative (BFHI). To promote and sustain breastfeeding amongst working women, it is essential to ensure adequate maternity leave, crèches at work place, flexible working hours, and provision of physical space for breast feeding at work place. It is imperative to also create public awareness about the dangers of bottle and formula feeding and to provide accurate information on the appropriate complementary food to be given to infants.

CONCLUSION

In conclusion, India needs to make serious efforts to overcome malnutrition with not only prioritized IYCF policies but also their effective implementation in place.

Development of a New Growth Standard for Breastfed Chinese Infants: What Is the Difference from the WHO Growth Standards?

The objectives of this longitudinal study were to examine the trajectory of breastfed infants' growth in China to update growth standards for early childhood, and to compare these updated Chinese growth standards with the growth standards recommended by the World Health Organization (WHO) in 2006.This longitudinal cohort study enrolled 1,840 healthy breastfed infants living in an "optimal" environment favorable to growth and followed up until one year of age from 2007 to 2010. The study subjects were recruited from 60 communities in twelve cities in China. A participating infant's birth weight was measured within the first hour of the infant's life, and birth length and head circumference within 24 hours after birth. Repeated weekly and monthly anthropometric measurements were also taken. Multilevel (ML) modelling via MLwiN2.25 was fitted to estimate the growth curves of weight-for-age (WFA), length-for-age (LFA), and head circumference-for-age (HFA) for the study sample as a whole and by child sex, controlling for mode of delivery, the gravidity and parity of the mother, infant's physical measurements at birth, infant's daily food intaking frequency per day, infant's medical conditions, the season when the infant's physical measurement was taken, parents' ages, heights, and attained education, and family structure and income per month. During the first four weeks after birth, breastfed infants showed an increase in weight, length, and head circumference of 1110g, 4.9 cm, and 3.2 cm, respectively, among boys, and 980 g, 4.4 cm, and 2.8 cm, respectively, among girls. Throughout infancy, the total growth for these three was 6930 g, 26.4 cm, and 12.5 cm, respectively, among boys, and 6480 g, 25.5 cm, and 11.7 cm, respectively, among girls. As expected, there was a significant sex difference in growth during the first year. In comparison with the WHO growth standards, breastfed children in our study were heavier in weight, longer in length, and bigger in head circumference, with the exception of a few age points during the first two to four months on the upper two percentile curves.Our data suggested the growth curves for breastfed infants in China were significantly different in comparison with those based on the WHO standards. The adoption of the WHO infant growth standards among Chinese infants, as well as the methods used in the development of such growth standards in China, need careful and coordinated consideration.

The timing of complementary feeding in preterm infants and the effect on overweight: study protocol for a systematic review

BACKGROUND

In term infants, there is evidence that early complementary feeding is a risk factor for childhood obesity. Therefore, timely introduction of complementary feeding during infancy is necessary. The World Health Organization (WHO) and European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) both developed recommendations for the start of complementary feeding for term-born infants. However, these guidelines cannot be directly translated to preterm infants. Recent literature looking at the introduction of complementary feeding in preterm infants gives contrasting information. Given these contrasting reports on the introduction of solid foods in premature born infants, a systematic review is needed. The primary objective of this study is to analyze the effect of the time starting complementary feeding on overweight (including obesity) in preterm infants.

METHODS

An electronic systematic literature search with pre-defined terms will be conducted in Cochrane, PubMed, EMBASE, Web of Science, Scopus, and CINAHL. There will be no restriction for time period. Primarily, data from randomized controlled trials (RCTs) will be included in this systematic review. Search terms will include preterm infants, complementary feeding, overweight, and their synonyms. Article selection, including risk of bias assessment, will be performed by three reviewers independently. Body mass index standard deviation score (BMI-SDS or BMI-Z-score) will be used to compare studies. The consistency of results across the studies will influence the decision whether or not to combine results in a meta-analysis. Studies that cannot be included in the meta-analysis will be described in a narrative analysis.

DISCUSSION

This systematic review will give an overview of the existing knowledge on the timing of complementary feeding in preterm infants and the effect on overweight. It will form a basis for future guidelines for complementary feeding for preterm infants.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015014215.

Comparison of the complementary feeding practices between mothers with twins and mothers with singletons

INTRODUCTION

Several studies have been done on infant feeding practices but few have focused on twins. The aim of this study was to compare the complementary feeding practices between mothers with twins and mothers with singletons.

