Cows Milk or follow on Formula. Hilton 26/10/2014

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1 Iron Deficiency Anemia Cows Milk or follow on Formula Dr Antoine Farah Clinical associate Prof. American University Hospital Hilton 26/10/2014

2 Iron in infant nutrition: what is the evidence in 2014

3 IRON DEFICIENCY ANEMIA A d i th b f d bl d ll i th bl d d t l k f A decrease in the number of red blood cells in the blood due to a lack of iron

4 ESPGHAN Committe on Nutrition

5 ESPGHAN Committe on Nutrition Aim To review the field and provide recommendations regarding iron requirements of infants and toddlers (1 3 years of age), including those of moderately or marginally These low recommendations birth weight. are valid for Europe and regions with a low general prevalence of IDA.

6 Anemia prevalence Lebanon moderate Globally, Pre-school approx. children 25% of pre-school children 28.3% have IDA

7 Causes of Hypochromic Microcytic Anaemias Inade equate e intak ke Enterocyte Malabsorption Erythroid precursor Defectsinheme synthesis or iron acquisition losses s Blood Breastfeeding with inadequate supplementary food Preterm, low birth weight Growth spurt Inadequate calorie intake Vegetarian diet Celiac disease Helicobacter pylori gastritis Autoimmune atrophic gastritis IRIDA (TMPRSS6 mutation) Chronic inflammation Graphic courtesy of Dr. Mariane de Montalembert. Haemoglobinopathies Sideroblastic anaemia Erythropoietic porphyria DMT1 mutations Ferroportin disease Hereditary atransferrinaemia Hereditary aceruloplasminaemia Polymenorrhea Parasitic infestations Peptic ulcer Inflammatory bowel disease Meckel diverticulum

8 What is the most vulnerable period for the child and future adult Is it between 1 and 5 years Or when nothing can change after 30 or 40 years????

9 Parameter Iron Deficiency Stages Stage Prelatent Latent IDA Reduced iron stores with normal serum iron levels Exhausted iron stores with normal haemoglobin Low haemoglobin Haemoglobin Normal Normal Decreased MCV/MCH Normal Normal Decreased Serum iron Normal Decreased Decreased TIBC Normal Increased Increased Transferrin Normal Decreased Decreased saturation Serum ferritin Decreased Decreased Decreased Marrow iron Decreased Absent Absent Abbreviations: IDA, iron deficiency anaemia; MCH, mean corpuscular haemoglobin; MCV, mean corpuscular volume; TIBC, total iron binding capacity. Slide courtesy of Dr. Adlette C. Inati, MD.

10 Iron ESPGHAN Committee on Nutrition General prevalence of IDA in European infants and toddlers Age Prevalence <6 mo <2% 6-9 mo 2-3% 1-3 y 3-9% ESPGHAN Committee on Nutrition. JPGN 2014;58:

11 Iron ESPGHAN Committee on Nutrition Definition of IDA A combination of Hb and ferritin is recommended. Age specific cutoffs for iron status should be used. Suggested cutoffs for definition of anemia and low serum ferritin at different ages 0-1 wk 2 mo 4 mo 6-24 mo 2-5 Y Hb (g/l) S- ferritin (μg/l) IDA, iron deficiency anaemia ESPGHAN Committee on Nutrition. JPGN 2014;58:

12 Iron ESPGHAN Committee on Nutrition Age Theoretical iron requirements <6 mo Low 6-12 mo mg/kg/d 1-3 y mg/kg/d /d ESPGHAN Committee on Nutrition. JPGN 2014;58:

13 Iron ESPGHAN Committee on Nutrition Strictly regulated Iron absorption as iron can not be excreted from the body Generally low Depends on diet ascrobic acid, human milk, meat phytates, cow s milk Infants and toddlers can upregulate absorption when iron stores decrease ESPGHAN Committee on Nutrition. JPGN 2014;58:

14 Iron ESPGHAN Committee on Nutrition Health effects related to iron deficiency IDA in young children is associated with long-lasting lasting poor neurodevelopment Also, Growth retardation Impaired immune response IDA, iron deficiency anaemia Neurons ESPGHAN Committee on Nutrition. JPGN 2014;58:

15 Iron supplementation in early infancy Effect of Mental and Psychomotor Developmental Indexes (MDI & PDI) Szajewska et al. Am J Clin Nutr 2010;91:

16 Iron ESPGHAN Committee on Nutrition Iron supplementation of pregnant women Does not improve infant iron status in European setting ESPGHAN Committee on Nutrition. JPGN 2014;58:

17 Iron ESPGHAN Committee on Nutrition Delayed umbilical cord clamping Improves iron status ESPGHAN Committee on Nutrition. JPGN 2014;58:

18 Iron ESPGHAN Committee on Nutrition Breast-fed infants <6 mo But preventive iron supplementation may be provided for Infants from high-risk groups (low-socieconomic status or living in areas with high prevalence of IDA) if the infant has a low intake of iron-rich complementary foods IDA, iron deficiency anaemia ESPGHAN Committee on Nutrition. JPGN 2014;58:

