QUALE LATTE PER IL TUO BAMBINO 

Carlo AgostoniCarlo Agostoni

Dipartimento di Scienze Dipartimento di Scienze

Cliniche e di ComunitàCliniche e di Comunità

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

LATTE MATERNO 24 mesi e anche oltre se la mamma o il bambino lo

desiderano

WHO

IGF-I at 9 Months and Number of Breastfeedings SKOT Cohort

P=0.0006

n=115 n=88 n=46 n=3

Madsen AL, et al. Growth Hormone IGF Res. 2011;21:199-204.

4

In all infants recorded different daily intakes of cow’s milk, infant formula and meat

Fasting Insulin at 9 Months and Number of BreastfeedingsSKOT Cohort

P=0.0015

n=115 n=88 n=46 n=3

Madsen AL, et al. Diabet Med. 2010;27:1350-1357.

5

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

Taveras EM et al 2004; 114: e577

Life expectancy at birth in EU member states has increased by over 6 years between 1980 and 2010. On average across the European Union, life expectancy at birth for the three-year period 2008-10 was 75.3 years for men and 81.7 years for women.

Most European countries have reduced tobacco consumption via public awareness campaigns, advertising bans and increased taxation

Alcohol consumption has also fallen in many European countries. In the European Union, 52% of the adult population is now overweight and 17% is obese. The obesity rate has doubled since 1990 in many European countries. Obesity tends to be more common among disadvantaged social groups, and especially women

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)

Ljung K et al

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

Elementi chiave delle formule

1. Proteine (quantità e qualità)

2. Grassi (quantità e qualità acido linolenico, acido docosaesaenoico)

3. Qualità carboidrati (digeribili/non digeribili)

4. Minerali e micronutrienti (ferro, zinco, calcio, Vitamina D), altri composti “funzionali”

Is Cows' Milk Harmful for a Child's Health ?

Key-note lecture - NUTRITIONKey-note lecture - NUTRITION

Carlo AgostoniCarlo Agostoni

Fondazione IRCCS Cà GrandaFondazione IRCCS Cà Granda

Ospedale Maggiore PoliclinicoOspedale Maggiore Policlinico

University of Milan, ItalyUniversity of Milan, Italy

CHAIR PERSON: Dominique Turck, Lille, France

Conclusions: Cow’s Milk harmful? • Negative effects on iron status up to 9-12 months,

then no negative effects if adequately complemented with iron enriched foods

• Lactose intolerance easily managed• Allergy to WCM proteins may be transient. Atopics

may independently be at risk of poor growth• A cause-effect relationship with T1D is not

established, and the same for ASDs• Cow’s milk stimulates IGF-1 and may affect linear

growth , but associations with non-communicable diseases is still not convincing

Conclusions: Cow’s Milk Safety

• From 12 months of life onwards• Up to around 500 mL per day • 250 mL in lactose intolerants• Fat-reduced milks after 24-36 months on

individual basis

Reports of nutrient intakes in European Countries in the 8-24 mos period

Country age(mos) Pg/kg P % Lip% Cho%

• Spain 9 4.4 15.7 26.4 58• France 10 4.3 15.6 27.1 57• Italy 12 5.1 19.5 30.5 50 • Denmark 12-36 3.3 15 28 57 Rolland-Cachera et al. Acta Paed 1999; 88:365

Protein/obesity association

Author Prot% Age Observation: P (obesity, BMI)

Rolland-Cachera 1995 >14.8 2 yrs 8 yrs <0.05Int J Obes Rel Dis 19:573

Scaglioni 2000 22 1yr 5 yrs <0.05Int J Obes Rel Dis 24:777

Dorosty 2000 14 18ms Adiposity Rebound NSPediatrics 105: 1115

Hoppe 2004 13,F, 14,M 9ms 10yrs NSAm J Clin Nutr 79:494

Scaglioni 2004 14 1y 8yrs NSActa Paediatrica 93:1596

LARN 2012- PROTEINE AR e PRI

Anni kg AR g/d PRI g/d En%* 0.5-0.99 8.6 9 11 --

1-3 13.7 11 14 4M, 3.7F

4-6 20.6 16 19 4.1M, 4.3F

7-10 31.4 25 31 5M, 5.4F

11-14M 49.7 39 48 5.7M

11-14F 50.7 39 48 6.5F

15-17M 66.6 50 62 6.25M

15-17F 55.7 40 50 6.3F

*En% calcolata come AR (fabbisogno medio) proteine vs mediana (kcal/die) fabbisogno energetico per LAF

Come ridurre le proteine ?• Latte vaccino 500 mL (o equivalente) circa

3.5 g/dL 18 g proteine 72 kcal

• Latte “formula” 1.5 g dL circa 7.5 g proteine 30 kcal

• In una dieta giornaliera intorno a 1000 kcal il bambino (con 500 mL di prodotto) passerebbe da circa 45 g proteine (180 kcal, 18% energia) a circa 35 grammi proteine (140 kcal, 14% energia)