METHODS

Mother-infant pairs (50 mother-twin pairs and 50 mother-singleton pairs) with children aged 6 to 23 months were recruited from two public health clinics and communities in Tema and Ashaiman. Information was collected on the background characteristics of the mothers. Recumbent length and weight of the children were measured. Dietary information on the infants was collected using 24 hour recall. The differences between two groups were tested using independent t-student test for continuous variables and chi-square test for categorical variables.

RESULTS

The minimum dietary diversity (4+ food groups) was met by only 32% of the twins and 40% of the singletons, and 28% of the twins and 38% of the singletons met the requirement for minimum acceptable diet (minimum dietary diversity and the minimum meal frequency). Minimum meal frequency was met by 78% of the twins and 76% of the singletons. There were no significant differences between the two groups of infants. Prevalence of undernutrition was not significantly different among the two groups (twins versus singletons: underweight-26% versus 24%, stunting-20% versus 24% and wasting-14% versus 10%.

CONCLUSION

Complementary feeding practices were suboptimal in both groups of mothers requiring interventions to improve infant feeding practices.

Orange-fleshed sweet potato-based infant food is a better source of dietary vitamin A than a maize-legume blend as complementary food

BACKGROUND

White maize, which is widely used for complementary feeding and is seldom fortified at the household level, may be associated with the high prevalence of vitamin A deficiency among infants in low-income countries.

OBJECTIVE

The nutrient composition of complementary foods based on orange-fleshed sweet potato (OFSP) and cream-fleshed sweet potato (CFSP), maize-soybean-groundnut (Weanimix), and a proprietary wheat-based infant cereal (Nestlé Cerelac) were assessed using the Codex Standard (CODEX STAN 074-1981, Rev. 1-2006) specification as a reference. Additionally, the costs of OFSP complementary food, CFSP complementary food, and Weanimix production at the household level were estimated. Phytate and polyphenols, which limit the bioavailability of micronutrients, were assessed.

METHODS

Energy, macronutrients, and micronutrients listed as essential composition in the Codex Standard were determined and expressed as energy or nutrient density.

RESULTS

All the formulations met the stipulated energy and nutrient densities as specified in the Codex Standard. The beta-carotene content of OFSP complementary food exceeded the vitamin A specification (60 to 180 microg retinol activity equivalents/100 kcal). All the formulations except Weanimix contained measurable amounts of ascorbic acid (> or = 32.0 mg/100 g). The level of phytate in Weanimix was highest, about twice that of OFSP complementary food. The sweet potato-based foods contained about twice as much total polyphenols as the cereal-based products. The estimated production cost of OFSP complementary food was slightly higher (1.5 times) than that of Weanimix.

CONCLUSIONS

OFSP complementary food is a good source of beta-carotene and would therefore contribute to the vitamin A requirements of infants. Both OFSP complementary food and Weanimix may inhibit iron absorption because of their high levels of polyphenols and phytate, respectively, compared with those of Nestlé Cerelac.

A preference based measure of complementary feeding quality: application to the Avon longitudinal study of parents and children

This paper presents the development of the Complementary Feeding Utility Index (CFUI), a composite index aimed to measure adherence to infant feeding guidelines. Through an axiomatic characterization this paper shows the advantages in using the CFUI are the following: it avoids the use of arbitrary cut-offs, and by converting observed diet preferences into utilities, summing the score is meaningful. In addition, as the CFUI is designed to be scored continuously, it allows the transition from intake of beneficial foods (in low quantities) and intake of detrimental foods (in high quantities) to be more subtle. The paper first describes the rationale being the development of the CFUI and then elaborates on the methodology used to develop the CFUI, including the process of selecting the components. The methodology is applied to data collected from the Avon Longitudinal Study of Parents and Children to show the advantages of the CFUI over traditional diet index approaches. Unlike traditional approaches, the distribution of the CFUI does not peak towards mean value but distributes evenly towards the tails of the distribution.

Three decades of the WHO code and marketing of infant formulas

PURPOSE OF REVIEW

The International Code of Marketing of Breast Milk Substitutes states that governments, non-governmental organizations, experts, consumers and industry need to cooperate in activities aimed at improving infant nutrition. However, the evidence from the last three decades is that of a series of disputes, legal proceedings and boycotts. The purpose of this review is to assess the overall progress in the implementation of the Code and to examine the problematic areas of monitoring, compliance and governance.