19 Iron ESPGHAN Committee on Nutrition Formula-fed infants < 6 mo Iron-fortified formula prevents IDA and possibly improves neurodevelopment Iron-fortified formulae Fe 4-8 mg/l ( mg/kg/d) IDA, iron deficiency anaemia ESPGHAN Committee on Nutrition. JPGN 2014;58:

20 Iron ESPGHAN Committee on Nutrition Complementary foods 4-12 mo Iron-rich complementary foods and avoidance of unmodified d cow s milk prevents IDA IDA, iron deficiency anaemia ESPGHAN Committee on Nutrition. JPGN 2014;58:

21 Iron ESPGHAN Committee on Nutrition Complementary foods 4-12 mo It is up to national authorities to decide what type of iron-rich foods should be encouraged in their own country, depending on food habits, and so on. IDA, iron deficiency anaemia ESPGHAN Committee on Nutrition. JPGN 2014;58:

22 Cow s milk Low in iron Can displace iron-rich foods Can inhibit iron absorption As sa main milk source for infants <6 mo can cause gastrointestinal bleeding and increased occult blood loss in stool Michaelsen, 2000; Fomon, Nelson, Serfass, & Zeigler, 2005; Bondi & Lieuw, 2009; Ziegler et al., 1999; Jiang, Jeter, Nelson, & Ziegler, 2000; Leung, & Sauve, 2003; Fernandes, de Morais, & Amancio, 2008).

23 Goat milk Poses the same risks for the development of iron deficiency i as cow milk when consumed in excessive amounts by young children CDC, 1998

24 Iron ESPGHAN Committee on Nutrition Iron supplements 4-12 mo Prevents IDA and may improve neurodevelopment but only in populations with high (>10%) prevalence of IDA at 6-12 mo of age IDA, iron deficiency anaemia ESPGHAN Committee on Nutrition. JPGN 2014;58:

25 Iron ESPGHAN Committee on Nutrition Low-birth-weight infants <6 mo mg/kg g <2000 g 2-3 mg/kg g Prevents IDA Possibly improve neurodevelopment from 2-6 wk to 6 mo IDA, iron deficiency anaemia ESPGHAN Committee on Nutrition. JPGN 2014;58:

26 Iron Not too little, not too much

27 Learnings Iron requirements What ESPGHAN recommends in 2014? Growing-up milks To use or not to use? Plus new data on growing-up milk ESPGHAN, European Society for Paediatric Gastroenterology, Hepatology and Nutrition

28 Growing-up milk (GUM) Toddler s milk In general, compared with cow s milk protein iron vit. A, D Various countries are working to develop international standards for them (Codex Alimenatarius Commission, 2011). Ghisolfi J. Arch Pediatr 2010;17 (suppl 5):S BfR The Federal Institute for Risk Assessment 2011.

29 Growing up milk Belgian statement (2014) Vandenplas et al. Eur J Pediatr 2014 (on line)

30 Growing up milk Belgian statement (2014) A literature search (Pubmed, Embase, Cochrane) on the use of GUM in 12- to 36-mo-old young children Only limited data are available GUM have a highly variable composition as their marketing is not regulated. All papers conclude thatt GUM help to cover nutritional titi requirements of 12- to 36-month-old infants Vandenplas et al. Eur J Pediatr 2014 (on line)

31 Growing up milk Belgian statement (2014) Conclusion Appropriate intakes of macro- and micronutrients in 1- to 3-year-old children have long-term health benefits. Present diets offered to toddlers do in general not meet the requirements. Supplemented foods are therefore helpful, of which h GUM is a great possibility Vandenplas et al. Eur J Pediatr 2014 (on line)

32 What is new on growing-up milk? Chatchatee et al. JPGN 2014;58:

33 New data on growing-up g milk Design Population Intervention Comparison Primary outcome RCT, DB, multicenter Children, aged 11 to 29 mo GUM with scgos/lcfos (for 52 wk) GUM (for 52 wk) Non-randomized control group cow s milk (for 52 wk) Number of episodes of upper respiratory tract infections or gastrointestinal infections Chatchatee et al. JPGN 2014;58:

34 New data on growing-up g milk decreased risk of developing at least 1 infection total number of infections confirmed by one of the investigators Chatchatee et al. JPGN 2014;58:

35 New data on growing-up g Conclusion milk This is the first study in children to show a reduced risk of infection following consumption of GUM supplemented with scgos/lcfos/n-3 LCPUFAs. Further studies to confirm this finding are needed. Chatchatee et al. JPGN 2014;58:

36 Cows milk Low iron with very poor absorption High ca++ with very bad Ca++/ph ratio 1.1 Very big protein size/allergic diseases Very high Sodium level(water retention) Higher risk of childhood obesity(fat content) Maybe a bit cheaper Recommended for marketing conclusion Follow on formula 1 5 years of age Higher iron with better absorption Optimal ca++/ph ratio of 1.8 Adapted smaller proteins (optimal growth) Less Na+ load to the immature kidney Lower fat content with adequate amount of MCTs But much more cost/effective Pediatricians choice for healthychildren's hild

37 THE CHOICE IS YOURs Thank you Dr Antoine Farah aa