formulas)infantiles)...table 1. proposed compositional requirements of infant formula component unit...
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FORMULAS INFANTILES
Dra. Paulina Canales R Gastroenteróloga Infan@l
Hospital Dr. Exequiel González Cortes Universidad de Chile
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Conflicto de Interés
• Invitada por Laboratorio AbboN a Congreso Mundial de Gastroenterología Pediátrica el año 2014
• Invitada a congreso EPSGHAN por Laboratorio Nestlé año 2018
• No soy Speaker de ninguno de ellos
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Definición
• Alimento cuyo propósito es cubrir las necesidades nutricionales propias de los lactantes ( menores de 1 año), dichas formulas simulan las caracterís@cas de la leche humana, pudiendo ser u@lizadas como complemento o sus@tuto de la leche materna.
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Caracterís@cas de la Leche Humana
• 87% Agua • 3,8% Grasa • 7% Lactosa • 1% Proteínas • Grasa provee 50% del aporte calórico • Lactosa provee 40% del aporte calórico
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Proteínas
• Proporción Caseína/Suero fluctúa 30/70 -‐ 80/20 hasta 50/50
• La proporción de proteínas varia de acuerdo a la etapa de lactancia
• 1,4-‐1,6g/% en etapa precoz • 0,8-‐1,0 g/% después de los 3 meses • 0,7-‐0,8 g/% después de los 6 meses
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Lactosa
• Principal Carbohidrato, efecto prebió@co • Concentración estable después de los 21 días de lactancia
• Man@ene un gradiente osmó@co estable • Favorece la absorción de Calcio • Une otros componentes bioac@vos como Oligosacaridos
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Grasas
• Componente mas importante • Provee Energía y cumple funciones estructurales en SNC y Re@na
• Da cuenta del sabor y el aroma de la LH • La principal fracción son Triglicéridos • 50% es grasa saturada, 23% de esta es Acido Palmí@co • 36% es grasa mono insaturada principalmente Acido Oleico
• 15% Acido Linoleico (C18ω6) 0,35% Acido Linolenico (C18ω3)
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Vitaminas y Minerales
• Con@ene can@dades adecuadas de la mayoría de vitaminas y minerales excepto Vitamina D y K
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QUE MAS TIENE LA LH?
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Componentes bioac@vos
• Se definen como elementos que afectan procesos biológicos o sustratos, con impacto en la función corporal y que úl@mamente impactaran la salud
• Algunos son producidos localmente en la glándula mamaria y otros son transportados a través del epitelio
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Formulas Infan@les, clasificación
• Formulas basadas en Leche de Vaca • Formulas basadas en Proteína de Soya • Formulas Especiales • Formulas Hipo alergénicas • Formulas para Enfermedades Metabólicas • Formulas para otras condiciones
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TABLE 1. Proposed compositional requirements of infant formula
Component Unit Minimum Maximum
Energy kcal/100 ml 60 70ProteinsCows’ milk protein g/100 kcal 1.8* 3Soy protein isolates g/100 kcal 2.25 3Hydrolyzed cows’ milk protein g/100 kcal 1.8† 3
LipidsTotal fat g/100 kcal 4.4 6.0Linoleic acid g/100 kcal 0.3 1.2a-linolenic acid mg/100 kcal 50 NSRatio linoleic/a-linolenic acids 5:1 15:1Lauric + myristic acids % of fat NS 20Trans fatty acids % of fat NS 3Erucic acid % of fat NS 1
CarbohydratesTotal carbohydrates‡ g/100 kcal 9.0 14.0
VitaminsVitamin A mg RE/100 kcal§ 60 180Vitamin D3 mg/100 kcal 1 2.5Vitamin E mg a-TE/100 kcalk 0.5{ 5Vitamin K mg/100 kcal 4 25Thiamin mg/100 kcal 60 300Riboflavin mg/100 kcal 80 400Niacin# mg/100 kcal 300 1500Vitamin B6 mg/100 kcal 35 175Vitamin B12 mg/100 kcal 0.1 0.5Pantothenic acid mg/100 kcal 400 2000Folic acid mg/100 kcal 10 50Vitamin C mg/100 kcal 10 30Biotin mg/100 kcal 1.5 7.5
