nutrition during lactation that is chapter six

0:14

so there are benefits of breastfeeding the benefits are both to mother and

0:19

infant and these benefits have been well established human milk is the preferred food for

0:25

healthy premature and sick newborns

0:30

adequately experienced informed healthcare professionals provide support for successful breastfeeding

0:38

so in most cases women are able to breastfeed

0:45

and even if the newborn is sick breastfeeding is still the preferred

0:52

food for the infant now we'll talk about or i'll show you a

0:59

video about lactation physiology um that is by khan academy videos

1:08

so let's watch that lactation is the process where milk is made and ejected

1:14

from the mammary glands inside the female breast lactation is the process where the milk is made and
ejected from

1:21

the mammary glands inside the female breasts besides being really nourishing for a suckling baby

1:27

breast milk can also boost the newborn's immune system because it contains antibodies that the baby
can't yet

1:33

make on its own but overall breast milk supplies all the nutrients that are growing in
1:41

so before we look at the mechanism of lactation let's just get oriented to the anatomy of

1:46

females up in the air so this is a woman's left side here and here's her left arm raised

1:54

up in the air primary muscle and this here is her pectoralis major muscle and the pectoralis major

2:00

is the primary muscle of the chest and the reason i mentioned the pectoralis major or the pec

2:06

major is just because the breasts on the left and right side overlay the the pec

2:12

major on the left and right side so it's just to give you a clearer idea

2:18

in relation to the chest wall so we can look at deeper and so what i've done here is i've cut away the
overlying

2:24

skin on part of the breast so we can look at deep structures on the right side of the breast

2:29

that we can look at superficial structures on the left side of the breast and remember i mean right side
and left

2:35

side from the perspective of our lady here and memory glands so the breast in

2:40

both females and males contain special glands called mammary glands and memory glands are actually

2:46

modified sweat glands that are able to produce

3:03

but during pregnancy they sort of expand and branch out in a big way in response to stimulation

3:09
by hormones such as estrogen and prolactin and so they're actually a little bit tough to see on

3:14

this drawing here so i'll just blow them up for you glance surrounding them almost so we can get a

3:20

better look at the anatomy of a mammal so these mammary glands surrounding them

3:26

almost like a net encasing them called myoepithelial cells

3:31

and the myoepithelial cells are special cells in that not only are they lining the outside of the mammary
glands

3:37

but they also can contract and squeeze down on these glands to squeeze milk out from there so milk

3:43

is drained toward the nipple

3:55

so we've got our myo so let's take a look at what this would look like on the on the bigger drawing here

4:01

and then so we've got our myo epithelial cells lining the outside of these mammary glands and then
they'll

4:08

squeeze the milk out of the mammalian remembrance send the milk along the lactiferous duct

4:13

and then it's ejected toward the nipple and remember this is happening in all of the

4:18

glass nipple and then it's ejected and actually labeled this through tiny holes in the

4:24

nipple called nipple pores and while we're in this actually let me label it you might notice this there's a
lactiferous duct

4:30
area around the nipples and while we're in this nipple area and you might notice that there are these
dark circular areas around this

4:38

one they're called areolae

4:44

the first one is that they contain these little bubbles called the areolar glands or montgomery glands
that's the other

4:50

name for them and then the areolar blends secrete a bit of an oily substance called lipoid fluid and the
lightweight

4:58

fluid moisturizes the nipple so it doesn't get dry or darker give the infant the second function is

5:05

more for the baby's good it turns out that the darkened areolae sort of give the infant a target
something to aim for

5:12

quicker they actually don't have the best vision when they're born so this helps them to find their food
source a little bit

5:18

easier and actually i forgot to mention there's some research that suggests that the lipoid fluid

5:24

by the areolar glands that it has a certain smell that attracts the baby as well so the areola serves a
couple different

5:31

functions the breast also has a fair amount of fatty acid or adipose tissue making up most of it

5:37

so with all this stuff going on the fat actually also supports all of the glandular structures

5:42

heavy especially so with all of this stuff going on in the breast the glands and all the fat it can get a

5:48

little heavy especially when the memory bands

6:03

so now that we've looked at the major anatomy of the breast let's get to what happens in lactation

6:08

let's take a closer look lactation begins when an infant begins to suckle on mom's breast

6:14

but let's take a closer look because there's some pretty cool literal pathways that are involved so when a

6:20

baby starts to suckle special receptors called mechanoreceptors in the nipple

6:25

they get activated and they start to send messages spinal cord

6:32

and at this point the hypothalamus when it receives these messages it does two really cool things it
sends on

6:39

signals to a set of oxytocin neurons in the posterior pituitary gland telling them to make a hypotonosis
and

6:46

so the hypothalamus also sends an off

6:54

signal to a special type of neuron in the anterior pituitary that releases a hormone called prolactin
inhibiting

7:01

they have a bit of a function and these neurons in the anterior pituitary are called pih neurons other
neurons and

7:07

they have a bit of a funny job so as their name might suggest they inhibit other neurons in the outer

7:14

particular so since the hypothalamus has turned them off and now the prolactin neurons

7:21
in the anterior pituitary are freedom they prolact into their heart's content well it's important and you
can see them

7:26

producing memory glands to start producing but why is this important well it's important because
prolactin

7:33

causes mammary glands to start producing epithelial cells that surround the mammary glands it's

7:39

oxytocin and oxytocin stimulates these myo that surround the mammary glands it

7:45

oxytocin stimulates them to eject the milk out of the nipple so the baby can be fed proper breastfeeding
and

7:53

interestingly i said at the beginning so you kind of need both of them to have proper fever it kicks off
this whole

7:58

neuronal catheter and interestingly i said at the beginning that it's the suffering of the baby that sort of

8:03

sort of kicks off this whole neural cascade to cause the letdown of milk but remarkably even the sound
of a

8:10

baby's cry and it doesn't have to be mom's own baby it can be a baby of a complete stranger

8:15

but when mom hears the sound of a baby's cry her hearing centers and your brain will actually trigger
this cascade from

8:21

here and will cause milk creation and ejection

8:29

to ensure that crying babies could still be fed by by other lactating women even if their

8:34

own mother wasn't around so that they could still grow and stay healthy
8:50

so i'm not gonna read this out to you um

8:59

now there are three stages of lactogenesis lecture genesis is human milk production

9:06

lactogenesis one two and three the first few days after birth um that's when

9:14

the milk formation begins two to five days after birth there is

9:20

increased blood flow to the breast and milk comes in and that's lecture genesis 2

9:26

and lactogenesis 3 is about 10 days after birth that's when it begins and it's

9:33

at this point the milk composition becomes stable so that is the mature milk we call

9:39

so the first two three days it is colostrum then the milk composition starts to

9:46

change matures and ultimately after about 10 days after birth there is a

9:54

stable mature milk so those are the three stages

10:02

so okay i think we have all the information here

10:08

now let's uh we've just talked about the hormone control of lactation through that video

10:13

so you know the role of prolactin you know the role of oxytocin

10:21

you can read it here and you already watched the video

10:28
so this is just a summary of different hormones what they do during lactation and breast development

10:37

so estrogen is needed for ductal growth

10:43

progesterone alveolar development human growth hormones are needed for

10:48

development of terminal n-buds human placental lactogen

10:54

is needed for alveolar development prolactin is needed for both alveolar development

10:59

and milk secretion and oxytocin is needed for let down that is the

11:04

ejection of milk from myoepithelial cells as you just

11:12

watched

11:22

so um you've watched

11:31

the role of hormones in lacto lactation now there are

11:38

several mechanisms pathways for milk secretion the cells that produce milk

11:46

and the components for the milk they produce lipids for example for the

11:53

milk formation so it is the

12:03

so there are secretary cells um that produce components of milk so

12:11
some components like lactose are made in these cells secreted cells and they're secreted into the duct
so that is by

12:16

exocytosis other components are made in cell and secreted either with or without protein carriers

12:24

milk fat comes from the mother's blood and from the new fatty acids produced in the

12:31

breasts these fats are made soluble in milk

12:38

by addition of a protein carrier to form milk fat globule you know fat doesn't dissolve in water

12:45

but it is held as an emulsion in the milk and that occurs with the help of special

12:53

proteins that keep the fat suspended or emulsified in the milk

13:03

other components originate in mother's blood and are then secreted

13:10

so for example immunoglobulin a and other plasma proteins are captured from mother's blood and
taken into

13:17

alveolar cells these proteins are then secreted into the milk ducts

13:23

there's also passive decision diffusion that allows water sodium potassium and chloride to pass through

13:30

alveolar cell membranes in either direction you know what is passive diffusion

13:36

um lego sites also pass directly between cells so

13:44

the various mechanisms in producing this milk

13:49

of different components of the milk now let down reflects this is

13:58

the stimulation of milk

14:03

it stimulates milk release from the breasts okay

14:10

as you watched in the video um the stimuli from the infant suckling

14:19

can lead to let down reflex or it could be a baby crying that can also cause

14:24

letdown reflex okay this is just a secretary cell and it

14:31

shows various mechanisms how

14:36

lactose is formed in the cells and it is excreted by pinocytosis or

14:42

exocytosis okay this is

14:50

a fold forms in the cell membrane and it has lactose trapped in it it is

14:57

pushed out of this fold that is exocytosis

15:03

okay this is fat being formed

15:14

so we've already watched the video for this

15:19

so human milk is the only food needed by most healthy infants for the first six months for six months the
infants should be
15:27

exclusively breastfed this milk nurtures and

15:32

protects the infant from infectious diseases

15:37

the composition of the milk changes over a single feeding over a day

15:44

or based on infants age presence of infection or with menses and maternal nutrition status so

15:51

there are a lot of factors that lead to change in composition including nutritional status of the mother

16:08

hundreds of components of human milk have been identified and their nutritive and non-native roles
are under

16:14

investigation so there's a lot more to be learned with new technology being developed new methods
being developed

16:21

we're learning more about the composition of human milk

16:27

the basic nutrient composition of colostrum the first milk and mature milk is quite different there

16:34

is a table in your textbook that compares this so you can have a look at this

16:50

colostrum is the first milk okay it is thick often yellow

16:57

fluid produced during lactogenesis we have slide on that yeah

17:05

so it is the first milk it is thick often yellow in color due to beta-carotene mainly

17:15
and it is produced during lactogenesis 2 that is day 1 to 3 after infant birth

17:23

infants may drink only 2 to 10 ml of colostrum per feeding in the first

17:29

two three days and colostrum provides about 580 to 700

17:34

kilocalories per liter and is high in protein and lower in fat and carbohydrates than

17:42

mature milk it has more protein and most of these proteins are actually

17:49

secret immunoglobulins and lactoferrin

17:54

these other proteins are also present but these are the ones that are present in major amounts large

18:01

amounts the concentration of mononuclear cells a

18:06

specific type of white blood cells from other is highest in colostrum so colostrum

18:13

provides a lot of immunity to the new one

18:21

colostrum also has higher concentration of sodium potassium vitamin e carotenoids and chloride than
mature

18:27

milk and that that carotenoids are the ones that

18:32

give them that yellow color

18:41

so let's look at the composition of human milk um water that's a major component in

18:47
human milk or in milk now the human milk is isotonic

18:55

isotonic means similar salt concentration as blood so if

19:03

the salt concentration is similar that means drinking the human thinking the breast

