March Board Review

1. March Board Review Nutrition

2. Test Question • Sean Payton should be suspended for the whole 2012-2013 season • A. True • B. False

4. Current Evidence for Infants • Meta-analyses or systematic reviews strongly favored breastfeeding for a reduced risk of: • Acute otitis media • *GI infections • Asthma (regardless of family history) • Type 2 DM • Leukemia • SIDS • Lower risk for atopic derm in infants with family history for BF exclusively for 3 months • *Reduced risk of hospitalization for LRTI in infants who were breastfed exclusively for 4 months

5. Current Evidence for Mamas • Reduced risk of breast cancer in premenopausal women • Association between BF and a reduced risk of ovarian cancer (more studies needed) • Reduced risk of type 2 DM in women who did not have a history of gestational DM

6. Beyond the Evidence • Attachment and bonding between infant and mother • Psychological and developmental benefits for both • Skin-to-skin contact • Positive attachment • Successful breastfeeding • Longer duration of breastfeeding • Allow in the first hour after birth

7. Question #1 • As you are completing the physical exam on a newborn, the father mentions that he and his wife have allergic rhinitis and asthma. He asks whether his son is at increased risk for allergies and how to reduce his chance of developing them. • Of the following, the MOST appropriate next step is to explain: • A. Because both parents have asthma, breastfeeding will not reduce the risk of eczema • B. Breastfeeding or formula choices do not matter now, because mom did not restrict her diet during pregnancy • C. You need to obtain a cord blood IgE level to determine the risk • D. Exclusive breastfeeding with the addition of hypoallergenic formula if needed is the best option to decrease and delay allergies • D. The parents should start a cow milk formula, and then switch to breastfeeding if he develops eczema

8. Breastfeeding to Avoid Allergy • *Breastfeeding for the first 6 months with supplementation with a hypoallergenic formula will decrease the severity and delay the onset of allergic disease • 42% reduction in atopic dermatitis (with family history) • 27% reduction in risk of asthma (no family history) • 40% reduction in risk of asthma (with family history)

9. Question #2 • A mother is trying to decide between breastfeeding and formula feeding and asks you for information on the composition of human milk compared with cow milk infant formula. • Of the following, the MOST accurate statement is that human milk has a • A. Lower concentration of protein than cow milk formula • B. Higher concentration of vitamin D than cow milk formula • C. Higher concentration of vitamin K than cow milk formula • D. Same amount of cells, enzymes, and antibodies as cow milk formula • E. Lower concentration of docosahexaenoic acid (DHA) than cow milk formula

11. *Protein

12. Colostrum • “The first immunization” • *High concentrations of antibodies and infection-protective elements • *Provides local GI immunity against organisms entering the body via GI tract • High in total protein, low in carbohydrate, and lower in fat than mature milk • After processing, cow milk and infant formula contain no cells, no enzymes, and no antibodies or other active protective agents • Do not support the maintenance of physiologic gut flora

13. Vitamins • Vitamin C is significantly higher in human milk • Vitamin D • Diminished from skin exposure to sun • Women pass less to the fetus, so newborns lack sufficient stores • Breastfed infants are given 400 U daily from birth • Formula contains 400 U in 26 to 32 oz • Vitamin K • *Low content in human can contribute to hemorrhagic disease of newborn • All newborns receive 1mg IM at birth regardless of proposed feeding method

14. Question #3 • There are numerous bioactive factors in human milk that boost the immune system. Immunoglobulins are the most recognized and studied. • Which of the following is found in the highest concentrations in human milk? • A. IgG • B. IgA • C. IgM • D. IgE

15. Immunology • Human milk bolsters the infant’s immature immune response and mucosal immunity • Bioactive factors • *Igs are predominantly secretory IgA • Smaller amounts of IgM and IgG • *Act at mucosal level in infant’s mouth, nasopharynx, and GI tract • Actual antibodies against specific microbial agents depend on mom’s exposure and response to particular agents • Other proteins include: lactoferrin, lysozyme, alpha-lactalbumin, casein • Lactose, oligosaccharides, glycoconjugates, lipids, nucleotides, cytokines, hormones, and growth factors

