Maternal, Infant and Early Childhood Nutrition — The Thousand Day Window of Opportunity

Maternal, Infant and Early Childhood Nutrition — The Thousand Day Window of Opportunity



good afternoon good evening or good morning depending on from when and where you're joining us I'm doctor Phoebe's pleasure to welcome you to CDC Public Health Grand Rounds maternal infant and early childhood nutrition the thousand day window of opportunity we have an exciting session so let's get started Grand Rounds has continuing education available for physicians nurses veterinarians health educators pharmacists and others the course code is public health is phg r10 please see our website for the tceo website for additional information Grand Rounds is available on the web and all your favorite social media sites please send the questions to Grand Rounds at cdc.gov/scienceclips want to know more we have a featured video segment on YouTube and our website called beyond the data which is posted after the session this month's segment features my interview with Lucy Sullivan from the thousand days we have also partnered with the CDC Public Health Library to feature scientific articles about this session the full listing is available at cdc.gov/scienceclips in addition to our outstanding speakers I'd like to take a moment to acknowledge the important contributions of the individuals listed here it does take a village thank you here is a preview of our July session please join us on the web at your convenience for a few words from CDC's deputy director dr. shooken thanks Phoebe and it's great to see you all here and welcome to our first in a series of Grand Rounds on the shamily campus for those joining us in person and welcome to our great speakers a thousand days from now is going to be March 2022 so have that date in mind as you learn from our speakers the first thousand days refers to an important time for human growth and development from conception through to a child's second birthday optimal nutrition is critical for brain development healthy growth and lifelong health now today I want to give you a challenge you're going to be hearing from four terrific speakers about what you do during pregnancy what you what happens to a child in those first two years the food they eat the vitamins and minerals that they should consider whether they're breastfed or not and a number of other factors that turn out to be extremely important to what happens as we develop but as I was trying to think of how to begin welcoming you to this session I was trying to go for a really simple message and I I couldn't get there so I would like you to be challenged to listen to what you hear and then come up with your own solution to the equivalent of Michael Pollan's advice about eating for us grown-ups the idea of eat food not too much mostly plants really easy to remember if we can do that for the thousand days I think that we could have t-shirts so I really hope that diamond I hope that as you're hearing an enormous amount of really important information that is actionable for any of you who are pregnant or have a loved one who's pregnant and any of you with small children that we should try to get that really important medical and public health advice down to things that are really easy for consumers and health care providers to remember with that I'm really looking forward to these talks and welcome to the session thank you dr. shooked and now for our first speaker dr. Sharma good afternoon and welcome the first thousand days is a continuum beginning their pregnancy and ending at the child's second birthday while good nutrition is important throughout the lifespan optimum nutrition during these first 1000 days is essential for maternal health child survival growth and neural development and laying the foundation for overall health and well-being throughout life during this 1000 day period growth rates and brain development are at their peak nearly 80% of brain development happens before age 2 some vitamins and minerals are particularly important to support the high rate of growth and brain metabolism during this period nutritional deficiencies can have significant and severe consequences in a well-known example is folic acid a b vitamin that's essential that's needed before and during early pregnancy to prevent serious birth defects of the brain and spine two important minerals also essential for growth and brain development are iron and iodine during pregnancy there's a substantial increase in the iron requirement needed to support the expansion of blood volume and the mother and fetal personal growth iron is required to make hemoglobin to compel the component of red blood cells that transport oxygen iron deficiency is a common cause of anemia or low hemoglobin without enough iron tissues and organs can't get the oxygen they need iron is also a key determinant of neural development affecting brain structures neurotransmitter systems and myelination of nerve fibers when iron stores are low iron is preferentially used for hemoglobin synthesis leaving the brain at risk for abnormal development even in the absence of anemia iodine is also critical for brain development and growth iodine is essential component of thyroid hormones which are the key drivers of metabolic activity during pregnancy the babies thyroid begins to produce thyroid hormone on its own but remains dependent on the mother for ingestion of adequate amounts of iodine iron and iodine deficiency in pregnancy and early childhood are associated with poor birth outcomes and physical growth impaired cognitive and motor development and poor quantitative and language abilities and importantly like Croxon a foundation deficiencies in this sensitive 1000 day period even mild deficiencies can result in long-lasting abnormalities even if the deficiency is later resolved during pregnancy the health nutritional status and eating habits of a pregnant woman are directly connected to the growth and health of her infant a woman's weight when she becomes pregnant and her weight gain during pregnancy are important predictors of many pregnancy and health outcomes for example too little weight gain is associated with babies being born too small or too early and too much weight gain is associated with high birth weight cesarean delivery and postpartum weight retention there are specific recommendations for how much weight a woman