19:11

milk doesn't make the child thirsty so that

19:16

means there's no additional water that needs to be given to the child this milk itself would

19:22

satisfy this thirst

19:33

then milk has approximately human milk has approximately 0.65

19:39

calories or kilocalories per ml but the energy content varies with

19:47

its fat composition in general breastfed infants

19:55

consume fewer calories than the infants fed with human milk substitute hms

20:14

now lipids provide half the calories in human milk almost 55 percent

20:22

now the milk composition as i said within a feeding

20:27

time in one feeding it can be different it is different so there is four milk for milk is the

20:34

milk that comes first and then there is high milk that comes later so during of

20:39

when the infant is being fed in the beginning the milk has
20:45

lower fat content and the hind milk has higher fat content

20:55

maternal diet can impact fat composition of the milk so

21:04

the kind of fatty acids the mother consumes that will be reflected in the milk

21:10

as well

21:16

overall the energy range from ranges from 20.9 to 26.2 calories per ounce

21:23

the fat value in four milk ranges from 39.7 to 46.7 percent energy

21:29

and high in milk from 60 to 80 percent energy

21:35

dha which is um you already know it is one of the

21:41

omega-3 fatty acids it is needed for retinal development

21:46

and in the eyes and it accumulates during the last month

21:53

of pregnancy so one of the very big advantages of

22:00

human milk is um

22:05

especially to premature infants born before 37 weeks

22:11

is that the concentration of dha are high in milk of mothers delivered free term infants

22:19
as compared to full term infants so preterm infants they need to be breastfed

22:26

as well as full-time infants but the pre-term infants if they're

22:32

breastfed during the first month the amount of dha is

22:38

higher

22:43

trans fatty acids these you know they're the harmful type our government has banned these fatty

22:49

acids in our processed foods we should see that effect on our processed foods pretty soon

22:57

trans fat concentration in u.s and canada used to be similar

23:04

but lower in european countries now since canada has made changes for example one

23:11

of the changes the government made in i think 2011 was to label the to on the label indicate

23:17

the amount of trans fat since then the consumption of trans fat in canadian diet has gone dramatically
down

23:24

and that has the studies have shown that the mother's milk

23:32

since this change is lower in trans fat as well so this is one of the harmful

23:38

types of fat and we are reducing its concentrate its intake and we are seeing

23:44

the impact on in human milk as well

23:52
cholesterol is an essential component of all cell membranes you know this this gives a strength to the
cell membranes

23:59

some kind of rigidity to the cell membranes it is needed for growth and replication

24:05

of cells as well um the

24:10

there is fair bit of cholesterol in human milk 6.5 to 18.5 milligrams per 100 ml

24:19

again it varies between women and also within a woman from day to day

24:26

breastfed infants have higher intake of cholesterol and higher level of serum cholesterol

24:32

than infants fed on human milk substitutes

24:44

proteins um in human milk the protein composition

24:51

content is lower than it is in whole cow's milk

24:59

um the proteins in human milk breast milk have antiviral and

25:06

antimicrobial effects because of the presence of all those immunoglobulins and those

25:12

white blood cells and so on despite relatively low concentration

25:18

human milk proteins have important iterative and non-negative values

25:27

the antimicrobial antiviral effect is that there are enzymes present in milk that

25:33
might also provide protection by facilitating actions that prevent

25:38

inflammation as well so there are quite a few protective effects

25:47

major protein in milk as in any milk and also in human milk is

25:52

casein it is the major class of proteins in mature milk from women

25:58

uh who deliver either a term or pre-term casein which is calcium phosph

26:05

fate it has calcium phosphate attached to it and other ions such as magnesium and

26:10

citrate also aggregate our source of milk's white appearance

26:26

then there are this casein facilitates calcium absorption

26:34

there are whey proteins as well way is if you remove casein proteins from milk

26:40

the remaining liquid that remains is called the whey there are some proteins that are

26:46

dissolved in that way other than casein those proteins are called

26:51

whey proteins

27:02

this is incorrect these are soluble proteins that do not precipitate

27:12

by acid or enzyme so casein proteins they precipitate if

27:18

you add acid or enzyme set an enzyme to the milk casein will coagulate and you remove that remaining
27:25

part of the milk the fluid is way and there are proteins in there that did not

27:30

coagulate due to acetyl enzyme those proteins are called whey proteins

27:40

so these proteins include milk and serum proteins enzymes and immunoglobulins and

27:45

other proteins several mineral hormone or vitamin binding proteins are

27:52

also identified as components of whey proteins these include lactoferrin

27:57

which is a carrier of iron

28:03

in in a form that is easily absorbed and also can inhibit bacterial growth

28:12

the enzymes present in the whey proteins aid in digestion and protect against several bacteria

28:20

there's also a non-protein nitrogen in milk so there is some nitrogen that

28:26

is not in the form not a part of proteins this provides actually about 20-25 of

28:33

the nitrogen and milk so that's quite substantial it is used to produce non-essential amino acids

28:40

mainly that's its main purpose the part of this is urea

28:48

and this non protein nitrogen

28:59

okay um let's talk about milk carbohydrates one major dominant milk avoid it is

29:06
lactose which you know is a disaccharide made up of glucose and galactose

29:14

this sugar enhances calcium absorption

29:20

milk also contains other carbohydrates such as some monosaccharides like

29:25

glucose it also contains some polysaccharides complex sugars and

29:33

oligosaccharides oligomeans a few poly means many you you know the classification of

29:39

carbohydrates so there are some oligosaccharides that are also present that are small

29:44

carbohydrates they contain three to ten sugar molecules

29:56

um and also there are some proteins some carbohydrates attached to proteins

30:02

those are called galactoprotein sorry glycoproteins

30:07

they're also present oligosaccharides are the second largest

30:12

type of carbohydrates in human milk and they contribute calories at low osmo

30:18

us molality osmolality is a measure of concentration

30:23

of particles and solution okay they stimulate the growth of bifidus

30:28

bacteria in the gut these are the good type of bacteria that

30:34

inhibit the and the these oligosaccharides also inhibit the growth of e coli
30:39

harmful type of harmful strains of e coli and other harmful bacteria so

30:47

oligosaccharide has quite a bit of protective effect on the large intestine of the infant

31:01

okay so let's talk about vitamins

31:06

vitamin a colostrum has approximately twice the concentration of vitamin a as mature milk

31:17

some of the vitamin a in human milk is in the form of beta-carotene you probably remember from 1210
that

31:23

beta-carotene is a precursor

31:30

of vitamin a and it is yellow orange in color and

31:37

that's why the yellow color of colostrum because the concentration of it is high in colostrum

31:52

the amount of vitamin a present in milk is adequate for infant needs

32:00

maternal diet does impact vitamin a levels um but there is no need for

32:08

supplementation because it seems that there is sufficient amount of vitamin a in human milk the next
one is vitamin d

32:15

cauli calcium for all um most of it is in the form of 25 oh2

32:22

vitamin d and vitamin d3 different forms of vitamin d so some are

32:29
better absorbed than the other vitamin d3 and this one 25oh2 are better absorbed

32:37

maternal exposure to sunlight has been reported to increase vitamin d3 levels

32:42

in milk 10 folds so that there is a quite a bit of impact on exposure of sunlight

32:48

to the sunlight for mother for sufficient vitamin d production

32:56

then vitamin e it is believed that level of total tocopherols vitamin e if you remember it's called
tocopherol

33:04

the alpha beta delta gamma different types of tocopherols so um

33:13

the total to cough roll in human milk is related to milk fat content the more the it's a fat soluble vitamin

33:19

so the more fat is present in the milk the higher is the amount of tocopherols

33:25

the alpha tocopherol which is the gold standard for vitamin e its concentration decreases

33:31

from colostrum to transition milk to the mature milk

33:38

but other beta and gamma tocopherols their concentration doesn't change

33:45

much the amount of vitamin e

33:53

in the milk is not sufficient to meet the needs of pre-term

34:04

infants next one is vitamin k

34:16
did some infants have a rare condition about five percent infants have a risk

34:22

for deficiency of vitamin k and that vitamin k deficiency can cause

34:29

vitamin k deficiency bleeding vitamin

34:34

k deficiency bleeding some infants have that

34:41

and that is why it is recommended that all children born in canada they must be

34:48

given an injection of vitamin k at the time of birth to prevent this vitamin k deficiency

35:00

bleeding for water soluble vitamins the content of these vitamins in

35:07

mothers sorry in in the milk um is related to the the content of

35:13

these vitamins in mother's diet or supplements she takes milk of well

35:19

nourished mother women provide nutrients in

35:24

quantities meaning estimated needs for their infants so typically

35:29

that's what we see if there is a balanced diet then that's sufficient to meet their

35:35

water soluble vitamin needs we have talked about folate earlier

35:44

right it is bound to whey proteins

35:50

it is it is less influenced by a mother's diet

36:04

minerals minerals contribute to osmolality

36:09

of the milk

36:14

the content of mineral is related to growth of infant mineral content in milk is

36:22

much lower than the concentration of cow's milk and the milk of other animals

36:30

with the exception of magnesium the concentration of minerals decreases over the first four months

36:35

after the birth of the child this decline in mineral content of milk during the period of rapid growth is not

36:42

what one would expect but infant growth is well supported because

36:47

as the infant is growing there is more consumption of milk since there is low concentration of

36:53

minerals in human milk this milk is actually puts less work

37:00

makes less work for kidneys kidneys have to get rid of extra minerals that we consume so this infant
who is being

37:08

breastfed their kidneys not are not overloaded with the work of removing extra minerals

37:18

this is considered a significant benefit of human milk

37:26

now by availability of minerals viability see by availability is how much of this

37:33

mineral or nutrient would actually be utilized by is available to our body and would be
37:38

absorbed by our body

37:45

one important feature of breast milk human milk is

37:52

um that the the minerals in human milk are packaged

37:58

in a way that they are highly available to the infant even if the concentration is low

38:04

they are highly available so their bioavailability is really high

38:11

so infants can use these mentals more efficiently that reduces the burden to the mother

38:18

because less of mineral is needed in the milk

38:24

for example zinc from human milk is 49 available but only 10 percent

38:31

by available from cow's milk so there is substantial difference

38:37

same goes for iron iron is way better absorbed from human milk than from cow's milk and

38:45

even if the concentration of iron in human milk is quite low

38:51

breastfed infants have little risk of iron deficiency anemia

39:04

okay um zinc is another mineral which is bound

39:10

to proteins and is highly available in from human milk

39:17
a rare defect in memory gland uptake of zinc may cause zinc deficiency

39:24

that appears as diaper rash so it's it's quite rare

39:32

human milk zinc levels are maintained even in face of low maternal zinc intake

39:40

okay then the trace minerals trace minerals

39:45

are not less important melons minerals but these are the minerals that are required in smaller amounts

39:51

copper selenium chromium manganese molybdenum nickel and fluoride

39:57

their concentration in the milk is not typically altered by mother's diet except for fluoride

40:07

the dri for fluoride is 0.1 milligram daily for infants less than six months of age the

40:14

community water in canada is sufficient

40:19

um for breastfeeding women and their infants to get the fluoride

40:30

so just tap water is good enough

40:36

the flavor of the milk is impacted by mother's diet and it seems that

40:44

infants are see more interested in milk mother's milk if

40:51

there's a new flavor so if mother try consumes different flavors of food then the infant seems to be
more

