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LATTE MATERNO: per 6 mesi non avrai altro alimento

all’infuori del mio

Beatrice Dalla Barba

Dipartimento di Pediatria di Padova

Padova, 12 ottobre 2013

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svezzamento…

???

QUANDO INTRODURRE LO SVEZZAMENTO…?

QUALI LE EVIDENZE..?

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CONFLITTO DI INTERESSI Il mio primo obiettivo, come professionista pediatra è quello di

proteggere la salute dei bambini. Per questo motivo io non posso e non desidero ricevere doni o

fondi da compagnie coinvolte nella commercializzazione di alimenti per l’infanzia, in quanto potrebbero influenzare il mio

giudizio.

Io dichiaro di essere membro e di aderire ai principi dettati da:

www.ibfanitalia.org www.nograziepagoio.it

PROVIAMO A… l  Presentare e discutere le evidenze a

disposizione sulla durata ottimale dell’allattamento esclusivo

l  Presentare e discutere le evidenze a disposizione sull’epoca di introduzione di alimenti complementari

l  Presentare e discutere le evidenze a disposizione sull’appropriatezza dell’alimentazione complementare

The AAP recommends exclusive Breastfeeding for about 6 months, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant, a recommendation concurred to by the WHO and the Institute of Medicine.

POLICY STATEMENT Breastfeeding and the Use of Human Milk –Pediatrics 2012

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“L’AS è la norma e il modello di riferimento rispetto al quale tutti i metodi alternativi di alimentazione devono essere misurati in termini di crescita, salute, sviluppo e qualsiasi altro esito a breve o lungo termine”

AAP 2005

non dimentichiamo mai che:

e che: vi sono evidenze scientifiche che identificano chiaramente quali sono gli interventi che hanno maggiore efficacia:

ADOTTIAMOLI!

Followed by years of fierce debate

l Advocates of breastfeeding: EBF to 6 months

l Advocates of industry: EBF 4 to 6 months

l Developing vs. developed countries l  “Weanling’s dilemma”

Compared with infants who never breastfed, infants who were exclusively breastfed for 4 months had significantly greater incidence of lower respiratory tract illnesses, otitis media, and diarrheal disease than infants exclusively breastfed for 6 months or longer. When compared with infants who exclusively breastfed for longer than 6 months, those exclusively breastfed for 4 to 6 months had a fourfold increase in the risk of pneumonia. POLICY STATEMENT

Breastfeeding and the Use of Human Milk –Pediatrics 2012

HEALTH

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The AAP is cognizant that for some infants, because of family and medical history, individual developmental status, and/or social and cultural dynamics, complementary feeding, including glutencontaining grains, begins earlier than 6 months of age.

POLICY STATEMENT Breastfeeding and the Use of Human Milk –Pediatrics 2012

Because breastfeeding is immunoprotective, when such complementary foods are introduced, it is advised that this be done while the infant is feeding only breastmilk. Mothers should be encouraged to continue breastfeeding through the first year and beyond as more and varied complementary foods are introduced. POLICY STATEMENT

Breastfeeding and the Use of Human Milk –Pediatrics 2012

GLUTENCONTAINING PROBLEM

A detailed pediatric cost analysis based on the AHRQ report concluded that if 90% of US mothers would comply with the recommendation to breastfeed exclusively for 6 months, there could be a savings of $13 billion per year.

POLICY STATEMENT Breastfeeding and the Use of Human Milk –Pediatrics 2012

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Similarly, there are no convincing data that delaying introduction of potentially allergenic foods after 6 months has any protective effect. One problem in analyzing this research is the low prevalence of exclusive breastfeeding at 6 months in the study populations. Thus, research outcomes in studies that examine the development of atopy and the timing of introducing solid foods in partially breastfed infants may not be applicable to exclusively breastfed infants.

POLICY STATEMENT Breastfeeding and the Use of Human Milk –Pediatrics 2012

Celiac Disease There is a reduction of 52% in the risk of developing celiac disease in infants who were breastfed at the time of gluten exposure. Overall, there is an association between increased duration of breastfeeding and reduced risk of celiac disease when measured as the presence of celiac antibodies. The critical protective factor appears to be not the timing of the gluten exposure but the overlap of breastfeeding at the time of the initial gluten ingestion. Thus, gluten-containing foods should be introduced while the infant is receiving only breast milk and not infant formula or other bovine milk products.