should gain during pregnancy depending on her pre-pregnancy weight status the quality of a mother's diet influences the availability of nutrients needed to support a healthy pregnancy and her baby's development and nutrient stores a prenatal vitamin is recommended to supplement the diet with vitamins and minerals dr. Coleman Eric will be presenting on strategies to improve maternal nutrition during infancy from birth through the first year breastfeeding is the best source of nutrition for most infants and gives babies the healthiest start to life by supporting a strong immune function and protecting infants from illness and infection breastfeeding reduces health risk for both the mother and the baby for example infants who are breastfed have a reduced risk of ear and respiratory infections asthma and obesity and among mothers breastfeeding reduces risk of high blood pressure type 2 diabetes and some types of cancers because the benefits of breastfeeding on health lower rates of breastfeeding add three billion dollars per year in total medical costs for mothers and babies in the u.s. the World Health Organization and the American Academy of Pediatrics recommends that babies are fed only breast milk for about six months and as complementary foods are introduced continue breastfeeding for at least one to two years of age the dietary patterns established in infancy in early childhood can set the foundation for healthy eating habits at about six months of age children can begin eating nutrient-rich complementary foods to help fuel growth and ongoing brain development giving children foods with a variety of tastes and textures can help them develop fine motor skills chewing skills and learn to accept and like a variety of foods importantly the nutrient requirements relative to caloric requirements of young children is high so there's little room for high-calorie non nutrient dense foods for example young children are unlikely to get enough iron daily if they're not fed iron rich foods next I'll present some of the troubling trends in the nutritional health of pregnant women and toddlers in the u.s. over half of births are two women who begin pregnancy above a healthy weight that is overweight or with obesity and there are notable disparities across racial and ethnic groups further only one-third of women gain weight during pregnancy within recommendations shown here in green nearly half gained weight above recommendations shown in maroon and this is particularly common among women who have starting pregnancy overweight or with obesity with about 60% gaining above recommendations overall 60% of pregnant women in the US have iron deficiency and the prevalence of iron deficiency is lowest among non-hispanic whites and higher among other racial and ethnic groups iron deficiency is also high as later in pregnancy when the need for iron is at its highest iodine status of pregnant women in the US has been insufficient for many years this is supported by the finding that although about 75% of pregnant women report taking a dietary supplement less than 20% to the dietary supplement that contained iodine breastfeeding rates have been increasing in the US however the majority of babies are still not breastfed in accordance with recommendations while 83% of infants overall are ever breastfed this means almost one in five babies are never breastfed we also have disparities nearly one-third of non-hispanic black infants are never breastfed many infants start with exclusive breastfeeding we see that most are not many recommendations in the first year specifically only 25% of infants are exclusively breastfed through six months and only 36% of infants are breastfeeding at 12 months dr. Perez Escamilla will be presented on strategies to improve breastfeeding rates the diets of infants and toddlers mirror the adult American diet too few fruits and vegetables and too much added sugars it's all these dietary patterns are putting our children's health and neural development at risk one in four one year olds do not consume the recommended dietary allowance of iron and fifteen percent of one year olds have iron deficiency among one-year-old children on a given day fewer than half of eating a vegetable and one in three drinks a sugar sweetened beverage these early nutritional patterns can affect growth by 2 to 5 years of age 14 percent of children have obesity in the burden of malnutrition including both under nutrition and overweight and obesity is exacerbated by food insecurity in the u.s. nearly 1 in 5 children under 6 years of age live in a food insecure household these children are at even greater risk of health and developmental problems caused by poor nutrition our final speaker dr. Greer will be presenting more on complementary feeding there are opportunities to improve nutrition during these first 1,000 days and the health of mothers and children in America and I'll highlight two first the Dietary Guidelines for Americans is a cornerstone of federal nutrition policy and programs and provides food based recommendations to meet nutritional needs promote health and prevent diet-related chronic disease today guidance has only been for individuals two years of age and older however the upcoming 2020 edition will include dietary guidance for the unique nutritional needs of pregnant women and children from birth to age 2 for the first time second there's an opportunity to focus research and surveillance efforts on gaps in our understanding of nutrient intake and nutritional deficiencies among pregnant women in children under 2 currently we have little data on nutritional deficiencies like iron by state and our national surveillance systems including in Hanes do not include enough pregnant women in young children to allow for precise estimates without grouping many years of data together we also have no data on nutritional deficiencies among children under 1 better research and surveillance data can be used to improve recommendations target interventions and inform policies and programs our next speakers will highlight additional opportunities to improve nutrition during these first critical 1000 days starting with nutrition during pregnancy I'd like to introduce dr. Michelle common Eric thank you [Applause] perhaps one of the best ways to plan for a pregnancy is top demise one's weight and nutrition pregnancy is not a time for dieting or weight loss so issues