RECENT FINDINGS

There are continuing issues of implementation, monitoring and compliance which predominantly reflect weak governance. Many Member States have yet to fully implement the Code recommendations and most States do not have adequate monitoring and reporting mechanisms. Application of the Code in developed countries may be undermined by a lack of consensus on the WHO recommendation of 6 months exclusive breastfeeding. There is evidence of continuing conflict and acrimony, especially between non-government organizations and industry.

SUMMARY

Measures need to be taken to encourage the Member States to implement the Code and to establish the governance systems that will not only ensure effective implementation and monitoring of the Code, but also deliver the Code within a spirit of participation, collaboration and trust.

Altered body composition in preterm infants at hospital discharge

AIM

To test the hypotheses that body size is reduced and body composition altered in preterm infants at hospital discharge.

METHODS

Preterm infants (< or = 34 weeks gestation, < or = 1750 g at birth) were enrolled. Body weight, length and head circumference were converted to standard deviation or z-scores. Body composition was measured using dual emission X-ray absorptiometry. The results were analysed using standard statistics.

RESULTS

One hundred and forty-nine infants (birth weight = 1406 +/- 248 g, gestation = 31 +/- 1.7 weeks) were studied. Postmenstrual age at discharge was 37 +/- 1.2 weeks. Z-scores for head circumference, weight and length differed (-0.1 +/- 0.6 > -1.4 +/- 0.6 > -1.9 +/- 0.6; p < 0.0001). Global fat-free mass was less in study infants than the reference infant at the same weight (2062 < 2252 g; p < 0.0001) or gestation (2062 < 2667 g; p < 0.0001). Global fat mass was greater in study infants than the reference infant at the same weight (307 > 198 g, 13 > 8%) or gestation (307 > 273 g; 13 > 9%; p < 0.0001). Changes in central fat mass closely paralleled those in global fat mass (r(2) = 0.76, p < 0.0001).

CONCLUSION

Reduced linear growth and a reduced fat-free mass suggest that dietary protein needs were not met before discharge. A reduced fat-free mass coupled with an increased global and central fat mass echoes concerns about the development of insulin resistance and metabolic syndrome X in these high-risk infants.

Research evidence can successfully inform policy and practice: insights from the development of the NSW Health Breastfeeding Policy

Strengthening the bridge between research and policy has been identified as a priority if evidence-based policy is to become the norm. However, current understanding of the research-policy interface is limited. A recent policy in NSW was the first evidence-based directive with specific actions to promote and support breastfeeding within a state health system in Australia. This paper explores the development of this policy, highlighting the factors that facilitated the incorporation of research evidence into the policy. The funding of a research centre to support NSW Health policy and workforce development was significant to the process. The existing organisational linkage ensured that the research evidence was identified, synthesised and effectively communicated, with the needs of the research users in mind and within a clear framework to guide action. The research evidence was not only strong, but also relevant with regard to prevailing political interests. The process was strengthened by the commitment of key researchers and policy makers to breastfeeding. Other types of evidence were considered, including the expert opinions of senior service providers regarding the capacity to act on the research evidence.

Nutrient-enriched formula versus standard term formula for preterm infants following hospital discharge

BACKGROUND

Preterm infants are often growth-restricted at hospital discharge. Feeding infants after hospital discharge with nutrient-enriched formula rather than standard term formula might facilitate "catch-up" growth and improve development.

OBJECTIVES

To determine the effect of feeding nutrient-enriched formula compared with standard term formula on growth and development for preterm infants following hospital discharge.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group were used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared the effect of feeding preterm infants following hospital discharge with nutrient-enriched formula compared with standard term formula.

DATA COLLECTION AND ANALYSIS

Data was extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two authors, and synthesis of data using weighted mean difference and a fixed effects model for meta-analysis.

MAIN RESULTS

Seven trials were found that were eligible for inclusion. These recruited a total of 631 infants and were generally of good methodological quality. The trials found little evidence that feeding with nutrient-enriched formula milk affected growth and development. Because of differences in the way individual trials measured and presented outcomes, data synthesis was limited. Growth data from two trials found that, at six months post-term, infants fed with nutrient-enriched formula had statistically significantly lower weights [weighted mean difference: -601 (95% confidence interval -1028, -174) grams], lengths [-18.8 (-30.0, -7.6) millimetres], and head circumferences [-10.2 ( -18.0, -2.4) millimetres], than infants fed standard term formula. At 12 to 18 months post-term, meta-analyses of data from three trials did not find any statistically significant differences in growth parameters. However, examination of these meta-analyses demonstrated statistical heterogeneity. Meta-analyses of data from two trials did not reveal a statistically significant difference in Bayley Mental Development or Psychomotor Development Indices. There are not yet any data on growth or development through later childhood.