40:59
interested in milk

41:09

now there are several benefits of breastfeeding both to mother and to the infant for mother

41:16

there are hormonal benefits inc there's increased oxytocin

41:23

production which stimulates the uterus to return to pre-pregnancy status so it shrinks back because of

41:32

breastfeeding there are physical benefits as well

41:38

there is a delay in monthly ovulation resulting in longer intervals between pregnancies so

41:43

typically a breastfeeding woman doesn't get pregnant but that should not be used as

41:49

considered as uh an alternative for um

41:58

birth control methods because it's not foolproof but typically women who are exclusively

42:05

breastfeeding as long as they're exclusively breastfeeding they typically don't ovulate and they cannot
get pregnant

42:12

again typically the psychological benefits as well

42:19

um

42:25

this is increased self-confidence and bonding with the infant

42:42

the huge the long list of benefits to the infant from breastfeeding is here

42:50
uh optimal nutrition this is the perfect food for the infant for our first six months

42:57

exclusively the nutrients are balanced it is also

43:03

isosmartic so that means it doesn't make the child thirsty

43:10

meats protein needs without overloading the kidneys contains soft easily digestible curd

43:18

provides generous amount of right the right lipids long chain polyunsaturated fatty acids

43:24

are present as well and there is enhanced availability of minerals

43:33

there are immunological benefits in countries where especially in poor

43:39

countries but not just in poor countries even in countries like canada and the us

43:44

it has been seen that the more breastfeeding is done

43:51

especially during the first few months six months the lower is the infant

43:56

mortality rate there is protection from infections

44:06

the children with who are being breastfed they are less likely to have any acute illnesses or even

44:12

they have reduced risk of chronic illnesses this reduced risk of celiac disease

44:19

irritable bowel syndrome leukemia reduced risk of allergies and

44:24

asthmatic diseases
44:35

typically breastfed infants are leaner at one year of age than the

44:41

children who are fed on human milk substitutes but this difference is not seen later in

44:48

life there are definitely cognitive benefits

44:55

there is substantial research showing that the children who are breastfed they have

45:00

slightly higher iq especially the children who are born pre-term

45:07

if they are breastfed this they have much better iq than the children preterm born children

45:13

who are not breastfed there is also an energistic effect of

45:20

breastfeeding which is reduction of pain analgesic means

45:25

relieving pain so breast milk gives some relief to the children

45:40

okay now let's talk about

45:46

also it is important to note that there are economical benefits especially people

45:53

living in developing countries the

45:58

human milk substitutes can be very expensive um and may not be available to the poor

46:04

people or may not be prepared hygienically so

46:09
breast milk provides economic benefits also also reduces the

46:14

chances of acute and chronic illnesses and infants thus reducing the medical care expenses for these

46:20

families now often women think some women think

46:27

that they cannot produce enough milk the studies show that that

46:36

the milk synthesis is related to how vigorously an infant nurses how much

46:42

time the infant is at the breast and how many times per day the infant

46:47

nurses most women have the ability to produce sufficient

46:52

amount of milk so even if there is an illness or any condition typically

47:04

it is important

47:15

and it is convenient for the infant as well any infections arising and the breasts

47:24

must be taken care of by the

47:36

professionals

47:50

um

47:59

the amount of milk you can make the rate of centipede

48:16

it is important that the infants are fed from one breast at a time because
48:25

with the composition of food milk and high in milk

48:46

[Music]

49:14

good

49:56

please

50:03

there's no strain on the on anyone's

50:10

body [Music]

50:22

thank you

50:50

[Music] oh

51:06

uh when close to breast and thirsting

51:13

tongue forward then there is a rooting and uh reflex which is infant's turn to

51:20

sideways you touch them on one side left hand side they will move

51:26

their head to that side so that way they can search the breasts and

51:34

circle

51:43

now it's important that the children are the infants are fed when they get hungry and there are some

51:51
signals infants give and they're hungry hunger is by infant bringing hands to mouth

52:00

they suckle on their hands they move their head from side to side

52:07

the mothers should not wait until the infant cries due to hunger and that is a late sign

52:14

sign of hunger so the mother is aware of these signs

52:19

the head movement the hand movement and so on they can feed the infant in time

52:32

and newborns they will feed several times a day they have small

52:38

belly but they're growing very fast so they may need as many as 10 to 12

52:44

feedings in a day which is absolutely normal so every couple of hours

52:51

the stomach empty emptying occurs in about an hour and a half

53:02

it is normal to see some weight loss in infants in newborns

53:16

if there is more weight loss occurring after five days then that might be a reason to

53:24

visit a doctor

53:38

five to seven infants should have six wet and three to four salt diapers that is

53:44

normal so this could be monitored to ensure that there is no

53:50

and that the infant is being fed enough there is no more nourishment happening
53:59

some people think that only bottle fed children can have tooth decay tooth decay can

54:06

occur in children who are breastfed as well

54:11

especially the children who are breastfed they

54:18

wake up more often during night maybe because they smell mother

54:25

or breast milk they don't fill themselves up as much as

54:32

bottled wine children might so they may wake up more often at night

54:39

and they may have leftover milk in their mouth as they are sleeping

54:46

so cavities may develop because in the mouth there is sugar now all

54:52

children should be seen six months after first adopts or one year of age by a

54:58

dentist

55:04

i don't know if i mentioned earlier but all infants i think all infants at the time of birth

55:13

are given an injection of vitamin k in the us and in canada

55:18

i think i've mentioned this before

55:24

exclusively breastfed infants may need supplements of vitamin d at two months

55:32
and there is no recommendation for fluoride or iron supplementation

55:37

it is generally enough in breast milk

55:47

uh during breastfeeding a woman can achieve some weight reduction without

55:53

compromising infant weight pain so the infant can still grow properly

55:59

while the mother can lose some weight

56:04

about 0.8 kilograms of weight loss per week may occur

56:11

due to breastfeeding

56:20

um what forms a healthy diet for a mother it is

56:28

essentially eating according to the canada food guide

56:34

a balanced healthy diet um at specified calorie levels so if the

56:41

mother is breastfeeding obviously her needs for calorie increase due to the production

56:47

of milk and therefore she may get hungry more often and she may need

56:54

more food her body needs more calories and nutrients but as long as the diet is balanced

57:00

everything in the same proportion just the larger amount that should typically do it

57:12
it's important to do the nutrition assessment of benefiting women to ensure that they are consuming
enough calories to meet the

57:23

baby's weight gain and the same time to maintain healthy

57:29

maternal body weight

57:34

now energy and nutrient needs ready and especially energy needs really quite a lot

57:41

based on the activity level it's common knowledge now that the more

57:48

active they are the more energy would be needed

57:54

so on average

58:00

um 450 calories per day needed to ensure that

58:05

our 500 for six months and then less in the later months on average 450

58:11

calories per day will be needed for milk production

58:18

a single recommendation for energy needs should never address all individual variations and energy
needs

58:24

because of physical activity level because of the amount of milk production and at what stage at what

58:32

how old is the infant anyone infant may be consuming different amount of

58:39

milk as compared to an older infant

58:52

so methane energy balance and milk composition the composition of breast

58:57

milk depends on maternal status protein calorie malnutrition results in an

59:03

energy deficit that reduces the volume of milk produced but it doesn't usually change the composition
of the milk

59:13

[Music] weight loss during breastfeeding as i mentioned earlier approximately 0.8 kilograms per week

59:21

weight loss um an occur in about 12 months women

59:28

typically way uh the same as their pre-pregnancy

59:35

weight um but doesn't always happen and there are lots

59:42

of lots of factors including how many calories they're consuming and how much they're burning

59:47

per day if there's a modest reduction in

59:54

energy intake up to 500 calories

1:00:00

that doesn't seem to decrease the milk production so that much calorie reduction to lose body fat

1:00:07

by the mother uh may be considered safe for proper growth of the infant animal collection

1:00:26

exercising the studies suggest that it is safe

1:00:35

to exercise during breastfeeding but they don't promote weight loss as

1:00:41

compared to diet or a combination of that and exercise

1:00:46

the available evidence suggests that modest energy restriction combined with increases in activity may

1:00:52

be the effective way to help women lose weight as well as

1:00:57

stay healthy vitamin and mineral supplements are not

1:01:04

needed in well nourished women if they have if

1:01:16

in the diet is appropriate there is absolutely no need for additional vitamins and minerals at this

1:01:22

stage

1:01:29

there are lots of functional foods being promoted but um

1:01:38

it's important to do some research making sure that these

1:01:46

functional foods are not um harmful for people typically if they're just food they know

1:01:53

capsule forms they're safe

1:02:01

there's insufficient data to actually conclude one way or the other what supplements

1:02:06

what functional foods should be should bring benefits or not or may be

1:02:12

harmful women should drink to thirst hardly

1:02:17
ultimately should guide our fluid consumption so be it lactating on non-dictating

1:02:24

women vegetarian diets [Applause]

1:02:31

the kind of food women consume that can impact the composition of the milk and thus it is important
and this can

1:02:38

vary vegetarian is a pretty broad term vegetarian somebody could be

1:02:43

vegan a strict vegetarian could be lacto-vegetarian

1:02:49

could be lacto-ovo vegetarian and so on so there are so many different

1:02:55

types of vegetarians uh depending upon which kind of food is restricted in their diet that can

1:03:05

be used to determine if these women need any supplements for example if a woman is vegan

1:03:13

then vitamin b12 there's no natural source of vitamin b12 in their diet because it comes only

1:03:19

from animal products or fermented products and so lack of these

1:03:24

animal products in the diet can actually impact vitamin d composition content of the milk

1:03:35

uh some infants ha alcoholic infant colic is defined as crying for

1:03:40

more than three hours a day with no medical cause excessively crying infants with no

1:03:48

because of no apparent reason that might be because of the gas formation in that abdomen which is

1:03:53
causing the um the infinity cry

1:04:01

um it seems like cows milk onion cabbage

1:04:07

broccoli and chocolate these are some of the things that can actually

1:04:13

in mother's diet that are associated with greater likelihood of colic in the

1:04:18

infant breastfeeding infants probiotics have been proposed as a

1:04:25

treatment or potential prevention for colic

1:04:31

but the research is limited and

1:04:37

what a probiotics probiotic are live

1:04:46

bacteria microbes that provide

1:04:54

benefits to the gut

1:05:02

so because colic is gas production in the large intestine

1:05:09

there is some evidence not much that indicates that giving some

1:05:16

probiotics some food that contain live micro organisms that are

1:05:23

that support better health of the large intestine may reduce colic but there is inefficient and sufficient

1:05:30

evidence to suggest that there is one bacterium

1:05:38

achieve i'll write that down

1:05:52

that may may provide some help but again evidence is limited

so today we'll um go over infinite nutrition that will cover chapter eight and nine

0:07

i'll begin with chapter eight um so in this uh unit we'll mainly talk

0:13

about healthy full-term infants born at or after 37 weeks of gestation

0:22

these infants are expected to achieve normal patterns of growth and development in their first year