of weight and nutrition need to be addressed prior to pregnancy several national societies such as the American College of Obstetricians and Gynaecologists recommend weight loss prior to pregnancy for women with overweight or obesity however the magnitude the weight loss varies with some recommending that women reach a normal body mass index prior to pregnancy and others recommending a weight loss of 5 to 7 percent from their current weight health behavior changes such as diet and exercise are typically the first approach to weight loss in fact the 2012 United States Preventive Services Task Force guidelines state that all adults with a body mass index greater than or equal to 30 should be offered or referred to intensive multi-component behavior interventions for weight loss in response to the guidelines the American College of Obstetricians and Gynecologists created an obesity toolkit this toolkit offers resources to help providers address overweight and obesity and their daily practices the toolkit contains several resources for providers for example it has downloadable forms and web links on how to screen patients for obesity how to assess their readiness for weight loss and how to assess for obesity related risk factors resources for treatment options such as lifestyle medications and surgery are also available in several formats the toolkit also has resources for coding after nutrition is just as important to achieve prior to pregnancy as is optimal weight nutrition during pregnancy has a direct influence not only on fetal growth but also on infant and childhood outcomes sar well decades ago we learned of the association between folate and neural tube defects or spina bifida all women who are pregnant or who are planning or able to become pregnant should take a daily supplement of folic acid daily to reduce the risk for neural tube defects there are also associations between iodine intake and filled brain development sarples societies including the American Thyroid Association and the American Academy of Pediatrics recommend that women who are planning a pregnancy supplement their iodine intake because maternal anemia is linked to adverse outcomes women should also optimize iron stores prior to conception one of the easiest ways to meet these requirements is to take a prenatal vitamin daily at least one month prior to conception the current guidelines for weight gain were published in 2009 by the Institute of Medicine now known as the National Academy of Medicine and they're shown in the accompanying table of notes the guidelines are based on a woman's body mass index prior to pregnancy such that women who are underweight prior to pregnancy are recommended to gain a higher amount of weight and women with obesity prior to pregnancy I recommend to gain a lower amount of weight inadequate or excessive weight gain associate with several maternal and offspring outcomes as dr. Sharma mentioned in her presentation according to studies from national databases the majority of women in the United States exceed their weight gain goals prenatal care providers have an important role in helping women meet their weight gain goals providers often comment that they don't have adequate training and nutrition or weight management issues and as a result they do not feel comfortable talking to patients about diet and weight providers also may not be aware that the guidelines that need to be adapted for a woman's body mass index prior to pregnancy instead of just recommending the same amount of weight to all women when patients are asked about their weight gain counseling many don't recall being counseled and weight gain goes below and above the guidelines are commonly reported it is important for providers to communicate the correct weight gain goals because studies show that women who recall receiving counseling with the correct calls actually were more likely to reach them next we'll review strategies that providers and patients can use to help women meet their goals here are some suggestions for providers providers can dispel myths about eating in their everyday prenatal care practices I'm going to receive advice from family friends and social media about health behaviors during pregnancy many of which contradict clinical advice and evidence-based medicine themes such as eating for two and the harms of exercise to a fetus are examples of conflicts providers can dispel these myths by saying that eating for two means eating twice as healthy not twice as much most women only need to consume 300 ition calories per day in the second and third trimesters the figure in this slide gives six examples of serving sizes that are all contained 300 calories my patients are frequently surprised to learn that a greater amount of fruits and vegetables can be consumed in comparison to servings that are higher in simple carbohydrates physical activity is safe during pregnancy very few women have contraindications to exercise during pregnancy the Physical Activity Guidelines for Americans recommend 150 minutes per week of moderate-intensity aerobic activity during pregnancy the American College of Obstetricians and Gynaecologists also recommend that women engage in 30 minutes of physical activity every day during pregnancy to maintain physical fitness the box gives examples of exercises that are safe to perform in pregnancy as shown in the top box as well as activities that should be avoided during pregnancy as shown in the Box on the bottom behavior interventions are interventions designed to affect the actions that individuals take with regard to their health during interventions for weight gain women either meet with nutritionists to receive counseling on diet food choices and food portions or meet with exercise physiologist or coaches to learn about and perform safe exercises routinely during pregnancy in some instances the interventions combine both diet and exercise regimens meta-analysis of 49 randomized controlled trials consisting of over 11,000 women at very promising findings compared to the control group women who participated in either diet or exercise I mentioned during pregnancy for 20% less likely to have excessive weight gain health behavior interventions for weight gain are active areas of research however there are some limitations to the current studies for example not all women and providers have access to these intensive lifestyle interventions