Infant Feeding: Getting it Right From the Start - PowerPoint Presentation

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Infant Feeding: Getting it Right From the Start

Julie Matel, MS, RD, CDESlide2

Nutrition for Infants with CF

Should I drink breast milk or formula?

Do I need a high calorie formula?

Does early growth matter?

When can I eat real food?Slide3

Evidence-based practice recommendations for nutrition-related management of children and adults with cystic fibrosis and pancreatic insufficiency: results of a systematic review. J Am Diet Assoc. 2008;108:832-839.

Stallings VA, et al. Slide4

© Children’s Hospital of Wisconsin. All rights reserved.

Better nutritional status in early childhood is associated with improved clinical outcomes and survival in patients with cystic fibrosis.

Elizabeth H. Yen, MD; Hebe Quinton, MS;

Drucy

Borowitz

, MDAim: To evaluate the impact of nutritional status early in life on the timing and velocity of height growth, lung function, survival and CF complications through age 18 Slide5

Conclusions

Greater weight at age

four

is associated with

greater height

better pulmonary functionfewer complications of

CFGreater weight for age in the peripubertal period is associated with improved growthGreater weight at age

four is associated with better survival through age 18Slide6

How do we achieve optimal growth during the first year of life?Slide7

Breastmilk

vs FormulaSlide8

Breastmilk vs

Formula

Breast feeding has long been recommended as a first feeding for infants with Cystic Fibrosis

1992

Consensus statement promoted breast feeding

Current CF Nutrition Consensus continues to recommend breast

milk Slide9

Breast Feeding Advantages

Lower rates of ear infections, colds, GE

Bonding between mom and baby

Maternal advantages

Saves money

Convenient

Less post-partum depressionAntimicrobial components of breast milk protect against respiratory infections in CFSlide10

Breast Feeding Disadvantages?

In High risk* infants with CF, breast milk may be inadequate in…

Calories

Protein

Essential fatty acidsSodium

* High risk: Meconium ileus, pancreatic insufficientSlide11

Growth and Pulmonary Outcomes During the First 2 years of Life of Breast Fed and Formula Fed Infants with CF Through the Wisconsin Routine Newborn Screening Program

103 Wisconsin infants

born 1994-2006

diagnosed through newborn screening

53 infants were breast fed (BF) and 50 infants received only formula (FM)in the first year of life

Infants were classified into 3 categoriesDiagnosed with meconium ileus [

24 babies]Pancreatic insufficiency [70 babies]Pancreatic sufficient [9 babies]Slide12

Study Design

Retrospective medical record review

Data included:

Type and length of feedings

Introduction of solids and cow milkGrowth dataRespiratory cultures and infections; CXR

Genotype; age at diagnosisSlide13

Study Conclusions

Pancreatic insufficient

infants who were exclusively BF

<

2

mo:achieved adequate weight gain

had fewer pseudomonas infection during the first 2 years than infants who were exclusively formula fedExclusively BF ≥ 2

mo:associated with reduced weight gain

without an additional respiratory benefitSlide14

FIRST (

Feeding I

nfants

R

ight from the Start)

Prospective study to investigate the potential benefits and risks of breastfeeding in infants with CF

160 CF infants to be enrolled over 4 years (2012-15)5 sites: Madison and Milwaukee, WI, Indianapolis, Boston, and Salt Lake CitySlide15

Study design

Follow up for 2 years

Primary outcomes

Weight gain and Pa infections

Secondary outcomes

Nutritional: Length, head circumference, essential fatty acid

and vitamin levelsPulmonary: Inflammatory markers, other respiratory pathogens, chest x-ray scores, respiratory symptomsSlide16

Preliminary analysis of the FIRST Study

Aim is to identify optimal feeding for infant with Cystic Fibrosis

F

ocused on 82 infants

pancreatic insufficient, without meconium ileus

Evaluated feeding patterns for 6 monthsSlide17

Results: Feeding Patterns (82 infants)

Most infants were exclusively breast fed at 1 month

Most Infants were exclusively Formula Fed

at 6 monthsSlide18

Results: Caloric Density of Feeds

More than half of infants received fortified breast milk or higher calorie formula by six monthsSlide19

