Il latte nel divezzamento

Carlo AgostoniCarlo Agostoni

Dipartimento di Scienze Dipartimento di Scienze

Materno-InfantiliMaterno-Infantili

IRCCS Policlinico Cà GrandaIRCCS Policlinico Cà Granda

Università degli Studi di MilanoUniversità degli Studi di Milano

Il latte nel divezzamento (e oltre)Quale latte?

• Latte materno

• Formule

• Latte vaccino

Il latte materno• 1.   Basso apporto proteico (< 1 g / 100 ml; latte

vaccino 3.5 g/100 ml, formule non meno di 1.2-1.4 g/100 ml)

• 2. Ottimale rapporto energia/proteine

• 3. Presenza di numerosi fattori anti-infettivi

• 3. Grassi e carboidrati con valore funzionale (LCPUFA, oligosaccaridi)

Allattamento al seno e prevalenza di sovrappeso e obesità in 9357 bambini di età compresa tra 5 e 6 anni

(Von Kries R et al, BMJ 1999; 319:147)

0

2

4

6

8

10

12

14

neverbreastfed

breastfed < 2 mos 3-5mos 6-12mos >12 mos

breastfeeding duration (months)

prev

alen

ce (

%)

overweight°

obese'

sovrappeso : BMI> 90o percentile per età e sessoobesità: BMI>97o percentile per età e sesso

Breastfeeding and prevalence of overweight° in over 15000 adolescents aged 9-14 years. (adapted from

Gillmann et al, JAMA 2001:285:2461-67)

0

2

4

6

8

10

12

14

neverbreastfed

breastfed <1 mos 1-3 mos 4-6 mos 7-9 mos >9 mos

breastfeeding duration (months)

prev

alen

ce %

prevalence ofoverweight°

°Overweight was BMI>95th percentile for age and sex

Hypothesis of Programming of IGF-I axis Breastfeeding versus formula feeding

During breastfeeding________________

↓ Linear growth √

↓ IGF-I levels √

During childhood and adulthood_________________

↑ height – stature (√)

↑ IGF-I levels (√)

Taveras EM et al 2004; 114: e577

A high percentage of breastfeeds among all milk feeds accumulatedduring the first 14 months was positively related with child mental

development (0.37 points/month of full breastfeeding [95% CI: 0.06–0.67])

% di soggetti con QI (WAIS) subottimale (<90)

0

5

10

15

20

25

30

< 1mo 2-3 mo 4-6 mo 7-9 mo > 9 mo

%

p<0.001

JAMA 2002; 287:2365

PUFA (DHA) contro of hepaticmetabolic processes

n-3 PUFA, enhance hepatic fatty acid oxidation and inhibit fatty acid synthesis and VLDL secretion by regulating gene expression

Chem Phys Lipids 2008;153:3    

1) permanent structural changes in an organ

2) persistent alterations in epigenetic modifications (eg, DNA methylation and histone modifications) that lead to changes in gene expression (eg, several transcription factors are susceptible to programmed changes in gene expression through such mechanisms)

3) permanent effects on the regulation of cellular aging

The identification of primitive cell types within human breast milk may provide a non-invasive source of relevant mammary cells for a wide-range of applications; even the possibility of banking one’s own stem

cell for every breastfeeding woman.

Formule : quali• Formule standard

fino a 6 o 12 mesi?

• Formule di seguito

tra 6 e 12 mesi?

• Formule di crescita

2 e 3 anni ?

Quale “riferimento” usare?

Riferimento: non la composizione biochimica del latte materno ma la crescita ed i marker biochimici

e funzionali dell’allattato al seno

GLOBAL STANDARD FOR THE COMPOSITION OF INFANT FORMULAS

JPGN 2005; 41: 584-99

Elementi chiave delle formule

• Proteine (quantità e qualità)

• Grassi (quantità e qualità acido linolenico, acido docosaesaenoico)

• Minerali e micronutrienti (ferro, zinco, calcio, Vitamina D)

15%

Influence of Protein Intake on Metabolic-endocrine Response in Infants

Socha P, et al. Am J Clin Nutr. 2011.

DHA in forebrainin 34 infantsup to 2 years

EPA

LC-PUFA supply: short-term effects from trials in the complementary feeding period

Complementaryfeedingperiod

enriched formulas or eggs in previously

breastfed infants

LC-PUFA in PKU infants

through a specific product

Visual acuity at 12 months:no direct effects,

visual acuity associated with DHA status

irrespective of the type of diet

Visual acuity at 12 months:

positive effects from 3 studies

Limited sample size justified by the end-points DHA status, changes of VEP parameters

Cow’s milk andiron deficiency anemia in infants

• Mechanisms: low iron content in WCM, occult intestinal blood loss in up to 40% infants fed WCM, the inhibiting effect of calcium and casein

• Infants fed milk-based formulas from birth had a lower incidence of blood loss

• Blood loss also with fermented milk• A low iron content is a concern only when milk as

food is the predominant source of energy , as would be the case in a 6-month old infant fed cow’s milk

• Signficant negative associations of iron status with cow’s milk consumption at 9 and 12 months of age when > 460 ml/day

Ziegler EE, NNWS 60, 2007: 185-199

Thorsdottir I, Eur J Clin Nutr 2003; 57:505

“antigenic” effect?

Whole cow’s milk as main source of milk : not before 12 months

(limited amounts from a cup starting at 9 months)

to prevent iron deficiency (ESPGHAN CoN, 2002)

JPGN 2008; 46: 99-110

Iron-sensitivesubjects

emerging insmaller studies?

Limited sample size!

Ghisolfi et al, Public Health Nutr, accepted

LATTE TRA 6 E 12 MESI• Latte materno se possibile durante tutto il periodo

del divezzamento

• Se manca il latte materno una formula adattata “funzionalmente” (tipo 1 / tipo 2?)

• NO latte vaccino come fonte principale di latte (piccole quantità tra 9 e 12 mesi?)

TRA 12 E 36 MESI AREA “GRIGIA”LATTE VACCINO può essere introdotto

LATTI DI CRESCITA migliore equilibrio nutrientiMANCANO evidenze “funzionali”