and even though there may be a positive effect on weight gain the studies have not shown as great of an improvement and other important outcomes such as caesarean delivery and birth weight another way that both providers and patients can work together to achieve weight gain goals is to track their weight gain across the pregnancy there are paper versions of the charts as shown in the figure but many electronic medical record systems have the ability to graphically display weight gain across pregnancy weight gain trackers are also available in apps or online for patients in this technical age of smartphones and activity trackers the graphical depiction of the way changes helps women understand their progress and track their own goals in doing so this empowers women to take ownership of their health care next we'll address some of nutritional aspects of pregnancy as we heard in the prior talk iron needs increased during pregnancy iron deficiency is the leading cause of anemia during pregnancy and anemia in pregnancy particularly when it's severe increases the risk for preterm birth low birth weight and maternal death due to postpartum hemorrhage non-hispanic black women and women who've had bariatric surgery are the group's at highest risk for iron deficiency routine screening for anemia during pregnancy is recommended at the first prenatal visit and again in the third trimester our deficiency can be treated with diet adjustments to increase iron rich foods and oral iron supplementation but parental or intravenous iron is the next line of treatment if there's no improvement from the oral iron at every delivery the umbilical cord is clamped and cut during a process called delayed cord clamping the procedure is the same but the timing occurs at least 30 seconds after the delivery studies have shown that delayed cord clamping improves hemoglobin levels at birth and iron stores for the first type of months for infants that are born at term studies have also showed that delayed cord clamping improves transitional circulation decreases the need for blood transfusion and lowers the incidence of adverse outcomes such as advertising enterocolitis and interventricular hemorrhage and preterm infants delayed cord clamping is a practice that is becoming more routinely performed during deliveries in the United States there is also evidence that delayed umbilical cord clamping can not only improve iron parameters but also increase brain myelin and this is according to a randomized controlled trial an infant follow-up at four months current studies are targeting the relationship between iron and critical neurodevelopmental outcomes another active area of research so concerns from internal nutrition do not end at delivery women are still advised to consume additional calories approximately 500 a day providers frequently recommend to continue a prenatal vitamin supplement during breastfeeding but most women may not require supplements if they have a balanced diet and no known vitamin or mineral deficiencies the amount of weight gain during pregnancy is still an important topic as up to 75% of women weigh more than their pre-pregnancy weight at one-year postpartum postpartum weight retention or the the failure to lose weight gain during pregnancy by one year postpartum increases the risk for adverse outcomes in future pregnancies and influences of women's long to her health by increasing her risk for developing problems later in life such as hypertension and diabetes in summary opto nutrition before and during pregnancy requires attention to not only diet quality but diet quantity as well as vitamin and mineral supplements excessive weight gain is very common for women but meeting weight gain goals through health behavioral interventions is an active area of research approaches to improve anaemia and iron deficiencies include routine screening for anemia during pregnancy and delayed umbilical cord clamping next dr. Perez s Camilla will talk to us about the importance of breastfeeding for infant outcomes and how we can support women during breastfeeding [Applause] good afternoon everyone as previously shown by dr. Sharma breastfeeding offers many health advantages to children under mothers making it a highly cost effective intervention this is not surprising as breastfeeding involves many beneficial hormonal changes and human milk is a complex biological substance that contains a constellation of nutrients another bioactive substances including stem cells human milk oligosaccharides antibodies and live bacteria human milk composition changes within a single nursing episode and as a child develops in full consistency with her physiological needs furthermore there is now strong evidence that the bioactive substance profile of human milk varies dramatically among healthy diets very likely as a result of diet level tailoring or optimization to their environments including the exposure to diverse pathogens which is why breastfeeding is indeed considered as personalized medicine a good example that illustrates the powerful benefits from bioactive substances in human milk is illustrated by the cognitive development benefit attributed to it based on sound randomized control trials observational studies as well as neuro imaging studies for example findings from Bliss and colleagues have recently shown through neuroimaging that a higher proportion of it's closely prez milk in the weeks after preterm birth was associated with substantially improved structural connectivity of developing networks in the brain a milk composition based a mechanism by which this happens is related to the fact that human milk is rich in omega-3 polyunsaturated fatty acids which are essential for the proper milah nation of the neuronal axons a process that in turn is crucial for the proper development of the central nervous system so given how much we know about the benefits of human milk and breastfeeding and how cost-effective breastfeeding interventions are a key question is quite still the great majority of women in the world who are choosing to breastfeed don't do it as long as they would like in response to this question my research group at Yale developed the breastfeeding care model based on a complex adaptive systems analysis analogous to an engine this model proposes the need for eight years that need to operate in synchrony for the proper functioning of large-scale