16. Question #4 • You are addressing a group of expectant mothers about the benefits of breastfeeding. One woman asks if it is ok to breastfeed if she has had CMV in the past. You explain that there are only a few infections that are contraindications to breastfeeding. • Of the following, breastfeeding is MOST likely to be contraindicated if a mother: • A. Has genital herpes without breast lesions • B. Is a CMV carrier • C. Tests positive for West Nile Virus • D. Is being treated with antibiotics for a Staph mastitis • E. Has active, untreated pulmonary TB

17. Infectious Disease • *Viral infections • HTLV-1 or -2 - contraindication to breastfeeding • HIV - advised not to breastfeed • Unless in area with increased infectious disease, nutritional deficiencies, morbidity, mortality, etc. • Latent or recent CMV - not a contraindication to BF • Unless preterm, low-birthweight

18. Infectious Disease (cont’d) • *Viral infections (cont’d) • WNV is transmitted through human milk, but not clinically significant, so no contraindication to BF • HSV, Varicella-zoster, vaccinia, or variola require temporary avoidance of BF and milk from a breast with identified lesion • Hepatitis • Hepatitis B surface antigen positive – can BF after routine prophylaxis (Hep B vaccine and HBIG) • Hepatitis C antibody positive – can BF safely (unless also HIV +)

19. Infectious Disease (cont’d) • *Bacterial Infections • TB mastitis • BF can continue once mother on appropriate anti-TB therapy and infant is on isoniazid • Staph or group A Strep • Temporary suspension of BF during first 24 hours of abx therapy for the mom • Group B Strep • Temporary suspension of BF during first 24 hours of abx therapy for the mom • Transmission via BF is uncommon compared to close direct contact

20. *Disorders of Breast • Previous breast surgery • No contraindication • May cause ineffective lactation • Inverted or flat nipples • Use nipple shields and lactation consultation • Breast cancer • No contraindication as long as not on antineoplastic medications • Candida breast infection • Continue to BF • Treat both mother and infant

21. Question #5 • A soon-to-be mother in your practice asks you to look at the list of medications that she is on at home to make sure that they are safe to take while breastfeeding. • Of the following, in which situation is it SAFEST to recommend breastfeeding? • A. A mother on tetracycline for a skin infection • B. A cocaine addict who has failed to comply with her methadone maintenance program • C. A diabetic mother on insulin therapy • D. A mom with leukemia on methotrexate • E. A mother with hyperthyroidism receiving radioactive iodine treatment

22. Maternal Medications • Drugs that are routinely administered to infants are safe to prescribe breastfeeding mother • Large molecules such as insulin, heparin, and many Igs do not pass into milk • *Maternal ingestion of drugs with sedative properties can potentially cause sedation in breastfed infants

23. *Maternal Medications • Drugs of abuse or street drugs are considered contraindicated • Women who have been stable on a methadone maintenance program should be permitted to breastfeed • Immunosuppressant drugs are contraindicated (ex: methotrexate) • Radioactive compounds • Use ½ life to calculate clearance time and determine how long a mother needs to pump and dump

24. *Maternal Medications

25. *Maternal Medications

28. Infant formulas

29. Cow Milk-based Formulas for Term Infants • “Standard” infant formulas • Available in: • Ready-to-use liquids • 20 cal/oz • Powder or liquid concentrates • Can yield caloric densities b/t 20-30 cal/oz

30. Content of Cow Milk-based Formulas for Term Infants • Protein • Whey vs. casein • The numbers: • Human milk: whey-to-casein ratio 70:30 • Bovine milk: whey-to-casein ratio 18:82 • The difference: • Casein forms large curds on exposure to gastric acid • Whey is resistant to precipitation and undergoes more rapid gastric emptying • Formula: • 50% higher total protein content to match the quality of human milk • Contains supplemental taurine • Casein-predominant (20:80), whey-predominant (60:40), and 100% whey formulas have all been shown to support normal growth patterns in term and preterm infants