AUTHORS' CONCLUSIONS

The available data do not provide strong evidence that feeding preterm infants following hospital discharge with nutrient-enriched formula compared with standard term formula affects growth rates or development up to 18 months post-term.

Progress in promoting breast-feeding, combating malnutrition, and composition and use of infant formula, 1981-2006

More than 90% of women in developing countries and 50 to 90% of women in industrialized countries now initiate breast-feeding, a marked improvement from 25 y ago. The duration of breast-feeding has lengthened, but fewer than 35% of infants worldwide are still exclusively breast-fed at 4 mo of age. Considerable progress has also been made in combating infant malnutrition. In 1980, 47% of under-5-y-old children in developing countries were stunted. This percentage declined to 29% in 2005. Major advances in formula use and composition include the introduction of formulas tailored to the perceived needs of low-birth-weight infants and the development of fortifiers to overcome the nutritional deficits of human milk for the preterm infant. More recently, postdischarge formulas were introduced and are now being used widely, often in combination with breast-feeding. Formulas for term infants also have undergone a number of changes in the past 25 y to better reproduce the composition of human milk and/or the response of the breast-fed infant. The use of whey-predominant rather than casein-predominant formulas has increased, as has the use of iron-fortified formulas. Cow's milk is introduced into the infant's diet much later than 25 y ago. Despite the progress that has been made in promoting breast-feeding and in the quality of infant formulas, further improvements in the duration of breast-feeding and in the composition of infant formulas are needed.

[Chinese guideline for newborn nutrition support in neonates]

The guideline provides evidence-based recommendations for parenteral and enteral nutrition to neonates in a critical state. It is developed by the interdisciplinary expert group in accordance with officially accepted standards based on various relevant literatures. The guideline is organized into the following sections: enteral nutrition (EN) support, parenteral nutrition (PN) support and a combination of PN & EN support. The EN or PN therapy provides appropriate energy and nutrients to babies that cannot be fed by oral route. For the premature and the very low birth weight infants with delayed gastric emptying and intestinal peristalsis, neurological immaturity and respiratory compromise, the PN therapy is the only choice. The formula to calculate the calorie supplement by PN is offered in the guideline when a combination of PN & EN support is administered.

Parenteral nutrition in neonatology--to standardize or individualize?

Premature very low birth weight (< 1500 g) infants comprise one of the largest groups receiving parenteral nutrition. PN should be optimized to answer their high nutritional requirements and suit their metabolic status, but should also be validated pharmaceutically. PN can be provided as a standard, usually commercial, formulation, representing the average needs of a large group of patients. Alternatively, an individualized PN compound adapted to the patient's needs can be prescribed and prepared, usually on a daily basis. The main advantage of individually prescribed PN is that it is tailored to suit a specific patient, thereby assuring the best possible nutrition and biochemical control. Batch-produced standardized PN bags can be readily available as ward stocks in neonatal intensive care units, enabling initiation of early PN immediately after the delivery of a premature infant. Moreover, standard PN solutions incorporate expert nutritional knowledge and support. A combination of standardized PN bags, prepared under strict standardization criteria, for most neonates, with a small number of specifically tailored individualized PN formulations for those in need for them, could reduce pharmacy workload and costs and increase safety, while maintaining the desired clinical flexibility. For those in need of the individualized PN formulations, a computerized ordering system can save time, decrease prescription and compounding errors, and improve quality of nutritional care.

The timing of complementary feeding of infants in Switzerland: compliance with the Swiss and the WHO guidelines

BACKGROUND

The importance of adequate complementary feeding of infants is increasingly acknowledged. Little is known of the actual complementary feeding practices in Switzerland.

AIM

To report the prevalence of adequate timing of complementary feeding, comparing the compliance to Swiss and World Health Organization (WHO) guidelines, and to investigate factors influencing infant complementary feeding.

METHODS

In 2003 a cross-sectional study was conducted of mother-and-infant pairs in Switzerland. The mothers, randomly chosen by local community mother-and-child health services, completed a 24-h dietary recall questionnaire and reported the infant's age at the first introduction of various foods. Descriptive analysis, group testing and regression analysis of data collected were conducted.