breastfeeding programs first evidence based advocacy generates the political will that is needed to develop and pass legislation to protect breastfeeding and release the needed resources for proper protection promotion and support of breastfeeding these resources support implementation and enforcement of key protection measures including maternity protection for women employed in formal and informal economy sectors and the total code they are also needed for developing the workforce responsible for implementing key health facility and community-based initiatives demand creation for breastfeeding services can strongly be supported through sound behavior change based social marketing campaigns operational research is key for identifying implementation bottlenecks and addressing them on time I heard at the heart of the breastfeeding year model is a master gear which is responsible for overall coordination including timely communication across and monitoring of pre-established calls based on multi-level decentralized management information systems that allow for evidence informed local decision-making I am very pleased to report that the breastfeeding year model feasibility and utility to guide large-scale implementation efforts has now been confirmed in eight countries across five world regions over the past three and a half years of work the effective scaling up of breastfeeding problems can be greatly facilitated by the fact that key initiatives needed to make it work at scale have been extensively tested and operationalized a prime example is indeed the Baby Friendly hospital initiative which is based on implementation of the ten steps consisting of a best practice package that includes includes breastfeeding protection policies monitoring and evaluation and staff training and as we all know clinical procedures such as rooming in when supervised skin-to-skin contact immediately after birth breastfeeding support and counseling and breastfeeding support coordination after hospital discharge even that there is very consistent evidence indicating that the ten steps work and that there is adults rearing those response relationship between the number of steps implemented and breastfeeding outcomes as shown with data from the CDC infant feeding practices story it is important to follow the advice from the World Health Organization that all facilities providing maternity and newborn services worldwide increase their efforts implementing the ten steps for this reason it is very encouraging that the percentage of maternity facilities that have implemented at least five of the ten steps has rapidly increased over time in the US as documented by the CDC mping impressive monitoring system however still one only about one quarter of births in the US are happening at baby friendly facilities and as this map shows special attention needs to be paid to inequities in Baby Friendly hospital coverage across States I will now move on to breastfeeding counseling she's a second key global strategy for scaling up effective breastfeeding programs based on the large amount of evidence that has accumulated over the past decades in many countries including the US the World Health Organization recently released its first-ever guideline on breastfeeding counseling highlighting the need for breastfeeding support during the prenatal perinatal as well as postnatal period the guideline emphasizes the great importance of breastfeeding support during the first hours and days after birth as well as a need to provide anticipatory guidance for mothers so that they know what to expect regarding the different milk production phases that are awaiting them in the near future as an illustrative example of how powerful breastfeeding counseling is these slideshows findings from an RCT clearly documenting the strong impact that breastfeeding peer counseling after hospital discharge has on improving exclusive breastfeeding rates this instance among women delivering in northern Brazil in a Baby Friendly hospital a comparison of the blue with the orange bars clearly shows that the major short-term effects of the Baby Friendly hospital on exclusive breastfeeding was only sustained as such if the intervention group received the home visits from breastfeeding peer counselors and this is not unique to Brazil similar findings have been documented among low-income mothers in Connecticut where again prenatal perinatal and postnatal breastfeeding counseling support increased substantially the prevalence of exclusive breastfeeding family friend friendly maternity protection policies are also recognized in the breastfeeding year model as been crucial for enabling the environment for women to breastfeed as long as a one to two important pillars for breastfeeding protection are paid maternity leave and breaks during the work for breastfeeding or breast milk extraction paid maternity leave has been associated with improved breastfeeding outcomes as well as reductions in infant mortality unfortunately the u.s. is the only high-income country that does not have legislation for paid maternity leave as a result one in four women return to work by ten days after giving birth in our country additional evidence informed maternity protection policies that have been endorsed to support breastfeeding include family friendly work policies once employed women returned to work including breaks during the workday lactation rooms for Brits breast milk expression on flexible work hours and affordable high-quality child care services in proximity to the workplace the International Labour Organization maternity protection convention also recommends a parental or father's leave in addition to maternity leave a recommendation that has also been associated with positive breastfeeding outcomes in conclusion as presented by dr. Sharma breastfeeding and human milk is a major cost saving intervention family-friendly social and economic policies are needed to enable the breastfeeding environments the Baby Friendly hospital initiative works community-based breastfeeding counseling works there is a need for better integration of facility and community-based breastfeeding support to assure the quality of the continuum of care for breastfeeding moms investing more in evidence informed breastfeeding protection promotion and support should be a top priority in the US and beyond thank you very much and it is now my great pleasure