31. Content of Cow Milk-based Formulas for Term Infants • Carbohydrate • Lactose • In both cow milk-based formulas and human milk • Fat • Human milk • Rich in palmitic, oleic, linoleic, and linolenic fatty acids • Docohexaenoic acid (DHA) and arachidonic acid (ARA) are LCPUFA present in human milk • Found to accumulate rapidly in the fetal retina and brain during the last trimester 2 years of age

32. Content of Cow Milk-based Formulas for Term Infants • Fat (con’t) • Formula • Contains specific blends of vegetable oils designed to mimic the ratios of saturated, monounsaturated and polyunsaturated fatty acids in human milk • Now supplemented with DHA and ARA • Based on recent studies that have shown that higher doses of DHA and equal amounts of ARA yielded improved visual and neurodevelopmental outcomes • No negative effects observed

33. Question #6 • The mother of a 5-month-old boy has come to your office seeking nutritional advice. She exclusively breastfed the infant for the first 4 months, then weaned the baby to a standard, cow milk protein-based infant formula. One week after weaning, she noted that the baby "strained with stool." Because of her concerns regarding the development of constipation, the mother switched him to a low iron formula (containing 2 mg/L iron).Of the following, the MOST important dietary recommendation for this infant is to • A. Add pureed vegetables to the diet • B. Change back to a cow milk protein-based formula containing 12 mg/L iron • C. Change to a soy protein-based formula • D. Continue the present regimen and supplement with 4 oz/day diluted apple juice • E. Substitute oatmeal for rice cereal in the diet

34. Content of Cow Milk-based Formulas for Term Infants • Vitamins and minerals • Iron • Absorbed at a higher rate from human milk (20-50%) compared with cow’s milk (4-7%) • In order to compensate for lower bioavailability, all fortified formulas contain double to triple the amount of iron • Formula-fed infants should be on iron-fortified formula

35. Content of Cow Milk-based Formulas for Term Infants • Nucleotides • Composed of one RNA nucleoside, one 5-carbon sugar moiety, and one or more phosphate groups • Supplementation shown to (?): • Enhance growth in SGA infants • Enhance IgA and IgM concentrations in preterm infants • Decrease incidence of diarrheal disease • Enhance Ab response to certain vaccines

36. Content of Cow Milk-based Formulas for Term Infants • Prebiotics, probiotics and synbiotics • Basic principles • BF infant intestinal flora • Bifidobacterium, Lactobacillus • Formula-fed infant intestinal flora • Complex; also includes Bacteroides, Enterobacteriaceae, Clostridium and Streptococcus

37. Content of Cow Milk-based Formulas for Term Infants • Pre/pro/synbiotics attempt to reproduce the intestinal flora of a BF infant • Specifics: • Prebiotics: stimulate growth and function of specific species of bacteria • Probiotics: live microorganisms that survive digestion and colonize the colon more beneficial colonic microbiota • Synbiotics: combination of pre and probiotics • Proposed benefits (probiotics) • Decreased incidence of clinical eczema in high-risk infants • Decreased incidence of NEC and all-cause mortality in VLBW infants • Decreased respiratory and intestinal infections

38. Preterm Infant Formulas • Higher caloric density • 24 cal/oz • Increased protein content (whey-predominant) • Fat and CHO compositions designed to overcome nutrient losses from low concentrations of lipase, bile salt and intestinal lactase • Medium-chain triglyceride (MCT) oil provides b/t 40-50% of total fat • 60:40 or 50:50 mixture of glucose polymers and lactose

39. Preterm Infant Formulas • Higher amounts of vitamins and minerals • Calcium • Phosphorous • Vitamins A&D • Intake of some nutrients may be excessive if preterm formulas are consumed in quantities >12 oz/d • Preterm formulas should always be d/ced before hospital discharge

