The Effects of Infant Feeding Techniques and Nutrient Intakes on Formula fed Infants Misty Schwartz, PhD, RN, Barbara Synowiecki, MSN, APRN, C PNP Creighton University College of Nursing Thank You: Health Future Foundation Faculty Development Grant Background Obesity Childhood obesity epidemic well established pre stages adult obesity Racial & socioeconomic disparities influence Breast vs. Formula feeding Emphasis on breast feeding irrefutable Feeding method decisions complex based on lifestyle, socioeconomic status, education level, medical considerations of mother & infant Formula feeding parents receive less education and support Less education results in formula inaccuracies & earlier introduction of complementary foods Conflicting & inconclusive findings on infant feeding practices & outcomes 1
Obesity risk factors Formula Feeding Maternal BMI Formula Feeding Maternal smoking Minority race Low Maternal education Low SES Overfeeding Early introduction of complimentary foods Higher protein in formula Errors in formula preparation Lifestyle Socioeconomic Status Education Level Medical considerations Younger mothers Lower maternal education Lower socioeconomic status Lower education Feeding decision (BF vs FF) Early introduction of complimentary foods Purpose & Specific Aims: Purpose: To assess prospectively the feeding techniques and nutrient intakes of infants who are formula fed from birth to six months of age. Specific Aim # 1: To determine whether formula fed infants consume more calories and protein than amounts recommended by the NAM, NAS between birth and six months of age. Specific Aim #2: To determine the age at which formula fed infants have solid (complementary) foods introduced. Specific Aim #3: To determine skin fold thickness and height and weight velocity in FF infants and to compare these velocities to WHO growth charts. 2
Methods This was an exploratory prospective approach Sample = 30 exclusively formula fed infants Growth of infants was studied over a 6 month time frame. Each infant was followed for 4 months (from 2 6 months of age). Growth parameters from birth were gathered and then we assessed at 2, 4 & 6 months. Diet diaries were also collected at each visit. Demographic information Enrolled 30 28 completed 2 lost to follow through (after 1 visit & 1 after 2 visits) Females N = 13 (43%) Males N = 17 (57%) Female Male Race & Ethnicity: Black/African American N = 10 White N = 10 Native American N = 2 More than one race/ethnicity identified N = 8 Hispanic/Latino N = 8 Hispanic White Black Native American Recruitment 57% 43% 33% 7% 27% January, 2014 August, 2015 33% 3
Median Income 80000 70000 60000 50000 40000 30000 20000 10000 0 Medican Income FFS Study Douglas Sarpy Pott Percent (%) Below Poverty Level 40 35 30 25 20 15 10 5 0 All Age: 18 & below Age: 5 & below FFS Douglas Sarpy Pott 4
Symptoms per Visit 20 18 16 16 14 14 12 12 10 10 8 8 6 6 4 4 2 2 0 Rash Restless Fussiness Fever 0 Constipation Diarrhea Gassiness Appetite Vomiting Visit 1 Visit 2 Visit 3 Visit 1 Visit 2 Visit 3 Medication Information 16 different babies were given 29 medications Time 1 10 (33%) Time 2 14 (47%) Time 3 13 (43%) Symptoms and related medications: Rash: Hydrocortosone Cream Constipation: Glycerin Supp Miralax Lactulose Reflux: Ranitidine (Zantac) Omeprazole (Prilosec) Nazitidine (Axid) Previcid Nutrition Polyvitamin Infection: Amoxicillin Albuterol Nutrition 9% Infection 14% Reflux 48% Rash 5% Constipation 24% Rash Constipation Reflux Nutrition Infection 5
Specific Aim # 1: To determine whether formula fed infants consume more calories and protein than amounts recommended by the IOM, NAS between birth and six months of age. Methods: Calculated individual recommendations for calories and protein for each infant based on their age, gender, and weight for each visit. Paired samples t test & one sample t test Calories Actual Calorie Intake vs Recommended Calorie Intake Protein Actual Protein Intake vs Recommended Protein Intake Statistical Results: Mean difference Time1= 112 (SE = 28), 95% CI [55, 169], t(29) = 3.99, p <.001. d =.73, representing a medium to large effect. Mean difference Time2 = 123 (SE = 40), 95% CI [41, 205], t(29) = 3.06, p =.005. d =.47, representing a medium effect. Mean difference Time 3 = 151 (SE = 50), 95% CI [49, 254], t(27) = 3.03, p =.005. d =.57, representing a medium effect. On average, infants received significantly more calories than their individual calorie recommendations. Specific Aim # 1: To determine whether formula fed infants consume more calories and protein than amounts recommended by the IOM, NAS between birth and six months of age. Methods: Calculated individual recommendations for calories and protein for each infant based on their age, gender, and weight for each visit. Paired samples t test & one sample t test Calories Actual Calorie Intake vs Recommended Calorie Intake Protein Actual Protein Intake vs Recommended Protein Intake Statistical Results: Mean difference Time1= 7 (SE =.77), 95% CI [5, 8], t(29) = 8.97, p <.001. d = 1.64, representing a large effect size. Mean difference Time2 = 6 (SE =.97), 95% CI [4, 8], t(29) = 5.73, p <.001. d = 1.05, representing a large effect size. Mean difference Time 3 = 7 (SE = 1.6), 95% CI [3, 10], t(26) = 4.22, p <.001. d =.81, representing a large effect size. On average, infants received significantly more protein than their individual calorie recommendations. 6
60 Overfed by Classification 50 40 Mean Overfed (%) 30 20 10 0 Time1 Time2 Time3 Low ( < 25%) High ( 25%) This seems to suggest that overfeeding early is related to overfeeding later or continued overfeeding. 7
Specific Aim #2: To determine the age at which formula fed infants have solid (complementary) foods introduced. 50% # of babies 11% 11% 28% Visit 1 Visit 2 Visit 3 NONE First introduction to complementary foods: Visit 1 3 babies Visit 2 8 babies Visit 3 14 babies No complimentary foods 5 babies Before 6 months: Early introduction 11/29 babies (38%) were receiving complementary foods. At 6 months: 25/28 babies (89%) were receiving complementary foods. Specific Aim #3: To determine skinfold thickness and height and weight velocity in formulafed infants and to compare these velocities to WHO growth charts. Growth Assessments Weight** Length Head circumference Arm circumference Triceps skinfold Subscapular skinfold 8
Average Weights (percentiles) 47 46 45 44 43 42 41 40 39 38 37 Visit 1 Visit 2 Visit 3 %ile Conclusions In general, parents in this study were mixing the formula correctly and they were fairly consistent in their daily feeding patterns. We found that the parents in our study were overfeeding both in calories and protein. Many parents in this study were introducing complementary food before the AAP recommendations of around 6 months of age. Growth patterns are increasing and may be increasing at a higher rate than the WHO growth curve patterns. Also it seems that there is a fairly large number of medications and especially meds related to GI and/or other symptom related. 9
Recommendations for Future Research Next: Another exploratory study but externally funded Collect more demographic data Consider dual energy absorptiometry (DeXA) scan as an assessment Focus on health disparities and high risk populations in order to provide the best health outcomes possible Examine both parent and infant cues Then: Intervention Study with infants in the first year of life Focus on education to prevent overfeeding and appropriate timing of the introduction of complimentary foods Follow infants through toddler stage while introducing new foods and establishing dietary habits. 10