to introduce my colleague Frank Greer thanks Raphael let's start with a couple definitions complimentary foods this refers to the nutrient and energy containing solid semi solid or liquid foods fed to infants in addition to human milk or formula the complementary feeding period generally occurs between six months and the child's second birthday with the progression from a fully liquid diet to the mixed diet of family foods I note that this takes up 500 of the first thousand days as shown at this slide by the yellow bar so indeed this is a critical period for growth and brain development well the history of complementary food introduction is a long and torturous one as you can see here this goes over about a hundred years in 1900 infants typically didn't receive complimentary foods until 11 to 12 months of age the recommendation gradually changed over time and by the mid fifties it was down to introduced foods between 1.5 and two months increased up to around for about six months by the year 2000 which is where it is today I'd like to note that this slide mimics the slide of the decline of breastfeeding rise and fall of breastfeeding in the United States breastfeeding reached its low point in 1958 with only 25% of us infants breastfed at seven days let alone six months but what drives the introduction of complementary foods it's a balance between nutritional benefits versus developmental readiness the nutritional benefits of the closest breastfeeding have been well described here and the strongest evidence I know in Western countries westernized countries is for the first four months of life developmental readiness varies widely but typically occurs between four and six months of age sitting upright with little or no support and oral motor skills like to note as a father and now more times as a grandfather that when the infant joins the dinner table he will tell you when their development eärendil developmentally readily the right nutritional limitations of the Kushi breastfeeding after six months however these include the need for additional iron and zinc and then gradually increasing needs for additional calories and protein which cannot be supplied by human milk well where are we with complementary foods today in the United States two recent surveys have shown that sixteen percent of infants are introduced to complementary foods earlier than four months which is too early thirteen percent are introduced at seven months or a little too late and the remaining infants are mainly introduced to come of every foods between the beginning of the fourth month of life and the end of the sixth month of life what do we know about macro nutrient intakes and complementary fed infants toddlers aged 12 to 23 months well the goal of protein is for 5 to 20 percent of energy intake from two recent surveys we know that 94% of toddlers ages 12 to 23 months meet the goals carbohydrate goal is 45 to 65 percent of energy intake and 84 percent of toddlers meet these goals the goal for fat is 30 to 40 percent of energy intake and much to everybody's surprise in these recent surveys about 28 percent of toddlers have less than the recommended fat intake not enough and as fatty to intake is essential for brain growth and development people are wondering if this is something to be concerned about this is pretty amazing when you think about the current obesity epidemic well what about the micronutrients supplied by complementary foods there's no question that iron is the most important that's because the iron requirements are relatively large compared to all the other micronutrients have you've heard in the yellow box here on the right you see the iron requirement for seven to twelve month old is 11 milligrams a day for ages 12 to 36 months it falls to seven milligrams and there's very strong evidence that supports consuming contrary foods with substantial amounts of iron ID in meat and cereals with iron maintain iron status and prevent iron deficiency anemia I will add that the benefits for infants who consume iron fortified formula which contains 12 milligrams per liter are less evidence than for breastfed infants what is the source of iron and complimentary foods well it's heme iron that's found in red meat and dark poultry meat with as much as two milligrams 400 grams of food iron is bound to animal protein and thus absorbed intact this gives it the highest absorption rate of any dietary source of iron at 25 to 35 percent unfortunately or to some people fortunately it's not common as a complementary food before 12 months non heme iron on the other hand found in green vegetables and eggs is poorly absorbed at most 10 percent generally less iron salts added to infant formulas and cereals are the most poorly absorbed of all at 2 to 5 percent but they're added miss at large amounts that they offset poor absorption rates well there is something new about comfortably feeding which I'm really excited to talk about that today and that is the early early introduction of allergenic complementary foods historically we have not recommended allergenic foods be introduced to the human diet until the second to third year of life allergenic foods which are nutrient-rich include peanuts eggs milk fish and wheat new evidence does not support delaying the introduction of allergenic foods beyond 6 to 11 months of age in fact the evidence is strongest for introducing peanuts between 4 and 11 months of age and high-risk infants high-risk infants are those that have severe eczema or an egg allergy at the time that peanuts are introduced until recently what pediatrician dietitian or family member would put a kid on peanuts who has eczema and an egg allergy well they did this in the study which I'll show you on the next slide and it reduced peanut allergy at six years of age by eighty percent an amazing study published in the New England Journal of Medicine in 2015 also known as the leap trial and they looked at prevalence of peanut allergy at age six years in a group of 600 round infants but no peanut group received no peanuts until they were 5 years of age the peanut group started peanuts 2 grams 3 times a week between 4 and 11 months and continued as through 5 years of age and you can see a dramatic dramatic decline in peanut allergy in the peanut group there's very few dietary studies that ever show this much significant difference so not very informative study there are some