0:29

so this is the stage the first year of life that is the uh stage

0:37

of life in which the growth is the fastest so that's how this first year of life

0:43

differentiates from the all other ages from birth to six months of age the

0:49

growth occurs most rapidly than any other stage of life

0:56

cycle so um

1:03

let me go in let's talk about assessing newborn

1:09

health that is by body birth weight and gestational age um

1:17

so full-time infants that are born between 37 to 42 weeks

1:24
um their normal body weight is 2500 to 3800 grams

1:31

that is five and a half to eight hundred eight and a half pounds

1:38

for pre-term infants that's before 37 weeks of gestation

1:45

an infant is considered low birth weight if the weight is less than 2500 grams

1:54

considered very low birth weight if their body birth weight is less than 1500 grams

2:00

and extremely low birth weight when infant weighs less than thousand grams

2:07

birth weight and the length of gestation are two of the most important predictors of an infant survival
and

2:13

later health very pre-term and very low birth

2:21

weight infants are at much higher risk of death and disability than infants born at term or with birth
weight over 2500 grams

2:32

let's talk about um infant mortality what is infant

2:38

mortality the death occurs within the first year of life

2:43

that is called infant mortality and it is recorded or it is reported

2:51

number of deaths that occur within first year of life per thousand

2:58

life births so um mortality

3:05

rate of any country is an indicator of the health of a nation it is associated

3:12

with numerous factors including maternal health quality and access to medical care socio-economic
conditions and public

3:20

health practices in canada the infant mortality rate is 4.4 per thousand life births

3:28

which is higher than many other developed countries

3:34

amongst the developed countries the u.s has higher infant mortality rate than canada

3:40

but other than that most other developed oecd countries those are

3:45

the developed economically developed countries um most of them have high lower

3:52

infant mortality rate than canada except u.s

3:58

in the u.s it is 6.1 and canada is 4.4

4:04

per thousand life worths so the leading causes of infant

4:11

mortality are congenital malformation low birth weight

4:16

pre-term birth sudden infant death maternal complications and unintended injuries

4:22

and also multiple births there are discrepancies between how

4:29

different countries measure uh record their

4:34

infant mortality rate so depending upon at what time is the birth

4:41

registered for example in canada um immediately after birth the the child

4:48

the birth is registered as a life birth and um

4:55

in other countries like uk um they also have pretty similar infant

5:02

mortality rate reported as canada but their registration is a little later so

5:08

if it happens after two days then uh if the death has occurred within the first two days of registration

5:15

and before registration then that birth is not even counted as a life birth

5:21

so there is some discrepancy and that's why canada claims that we have if we were

5:27

measuring the infant mortality rate exactly the same way then would

5:33

compare will do much better than many other countries that are doing

5:39

better than us right now so we gotta have look at the data with a little bit of caution

5:45

another reason um why we have not seen much improvement in

5:51

recent years in infant mortality rate in canada one of the reasons is that with improved

5:56

technology and healthcare system we're able to

6:03
save very extremely low birth weight very an extremely low birth weight

6:09

infants um they're born alive but they do have high

6:15

risk of not surviving even the first day um so we are just saving more lives at the

6:23

time of birth and that's why uh you know within a day we have seen in canada that within the first day

6:30

more deaths occur now than they used to so that might explain why canada has

6:38

a comparatively higher infant mortality rate despite having a pretty good health care

6:46

system

6:56

so a newborn growth assessment is done based on gestational age birth weight

7:01

length and head circumference so these are the three main

7:08

things apart from gestational age birth weight or length

7:15

so weight length and head circumference these are the three major measurements anthropometric
measurements

7:23

that are used to assess the newborn growth assessment so if a newborn is uh born

7:32

um between the 10th and the 90th percentile

7:39

for their age then they are considered appropriate for gestational age

7:45
so that is 10th to 90th percentile

7:55

and if um

8:05

if they plot below the tenth percentile so less than the 10th

8:12

uh 10th percentile

8:18

then they're considered small for gestational age and then large for gestational age would

8:24

be greater than 90th percentile

8:30

for any of these measures birth weight length or head circumference

8:36

if a child has had intrauterine growth

8:42

retardation then it is called iugr that is intrauterine growth retardation

8:48

that is fetal undergrowth from any cause resulting in a disproportionately in

8:55

disproportionality in weight length or weight for length percentage for gestational age

9:03

okay so fetal undergrowth from any cause resulting in a disproportionality in

9:09

weight length or weight for length percentiles for gestational age

9:15

there could be various causes for iugr this could be genetic factors congenital

9:22

abnormalities infections multiple gestation maternal nutrition environmental toxins

9:28

for essential factors and maternal vascular diseases such as diabetes or chronic maternal

9:35

sorry chronic hypertension or advanced maternal age or morbid obesity so they could be

9:42

any of these or even other factors that result in intrauterine growth retardation

9:59

okay so

10:05

normal physical growth and development

10:11

there is now evidence that the rate and progression of early growth is a major risk factor for
development of

10:16

certain chronic illnesses including heart disease and type 2 diabetes

10:22

so what happens during early childhood or even before the birth of the child

10:29

that may impact their long-term health as well

10:36

so uh it's important to understand infants nutritional status

10:43

full-term newborns have a wider range of abilities than previously recognized for example they hear and
move in

10:49

response to familiar sounds such as their mother's voice

10:54

states of arousal describe sleep and awake states in infants and affect the way they respond

11:01
to any at any given time so um organs and organ systems that

11:10

develop during gitero uh in general but they continue to

11:15

increase in size and complexity during infancy so there's a lot of so

11:21

early infancy is especially a critical period for a lot of development of the child

11:28

the newborn central nervous system is still immature the neurons in the brain are less

11:33

organized compared to those of the older infants so

11:38

the newborn gives inconsistent cues

11:45

of hunger and other needs but the reflexes are

11:53

developed even before the birth of the child we've talked about it before the root and suckle

11:59

reflexes those are developed even before the birth of the

12:04

child these reflexes are important so that the

12:09

child can breathe suckle breastfeed

12:16

and without choking but these reflexes fade later as they're replaced by more

12:23

purposeful movements during the first few months of life so this development takes place we'll look at

12:29

um different stages of these

12:36

so you we have talked about these reflexes before you can read them but um there are more reflexes
major

12:43

reflexes found um you can read them i'm not gonna read these to you i'm not gonna specifically ask
these

12:50

reflexes as long as you know these ones that's good enough these are the ones that are important
related to nutrition

13:01

so um motor development is taking place during

13:08

intensive and continues throughout the childhood um motor development reflects an

13:16

infant's ably to control voluntary muscles so how motor development occurs is the

13:23

evidence show suggests that motor development is top down that means infants will learn to

13:29

control their head movement first and then down the body and then lower

13:35

legs lower legs are the last okay also the progression the development

13:41

progresses um central to peripheral

13:48

so the infants for example would learn to control their shoulder movements well before they can

13:55

learn to control their finger movement okay so from center of the body to outside periphery

14:01

of the body and these developments motor developments are important with respect

14:08
to nutrition because these will determine the infant's ability to feed themselves

14:17

do they need to be fed up to what age they need to be fed how they can be fed can they be fed with

14:22

a spoon or with a cup at what age they can be fed with that when can they start holding their

14:28

own cup and start drinking from their themselves so all these things impact their nutritional status

14:36

ultimately their feeding pattern and therefore they are these are critical stages of development that
must

14:42

happen here is a chart from your textbook that shows

14:48

at zero month this is how this is the fetal position i'm not going to read all of this to you but you can look

14:54

look at it um at

15:00

four months they can sit with support um by seven months they are able to

15:08

sit alone then they are able to stand by the month by eight months

15:17

and they can climb stairs steps 13 months they can walk alone by 14

15:22

months or 15 so these changes are taking place and

15:29

these are important milestones to observe because these give a good idea about a

15:36

child growing as as programmed and also that

15:42
impacts their ability to feed

15:52

there's a concept of critical period that is um is based on a fixed time period when

15:57

certain behaviors emerge that is critical period so um prj

16:04

suggests the stages of cognitive development badger was a psychologist and ericsson

16:10

also gave the psychological stages of development

16:16

so these are some examples of critical periods theories

16:27

it is necessary for sequential learning of skills and the children would learn to for

16:35

example suckle first and then even before the time of birth but then they learn to

16:41

feed to eat from a spoon

16:48

then they learn to drink from a cup and so on so these stages are important a critical period for the
development of

16:56

oral feeding skills may explain some later feeding problems in infancy

17:03

in a healthy newborn the mouth is a source of oral pleasure and exploring an important form of early
learning

17:09

an infant on prolonged respiratory support may not associate oral sensations and

17:15

stimulation with pleasure if if a child has tubes put into their

17:20

nose and or in their mouth they have experienced a lot of discomfort through their mouth and nose and
so they

17:27

may not ex have the same pleasure when it comes to oral sensation

17:36

so the critical predict for development um developing positive association with all sensations

17:41

stimulation and feeding may have adversely we have been affected in these cases

17:50

um

17:56

then after motor development let's talk about cognitive development cognitive is related to the brain's

18:03

ability to learn [Music]

18:13

the factors that impact cognitive motor and social emotional development are severe acute

18:19

malnutrition uh chronic under nutrition

18:25

iron deficiency anemia iodine deficiency and environmental interactions the baby's interactions

18:32

with the environment stimulate the brain developing brain which is now seen as structuring the nervous
system in the

18:38

long run research has shown that access to adequate energy and protein alone may

18:45

not be sufficient for maximizing brain maturation without simultaneously

18:51
providing psychosocial stimulation

18:57

so it's not just the nutrition that is important but it is also the psychosocial environment

19:08

um the development of the digestive system

19:14

um fetus swallows amniotic fluid

19:20

which we learned earlier this stimulates intestinal maturation and growth so that

19:25

the mucous membrane starts to mature in the intestine

19:33

so at birth the healthy neurons digestive system is sufficiently mature to digest fats protein and simple
sugars

19:42

and to absorb fats and amino acids however the healthy newborns do not have

19:48

the same level of digestive enzymes or rate of gastric emptying as older infants

19:57

but the gut is functional at birth after birth and through early infancy

20:05

the coordination of pestilences within the gastrointestinal crack improves

20:13

infants may experience conditions like gastries of agile reflux diarrhea or

20:20

constipation do you know what is gastro is a facial reflux between your esophagus

20:27

and your stomach there is a

20:32
muscle that is called gaso esophageal

20:46

sphincter

20:54

this is a pseudo wall we also call it cardiac strength it's got nothing to do

21:00

with heart but because it feels close to the heart so we call it cardiac sphincter

21:13

this is a pseudo wall that means it's not a true wall walls control the flow

21:20

so the food is supposed to move downwards not upward backward flow should not be allowed and

21:26

that's what this sphincter does but because it's not a true wall

21:31

so it does allow the food to move backward sometimes so you might have noticed that sometimes you
know

21:37

when we overeat food comes back so that's because this sphincter is it's not a true wall

21:45

and this tendency of food to flow backwards

21:52

and it can lead to gas or esophageal reflux this is this is called gasoline gastroesophageal reflux

21:59

[Music] because the in infants this muscle may may still be immature at the time of

22:05

birth [Music] then diarrhea is another thing because

22:12

the digestive system is still maturing and constipation may also occur

22:23
many factors that influence influence the rate of food passage through the colon and gastrointestinal

22:32

discomfort seen in infants and these include osmolarity let me see if i have here