POLICY STATEMENT Breastfeeding and the Use of Human Milk –Pediatrics 2012

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l  “The debate over whether to recommend EBF for 4–6 months vs. about 6 months has recently become more intense (weanling’s dilemma).”

l  Objective: to assess the effects on child health, growth, and development, and on maternal health, of EBF for 6 months vs. EBF for 3–4 months with mixed breastfeeding (introduction of complementary liquid or solid foods with continued breastfeeding) thereafter through 6 months

l  Methods: Cochrane review

Optimal duration of EBF (WHO, 2008)

Results l 16 independent studies met the selection criteria:

–  7 from developing countries (2 RCTs in Honduras) –  9 from developed countries (all observational studies)

l The 2 RCTs not of high quality, but nonetheless superior to any of the observational studies (variable quality)

l Neither the RCTs nor the observational studies suggest that infants who continue to be EBF for 6 months show deficits in weight or length gain

l Data on iron scarce, but in developing country, where newborn iron stores may be suboptimal, suggest that EBF without iron supplementation may compromise hematologic status

Reviewers’ conclusions l  No evidence of a “weanling’s dilemma” l  Infants EBF for 6 months experience less morbidity from

gastrointestinal infection than those mixed breastfed as of 3 or 4 months

l  EBF for 6 months: no deficits in growth among infants from either developing or developed countries

l  “Although infants should still be managed individually so that insufficient growth or other adverse outcomes are not ignored and appropriate interventions are provided, the available evidence demonstrates no apparent risks in recommending, as public health policy, EBF for the first 6 months of life in both developing and developed country settings”

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Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding.

Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003517. DOI: 10.1002/14651858.CD003517.pub2

l Objective: to update the 2001 review l  23 independent studies met the selection criteria:

–  11 from developing countries (2 RCTs in Honduras) –  12 from developed countries (all observational studies)

l  7 new studies included, but results and conclusions unchanged

studi recenti:

Nielsen SB et al. Adequacy of milk intake during exclusive breastfeeding: a longitudinal study. Pediatrics 2011;128;e907

l  Objective: to test whether and how human lactation and breastfeeding practices can adapt to fulfil infant energy requirements during EBF for 6 months.

l  Methods: 50 healthy and well supported EBF mother-infant dyads observed longitudinally to measure milk and energy intake (doubly labelled water method), anthropometry, and breastfeeding practices at around 15 and 25 weeks of age in Glasgow, Scotland; 47 (23 boys) completed the study, 41 were EBF to 25 weeks of age.

l  Results: milk intakes higher than literature values (923 [SD: 122] g/day and 999 [SD: 146] g/day at 15 and 25 weeks) and increased significantly between time points. Infant growth normal compared with WHO Child Growth Standards. Energy intakes adequate compared with requirements. No evidence of strain on breastfeeding practices.

l  Conclusions: when mothers are well supported and follow the WHO recommendation, milk intakes are high and increase over time, and there is adequate energy intake, normal infant growth, and no marked changes in breastfeeding practices. This new empirical evidence on adaptations during EBF should help health professionals promote the initiation, duration, and exclusivity of breastfeeding.

Wells JCK et al. Randomized controlled trial of 4 compared with 6 months of exclusive breastfeeding in Iceland: differences in breast-milk

intake by stable-isotope probe. Am J Clin Nutr 2012;96:73–9

l  Objective: to assess energy intake in EBF infants at 6 months compared to infants receiving breast milk and CF.

l  Methods: anthropometric outcomes, body composition, and breastmilk intake at 6 months in 119 infants recruited from health centres in Reykjavik and neighbouring municipalities in Iceland and randomly assigned at age 4 months either to 6-month EBF or to the introduction of CF with continued breastfeeding. In 100 infants who completed the protocol (50/group), breastmilk intake was measured by using stable isotopes, while CF intakes were weighed over 3 days in the CF group.

l  Results: breastmilk intake was 83 g/d (95% CI: 19-148 g/d) greater in EBF (mean ± SD: 901 ± 158 g/d) than in CF (818 ± 166 g/d) infants and was equivalent to 56 kcal/d; CF infants obtained 63 ± 52 kcal/d from complementary foods. Estimated total energy intakes were similar (EBF: 560 ± 98 kcal/d; CF: 571 ± 97 kcal/d). Anthropometric outcomes and body composition did not differ significantly between groups.

l  Conclusions: EBF to age 6 months did not compromise infant growth or body composition, and energy intake was comparable to that in CF infants whose energy intake was not constrained by maternal breastmilk output.