contra many foods in the other hand that should not be introduced these include 100 percent fruit juices not before 12 months of age and then limited to 4 ounces per day thereafter because these displace nutrient rich foods such as whole milk you should never introduce sugar sweetened beverages before 2 years and very limited thereafter because they are associated with weight gain and obesity later in life cow's milk particularly whole cow's milk should not be introduced before 12 months because of the SS protein calcium and phosphorus and there's no need for flavored cow's milk at any time in the first year of life because of their edits first two years of life because of their added sugar plant-based milks should generally be avoided with perhaps the exception of soy milk for those desiring a vegan diet are concerned about cow milk and tolerance well what do we know about the process event from feeding we really don't know very much it has been demonstrated though that repeated exposure of a fruit or vegetable every day for eight to ten days increases acceptability between the ages four to twenty four months another thing we've recently learned it's sequential introduction of foods whether it's green vegetables before yellow vegetables vegetables for meat or fruits etc it's not supported by any evidence whatsoever sequencing doesn't make any difference infants with infrequent intakes of fruits and vegetables that we've already heard about today less than one per day it aids 11 months are likely to continue this pattern at age six years well you've all heard about responsive reading you provide your child asides and that's recognizing a child's hunger and satiety cues can support feeding practices that lead to healthy growth and this includes all feedings beginning at birth through the two years of age including breastfeeding and formula feeding we also know that some caregiver feeding practices are associated with the children's weight and these to include restricting food or pressuring a child to eat and these are generally associated with a healthy weight and generally an unhealthy weight gain evidence suggests introducing a variety of foods across all food groups routine mealtimes promotes good dietary habits later in life if my may summarize my point by reading you the current recommendations for complimentary feeding on the American Academy of Pediatrics number one introduced top Trupti foods at about six months to introduce a variety of nutrient-dense complimentary foods especially iron rich foods do not introduce cow's milk or hundred percent fruit juices before twelve months avoid foods and beverages with added sugar and salt avoid plant-based milks in general introduce allergenic coyote food sooner rather than later again this is the big change no need to delay introduction beyond the age of six months and there's even an exception for introducing peanuts between four and six months of age for the infants with eczema and egg allergy and finally we need to encourage a lot more high quality research on the timing of introduction types and amounts of complementary foods I mean just look but one rel controlled randomized trial with peanuts did it changed decades of recommendations which were all based on expert opinion so in summary for the group opportunities to improve nutrition in a thousand day window include of course promoting breastfeeding empowering parents and care providers with understanding and best practices promoting the 2020 Dietary Guidelines when we finally get them and giving everybody access to high-quality care medical care thank you all right so we'll take questions if you have a question please come up to the in the room come in up to the microphone and Susan do we have any questions online and first I want to remind our online audiences they can send their questions to Grand Rounds at cdc.gov we'll get in as many as we can but everyone will receive a response our first question from Megan should routine vitamin and mineral supplementation during pregnancy be recommended at the population level as a universal recommendation or just on an individual basis okay great thank you for the question so there there's some discrepancies and in terms of current recommendations with some societies recommending supplemental premium prenatal vitamins for all women and and some suggesting that not all women may necessarily need a supplement and in the United States there is such a wide range of baseline health so to speak going into pregnancy that women have attic adequate stores whether it's related to certain vitamins or nutrients they may not necessarily need the additional intake but we currently don't have the recommendation the capability just to screen all pregnant women that are either beginning a pregnancy or prior to pregnancy for nutritional deficiencies and because the intake of a single prenatal vitamin is relatively inexpensive and without side effects it is one of the more common recommendations that as as providers we give to our patients and for women preparing for and during a pregnancy question here hi thank you all for your presentations very interesting my questions for dr. Greer specifically I'm curious as to why plant-based milks are never recommended against is it because they take the place of a more nutrient-dense food or just generally why Thanks yeah they're not you know them I guess I just speak to you know they're there something like nine nutrients which are found in human milk mainly potassium and things like found in cow's milk that are recommended by the USDA and dietary guidelines so that's basically why most of the most of the milks don't contain the same nutrients to the same degree a lot of are fortified but we don't have a lot of experience with things like almond milk for instance and there a bunch of others but soy milk we have a a lot of experience with that's generally why they recommended it that'd be the alternative quick follow-up question just in your opinion you think in additional testing with new milk products that would be found to be of more no nutritional composition or is it pretty standard that they'll never kind of reach the same I don't know the answer to that question but make sense thank you any questions I also want to comment that we had four additional questions both through the box and as well as on line about the issue of plant-based proteins so I think