22:41

that is osmolarity of foods or liquids we've talked about osmolarity before so

22:50

if if the concentration of solutes is higher in

22:56

the intestine fluid then the water from the

23:04

other parts of the body is drawn to the intestine right that's why we talked about the

23:09

breast milk being perfect uh because its solute concentration is same as

23:15

the infant's plasma concentration um then there is bacteria in the colon

23:24

are not yet fully developed and another thing is water and fluid balance

23:30

in the body that's another factor

23:41

parenting is parents need to recognize a few things

23:47

they must learn the cues of hunger and certainty as we talked earlier they should not wait until the

23:53

child child starts crying due to hunger they should learn the other cues that we

23:59

talked about in the previous unit infant temperament is also important to

24:06

notice the infant's

24:12

emotionality activity attention span and persistence reaction to food and suitability these

24:17

are the temperamental things that the parents need to notice infants who have

24:24

every infants also have variable eating styles [Music]

24:31

they may be distracted at meal time so

24:39

pens need to recognize the temperament of their infants

24:47

um and then how to respond to infant cues they need to learn that

24:55

if they understand that skills infants learn at different stages of

25:00

their infancy then the parents can expect

25:05

what infants can do at that stage or they can't do at that stage so that they can encourage

25:12

age-appropriate feeding skills

25:18

now let's talk about the nutrient needs during infancy

25:31

there are dietary guidelines for canadians

25:36

you know that rdas have been established or for infancy we have a is established

25:45

for energy

25:51
during infancy it ranges from 80 to 120 calories per kilogram of the body weight

26:00

the average energy need of infants in the first six months of life is

26:05

so zero to six months 108 calories per kilogram body weight from

26:16

six to 12 months

26:22

it's 98 calories per kilogram body weight

26:37

the factors that influence cal really need is weight obviously because these are

26:43

based on weight and growth rate how quickly the infant is growing um

26:51

the infants um they grow the fast during the first six

26:56

months right

27:03

they double their height in first year

27:08

their brain size doubles in the first year of their life they triple their body weight in in

27:16

first year so there's a lot of growth happening at that time so energy requirements

27:21

are very high then sleep in wake cycle

27:27

the more um sleep there um

27:34

they have the more time during the day during the 24 hours of sleep the less
27:40

energy is being spent so calorie requirement is dependent upon the more they are awake the more
active

27:47

they are temperature and climate you know that impacts the energy requirements

27:53

the body has to adjust to the temperature if it is too hot or too cold um

28:00

then physical activity and metabolic response to food that also impacts obviously physical how

28:05

active the infant is that will impact their energy requirements infants do not have a lot of fat stores

28:12

so these small changes can have

28:17

a quite major impact on their energy requirement

28:23

and health status and recovery from illness if they have been ill their nutrients may

28:29

deplete very very quickly the energy may deplete very quickly the stores of it

28:37

protein needs are also very high during the first six months it is recommended that they

28:44

consume 1.52 grams per kilogram of body weight that much protein

28:49

and from 7 to 12 months 1.2 grams per kilogram of protein how does

28:55

that compare to adults if you remember adults

29:01

need 0.8 grams per kilogram of body weight so per kilogram our
29:09

requirements are much lower because we are consuming protein to maintain our body tissue

29:14

but infants are consuming proteins to grow to to grow and

29:21

accumulate more body tissue

29:30

so infants who are breastfed or who consume appropriate amount of infant formula will obtain
adequate

29:38

proteins

29:44

fat needs fats are important component in the diet of infants if you

29:51

remember breast milk provide has approximately 50 percent calories from

29:58

fat so that is an important nutrient

30:05

fat provides essential fatty acids

30:11

it's a concentrated source of energy the needs are very high so this is a good way to get energy

30:17

it facilitates fat soluble vitamins absorption

30:26

infants use fat to supply energy to the liver brain and muscle including the heart

30:33

there is not enough stores of energy in infants and the glucose

30:39

stores are not high and therefore infants depend a lot

30:44

on fats for their energy

30:52

young infants cannot hold it fasting for long because it quickly uses up both carbohydrates and fat and

30:58

fat energy sources

31:07

fats and food provide not only the essential fatty acids but

31:13

also dha which is which we have talked about earlier as well

31:20

okay

31:27

so how do metabolic rate energy fat and protein how do they all tie together

31:33

metabolic rate of infants is the highest of any time after birth so

31:39

this rapid growth and high proportion of muscle growth

31:45

that is happening that that is why they have high metabolic rate

31:50

muscles are metabolically more active demanding than

31:55

adipose tissue

32:04

um when sufficient glucose is available the growth will progress

32:12

but when glucose from carbohydrates is limited then amino acids can be converted into

32:18
glucose i think we've talked about it before it is called gluconeogenesis

32:29

uh i don't know if i've talked about it before i have definitely talked about in one of

32:35

my classes so glucose for glucose

32:40

neo is new genes genesis means production

32:47

so production of glucose from non carbohydrate sources glucose we typically get from

32:52

carbohydrates when carbohydrates get just digested ultimately they are converted into glucose

32:59

so that's our primary source of glucose in our blood and glycogen stored in our muscles and liver

33:06

but if in infants if carbohydrates are restricted in the diet the body is using it very

33:13

quickly then the body needs to make glucose from non-carbohydrate sources and the only

33:20

non-carbohydrate source that can be can be used to make glucose is some amino acids

33:28

so when amino acids are converted into glucose that process is

33:34

called gluconeogenesis

33:50

that is called gluconeogenesis so um this is

33:57

um this amino acids where would they come from

34:06

if they if the infant is not getting enough carbohydrate

34:14

but they're getting proteins then some of that proteins would be used to make glucose but if

34:20

they're not getting enough proteins either then their body's muscles will

34:25

donate their proteins to make glucose okay and that is called catabolism

34:32

catabolism is break down so muscles will be broken down that will impact growth

34:44

other nutrients and non-nutrient needs fluoride we have talked about it earlier as well

34:52

fluoride is needed for strengthening the teeth

34:58

so fluoride prevents the solubilization of the

35:05

enamel and it also prevents the growth of bacteria in the mouth which otherwise would cause

35:13

damage to our teeth so that this fluoride is important mother's

35:20

milk typically doesn't have enough fluoride um but the water in canada

35:27

is fluoridated sufficiently fluoridated to provide all the fluoride infants need

35:34

vitamin d is important now vitamin d2 it comes from plants and fungi but it is

35:41

poorly absorbed vitamin d3 is what we call caulicalcy for all

35:48

it is recommended that infants get 400 iu of vitamin d3

35:55
breast milk typically doesn't have [Music] much vitamin d it has 22 iu

36:04

per liter but the recommendation is 400 iu per liter so it is recommended that all breastfed

36:11

and partially breastfed infants receive vitamin d supplementation

36:19

sodium during the first six months 120 milligrams of sodium is

36:27

recommended per day and 370 milligrams for 7 to 12 months of age per day

36:37

sodium in the breast milk is sufficient to meet this requirement

36:48

but salt need not be restricted in infants diet

36:57

breast milk is the best food for first six months anyway so there is no additional salt needed at that time

37:05

young infants do not sweat much so losses from sweating are not usually

37:11

problematic but if there is diarrhea or vomiting then there is loss of electrolytes you remember we can

37:19

when we have diarrhea are vomiting and sodium potassium chloride

37:26

these are the electrolytes that can be lost in significant amounts

37:32

and that can be uh if an infant has diarrhea or is vomiting

37:39

then their needs for these electrolytes are increased

37:45

iron um
37:51

the blood volume in infant will double

37:58

uh from the age of four months to 12 months so um

38:06

infants have uh high needs of iron it is recommended that for for six

38:14

months infants get the iron from breast milk which is even if it is low in iron it is better absorbed as we

38:21

talked about in the previous unit but after the age of seven so from seven to twelve months of

38:27

age um the 11 milligrams of iron is recommended

38:34

for infants for daily

38:44

um iron deficiency anemia is can occur

38:50

during infancy but it is more likely to occur during the later stages of life especially

38:55

during when the toddlers

39:02

lead is not a nutrient it's a toxin and it can be associated with iron and

39:07

calcium status during infancy so it is important that

39:15

lead levels are the infants are not exposed to high lead levels it is a neurotoxin

39:23

children living in houses very old houses where the pipes are old

39:31
um there may be lead in the water and old houses also

39:38

may have paints in which lead juice to be used now the paints don't have now we don't have lead-based
paints so

39:45

that exposure needs to be restricted because this

39:52

lead can cause poisoning especially neural poisoning that is damage to the brain

40:06

now let's talk about growth assessment physical growth is defined as the

40:11

increase in mass of body tissues that occurs in genetically determined rates patterns

40:19

and ages as a healthy infant grows into adulthood

40:26

adequate nutrition and physical activity are needed to achieve optimal growth and maturation

40:34

it is important to frequently measure weight length and head circumference during infancy

40:41

this monitoring will facilitate early identification of potential

40:46

problems such as slow or excessive weight gain

40:51

or slow linear growth

41:04

the growth variations may result from illness inappropriate feeding routine or

41:10

family disruptions the slight variations that occur but what is important is the overall

41:17
growth pattern so each assessment is compared to the overall health

41:23

assessment it is important that these measurements are taken accurately these are small

41:31

bodies infants so um if the measurements are not taken

41:37

properly then that can cause a lot of um

41:43

misreporting and so the tools measuring tools should be properly

41:48

calibrated the children should be positioned properly so that these measures are

41:53

measurements are taken properly you did this in unit 3 so i'm not going to repeat how

42:00

recumbent measurement is done and so on

42:14

so how do you interpret the growth data there are charts uh standardized charts

42:21

developed by who world health organization and cdc

42:28

the who charts for infants are 0 to 24 months

42:38

cdc charts are from zero to 36 months

42:47

um now who they recorded

42:55

um they made these charts based on what should be the ideal growth

43:02

pattern and they collected data from

43:10

various countries brazil ghana oman norway india

43:17

california in the u.s so they collected data from various communities

43:24

cdc data is based on various parts of the usa

43:30

the their data is their charts are based on what is the

43:36

growth pattern of healthy children infants but wh jos

43:43

charts are based on what should be the healthy pattern of healthy infants

43:52

so we're using who growth charts cdc also recommended that

43:57

who growth chart should be used for up to the age of two

44:07

i think the latest ones who grow charts were updated in 2011.