Minerals and trace elementsIron (formula based on cows’ milk protein and protein hydrolysate) mg/100 kcal 0.3** 1.3Iron (formula based on soy protein isolate) mg/100 kcal 0.45 2.0Calcium mg/100 kcal 50 140Phosphorus (formula based on cows’ milk protein and protein hydrolysate) mg/100 kcal 25 90Phosphorus (formula based on soy protein isolate) mg/100 kcal 30 100Ratio calcium/phosphorus mg/mg 1:1 2:1Magnesium mg/100 kcal 5 15Sodium mg/100 kcal 20 60Chloride mg/100 kcal 50 160Potassium mg/100 kcal 60 160Manganese mg/100 kcal 1 50Fluoride mg/100 kcal NS 60Iodine mg/100 kcal 10 50Selenium mg/100 kcal 1 9Copper mg/100 kcal 35 80Zinc mg/100 kcal 0.5 1.5
Other substancesCholine mg/100 kcal 7 50Myo-inositol mg/100 kcal 4 40L-carnitine mg/100 kcal 1.2 NS
*The determination of the protein content of formulae based on non-hydrolyzed cows’ milk protein with a protein content between 1.8 and 2.0 g/100 kcalshould be based on measurement of true protein ([total N minus NPN] 3 6.25) (31).†Formula based on hydrolyzed milk protein with a protein content less than 2.25 g/100 kcal should be clinically tested.‡Sucrose (saccharose) and fructose should not be added to infant formula.§1 mg RE (retinol equivalent) = 1 mg all-trans retinol = 3.33 IU vitamin A. Retinol contents shall be provided by preformed retinol, while any
contents of carotenoids should not be included in the calculation and declaration of vitamin A activity.k1 mg a-TE (a-tocopherol equivalent) = 1 mg d-a-tocopherol.{Vitamin E content shall be at least 0.5 mg a-TE per g PUFA, using the following factors of equivalence to adapt the minimal vitamin E content
to the number of fatty acid double bonds in the formula: 0.5 mg a-TE/g linoleic acid (18:2n-6); 0.75 mg a-TE/g a-linolenic acid (18:3n-3); 1.0 mga-TE/g arachidonic acid (20:4n-6); 1.25 mg a-TE/g eicosapentaenoic acid (20:5n-3); 1.5 mg a-TE/g docosahexaenoic acid (22:6n-3).#Niacin refers to preformed niacin.**In populations where infants are at risk of iron deficiency, iron contents higher than the minimum level of 0.3 mg/100 kcal may be appropriate
and recommended at a national level.NS, not specified.
ESPGHAN RECOMMENDED STANDARDS FOR THE COMPOSITION OF INFANT FORMULA 587
J Pediatr Gastroenterol Nutr, Vol. 41, No. 5, November 2005
Medical Position Paper
Global Standard for the Composition of Infant Formula:Recommendations of an ESPGHAN Coordinated
International Expert Group
*Berthold Koletzko,1 †Susan Baker, ‡Geoff Cleghorn, §Ulysses Fagundes Neto, kSarath Gopalan,{Olle Hernell, #Quak Seng Hock, **Pipop Jirapinyo, ††Bo Lonnerdal, ‡‡Paul Pencharz,
§§Hildegard Pzyrembel,2 kkJaime Ramirez-Mayans, {{Raanan Shamir, ##Dominique Turck,***Yuichiro Yamashiro, and †††Ding Zong-Yi
*Dr. von Hauner Children’s Hospital, University of Munich, Germany; †Department of Pediatrics, Univ. of Buffalo, NY, USA;‡Department of Pediatric s and Child Health, University of Queensland, Brisbane, Australia; §Department of Pediatrics, EscolaPaulista de Medicina, Universidade Federal de São Paulo, Brazil; kCentre for Research on Nutrition Support Systems, New Delhi,
India; ¶Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden; #Department of Pediatrics, NationalUniversity of Singapore, Singapore; ** Dept. of Pediatrics, Mahidol University, Bangkok, Thailand; ††Departments of Nutrition andInternal Medicine, University of California, Davis, USA; ‡‡Division of Gastroenterology and Nutrition; The Hospital for Sick
Children, Toronto, Canada; §§Federal Institute for Risk Assessment, Berlin Germany; kkDivision of Gastroenterology and Nutrition,Instituto Nacional de Pediatria, Mexico DF, Mexico; ¶¶Division of Pediatric Gastroenterology and Nutrition, Meyer Children’sHospital, Haifa, Israel; ##Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital, University of Lille, France;