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Not the only one: tens of articles l  Lanigan JA et al. Systematic review concerning the age of introduction of

complementary foods to the healthy full-term infant. Eur J Clin Nutr 2001;55:309–20

l  Fewtrell MS, Lucas A, Morgan JB. Factors associated with the age of introduction of solid foods in full term and preterm infants. Arch Dis Child 2003;88:F296–301

l  Reilly JJ, Wells JCK. Duration of exclusive breastfeeding: introduction of complementary feeding may be necessary before 6 months of age. Br J Nutr 2005;94:869–72

l  Prescott SL et al. The importance of early complementary feeding in the development of oral tolerance: concerns and controversies. Pediatr Allergy Immunol 2008;19:375-80

l  More J et al. BDA Paediatric Group Position Statement: weaning infants onto solid foods. British Dietetic Association, 2010

l  Fewtrell M et al. Six months of exclusive breast feeding: how good is the evidence? BMJ 2011;342:c5955

l  etc.

WHO recommendation on EBF to 6 months accepted worldwide

l UNICEF, UNAIDS, UNHCR and many other international agencies (and NGOs)

l US, UK, Australia, New Zealand, France, Italy and many other governments and/or governmental bodies in EU and worldwide

l American Academy of Pediatrics, Academy of Breastfeeding Medicine, SIP, AEP, ILCA and tens of other professional associations worldwide

The ESPGHAN’s affair

1.  ESPGHAN Committee on Nutrition. Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2008;46:99-110

2.  ESPGHAN Committee on Nutrition. Breastfeeding: a Commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2009;49:112-25

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1.  “Complementary feeding should not be introduced to any infant before 17 weeks, and all infants should start complementary feeding by 26 weeks.“

2.  “Exclusive breastfeeding for around 6 months is a desirable goal, but partial breastfeeding as well as breastfeeding for shorter periods of time are also valuable. Continuation of breastfeeding after the introduction of complementary feeding is to be encouraged as long as mutually desired by mother and child.”

The ESPGHAN’s affair

Conflicts of Interests (CoI)

l  A footnote on the first page of paper 1 states: –  “Declaration of CoI of members of the Committee on

Nutrition (CoN) are submitted yearly to the CoN secretary and are available on request”

l  Unusual way of dealing with CoI nowadays l  Tantamount to concealing CoI, because only a tiny minority

of meticulous readers will go to the trouble of writing to the CoN secretary or to the authors

l  A footnote on the first page of paper 2 states: –  “The authors report no CoI”

l  12 out of 13/14 authors appear in both papers

Yet l  The first author is since 2009 a member of the European

Food Safety Authority (EFSA) panel that issued the 4- to 6-month recommendation for complementary foods –  EFSA Panel on Dietetic Products Nutrition and Allergies. Scientific

opinion on the appropriate age for introduction of complementary feeding of infants. The EFSA Journal 2009;7:1-38

–  3 out of 7 members of the panel belong to ESPGHAN l  As such, he had to submit a declaration of conflicts of

interests, posted in the EFSA website

l  His declaration, dated 17 March 2010, shows that he has worked and written for Ferrero, Danone, Dicofarm, Dietetic Metabolic Food, Heinz, Hipp, Humana, Martek, Mead Johnson, Mellin, Milupa, Nestlè, Noos, Ordesa, SHS/Nutricia and for the federation of Infant Food Manufacturers

Please investigate CoI of other authors, and have fun!!!

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What about ESPGHAN itself?

l  ESPGHAN’s web page declares only the conflict of interests of individual members, not the funding sources of ESPGHAN as a group

l  Yet all its congresses and conferences are heavily sponsored by the infant food industry

l  And it used to hold its meetings at Nestlè headquarters in Switzerland until 2005

The ESPGHAN recommendation “Complementary feeding should not be introduced to any infant before 17 weeks, and all infants should start complementary feeding by 26 weeks.“

What is the evidence base for such a categorical recommendation???

Strength of the evidence l  ESPGHAN does not describe:

–  Methods used to search the literature –  Criteria used to select the articles –  Methods for rating the quality of the studies –  How the data used to support conclusions and

recommendations were extracted and analysed

l  All the evidence derives from observational studies, that ESPGHAN dismisses for other recommendations (e.g. that delaying or avoiding the introduction of allergenic foods prevents or delays the development of allergy)

l  The recommendation does not have a statement on the level of evidence or the strength of the recommendation

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l  ESPGHAN does not discuss the implications of implementing the recommendation

l  Does not indicate that some interdisciplinary and intersectoral consultation with various stakeholders took place

l  The recommendation was developed by a select group of paediatric gastroenterologists as “expert opinion”, the lowest level of evidence in Evidence-based Medicine

Moreover

The evidence itself l  Based on observational studies on allergy, celiac disease and

type I diabetes mellitus l  Allergy (5 cohort studies with 2-5 years of follow up)

–  No association between timing of introduction of foods and allergy –  ESPGHAN’s conclusion: there is no reason to support a delayed

introduction of solid foods beyond 6 or 4 months –  My conclusion: there is no reason to recommend an age of

introduction of solids based on the risk of allergy

l  Celiac disease (1 cohort study with 5 years of follow up, 1 concurrent comparison, 1 ecologic study)

–  Timing of gluten introduction may be associated with development of celiac disease in children at risk (1-3% of children?)