44:17

so these growth charts are the different road charges weight for age

44:23

is weight for length there is

44:28

length for age and head circumference for age

44:35

so there are four different types of growth charts that should be used so weight age rate

44:42

length and head circumference should be measured and they should be plotted on these growth charts

44:49
as we talked earlier that the normal would be considered appropriate for age

44:56

would be between 10th and 90th percentile

45:06

warning sighs if there is no increase in weight or length ar or length that is a warning sign during infancy

45:13

that happens um continued decline or rapid increase in weight

45:18

length or head circumference percentile that would be a reason for concern so

45:25

these are the warning signs where immediate attention is needed

45:32

okay let me see if i have a growth chart here somewhere

45:39

don't okay i'm gonna pause the video here and

45:45

find a growth chart that i can from birth to 12 to four months wh a growth chart

45:50

and is length for age and weight for age for boys so here you will see

45:57

um weight is listed here

46:05

so this is weight and the age is here okay

46:12

um this is a little chart to record a child's

46:18

mother's name father's name and that kind of stuff right so but this wouldn't show up in the

46:24

chart it would be separate and then you're looking at this is the

46:29

birth time let me change the color here this is three months this is six months of

46:35

age now if a child is the pattern is going like this

46:42

the weight is falling here and then there's falling here

46:48

and then if it stops to increase right

46:54

then that would be a reason of concern it's it would be a warning sign

47:00

uh now these are the percentiles percentiles do you understand what percentiles are

47:06

percentile is um what percentage of the population has values lower than

47:13

this value so if a child's body weight is at the 50th percentile that means 50

47:20

children of that age healthy children of that age have weight less than that okay so normal

47:28

would be 10 to 90 right um so you can read

47:34

for different if the child's weight is falling here let's say right

47:41

at this age whatever that age is you can read what percentile that is sorry

47:50

it's here so it is between this line and it is between this line so it is

47:56

somewhere between 75th and 19th percentile that's how you read the growth charts okay let me go
back to the powerpoint
48:08

uh so it is important to monitor frequently the growth pattern with respect to

48:15

weight length and head circumference

48:21

now um feeding in early infancy we have talked about breast milk being the ideal

48:26

food up to the age of six months and the breastfeeding should be exclu it should be exclu

48:32

the infant should be exclusively breastfed up till the age of six months and after that

48:37

um the breastfeeding still should continue along with supplemental food

48:44

for at least up to the age of one year but preferably up to the age of two years

48:51

um infant formulas are manufactured closely

48:58

to resemble human milk however numerous components cannot be replicated so it's not

49:04

a replica of breast milk growth and health status are better

49:10

indicators of dietary adequacy than volume of breast milk or formula alone so it is important not just to
monitor

49:17

how much the infant is consuming but also if they're growing well so growth charts are super

49:23

important now um there are different infant

49:28

formulas available depending upon if the child has allergy to something

49:34

if the wheat allergy then you would or or cow's milk allergy sorry then

49:41

you'd allow the cow milk base formulas instead the soy

49:46

based formulas available the hypoallergenic formulas available okay

49:54

now cow's milk reduced fat or skim cow milk should not

50:00

be used in infancy this can cause iron deficiency anemia because

50:12

this cow's milk milk proteins make the iron reduce the iron availability due to

50:20

gastrointestinal bleeding that can occur and also the infants who consume

50:27

too much cow's milk they may have reduced intake of other foods that are

50:34

rich in iron

50:42

so i've said this repeatedly infants are born with reflexes that will prepare them to feed successfully

50:48

right so we've talked about it at four to six weeks it reflexes fade infants begin to

50:54

purposely signal wants and needs um here are the sequence

51:01

of development and feeding skills in healthy and full-time infants i'm not going to read this to you you

51:07

can pause the video here you can read this yourself

51:20
um again parents should be um responsive to the cues for

51:27

feeding readiness um infants if they're watching food being opened in anticipation of eating they

51:34

are ready to be fed um they're making a tight fists or

51:40

reaching for spoon displeasure if the feeding is too slow

51:46

if they're being fed with a spoon or something and the patent is being slow in that they may get

51:51

impatient and we still show displeasure cry or they start playing

51:58

food or spoon um as as the citati sets in so

52:06

they're no longer keen to consume food that means they are getting full no longer hungry

52:13

and if they the intake is slow it is slowing down or they're turning

52:20

away from food refusing to eat spitting it out that is an indicator that they're full

52:28

okay so it is important that they're not overfed um these overeating patterns develop way

52:38

too soon in our life and so parents need to be careful that they wash the cues if the

52:43

infant is full then don't force eat them

52:55

introduction of the complementary food um

53:02

it is important to introduce complementary food after six months of age and

53:11

the goal of infant feeding are to meet all nutritional needs

53:16

so the purpose of introducing complementary foods is to provide additional energy and nutrients
because

53:23

breast milk alone will no longer provide adequate intake of energy and most micronutrients

53:28

after six months of age um it is important to watch

53:35

um a baby learn how to eat from a spoon is fun with for new parents

53:42

what did i just say uh watching a baby learn how to eat uh from a spoon is fun for new parents

53:51

so if the baby has achieved the developmental milestones that were

53:56

listed in that table it may take him only a few days of practice to start spoon feeding and to

54:03

learn to consume one tablespoon of semi-soft food as a meal so they learned pretty quickly if the

54:09

growth is normal and the babies may respond strongly to

54:16

new tastes or smells regardless of the first food so it is important that

54:26

the right time is used to start feeding with a spoon uh start introducing a new food um the

54:33

baby should not be too tired or too hungry when the new food is introduced

54:39

use small spoons with shallow bowl the temperature of the food should be
54:44

right not too hot not too cold allow the baby some time to

54:51

open their mouth and they extend their tongue that means

54:57

they're ready play spoon on the front of tongue with slight downward pressure

55:04

they will open their mouth then if they are ready to eat

55:09

place the bowl of spoon on the tongue with slight downward pressures towards the front of the mouth
the spoon

55:17

should be almost level

55:23

it's not a good practice to scrape the food off the spoon with the baby's gums by tilting the

55:28

spoon handle up too high the pace of feeding should

55:34

be based on infant's ability to swallow the food rushing will increase the risk of choking

55:41

the first meals may be small in volume okay and it may take a while

55:50

based on baby's interest the position of feeding is also

55:57

important improper positioning may cause choking discomfort and ear infections

56:03

so position young bottle fed infants in a semi upright position spoon feeding should be with infants

56:10

seated with back and feet supported

56:18

the adult should be making an eye contact when they're feeding the infant

56:27

then stage comes when weaning starts

56:32

so the process of winning starts in infancy usually is completed in toddlerhood

56:39

um so preparing for drinking from a cup developmental readiness for a cup begins

56:45

at 6 to 8 months green to a cup at 12 to 18 months

56:52

first portion from cup is typically one or two ounces very small

57:01

this drop in total fluids consumed because the child is learning new ways to

57:07

be fed that can cause constipation

57:18

infants can swallow period food at six months of age soft

57:26

period slightly lumpy food at six to eight months of age and by eight

57:31

to ten months they could eat soft mash foods

57:37

these these it's important for the parents to know these things so that they're feeding the appropriate

57:43

kind of food to their infants

57:49

so introduction of solid and semi-solid food begins at approximately six months of age

57:55
infant cereal mixed with breast milk formula or water is common single ingredient foods

58:02

are recommended the the type of food offered to children

58:09

vary from culture to culture

58:15

okay examples of food that can be introduced are

58:21

unsweetened apple sauce yogurt soft cooked vegetables soft dry fruits such as pear banana and
watermelon

58:27

mashed potatoes sweet potatoes cooked hot cereals etc

58:34

okay um inappropriate and unsafe foods would be um

58:44

anything that can cause choking like cookies um uncooked vegetables

58:53

hot fruits um crackers biscuits cow's milk

59:01

should not be given

59:12

i've just talked about this

59:22

this we have talked down 10 times about fluid needs during illness are of

59:28

concern because dehydration is a common response to illness and infancy so dehydration eats it means
water loss

59:37

so high amount of water may be needed when they're ill juice is not needed
59:43

to meet fluid needs juices and other sugar containing grains

59:48

can promote development of early childhood carries or dental cavities if juice is offered

59:54

it is recommended after the age of six months and from a cup not bottle often time parents put the
bottle

1:00:02

a juice in a bottle and let the child sleep with a bottle in their mouth and that leads to

1:00:11

rapid growth of bacteria in the mouth causing dental cavities

1:00:21

how much food is enough for infants patterns after wonder

1:00:27

that depends upon child's temperament

1:00:34

um if you sleep with wake cycles

1:00:41

also impact the requirement of the food infant who sleeps through usual

1:00:49

household noises and are less reactive the environment may be fed less often throughout the day as a
result of varying responses to

1:00:55

infant temperament a pattern of excessive adequate or inadequate intakes may result so it's

1:01:02

important to pay attention parent infant reaction

1:01:07

during early feeding can have a long lasting effect on how parents perceive their child's

1:01:13
temperament the ability to calm self-calm is a developmental step that

1:01:19

plays out differently with different temperaments and parenting styles

1:01:33

influences of food preference on feeding behavior infants have been exposed to flavors while in
geoterror so but

1:01:41

it is a normal genetic inclination of children or infants to

1:01:48

like sweet and salty food but dislike sour and bitter food that's that's how

1:01:54

we are wired that's our brain is wired so that's a normal thing um

1:02:03

breastfed infants get exposed to flavors through breast milk

1:02:10

the kind of food mother consumes that results in the changes in breast milk flavor so

1:02:15

that's one way to expose infant to variety of flavors

1:02:24

it is important that the environment the infants are growing in that is

1:02:31

a healthy environment don't expose them to smoking parents voices surpass electronic media

1:02:38

stimulus for language and communication so parents language is very important interaction with
parents is very

1:02:44

important for child's development it is advised not to put children infants into

1:02:52

those structured exercise programs they that may cause injury to them that may
1:03:00

cause damage to their body structure because they're a lot of their body structures are not

1:03:08

mature enough to handle that with physical stress

1:03:14

should any supplements be given depending upon the water intake and the fluoride level

1:03:19

in the water the fluoride supplements may be recommended for breastfed infants after six months

1:03:24

um iron after four months if the infants are breastfed then

1:03:30

iron supplements may be necessary and vitamin b12 supplements may be

1:03:36

needed if if the infants are breastfed

1:03:43

by a vegan mother

1:03:51

common nutritional issues and concerns colic we talked about it in the previous unit quite a lot so i'm

1:03:57

not going to repeat that

1:04:02

inadequate iron that can cause

1:04:08

iron deficiency without anemia or iron deficiency anemia so

1:04:14

iron deficiency or iron deficiency anemia anemia as you know is the reduced

1:04:20

capacity of the blood to carry oxygen so that can happen during iron deficiency but iron deficiency may

1:04:26
exist without anemia as well and as we've talked is very important

1:04:32

for neurodevelopment and behavior of the infant

1:04:38

research in infants who have long term and severe iron deficiency

1:04:44

anemia suggests inadequate iron contributes to long-term learning delays from its role in central

1:04:51

nervous system development iron deficiency is associated with poor cognitive motor

1:04:58

and social emotional development in infancy and later childhood with poor cognition

1:05:04

and school achievements the risk factors i think we talked about

1:05:10

that in the previous unit as well risk factors associated with a higher prevalence of iron deficiency
anemia

1:05:17

include low birth weight high cow milk intake low intake of iron

1:05:22

rich complementary foods low socioeconomic status and

1:05:27

immigrant status okay so iron is very important even

1:05:34

though iron deficiency is less likely to occur in infancy than in uh toddler edge

1:05:48

dalian constipation i think i just talked about this briefly but diarrhea three or more lose watery stools
per day

1:05:55

or a stool volume greater than 10 grams per kilogram of body weight that would be considered idea
1:06:02

this may result from infections food intolerances changes in food intake and excessive

1:06:07

food juice intake i remember i fed my

1:06:13

son when he was an infant egg yolk and he liked it so much

1:06:20

i was so excited that i a little baby a few months old

1:06:26

i gave him one egg yolk and he loved it and he wanted more and i gave him more and gave him two egg
yolks and that was