RESULTS

Introduction of solids mainly occurred between the 5th and 6th months. Five per cent of the mothers introduced complementary food before the age of 4 mo. The main influencing factors for infant feeding were maternal age, language regions, mother's BMI and smoking status, the presence of siblings, and an allergic predisposition of the infant.

CONCLUSION

The timing of the introduction of complementary foods meets with Swiss guidelines. WHO recommendations, however, are not met. This may be due to a misunderstanding of the Swiss Paediatric Association's age-range recommendations or insufficient promotion of the WHO recommendations.

Early introduction of non-formula cow's milk to southern Ontario infants

BACKGROUND

Early introduction of cow's milk is a risk factor for the development of anaemia and iron deficiency, which is associated with lower childhood developmental scores. The objective of this paper is to describe the incidence of the introduction of cow's milk before the recommended age of nine months and factors associated with early introduction.

METHODS

Mothers of healthy term infants were invited to take part in the Infant Feeding Survey in 2002-2003. These mothers, from Southern Ontario, were interviewed by telephone at three and nine months postpartum to determine infant feeding practices.

RESULTS

One in eight (12.7%) mothers completing the second interview indicated that they were feeding their infant non-formula cow's milk as the primary source of milk before nine months. Multivariate logistic regression analysis showed that mothers feeding cow's milk before nine months were younger, lived in households with lower annual incomes, and were less likely to have attended prenatal classes or to recall receiving information on the introduction of solid foods. They were also more likely to have introduced solid foods or skimmed milk before the recommended ages.

CONCLUSION

A substantial proportion of Southern Ontario infants are receiving cow's milk before the recommended age, putting them at increased risk for iron deficiency and the resulting sequelae. Further research into why guidelines are not followed is indicated.

State of the science: use of human milk and breast-feeding for vulnerable infants

Human milk is the preferred form of nutrition for all infants including those born preterm or otherwise ill. However, without the commitment of knowledgeable healthcare providers to ensure success during mother-infant separation, many infants fail to receive their mother's own milk. Care of the mother-infant dyad during infant illness requires vigilant monitoring of the lactation experience and the commitment of healthcare providers to take a family through the step-by-step process needed to ensure positive outcomes related to the use of human milk and breast-feeding for vulnerable infants. The science tells us that human milk is the best form of nutrition for all infants. As practitioners we must be doing everything in our power to make sure the infants we care for are able to receive their mother's own milk.

Prebiotic carbohydrates in human milk and formulas

Human milk oligosaccharides play an important role, as prebiotic soluble fibres, in the postnatal development of the intestinal flora. Infant formulas are virtually free of prebiotic oligosaccharides. As a consequence, formula-fed infants develop an intestinal flora significantly different to the flora of breastfed infants. Due to the complexity of human milk oligosaccharides, it is necessary to use alternative sources of prebiotic ingredients as components of infant formulas. The present review summarizes the data of experimental research and clinical studies with a prebiotic mixture containing 90% short-chain galacto-oligosaccharides and 10% long-chain fructo-oligosacchrides are summarized. The data demonstrate that, with this prebiotic mixture, the growth of bifidobacteria and lactobacilli can be stimulated, the faecal pH can be decreased, and the presence of pathogens can be reduced to levels similar to those of breastfed infants. Thus, prebiotic oligosaccharides such as the studied mixture provide beneficial effects for formula-fed infants.

Prebiotic carbohydrates in human milk and formulas

Human milk oligosaccharides play an important role, as prebiotic soluble fibres, in the postnatal development of the intestinal flora. Infant formulas are virtually free of prebiotic oligosaccharides. As a consequence, formula-fed infants develop an intestinal flora significantly different to the flora of breastfed infants. Due to the complexity of human milk oligosaccharides, it is necessary to use alternative sources of prebiotic ingredients as components of infant formulas. The present review summarizes the data of experimental research and clinical studies with a prebiotic mixture containing 90% short-chain galacto-oligosaccharides and 10% long-chain fructo-oligosacchrides are summarized. The data demonstrate that, with this prebiotic mixture, the growth of bifidobacteria and lactobacilli can be stimulated, the faecal pH can be decreased, and the presence of pathogens can be reduced to levels similar to those of breastfed infants. Thus, prebiotic oligosaccharides such as the studied mixture provide beneficial effects for formula-fed infants.