it's important that we let those people know we did get those but it got asked in the room and this one is to our Grand Rounds email box in cases where breastfeeding may not be an option such as for the LGBTQ community and other adoptive parents are there supplements besides formula to mimic the benefits of breastfeeding in order to ensure maximum nutrition in the first two years of life that's called infant formula there's no and ifs or buts infant formula is a complete food it has everything an infant needs to grow on opportunities might be breast feeding banks other opportunities might be breast feeding banks again from the Grand Rounds email box where do you stand on choline supplementation for pregnancy I don't have an opinion on choline supplementation for pregnancy I can keep going that's fine again from the email box okay if we have adequate intake values of most micronutrients iron and zinc are exceptions for children younger younger than two years of age how the Dietary Guidelines for this age group are going to be supported if we use adequate intake the percent of children with inadequate diets is going to be much larger than the reality and this is going to push for the use of micronutrients supplements probably without a need do you have an opinion on that my opinion is that these question illustrates the enormous urgency on investing more on improving our assessments of infant nutrient requirements because I agree they are not very reliable most of them they are dated in many many of them and it is very difficult to issue dietary guidelines or standards for food products targeting infants if we don't have reasonable estimates for the kids hi thank you so much for your presentations I think some of you touched on research gaps and I'd be curious to hear from each of you areas of research that you see as being critical over the next let's call it the next thousand days it's for for a greater attention and investment and then maybe a second question we talked a lot about what's needed in the first thousand days but can you comment a little bit about sort of the long-term implications of what happens in the first thousand days thank you so I want to comment that within the World Health Organization one of the divisions that has become the strongest champion for the first 1000 days is a non communicable diseases division because they're very persuaded by all the emerging evidence that the metabolic dysregulation x' that occur with regards to sugar metabolism and lipid metabolism and and so on really get established that blueprint for toes gets established during the first 1,000 days so I would say that in terms of basic research in the whole epigenetic question as to how the host poor dietary practices end up interacting with a genome and transfer from one generation to the next to determine a metabolic risk 34 years down upstream I think to me that severity should be a very high priority area and since we've already scored points with peanuts think about the value of fish and eggs and we could use some of the same randomized control trials for introducing fish and eggs I mean fish is hardly introduced in the u.s. diet is a complementary food you know there's some food manufacturers that are working on this but cheetah really nutrient dense foods both of them and yet kids commonly have allergies to both eggs and fish so to answer your first question about research gaps I think the alarming statistic that over or at least 50% women in the United States exceed their weight gain golds to me really targets the opportunity to help women meet those growth goals during pregnancy and it's also impressive that even though the health behavior interventions to date show that there's some benefit to the interventions during pregnancy in many of the studies there's still a large amount egde of women that continue to exceed the weight Gingles I think we need to find different avenues to reach patients and providers on different types of health behavior interventions such as diet and exercise and answer your second question about beyond the thousand days pregnancy is a window of opportunity to talk to women about their health and health behaviors and many women are motivated to have a healthy pregnancy and health behaviors that are established in the first pregnancy affect their health and a future pregnancy and in their later life and I was gonna say some of the same stuff that Michelle said but I'll just add there was also surveillance gaps so I know you asked about research but I think in understanding are the deficiencies their nutritional status of young children will be critical and that also helped drive some of the research needs and stuff is how do we improve deficiencies or how do we target programs same also with with pregnancy as well there's there's we just have a lot of gaps and yes from Regina while the benefits of breastfeeding are clear it's important to stress that a fed baby is more important than an exclusively breastfed baby how do we help support or not stigmatize and shame women who might not be able to exclusively breastfeed successfully you know at the end of the day I think it is a woman's choice the one that has to be respected and no matter what her choice is it should be supported the work that I do what other colleagues of mine do is to try to help establish a more level playing field where the vast majority of women who are choosing to breastfeed can breastfeed as long as they want and this includes providing them with breastfeeding counseling and support including lactation management support during the first hours days and weeks after birth were many many many of the human lactation problems happen and can be resolved and it's specially important to offer these services to first-time mothers and also to women who are socially economically vulnerable and in their groups are less likely to have that support for for breastfeeding and I just might add to that any breast fold any breast milk is better than none if it's two weeks three weeks four weeks five weeks six weeks that's great and you shouldn't be stigmatized if you have to introduce formula at some point all right please join me in giving a thank you to the speakers for an excellent presentation please join us next month for Public Health Grand Rounds

Related Posts

Leave a Reply

Your email address will not be published. Required fields are marked *