1:06:31

too much for that little child and and that caused diary and that was scary

1:06:37

so as parents we need to be careful um and if diarrhea does occur

1:06:45

then it is extremely important that the rehydrated water

1:06:53

sodium potassium and chloride must be supplied it is important to feed

1:07:00

the solution of electrolytes and water slowly rather than rapidly because their digestive system

1:07:06

is has experienced something some food that cause diarrhea or vomiting that the digestive system

1:07:14

is kind of extra cautious so if they are given a lot of fluid too quickly um to replenish

1:07:20

the electrolytes in water the digestive system may expel that out immediately so slowly feed the child

1:07:29

with this solution of water and electrolytes

1:07:35

so that's the first line of treatment they should be continue breastfeeding is

1:07:41

very important so that should be the first line of treatment for infants

1:07:54

so replenishment of these that can be done through breast milk also through

1:08:00

electrolyte solutions okay um constipation

1:08:08

um the frequency changes the size consistency it becomes too hard

1:08:15

dry faces become too hard and dry um or it's taking more effort

1:08:22

to pass the stools that's when the it is called constipation

1:08:27

uh typically it occurs for short duration of time there's a change in fluid intake especially when

1:08:33

the bleeding begins so that can cause constipation

1:08:41

so short term is typically not a concern but in long term that may have

1:08:48

to be addressed

1:08:55

um high dietary fiber foods are not recommended for infants because

1:09:01

they interfere with absorption of a lot of nutrients and also they may cause choking

1:09:12

another problem that

1:09:18
occurred during infancy is childhood carries or cavities in teeth infants have high oral needs

1:09:26

which means they love to suck or to explore by putting things in their mouths they derive comfort from
sucking and may

1:09:33

relax or fall asleep while sucking the use of bottle containing formula

1:09:39

juice or other sweetened liquids to calm a baby or at bedtime will contribute to demineralization of the

1:09:46

teeth so to prevent cavities avoid high frequency consumption of sugar

1:09:53

limit use a bedtime bottle avoid frequent breastfeeding after first tooth bottle

1:10:00

wean between 12 to 18 months if they're bottle fed see a dentist by

1:10:06

12 months and brush and wipe emerging teeth it's important to clean

1:10:12

those tiny little that i rubbed you

1:10:20

food allergies can occur

1:10:27

about six to eight percent of children under four years of age have allergies that started in infancy

1:10:35

allergies i think we've talked about it earlier that allergies are because of incomplete

1:10:42

protein incompletely broken down proteins large proteins entering the bloodstream

1:10:48

that's when it is an allergy um common symptoms wheezing skin rashes

1:10:58
these are seen cow milk allergies seen in quite a few infants

1:11:07

so guidelines are recommend they recommend breast milk for

1:11:14

infants though who are considered at risk we've talked about breast milk and its

1:11:21

role in reducing risk of allergy quite a bit lactose intolerance quite

1:11:30

does it feel that i've talked about this as well lactose is a milk sugar

1:11:39

disaccharide

1:11:44

made up of a glucose and a galactose

1:11:49

molecule to break down the bond between these two lactase is needed

1:11:58

uh if there is insufficient production of lactase that will result in this sugar not being

1:12:05

broken down lactose not being broken down it will end up in the large intestine where the bacteria will
break

1:12:10

it down and produce gas and cause diarrhea

1:12:16

this is not an allergy causes cramps nausea pain and alternating diarrhea and constipation

1:12:22

but it's not an allergy because allergy is an immune response there is no immune response

1:12:27

here it is just that the sugar is not getting digested so it is now becoming food for bacteria in the

1:12:33
large intestine

1:12:39

there are lactose reduced infant formulas available they contain less lactose and additional

1:12:45

carbohydrates provided by other sources such as modified corn starch or sucrose

1:12:51

typically young infants do not have lactose intolerance

1:13:02

lactose intolerance is more likely to occur later than in early infancy

1:13:17

vegetarian diets typically uh an over lactose vegetarian lacto-ovo means lactose from milk

1:13:26

always for eggs so vegetarian diet that includes

1:13:32

consumption of eggs and milk product that kind of diet is typically can support normal growth and
development

1:13:39

in infants when well planned to meet their nutritional needs

1:13:44

but more restrictive diets vegetarian diets such as vegan no animal products at all no milk no

1:13:49

eggs or macrobiotic diets that which you probably remember you read about in

1:13:56

uh hnc 12 10 these are where major foods are sequentially removed

1:14:02

from the diet these may increase risk of nutritional deficiency if we have discussed this

1:14:09

before dha content in breast milk as we've talked about before is lower in vegetarian mothers than

1:14:16
non-vegetarian mothers so need to be mindful of that

1:22:10

mention chapter 9 of your textbook most infants are born healthy and then

1:22:15

achieve normal growth and development but infants who are born prematurely or have special
healthcare needs or

1:22:21

developmental delay are at risk for compromised nutrition status

1:22:26

and altered growth up to 40 percent infants

1:22:31

of infants and children with special healthcare needs

1:22:37

also have uh are at risk at nutritional risk

1:22:45

the indicators of nutritional risk include altered growth increase or decrease energy needs

1:22:51

nutrient drug interactions metabolic disorders impaired nutrient utilization poor

1:22:56

eating skills and use of partial or exclusive internal

1:23:02

or very inter internal nutrition

1:23:10

internal nutrition is when the food is directly sent to the

1:23:16

digestive system um and um

1:23:24

pat in internal is when food is given to

1:23:31
a person the digestive system so directly into their bloodstream

1:23:39

nutrients are directly sent to their bloodstream that is par in terror

1:23:45

so we'll discuss some of the common nutritional concerns of freedom infants infants with special health
care needs

1:23:52

and or developmental delays in this

1:24:00

chapter the number of infants requiring nutritional services is increasing in large measures because of
advances

1:24:07

in perinatal and neonatal intensive care

1:24:14

um we've talked about the birth weight

1:24:20

earlier so um the infants um in extremely low birth weight

1:24:29

category and low birth weight category

1:24:34

the surviving more of them are surviving these days and thus they require specialized nutrition

1:24:42

services

1:24:51

term infants are born at or after 37 weeks as we have talked earlier late freedom infants are born
between 34

1:24:58

but less than 37 weeks

1:25:09

the infants who are born premature they have higher incidence of temperature instability respiratory
1:25:15

distress hyper bilirubin anemia we've talked about hyperbilirubinemia earlier so i'm not going to repeat
that

1:25:21

hypoglycemia feeding problems and rehospitalization than the term infants

1:25:30

later pre-term infants may have more difficulty with establishing breastfeeding and have

1:25:36

immature gastrointestinal functions as well so more attention is being given to the

1:25:43

medical needs and development issues of this population of inspects regardless of what condition is
involved these

1:25:50

nutrition questions are helpful how a caregiver or the health professional should be asking

1:25:56

these questions how often does your baby feed how long does a feeding generally take

1:26:03

how does your baby behave during feeding pulls away are just back looks irritable or calm

1:26:11

how does your baby behave after feeding satisfied still hungry anxious has your baby had

1:26:18

any other fluids from a bottle how many wet diapers and stools does jbb

1:26:23

have every day in-depth nutrition assessment are completed to determine adequacy of energy and
nutrient takes

1:26:30

and support in optimal growth and development

1:26:40

so families of infant with special healthcare needs

1:26:45
it is important to remember that um

1:26:50

be patient with the parents as well because there is an emotional impact of having

1:26:56

sick newborn uh that may overwhelm the parents all parents obviously

1:27:01

hope to have a healthy child they have dreams about that

1:27:06

and so it is overwhelming to the parents

1:27:12

healthcare providers must be sensitive to parents emotional needs

1:27:23

so let's talk about energy and nutritional nutrient needs of pre-term infants and

1:27:30

friends with special healthcare needs and a developmental delay nutrient requirements for high-risk

1:27:37

infants with health conditions are based on recommendations for healthy

1:27:42

infants special nutrients may be adjusted higher lower based on the health condition

1:27:47

so for certain conditions such as

1:27:52

infections fever difficulty breathing temperature regulation and recovery from surgery

1:27:59

these kind of conditions if an infant has then they have higher

1:28:04

calorie requirement because these conditions lead to more expenditure of energy

1:28:12

on the other hand certain conditions such as spinal bifida and down syndrome where the child
1:28:19

would have less mobility and thus will have less physical activity and

1:28:25

thus less expenditure of energy their calorie needs are typically lower than

1:28:32

a healthy infant so depending upon the condition

1:28:38

the energy requirements are between 105 to 130 calorie per gram

1:28:46

european society their recommendation is slightly higher

1:28:54

protein requirement this is the typical protein requirement we've already talked about

1:29:00

um but some infants may need um special type of protein

1:29:11

like hydrolyzed protein or single amino acid based formulas

1:29:19

many illnesses interfere with the functioning of the gastrointestinal tract and digestion even for term
infants born with intact

1:29:27

enzymes or protein digestion so protein and fight digestion depend on liver and pancreatic enzymes

1:29:33

for the intestinal absorption sick infants may require partially or

1:29:38

extensively hydrolyzed protein or amino acid based formulas

1:29:45

because they may not be able to digest they may not have sufficient enzyme production

1:29:50

so use of modified protein amino acid may also be indicated um with cow's milk protein
1:29:57

allergy or other protein intolerances

1:30:05

um fat provide 45 to 50 percent

1:30:11

five percent of the calories um in human milk um low fat diets are not

1:30:20

recommended for infants

1:30:26

in very very rare conditions low fat limiting fat might be needed fats are

1:30:33

more difficult for pre-term infants to digest um and absorb

1:30:41

medium chain triglycerides do not require bile for absorption and are

1:30:46

a routine source of fat and preterm infants short and medium chain fatty acids they

1:30:52

can directly go to the bloodstream rather than going into the blood because they do not require while
for their absorption

1:31:05

vitamins and minerals pre-term infants have higher iron needs

1:31:11

human milk fortifiers provide additional calories and nutrients

1:31:17

so preterm infant formulas provide similar amount of macronutrients and

1:31:22

micro nutrients as fortified breast milk

1:31:34

um protein in the human milk modifiers they have additional protein and they
1:31:41

may also have additional calcium phosphorus magnesium sodium potassium chloride zinc and copper

1:31:49

i may also be added growth reflex

1:31:58

nutrition status was most in since that's the most important way to determine if an infant is

1:32:04

um healthy so the use of growth chart is very important

1:32:09

an easy way to monitor a child's growth

1:32:15

there are specialty growth charts for down syndrome

1:32:20

there are other conditions for which there are no charts such as

1:32:26

fragile x syndrome rather villi syndrome

1:32:31

sickle cell disease turner syndrome quadriplegia and so on so there are some specialty

1:32:39

growth charts available because the growth of special need children

1:32:45

should not be compared with healthy children okay also it is important to look at

1:32:52

biochemical indicators of tissue stores of nutrients such as iron and proteins

1:32:58

and electrolytes such as potassium and sodium it's also important to obtain

1:33:06

additional anthropometric measurements to facility assessment of body composition so for example

skin
1:33:12

phones which you have learned about in unit 3.