[Fat-soluble vitamins in infants]

Vitamins are micronutrients not synthesised by the human body and should be provided by the nutrition. Liposoluble vitamins include vitamins A, E, D and K. Vitamins A and E are two potent antioxidant nutrients and play a significant role in immune function. Vitamin D plays a major role in intestinal calcium absorption and bone mineralization. Vitamin K intervenes in the synthesis of coagulation factors particularly in the prothrombin synthesis. Vitamin metabolism, placental transfer, vitamin status in newborns and infants are reported. Finally requirements of these vitamins are defined.

Dietitian Involvement in the Neonatal Intensive Care Unit: More Is Better

OBJECTIVE

Describe the level of registered dietitian (RD) involvement in neonatal intensive care units (NICUs) and associations with NICU nutrition practices.

DESIGN

Questionnaires were mailed to 820 NICUs in the United States with two follow-up mailings to nonresponders. Abbreviated phone surveys were conducted with a random sample of 10% of nonresponders. A nutrition care score was devised based on a sum of 10 survey questions (range 0 to 10) to summarize the intensity of reported practices.

SUBJECTS/SETTING

Directors of NICUs in the United States and RDs associated with them.

STATISTICAL ANALYSES

Chi2, analysis of variance, Bonferroni and Duncan multiple range tests, regression.

RESULTS

Respondents from 417 (54%) of the 772 NICUs eligible for the study provided completed questionnaires. Among NICUs responding, 76% involved RDs in care (41% employed full- or part-time RDs, 35% employed consult RDs), and 24% had no RD. NICUs with full- or part-time RDs provided fewer kilocalories and more protein parenterally, and more kilocalories and protein enterally. NICUs with less RD involvement were more likely to provide full-term infant feedings (eg, unfortified breast milk, full-term formula) to very-low-birth-weight infants. Mean nutrition care score varied with RD involvement from 4.6+/-1.7 (mean+/-standard deviation) for NICUs with a consult RD and 4.7+/-1.4 for NICUs employing no RD to 5.6+/-1.7 for NICUs with a full- or part-time RD (overall P<.001).

CONCLUSIONS

More involvement of RDs in NICUs increased the intensity of important aspects of nutrition care that may improve outcomes of very-low-birth-weight infants in NICUs. These findings highlight the importance of RDs as NICU team members.

[Enteral nutrition in the preterm and term newborn with low birth weight]

Nutritioinal practices vary dramatically among neonatal intensive care units (NICU) in other countries. In many hospitals, nutrition is introduced gradually over the first weeks of life because the risk of necrotizing enterocolitis or nutrient intolerance is considered inevitable. Enteral nutrition practices among premature and near term infants with low birth weight were investigated. We hypothetized these practices would be very different among facilities and among staff at these same facilities.

METHODS

We carried out a survey in public and private neonatal care units in urban and peri-urban areas of Mexico City. An adapted version of the Vermont-Oxford Neonatal Network was administered. We included 290 questions on practices, initiation, progression, methods, type and cessation of feedings. We also included milk feeds supplementation and written protocols.

RESULTS

116 surveys were administered in seventeen second and tertiary care facilities to 86 neonatologists and 30 neonatology residents.

CONCLUSION

We found great variability in progression, methods, type, suspension and supplementation among NICU and among staff There is an urgent need to standardize nutritional criteria among physicians and medical facilities.

Breastfeeding: benefits and implications. Part two

Recent guidelines from the Department of Health recommend exclusive breastfeeding for the first six months (26 weeks) of an infant's life with the late introduction of solids being cited as protective against the development of asthma, eczema and atopy. However, it has been suggested that national and international recommendations for the age of introducing solid foods (weaning) are founded on insufficient evidence. In part two of her update, June Thompson looks at the conflicting literature regarding whether exclusive breastfeeding for six months conveys significant benefits for babies and if current recommendations that a delayed introduction of solids is protective against the development of asthma and allergy are supported by the evidence.

Vitamin D and the Breastfed Infant

For infants and children, vitamin D deficiency causes a bone-deforming disease known as rickets. As breastfeeding rates have increased, so have the incidences of rickets. The current recommendation from the American Academy of Pediatrics, to supplement all breastfed infants with vitamin D, is controversial. The role of the nurse is to understand the vitamin D dilemma, promote breastfeeding, and prevent vitamin D deficiency rickets.

Calorie and protein-enriched formula versus standard term formula for improving growth and development in preterm or low birth weight infants following hospital discharge

BACKGROUND

Preterm and low birth weight infants are often growth-restricted at hospital discharge. Feeding infants post-hospital discharge with calorie and protein-enriched formula milk might facilitate "catch-up" growth and improve development.

