Cystic Fibrosis Infant Nutrition

1. Cystic Fibrosis Infant Nutrition Julie Matel, MS, RD, CDE & Jacquelyn M Zirbes, DNP

2. Newborn Screening • Newborn screening is a nationwide program to find infants born with certain health conditions in order to begin treatment early to prevent serious, lifelong problems. First few days of life Heel prick Blood spot on Guthrie Card CFF, March of Dimes

3. Prior to Newborn ScreeningSevere CF Malnutrition at Diagnosis(3 month old diagnosed during 2001 in a non-screening state) Potentially fatal protein-energy malnutrition with salt depletion Photo courtesy of Frank J. Accurso, MD

4. History of Cystic Fibrosis • First described 1930s “celiac disease” and lung disease • Dr. Dorothy Andersen Babies Hospital in New York Cystic fibrosis of the pancreas

5. Salty Sweat Dr. Paul di Sant’Agnese Columbia Presbyterian Medical Center, 1937

6. Care of Infants Identified Through NBS CF Care at an accredited care center At Initial Visit Diagnosis confirmed Basic genetic concepts Convey Difficult Facts Overview of symptoms Introduce Care Team Resources of Information Contact and follow up information • Initial visit 24-72 hours of diagnosis • Monthly visits to CF center ( at a minimum) for the first 6 months • *Sensitivity

7. Initial Visit • Knowledge about CF and factual information with straightforward answers (Tluczek, 2006). • Education/support personalized to match the family’s immediate needs. • Establish Coordination of Care with PCP with collaborative interdisciplinary team • Need for supplemental salt • Goal is ≥50th percentile weight-for length

8. Pancreatic Insufficiency can Develop at Any Time % PI Bronstein et al , 1992

11. Pulmonary Recommendations • Infection Control (separate newly diagnosed) • Smoke-Free environment • Airway Clearance (initiate first few months of life ) • Baseline Chest x-ray with first few months • Influenza prevention • Microbiology (first culture by 1 month and quarterly; more often if symptoms) • Antibiotic Therapy(staphyloccal and pseudomonas) • Chronic Therapy

12. Early Disease

13. Care Grid

14. Consensus • Phenotype more important than genotype • CFF recommends genetic counselor discussion • Communication with primary care to concurrently provide care • Many infants with CRMS will be healthy • Male higher risk of infertility • Benefit from new treatments • Update families as information becomes available • Treat P aeruginosa.

15. Infant Nutrition

16. Nutrition for Newborn Infants with CF

18. CF Infant Feeding Guidelines Birth to 4 Months • Rate of weight gain at 50th percentile or greater • Weight checks every 2-4 weeks • Infant formula or breast milk every 3 hours • Increase caloric density of formula/breast milk at first sign of inadequate weight gain • 1 ml per day of a CF infant multivitamin (can give 0.5 ml twice daily)

19. CF Infant Feeding Guidelines Cont’ 4-6 Months • Introduce iron-fortified infant cereal, 2 servings/day. Use dry cereal made with formula or breast milk instead of water • If weight gain is low add 1 tsp margarine per serving of cereal • Continue high calorie formula or breast milk

20. CF Infant Feeding Guidelines Cont’ 6-8 months Introduce pureed strained vegetables fruits, and meats as per infant feeding guidelines (one new food every 3-4 days) Add butter/margarine to food (1 tsp per 4 ounce serving) Add formula powder or instant breakfast powder to foods (1 Tbsp/serving) Begin finger foods such as cheerios and baby crackers

21. CF Infant Feeding Guidelines Cont’ 8-12 Months • Critical age for introducing textures • Mashed table foods with high caloric density • Limit juice to 4 oz/day and give by cup instead of bottle • Establish feeding schedule of 3 meals and 3 snacks per day • Consider change to a 30 kcal/oztoddler formula

22. Our CF Center Infant Data

26. Summary of Infant Data at Our CF Center • The majority of infants in this group were exclusively formula fed • The majority of infants that meet the nutritional goal of >50%tile wt/l are pancreatic sufficient and exclusively formula fed