40. Preterm Transitional Formulas • 22 cal/oz • Have intermediate nutrient concentrations • Transition usually occurs at 1800-2000g or 34 weeks • Continued until 6-9 months of age • 2007 Cochrane meta-analysis found no evidence that these formulas lead to improvement in growth or neurodevelopmental outcomes

41. Human milk Fortifiers • EBM alone inadequate to meet the nutritional needs of preterm infants (especially VLBW infants) • Contain protein, fat, CHO and 23 vitamins and minerals • Matches growth and metabolic effects of premature infant formulas • Ongoing use may eventually lead to excessive intake of certain nutrients (with potential for toxicity)

42. Question #7 • A young mother has brought her newborn to your clinic for his first visit. She has heard that soy formulas are better than milk-based formulas. For which of the following conditions is soy formula indicated? • A. Allergic enteropathy • B. Colic • C. Galactosemia • D. GER • E. Prematurity

43. Soy Formula • What’s the difference? • Protein: higher concentrations to improve biologic value, supplemental aa • CHO: glucose polymers, maltodextrin (NO LACTOSE) • Fat: similar to cow milk-based formula • Vitamins and minerals: 20% higher concentrations (Ca, Phos, Zinc, Fe) due to decreased bioavailability

44. Soy Formula • Safe for term infants • NOT Preterm infants • Cannot meet increased requirement for Ca and Phos osteopenia • Increased aluminum concentrations decreased Ca absorption further effects on bone mineralization • *Indications* • Congenital lactase deficiency • Galactosemia • (IgE-mediated allergy to cow’s milk) • 8-14% with cross-reaction

45. Question #8 • Atopic dermatitis may be delayed or prevented in high risk (non-BF) infants with the use of which type of formula? • A. Soy • B. Extensively hydrolyzed • C. Premature • D. Pre-thickened • E. Follow-up

46. Soy Formula • NOT indications • Infantile colic • Cow milk protein allergy • 30-64% have a cross-reaction to soy protein • Prevention of atopic disease • Transient lactase deficiency

47. Hydrolyzed and Amino Acid-based Formula • What’s the difference? • Protein: hydrolyzed casein or free amino acids • CHO: glucose polymers (lactose-free) • Fat: variable, similar to cow milk-based formula; some products contain MCT* • Examples • Extensively hydrolyzed (EHFs): Nutramigen, Pregestimil*, Alimentum* • Amino acid-based: Nutramigen AA, Neocate*, Elecare*

48. Question #9 • A mother brings in her 2 mo infant due to some blood streaks noted in her stool. She takes Enfamil Lipil 4oz q3-4h, and there has been no recent change in formula. In addition, she has been more irritable than usual and spitting up more frequently. Her stools are normal (other than the blood that was noted), occurring 1-3 times per day. On PE, you notice her weight has dropped from the 50th percentile at her 1 mo visit to just above the 10th percentile at this visit. There are no anal fissures. Stool is FOBT positive, but the infant otherwise appears well. Of the following, what are you most likely going to suggest to this mother? • A. Change to soy formula • B. Increase Enfamil feeds to 6 oz q4h to promote weight gain • C. Change to an extensively hydrolyzed formula • D. Change to whole milk • E. Thicken feeds with 1-3 tsp of rice cereal

49. Hydrolyzed and Amino Acid-based Formula • Indications • Infants with proven CMPA that are not BF should be fed EHFs • AA formulas should be reserved for those who do not respond to EHFs • Infants at high risk for developing atopic disease (have one first-degree relative with atopy) who are not BF exclusively for 4-6 mos or are formula-fed • Atopic dermatitis may be delayed or prevented with the use of EHFs

50. Finally… • Pre-thickened formulas not superior to formula thickened later with rice cereal • Follow-up formulas (for term infants) have no clear advantage over infant formulas designed to meet all nutritional needs throughout the first postnatal year