Kirsten Bennett MS, RD, LD PNT October 5, 2012

Transcription

1 Kirsten Bennett MS, RD, LD PNT October 5, To connect audio, please telephone Access code: # Please mute/un-mute your telephone line by pressing *6. You may also press your mute button on your headset or speakerphone during the webinar when you are not speaking. Do not place your phone on hold. If you wish to receive CME/CEU/ or an attendance certificate, you must announce your name when we ask who is participating both at the start and at the end of the session. This session is being recorded. If you are called on and do not wish to answer, feel free to say pass

2 Disclosure: UNM CME policy, in compliance with the ACCME Standards of Commercial Support, requires that anyone who is in a position to control the content of an activity disclose all relevant financial relationships they have had within the last 12 months with a commercial interest related to the content of this activity. The presenter discloses that he/she/they have no relevant financial relationships with any commercial interest. Accreditation: The University of New Mexico School of Medicine, Office of Continuing Medical Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Office of Continuing Medical Education designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. Envision NM is a division of the UNM Department of Pediatrics and receives funding from the NM Department of Health and the NM Human Services Department Given the many choices for infant feeding, how do I best support the feeding choices of the families and children I care for? When do I need to consider a non-standard infant formula? What are the nutritional implications of using formulas used for one specific pediatric population in another?

3 A. Anthropometrics B. Biochemical C. Clinical D. Dietary E. Environment F. Feeding skills/development G. Growth pattern How are dietary intake and dietary concerns identified and addressed in typically developing infants? What role does the feeding environment play in infant feeding practices? What can an infant s developmental progress tell us about approaches to feeding?

4 Duration of feeding Method of feeding Breast Bottle-breast or formula Li et al. (2012) Risk of Bottle-feeding for rapid weight gain during the first year of life. Arch Pediatr Adolesc Med. 166 (5); ) Special formula and rationale for use Formula preparation Meals at home Meals at school or child care Quantity estimate Quality estimate Supplement use Home Siblings Multiple households Primary caregiver Who prepares meals WIC participation Which food package? Cultural considerations Beliefs about feeding Introduction of solid food Breast feeding

5 Compare to typical development expected for age Large motor Posture What is the child able to do now? Small motor Oral motor control Feeding skills Self In response to caregiver Caregiver concerns regarding development Vitamin K Breast milk poor source Limited stores secondary to poor placental transport Gut flora not productive enough IM injection at birth of mg at birth Vitamin D AAP recommends 400 IU/day Supplement breast fed infants Iron To supplement or not? Fluoride

6 Energy ~50% needed to support rapid growth ~3.5 times the need of an adult use DRIs as a gauge Term infant 108 Kcal/kg/day Protein high quality use DRIs as a gauge 1.52 g/kg/day (2006 DRI) Term infant 2.2 g/kg/day (1989 RDA) tyrosine, taurine, cystine (conditionally essential) Fat 55% of breast milk calories human milk has EPA (eicosapentaenoic acid), AA (arachadonic acid), DHA (docosahexaenoic acid) Major source of calories for growth

7 Carbohydrate lactose predominant in human milk Minerals calcium retention is better with human milk sufficient in human milk and standard formulas renal solute load too high with undiluted cow or goat milk kg, 100 ml/kg +50 ml/kg for >10 kg +20 ml/kg for >20 kg 1.0 ml/kcal consumed

8 Folate and B 12 at birth and breastfeeding adequate in well nourished mothers Concern vegan diets goat s milk Iron healthy term infant with stores for 4-6 months if not breastfed, use iron fortified formula when solid foods are introduced, choose iron rich May begin to see meat offered as a first weaning food because of the concern for iron and zinc intake Age <0.3 ppm ppm >0.6 ppm 0-6m m-1y 0.25mg y 0.5 mg 0.25mg y 1.0 mg 0.5mg

9 Age (months) Energy (kcal/kg) DRI Protein (g/kg) Energy EER (kcal/day) Protein (g/day) AI Use the rule of thumb presented in the previous chart May need to increase or decrease estimate based on growth pattern or co-morbid conditions Preterm Catch-up growth Developmental delay Congenital anomalies

10 Encourage and support breastfeeding If exclusive breastfeeding is not possible or advisable, then choose an appropriate formula Initial Tolerance Digestion Absorption Metabolism Hydration Long Term Growth Support of optimal tissue synthesis and repair Support of optimal physical, cognitive, and behavioral development

11 Breastfeeding Term Infant Yes Support Not Exclusive No Intolerance to Standard Infant Formula Tolerance to Standard Allergy Mal-digestion Milk Based Protein Protein Carbohydrate Fat Soy Metabolic Other Lactose MCT Casein Hydrolysate Synthetic AA Specific Lactose Free Standard Some MCT Consider the water supply Is it safe? What is the level of flouride? Distilled water can be used Does the family have access to distilled water? Are there concerns about the ability of caregivers to mix formula correctly?