27. Maximizing Nutrition in the Exclusively Breast Fed Infant • Frequent f/u in clinic to determine adequacy of weight gain • Ensure enzymes are given with ALL feeds (even in the middle of the night) • Ensure salt is given as directed • Introduce bottle early, ?3 months (also helps with salt intake) • Pump and fortify breast milk to up to 28 cal/ounce • Evaluate for zinc or iron deficiency if appetite seems poor and/or poor growth • Evaluate need for acid-blocker • Address concerns with constipation

28. References • Balmer DF, Schall JI, Stallings VA.(2008) Social disadvantage predicts growth outcomes in preadolescent children with cystic fibrosis. J Cyst Fibrosis ;7(6):543-550. • Borowitz, D., Robinson, K., Rosenfeld, M., Davis, S., Sabadosa, K., Spear, S., Michel, S. Parad, R., White, T., Farrell, P., Marshall, B., Accurso, F. (2009). Cystic Fibrosis Foundation evidence-based guidelines for management of infants with cystic fibrosis. Journal of Pediatrics, 155, 6, suppl.4, 73-93. • Borowitz, D., Parad, R., Sharp, J., Sabadosa, K., Robinson, K., Rock, M., Farrell, P., Sontag, M., Rosenfeld, M. Davis, S., Marshall, B., & Accurso, F. (2009). Cystic Fibrosis Foundation Practice Guidelines for the management of infants with cystic fibrosis transmembrane conductance regulator-related metabolic syndrome during the first two years of life and beyond. Journal of Pediatrics: 155: S106-16. • Castellani, C., Cuppens, H., Macek, M. Jr., Cassiman J., Kerem E., Durie, P., et al. (2008) Consensus on the use and interpretation of cystic fibrosis mutation analysis in clinical practice. Journal of Cystic Fibrosis: 7: 179-96. • Doershuk, C. (2001) Cystic Fibrosis in the 20th Century. AM Publishing, Ltd. Cleveland, Ohio. • Farrell, P., Rosenstein, B., White, T., Accurso, F., Castellani, C., Cutting G., et al. (2008) Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report. Journal of Pediatrics,: 153: S4-14. • Feldmann, D., Couderc, R., Audrezet, M., Ferec, C., Bienvenu, t., Desgeorges, M., et al. (2003) CFTR genotypes in patients with normal or borderline sweat chloride levels. Human Mutation, 22: 340. • Hennekens and Buring, Epidemiology in Medicine, p. 327.

29. References continued • O’Connor GT, Quinton HB, Kahn R, et al.; ( 2002). Northern New England Cystic Fibrosis Consortium .Case-mix adjustment for evaluation of mortality in cystic fibrosis. Pediatric Pulmonology, ;33(2):99-105. • O’Connor GT, Marshall, B, Quinton H, et al.( 2006). Public Reporting of Cystic Fibrosis Outcomes: Methods for Case-Mix Adjustment [abstract]. Pediatric Pulmonology - Supplement.;29S:119-120. • Sosnay PR. Siklosi KR. Van Goor F. Kaniecki K. Yu H. Sharma N. Ramalho AS. Amaral MD. Dorfman R. Zielenski J. Masica DL. Karchin R. Millen L. Thomas PJ. Patrinos GP. Corey M. Lewis MH. Rommens JM. Castellani C. Penland CM. Cutting GR. (2013). Defining the disease liability of variants in the cystic fibrosis transmembrane conductance regulator gene. Nature Genetics. 45(10):1160-7. • Watts KD, Seshadri R, Sullivan C, McColley, SA. (2009) Increased prevalence of risk factors for morbidity and mortality in the US Hispanic CF population. Pediatric Pulmonology ;44(6):594-601. • Watts, K.& Schechter, M. (2010). Origins of outcome disparities in pediatric respiratory disease. Pediatric Annals, 39: 12, 793-799. doi: 10.3928/00904481-20101116-10

30. Questions and Discussion