1:33:17

close monitoring of head circumference is very important because that is a good indicator of proper
brain development

1:33:33

there are other evidence-based practices treatment guidelines

1:33:38

and protocols that have been established for conditions such as cystic fibrosis

1:33:44

or other inborn errors of um metabolism

1:33:50

can be used and then assessing medications that may affect weight gain

1:33:55

appetite or body composition the side effects of medication can explain rapid changes in weight so

1:34:01

it is important to consider those as well when assessing an infant's

1:34:07

growth

1:34:13

now growth in preterm infants there is a variety of growth charts

1:34:18

available phantoms pretend uh infant growth chart also intra uterine growth charts these are

1:34:26

available um

1:34:32

an important consideration when using phantoms and also in pre-term growth chart is that they reflect

1:34:37

cross-sectional birth chart not not longitudinal postnatal growth

1:34:43

actually achieved by preterm infants and keep that in mind

1:34:58

uh the corrected age is another thing that needs to be kept in mind what is that

1:35:04

um subtract gestational age at birth from 40 weeks um for example and if an infant is

1:35:12

born let's say um premature

1:35:21

right let's use an example let's say was born

1:35:27

at 32 weeks

1:35:32

that is normal is 40.

1:35:39

so this child is born eight weeks early which is approximately two months

1:35:49

so when this child is six months old

1:35:56

after birth six months old that child is actually two months less

1:36:02

old minus two months so their corrected age

1:36:08

a pretend child this freedom child's corrected age is four months

1:36:16

so they should be their growth should be compared with a four month old child rather than

1:36:22

a six month old child in this example that's a connected age

1:36:34
does intrauterine growth predict outside growth

1:36:39

an adequate and consistent pattern of weight gain of 20-30 grams per day is needed as pre-term infants

1:36:45

progress towards discharge

1:36:51

um a strong emphasis is placed on growth as a sign of improving health in small and

1:36:56

sick infants after discharge but complications may make this difficult to achieve for

1:37:02

example um a pre-term baby

1:37:08

may have you know it may be difficult to interpret the growth

1:37:14

if they have a lung condition bronchopulmonary dysplasia for example

1:37:26

these children who have this lung condition while they're recovering the growth

1:37:31

pattern is affected for the entire first year of life

1:37:36

their growth may be slower because their nutrition requirements are

1:37:43

higher there are changes in endocrine and pulmonary systems and perhaps they

1:37:48

have interactions amongst these symptoms systems so it is

1:37:53

important to note that this assessment is quite complicated and

1:37:59

one standard way of assessing without looking at the details it can be misleading
1:38:07

so changes in growth rate are associated with frequency of illness hospitalization medical history um

1:38:18

so those factors should be kept in mind intrauterine environment present of

1:38:24

presence of toxin nutrient depletion fetal origin and errors as well

1:38:41

in growth predict prediction um the fact is that during and after

1:38:50

pregnancy that have packed the growth rate in triutel environment that we have talked quite a

1:38:55

bit about in pregnancy then presence of toxins such as virus

1:39:02

alkaline maternal medications we've talked about that in pregnancy unit

1:39:08

the depletion of needed nutrients such as iron and folate again we've talked in detail

1:39:13

about that in the previous units and then some inborn fetal errors

1:39:25

this nutrients such as vitamin a have been implicated in such errors so research shows that some infants
were

1:39:32

born premature due to conditions originating during intrauterine period

1:39:39

infants with intrauterine growth retardation are at risk of metabolic disturbances

1:39:45

related to fatty acid and glucose metabolism and these abnormal fetal growth patterns

1:39:51

may persist despite adequate medical and nutrient support nutrition support after birth
1:39:58

other factors associated with iugr include genetic factors congenital

1:40:04

abnormalities infections multiple gestation metal nutrition environmental toxins and

1:40:10

so on

1:40:17

there are known association between uh birth weight below 10th percentile and

1:40:23

later development of hypertension hypercholesterolemia crystalline

1:40:30

um coronary heart disease impaired glucose tolerance diabetes so these

1:40:36

relationships have been seen intrauterine growth may not predict

1:40:42

postnatal growth always for some infants whose birth removes them from the

1:40:50

adverse condition so whatever adverse conditions were there in in during pregnancy after birth they are

1:40:56

no longer being exposed to those conditions so they may grow well after they are

1:41:02

removed from that for example an uncontrolled maternal diabetes while the mother was pregnant with

1:41:08

uncontrolled diabetes there are impacts on the infant's growth but once the child is born

1:41:15

um some of those impacts may not continue

1:41:22

smoking or drug abuse during pregnancy maternal phenylketonutia maternal

1:41:28
seizures treated by medications such things they

1:41:33

once the child is born the child is no longer exposed to those harmful exposures

1:41:49

so um as i keep repeating strong emphasis is

1:41:56

placed on growth as a sign of improving health in small and sick infants

1:42:02

are they it's not what their body weight is but how their body weight is changing how

1:42:08

the growth is happening that is a better indicator

1:42:13

and changes in growth rate are associated with frequency of illness hospitalization and medical history

1:42:29

um so nutrition for infants with special health care needs health conditions and events interfere

1:42:37

with growth and development most of the problems that occur it is all

1:42:42

but some do persist

1:42:48

nutrition plays an important role in preventing illness obviously maintaining health and

1:42:55

treating conditions in infancy so nutrition has a very important role especially during infancy

1:43:04

nutrition risk to development developmental delays range of symptoms reflecting slow

1:43:11

development what kind of symptoms can be seen feeding difficulties need for

1:43:16

internal or parenteral feedings altered growth drug nutrient

1:43:22

interactions these things can be seen a developmental disability may be

1:43:29

related to chromosomal abnormality congenital normality inherited metabolic

1:43:36

disorder or maybe not associated with any diagnosed condition

1:43:43

a high percentage that is 70 to 90 percent of children with special healthcare needs are found to have

1:43:48

nutrition related problems that's a pretty high proportion

1:43:56

[Music] nutrition diagnosis relating feeding are varied and

1:44:02

this can include difficulty in breastfeeding difficulty in swallowing difficulty in self-feeding

1:44:11

so that can vary quite a bit depending upon the condition not all infants with development delay

1:44:16

have developmental disabilities that continue into childhood

1:44:23

now uh potential nutrition problems in fact with special care needs are listed here growth slow rate of
weight

1:44:31

gain or accelerated weight gains slow linear growth disproportionate weight for length nutritional
adequacy

1:44:39

increase or decrease energy needs depending upon the condition all the nutrition nutrient requirements

1:44:45

vitamin mineral requirements may change and then feeding disruptions of

1:44:53
delivery of nutrients as a result of altered structure or function of the mouth oral cavity or

1:45:00

gastrointestinal tract disrupted interaction or response to cues between the infant and caregiver

1:45:07

difficulty with achieving or maintaining adequate positioning when feeding lengthy duration or

1:45:12

increased energy expenditure with feeding

1:45:20

nutrition in early in fancy infancy

1:45:25

[Music] severe pre-term birth how is that

1:45:30

related with nutrition

1:45:36

the key role in immediate neonatal survival growth

1:45:41

nero development and a conditioning factor for long-term health is provision of adequate energy and
nutrients to the

1:45:48

very pre-term infant requires parental nutrition support

1:45:56

followed by slow transition to internal feeding i've already explained what parenteral and internal

1:46:01

are um and i'll repeat internal feeding method

1:46:08

of delivering newton directly to the digestive system um so either through my

1:46:15

nose mouth and then going the tube being inserted from note to from the mouth or directly into

1:46:22
the digestive system bypassing the mouth

1:46:28

but this is done surgically para internal is delivering of nutrients directly into

1:46:34

the bloodstream so bypassing the digestive system

1:46:39

that is often required for severe preterm birth and children

1:46:47

the feeding method is selected based on projected length of time if it is going to last for three months

1:46:53

or more the internal feeding if it has to be done for more than three months then it will can be very

1:47:00

uncomfortable to have the pipe inserted from the mouth

1:47:06

therefore surgical insertion of the food pipe directly into the digestive system may

1:47:12

be preferred

1:47:34

three time babies have immature immunological system so they are more susceptible to

1:47:40

infections every effort should be made to ensure feeding meet food safety requirements so cleaning

1:47:48

the bottles properly the utensils properly

1:47:54

um not leaving the food at room temperature refrigerating promptly it's proper

1:48:01

storage those are very very important

1:48:06
we've talked about this umpteen time breast milk is the recommended source of nutrition when
initiated initiating internal feeds

1:48:14

are not available or contraindicated preterm infant formulas are also

1:48:21

available

1:48:27

this is just a list of nutrient requirement i'm not going to read this to you

1:48:35

there are quite a few challenges in feeding pre-term infants they'll be too tired

1:48:43

they may have low tolerance of volume not consume too much food at a time

1:48:48

they may get too stressed about feeding because it's uncomfortable it's too much work for them

1:48:59

there are signs of problems in high risk infants so you can

1:49:05

read these i'm not going to read these

1:49:12

some infants who are born at term but still require neonatal intensive care

1:49:17

could be cardiac genetic or chromosomal conditions such as cardiac malformation central nervous
system defects

1:49:24

chromosomal anomalies all these can also happen so it's not always the pre-term

1:49:30

children who have the problems

1:49:36

there is small s subset of congenital abnormalities that can happen phenylketonuria pku i think i've
talked
1:49:44

about it before so i'm not going to repeat that galactosemia that is not being able to

1:49:51

um metabolize galactose that's a metabolic disorder urea cycle

1:49:58

disorders can also be seen in very very small portion of children

1:50:04

so high nitrogen level in the blood that

1:50:10

can be extremely harmful fat related carbohydrate related

1:50:15

disorders also occur these are that's common but can happen

1:50:25

these require restriction on specific fatty acids then our specific type of carbohydrates have

1:50:32

to be on the amount of carbohydrates they consume has to be very closely monitored

1:50:38

disorders sensitive to high dose of vitamins sometimes occur especially vitamin b12

1:50:46

high doses of that may not be tolerated by some infants and then renal genetic disorders

1:50:53

um where kidneys you know means kidneys the kidneys are not functioning properly because of

1:51:00

genetic disorders their protein intake may be restricted

1:51:05

because extra protein increases nitrogen

1:51:13

excretion and kidney the kidneys are not functioning properly that work increases the wealth for the
kidneys
1:51:25

feeding problems can be seen in infants especially very low birth weight infants

1:51:31

40 to 45 percent of such infants have feeding problems which can cause

1:51:37

frustration to the family um term infants can be introduced to

1:51:43

complimentary food at the age of six months but

1:51:49

it may be as late as eight months for um an infant who was born at 32 weeks of

1:51:55

gestation right so corrected age should be used

1:52:02

so it is important that frequent growth assessments are made

1:52:08

infants fluid intake and food intake is monitored as well

1:52:14

um the depending upon the condition their feeding frequency volume and

1:52:20

concentration may have to be adjusted uh feeding times may have to be adjusted

1:52:26

assessing feeding positions they may be comfortable at different positions

1:52:34

if they're not able to eat too much food at a time then more nutritionally dense food needs to be given

1:52:40

parents need to be educated about the condition and they need to be provided the support

1:52:47

need it's important to observe the interactions between interaction

1:52:54
between the infant and the caregiver these interactions can help educate the parents better

1:53:03

about infants need

1:53:09

and consider developmental abilities what can they do that is important as

1:53:14

well so that concludes