12 Casein predominant Similac Advance Similac Organic Whey predominant Enfamil Premium LIPIL Triple health guard GoodStart Protect Plus Similac PM 60/40 Wyeth store brands Gentlease (MJ) Term infant Family history of cow s milk allergy Infant with suspected cow s milk allergy Diagnosis of Galactosemia (IMD) Lactose intolerance with concern for cow s milk based formula

13 Infant with suspected allergy Gastrointestinal issues Malabsorption Diarrhea (prolonged) Available formulas Enfamil Pregestimil Enfamil Nutramigen LIPIL Similac Alimentum Advance 3232 A (Mead Johnson) Suspected allergy with concern for exposing child to any form of cow s milk protein Suspected multiple food allergies Available formula Neocate Nutramigen AA

14 Lactose Intolerance, not associated with severe GI symptoms Available formulas Enfamil Lactofree LIPIL Similac Lactose Free Advance Wyeth store brands MCT provides some of the fat Malabsorption GI issues Formulas available Enfamil Pregestimil Similac Alimentum Advance Neocate Infant Formula (SHS) Elecare (Ross)

15 Predominantly MCT as the fat source Defect of intralumenal hydrolysis of fat Decreased pancreatic lipase Decreased bile salts Defect in mucosal absorption of fat Defective lymphatic transport of fat Chylothorax Formulas available 3232 A (Mead Johnson) 85% fat as MCT, need to add carbohydrate, will meet the needs of infants Portagen (Mead Johnson) 87% of fat as MCT, more appropriate for children and adults Enfagen RCF (Ross Carbohydrate Free) Soy based Add tolerated carbohydrate 3232 A (Mead Johnson) Protein hydrolysate Add tolerated carbohydrate

16 Additives to Human Milk Increase calories and protein 1 packet to 50 ml adds 2 kcal/oz Increase vitamin and mineral content Iron Calcium and phosphorus Caution with 25 packets per day Available powdered fortifiers Mead Johnson Human Milk Fortifier Similac Human Milk Fortifier Liquid fortifiers Mead Johnson Liquid Human Milk Fortifier DHA/ARA fortified Similac Natural Care Advance Low iron 24 kcal/oz Alternate with breast milk feedings Hospital feedings Similac Special Care Advance 20, 24, iron NEW! 30 kcal/oz Enfamil Premature LIPIL 20, 24, iron Post discharge feedings From 1800g until? Enfacare LIPIL 22 kcal/oz Similac Neosure Advance 22 kcal/oz

17 Allergy, Malabsorption, or Inherited Metabolic Disorder May need to use a formula designed for term infants to meet needs Diarrhea Similac Isomil DF Advance Use for infants 6 months and older Soy fiber 20 kcal/oz Thickened Feedings Enfamil AR LIPIL (Restful) Milk based Rice starch 10x viscosity of standard formula Increased viscosity in the stomach Iron containing

18 Oral maintenance solution Used during illness to maintain hydration and electrolyte balance kcal/oz Enfamil Enfalyte (Mead Johnson) Pedialyte (Ross) Liquilytes ( Gerber) Oral Rehydration Therapy Used to enterally rehydrate following significant dehydration Rehydralyte (Ross) 3 kcal/oz Designed to be used after 6 months with good solid food intake Cow s milk based Similac 2 Advance Next Step LIPIL (Mead Johnson) Good Start Follow-up Wyeth store brands Soy based Next Step Prosobee LIPIL (Mead Johnson) Similac Isomil 2 Advance Good Start Supreme Soy

19 Usual incidence <1:5,000 live births Most are autosomal recessive All states require screening of newborns Screening panels vary Require special medical foods Formula Modified solid food Products are specific to specific errors of metabolism, must have a diagnosis Care is provided by a clinician with expertise in this area according to published protocols Formulas are chosen based on diagnosis, composition, and specific patient needs

20 (Nestle) If you wish to receive CME/CEU/ or an attendance certificate, please tell us your name. Please un-mute your telephone line by pressing *

21 Envision New Mexico Staff Directory Telephone Jane McGrath, MD, FAAP Program Director Kris Carrillo, LISW Program Operations Director Dan Rifkin, MD Child and Adolescent Psychiatrist Kirsten Bennett, MS, RD, LD QI Training, Consultation and Outreach Paula LeSueur, CFNP CHIPRA Manager Carole Conley, LMSW QI Training, Consultation and Outreach Kristine Lucero Accountant II Terri Chauvet Administrative Assistant III Fauzia Malik, MPAS QI Training, Consultation and Outreach John Martinez QI Training, Consultation and Outreach Carolyn Salazar, RN QI Training, Consultation and Outreach Janette Schluter Program Data Specialist McKane Sharff CHIPRA Program QI Specialist Jeanene Sisk Administrative Assistant II Clancey Tarbox Program Coordinator Kevin Werling Systems Analyst ll Michelle Widener Data Analyst Nancy Vandenberg CHIPRA Program Youth Specialist