–  Incidence of celiac disease in non breastfed children varied with policies on timing of introduction of solids in Sweden

l  Evidence overall inconclusive

To conclude: the WHO recommendation to EBF to 6 months currently represents

the best distillate of available science

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As a corollary: l  Timing of introduction of different nutrients in

addition to breastmilk: –  after 6 months as a public health recommendation –  different for every single infant for individual

practice l  The most important factors for timing of

introduction of solids: –  Digestive and renal functions, metabolic pathways –  Ability to grab, bring to the mouth, keep in the

mouth, chew and swallow safely (i.e. neuro-motor development)

–  Progressive reduction of stores (mainly iron, zinc and some vitamins)

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Comp feeding

Signs that the baby is ready for solids

l  Can stay in a sitting position and can hold his/her head steady

l  Co-ordinates his/her eyes, hand and mouth and looks at food, grabs it and puts it in his/her mouth all by him/herself

l  Swallows food; babies who are not ready will push their food back out, so they get more round their face than they do in their mouths

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Iniziare lo svezzamento troppo precocemente non è raccomandabile

perché: l  Il latte materno può essere sostituito da liquidi o

cibi di minor qualità nutrizionale l  Offrire altri cibi o liquidi porta ad una riduzione

della produzione di latte materno l  Una precose esposizione ad agenti patogeni

aumenta il rischio di infezioni l  I lattanti non sono in grado di digerire alcuni

alimenti l  Una precoce esposizione a certi cibi può innescare

allergie l  La riduzione della suzione da parte del bambino

favorisce il ritorno della fertilità

Iniziare lo svezzamento tardivamente non è raccomandabile perché:

l  Il latte materno da solo non è sufficiente per la crescita del bambino che necessita di maggiori quantità di alcuni micronutrienti, soprattutto ferro, zinco ed alcune vitamine

l  Il latte materno da solo potrebbe non fornire sufficiente energia e nutrizione e causare una diminuzione della crescita

l  Lo sviluppo ottimale delle competenze motorie, come l’abilità di masticare, e la curiosità verso nuovi sapori potrebbero essere alterate

Baby-led weaning

l  If you: –  Respect the development of reflexes, skills, taste and preferences –  Do not force infants to eat, but adapt your offering of food to their

needs and demand –  Let the baby control quantities, thus reducing the risk of

overfeeding –  Build a good relationship, avoid stress, and have fun

l  Then you are letting the baby lead his/her way to a healthy diet and you are fulfilling the role of parent as facilitator

l  Babies are subjects, not objects, let alone consumers

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Il ruolo degli operatori sanitari

l  Non dimenticare la fisiologia (o ri-studiarla) l  Promuovere l’allattamento al seno, come raccomandato, ma

sostenere le decisioni dei genitori adeguatamente informati l  Aiutare I genitori a capire quando il loro bambino è pronto per I

cibi solidi: EMPOWERMENT l  Promuovere una corretta e sana alimentazione a tutta la famiglia l  Riconoscere i bisogni specifici dei singoli bambini e dei loro

genitori l  Ricordare sempre che l’alimentazione dei lattanti e dei bambini

non è solo nutrizione, ma anche momento sociale, culturale ed economico

l  Osservare il contesto locale e sociale per capire come trasferire adeguatamente le informazioni

per concludere… l  Proteggere e promuovere la fisiologia

–  de-medicalizzare

l  Proteggere l’allattamento esclusivo –  finché è naturale e fisiologico –  finché la mamma può o lo desidera

l  Proteggere l’alimentazione complementare –  da pressioni commerciali eccessive –  per una migliore alimentazione della famiglia

l  Proteggere l’aspetto relazionale –  alimentarsi non è solo biologia –  probabilmente è in gran parte relazione

Medicina Basata sulla Evidenza

M

B

M

M

M

M

B B

B

B E

E

E

E

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Evidenza Basata su Madre-natura

Grazie…

FINE..

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