Results: Growth patterns

In the first 2 months

all feeding groups

experienced a decrease in weight

for length

percentilesAt 6 months

only the ex formula fed and (Breast + formula fed) groups had an improvement in their weight and weight for length percentiles (achieved the 55-60 %ile)

Weight and weight for length percentiles remained low in the

ex breast fed groupExclusively breast feeding for 6 months was associated with lower weight gain at 4-6 months compared to exclusively formula fed and (Breast + formula fed) groupsSlide20

Essential Fatty Acid Content of Breast Milk and of Diets in Mothers of Infants with CF

Breast milk and diet content of 12 mothers with infants enrolled in the FIRST study (39 samples of breast milk were analyzed)

71% of breast milk samples would not be able to provide enough linoleic acid for infants with CF

57% of mothers’ linoleic acid intake was below the AI (adequate intake) for lactating womenSlide21

Conclusions

Prolonged exclusive breast feeding was associated with lower weight percentiles and lower weight gain at age 4-6 months, compared to formula or mixed feedings (breast feeding plus formula)

Most breast milk samples appear to contain insufficient linoleic acid for CF infantsSlide22

Starting Solid Food FeedingsSlide23

Introduction of Solids

Infants with CF need complimentary foods between 4-6 months of

age

Infants with CF have an advantage of practicing with enzymes for several months and are often “ready” to add solids to their feeding routine by this time.

Infants with CF need extra calories that can be included with solid food feedings

Added fats; carbohydrates; modulars

Selection of calorically dense foods (purees and finger foods)More liberal inclusion of nutrient dense, high calorie solids compared to healthy infantsSlide24

Introduction of Solids

Start with one meal per day (choose a time when infant is happiest)

Start with high calorie options such as…

Pureed meats

Infant cereals mixed with fortified breast milk or formula

Pureed vegetables with 1/4 to 1/2 tsp of oil, butter, or formula

Pureed avocadoEgg yolk

Full fat infant yogurt

Offer one new food at a time and wait a few days before offering anotherSlide25

Don’t forget the salt!

Low sodium status in cystic fibrosis—as assessed by calculating

fractional Na

+ excretion—is associated with decreased growth

parameters (

Knepper

et al; 2015)

Found lower weight, height, and BMI z-scores in sodium depleted children with CF compared to healthy controlsSlide26

Summary

Track growth rates closely and work with family to develop a plan of action if infant is not meeting goals

Intervene early with high calorie supplementation to either breast milk or

formula

Support family’s choice in type of feeding

CF

Returning to workFinancial considerationsFortify solids to provide adequate caloriesSupplement with recommended saltSlide27

Thank you! Slide28

References

Borowitz D, Robinson KA, Rosenfeld M, et al. Cystic Fibrosis Foundation evidence-based guidelines for management of infants with cystic fibrosis. J

Pediatr

. 2009;155:S73-S93

.Jadin SA, Wu GS, Zhang Z et al. Growth and pulmonary outcomes during the first 2 y of life of breastfed and formula-fed infants diagnosed with cystic fibrosis through the Wisconsin Routine Newborn Screening Program. Am J

Clin Nutr. 2011 May;93(5):1038-47.

Lai HJ, Zhang Z. Exclusive breastfeeding and growth in young infants with CF. Pediatric Pulmonology Suppl. 45. 2016. Ramsey BW, Farrell PM, Pencharz P. Nutritional assessment and management in cystic fibrosis: a consensus report. The Consensus Committee. Am J Clin

Nutr. 1992 Jan;55(1):108-16.Stallings VA, Stark LJ et al. Evidence-based practice recommendations for nutrition-related management of children and adults with cystic fibrosis and pancreatic insufficiency: results of a systematic review. J Am Diet Assoc. 2008, May; 108 (5) 832-9.

Yen EH, Quinton H, Borowitz D. Better nutritional status in early childhood is associated with improved clinical outcomes and survival in patients with cystic fibrosis. J Pediatr. 2013 Mar;162 (3):530-535.