OBJECTIVES

To review the evidence from randomised controlled trials that feeding following hospital discharge with calorie and protein-enriched formula compared with standard term formula improves growth and development for preterm or low birth weight infants.

SEARCH STRATEGY

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2004), MEDLINE (1966 - December 2004), EMBASE (1980 - December 2004), CINAHL (1982 - December 2004), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared the effect of feeding preterm or low birth weight infants post-hospital discharge with calorie and protein-enriched formula compared with standard term formula.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two authors, and synthesis of data using weighted mean difference and a fixed effects model for meta-analysis.

MAIN RESULTS

We found six trials that were eligible for inclusion. These recruited a total of 424 infants and were generally of good methodological quality. These trials found little evidence that feeding with calorie and protein-enriched formula milk affected growth and development. Because of differences in the way individual trials measured and presented outcomes, data synthesis was limited. Meta-analysis of data from two trials found a statistically significant effect on crown-heel length at 18 months post-term (weighted mean difference 9.7 millimetres (95% confidence interval 3.2 to 16.2)), but not on weight or head circumference. Meta-analysis of data from the two trials that assessed neurodevelopment at 18 months post-term did not reveal a statistically significant difference in either Bayley Mental Development Index (weighted mean difference 0.23 (95% confidence interval -2.99 to 3.45)) or Psychomotor Development Index (weighted mean difference 0.56 (95% confidence interval -1.95 to 3.07)). There are not yet any data on growth or development through later childhood.

AUTHORS' CONCLUSIONS

The limited available data do not provide strong evidence that feeding preterm or low birth weight infants following hospital discharge with calorie and protein-enriched formula compared with standard term formula affects growth rates or development up to 18 months post-term.

Screening for infants' and toddlers' dietary quality through maternal diet

PURPOSE

To investigate the relationship of mothers' dietary quality to that of their infants and toddlers in limited-income families at risk for poor health.

STUDY DESIGN AND METHODS

Secondary data analysis was conducted of dietary quality from 24-hour dietary recalls collected from 113 mother-infant/toddler pairs in limited-income families with a child at age 6 months and again at age 14 months. Dietary quality of mothers was evaluated on the basis of eating breakfast and having at least one serving of the five food groups from the Food Guide Pyramid. Diet quality of infants was determined by comparison to the Women, Infants, and Children feeding guidelines for their ages; the diet quality of the mother was then compared to that of her infant and, later, toddler.

RESULTS

Most mothers and their infants had poor diet quality at the first interview. By 14 months most mothers still had poor diet quality, but diet quality for the children improved such that only about one-half remained poor. Poor diet quality of mothers was useful to detect poor diet quality for her infant or toddler showing high concordance at both interviews.

CLINICAL IMPLICATIONS

A consistent marker for infants at risk for poor diet quality is having a mother who skipped breakfast and omitted fruits, vegetables, or dairy products. This could be a quick indicator to identify those at greatest risk for not following recommended guidelines in feeding their infants and toddlers.

[Recommendations for the complementary feeding of the breastfed child]

OBJECTIVE

To present a review on the evidence that support the current recommendations for breastfed children feeding.

SOURCES OF DATA

An extensive bibliographic review of the topic was carried out. Articles selected in the MEDLINE and Lilacs databases, publications from national and international organizations, theses and dissertations were reviewed. Some key articles were also selected from the citations referred in other papers.

SUMMARY OF THE FINDINGS

New knowledge acquired about child feeding over the last 20 years have led to a significant change in the current feeding recommendations for breastfed children in relation to the prior recommendations. The current recommended nutritional needs are lower than the old recommendations, complementary food is introduced in a more precise age, around 6 months, and new methods are recommended for promoting the child's healthy eating. The new recommendations emphasize the health feeding practices which comprise both the adequate food quantity and quality, including care with food handling and preparation, feeding and storage practices, and the respect and adequacy to the cultural characteristics of each people.

CONCLUSIONS

The adequate complementary feeding of the breastfed child is critical for the optimal child growth and development. Therefore, it is an essential factor for both the populations food security and the development of nations. The health professionals ought to effectively pass on to mothers/care takers the new recommendations for promoting the healthy complementary feeding of the breastfed child. It is up to the governments to provide the adequate conditions for supporting such a promotion.