Influence of Protein Intake on Metabolic-endocrine Response in Infants

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

FORMULA TYPE AND PROTEIN INTAKE g/d FORMULA TYPE AND PROTEIN INTAKE g/d (SD)En%(SD)En%

TimTimee

HPHP LPLP PP EFSA 2012 PRI g/dEFSA 2012 PRI g/d

T1 14 (3) 11

9 (1) 7 0.001 m f T6 10 9 T12 12 11 T18 12 11 T24 12 12

T2 16 (2) 11

9 (1) 7 0.001

T3 17 (3) 11

10 (1) 7 0.001

T4 18 (3) 11

11 (2) 7 0.001

T5 21 (5) 13

13 (2) 7 0.001

T6 24 (5) 14

15 (4) 8 0.001

T7 28 (6) 15

20 (5) 10

0.001

T8 30 (7) 15

22 (6) 11

0.001

T9 30 (7) 15

24 (7)11 0.001

T12 35 (9) 15

29 (8)13 0.001 31 (9) 14 0.001 0.028

T18 42(12) 16

42 (12) 16

0.626 39 (10) 15 0.004 0.013

T24 45(12) 16

45 (13) 16

0.679 43 (11) 16 0.025 0.073

BF P vs HP P vs LP

Energy and nutrient content per 100 ml of different milk based products for young children (modified from Nutrition Committee, Germany, 2011)

2.9%

6.9%

5.3%

Changing protein requirements in relation to different energy intakes: example in young adults

Nutrient:energy ratio requirement depends upon the activity level of the individuals in a population

29

REE, resting energy expenditure predicted with the equations of Henry (2005) using body mass and height.

LARN11201382

LARN10401346

mediana

TimTimee

HPHP LPLP EFSA 2013 EFSA 2013 AR M FAR M F

BFBF

T1 509.9 (118) 512.46 (110)

T2 563. (117) 559.2 (113)

T3 595.7 (116) 588.9 (118)

T4 631.1 (113) 632.3 (116)

T5 667.0 (115) 678.8 (131)

T6 700.9 (140)**

726.6 (147)**

T7 754.4 (143) 765.7 (153) 636 573

T8 791.4 (155) 810.2 (162) 661 599

T9 814.8 (155) 837.8 (188) 688 625

T12 891.5 (184)a

881.9 (176)a 777 712 792.5(224)b

T18 1043.3 (223)

1045.1 (223)

988.8 (195)

T24 1119.7 (240)

1112.6 (253)

1028 946 1079.4 (222)

FORMULA TYPE AND ENERGY INTAKE kFORMULA TYPE AND ENERGY INTAKE kcal/daycal/day

TimTimee

HPHP LPLP EFSA 2013 EFSA 2013 AR M FAR M F

BFBF

T1 509.9 (118) 512.46 (110)

T2 563. (117) 559.2 (113)

T3 595.7 (116) 588.9 (118)

T4 631.1 (113) 632.3 (116)

T5 667.0 (115) 678.8 (131)

T6 700.9 (140)**

726.6 (147)**

T7 754.4 (143) 765.7 (153) 636 573

T8 791.4 (155) 810.2 (162) 661 599

T9 814.8 (155) 837.8 (188) 688 625

T12 891.5 (184)a

881.9 (176)a 777 712 792.5(224)b

T18 1043.3 (223)

1045.1 (223)

988.8 (195)

T24 1119.7 (240)

1112.6 (253)

1028 946 1079.4 (222)

FORMULA TYPE AND ENERGY INTAKE kFORMULA TYPE AND ENERGY INTAKE kcal/daycal/day

Circa 20%energia in più

dell’AR raccomandato

Z- score of caloric intake per Countries

-0,8

-0,6

-0,4

-0,2

0

0,2

0,4

0,6

time

z-sc

ore

kca

l GE

BE

IT

PL

ES

T1 T2 T3 T4 T5 T6 T7 T8 T9 T12 T24

Energy costs of fat and protein deposition in the human infantAm J Clin Nutr 1988; 48:951

Total energy requirement for deposition 1.17 kJ/kJ (kcal/kcal) deposited for fat (ie, 1 kJ deposited and 0.17 kJ expended for deposition, and 2.38 kJ/kJ (kcal/kcal) for protein. The metabolizable-energy requirement for weight gain during infancy was calculated (range, 12.2-25.1 kJ/g, or 2.9-6.0 kcal/g; means, 18.7 kJ/g, or 4.5 kcal/g) from the energy costs of fat and protein deposition and published information on changes in body composition during the first year of life.

Energy expended by low birth weight infants in the deposition of protein and fat. Pediatr Res 1997 ;41:584

Using multiple regression analysis of energy expenditure against protein stored, and metabolizable energy, the energy expended in the deposition of protein was calculated to be 5.5 kcal/g +/- 1.1 kcal/g (SE) and the energy cost of fat deposited was 1.6 kcal/g +/- 0.3 kcal/g (SE).

Ghisolfi et al, Public Health Nutr, 2013; 16:524

AGE 17 (GUM) – 19 (CM) months

961 + 33 967 + 18

46

Quando introdurre il latte vaccino ?• Non prima del dodicesimo mese latte materno fino ad un

anno, anche più a lungo• Dopo il 12° mese può essere introdotto il latte vaccino

(limitare la quantità?)• Tra il 12° ed il 36° mese una formula di crescita - GUM-

può migliorare il bilancio dei nutrienti effetti funzionali non noti, mancano dati “diretti” su parametri ematici

ATTENZIONE al bilancio energetico nel suo complesso puo’ vanificare ogni altro tentativo di riequilibrio

qualitativo e quantitativo