***Department of Pediatrics, Juntendo University, Tokyo, Japan; and †††Beijing Children’s Hospital, Beijing, China1Chair of the International Expert Group; 2Observer as Chair of the Electronic Work Group on Infant Formula Composition of the
Codex Alimentarius Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU)
ABSTRACTThe Codex Alimentarius Commission of the Food andAgriculture Organization of the United Nations (FAO) and theWorld Health Organization (WHO) develops food standards,guidelines and related texts for protecting consumer health andensuring fair trade practices globally. The major part of theworld’s population lives in more than 160 countries that aremembers of the Codex Alimentarius. The Codex Standard onInfant Formula was adopted in 1981 based on scientific knowl-edge available in the 1970s and is currently being revised. Aspart of this process, the Codex Committee on Nutrition andFoods for Special Dietary Uses asked the ESPGHAN Com-mittee on Nutrition to initiate a consultation process with theinternational scientific community to provide a proposal on
nutrient levels in infant formulae, based on scientific analysisand taking into account existing scientific reports on thesubject. ESPGHAN accepted the request and, in collaborationwith its sister societies in the Federation of InternationalSocieties on Pediatric Gastroenterology, Hepatology and Nutri-tion, invited highly qualified experts in the area of infantnutrition to form an International Expert Group (IEG) to reviewthe issues raised. The group arrived at recommendations on thecompositional requirements for a global infant formula stan-dard which are reported here. JPGN 41:584–599, 2005. KeyWords: Bottle feeding—Food standards—Infant food—Infantformula—Infant nutrition—Nutritional requirements. ! 2005Lippincott Williams & Wilkins
BACKGROUND OF THE ESPGHANCOORDINATED INTERNATIONAL EXPERT
GROUP CONSULTATION
The Codex Alimentarius Commission was createdin 1963 by the Food and Agriculture Organization ofthe United Nations (FAO) and the World Health Orga-nization (WHO) to develop food standards, guidelinesand related texts such as codes of practice under
Received July 12, 2005; accepted July 12, 2005.Address correspondence and reprint requests to Berthold Koletzko,
M.D., Professor of Pediatrics, Dr. von Hauner Children’s Hospital,Ludwig-Maximilians-University Munich, Lindwurmstr. 4, D-80337München, Germany (e-mail: [email protected]).
Journal of Pediatric Gastroenterology and Nutrition41:584–599 ! November 2005 ESPGHAN Committee on Nutrition
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Formulas basadas en Proteína de Vaca
• Las proteínas vacunas son la base de la mayoría de las formulas lácteas
• Con@enen 64 a 67 Cal/% • Proteínas 1,3-‐1,7 g/% • Son for@ficadas con la mayoría de las vitaminas y minerales necesarios para sostener un crecimiento normal en lactantes
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Formulas basadas en Proteína de Soya
• Son opciones efec@vas para lactantes en situaciones especiales como Galactosemia
• No aptas para ser u@lizadas en lactantes menores de 6 meses
• Todas for@ficadas con aminoácidos azufrados ( cisteína-‐@rosina)
• Con@enen Fitoestrogenos
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Formulas “Confort”
• Formulas dirigidas a aliviar síntomas diges@vos frecuentes en lactantes
• Cólicos, malestar, meteorismo etc. • Proteínas Parcialmente Hidrolizadas • Menos contenido de Lactosa ( 70% menos) • Probio@cos • Poseen aportes de proteínas similares a las formulas estándar
• Su uso carece de validez cienlfica
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Formulas Hipo an@génicas (HA)
• Poseen proteínas parcialmente hidrolizadas • Poseen una can@dad reducida de Lactosa • Son de fácil diges@bilidad • Reducen el @empo de transito intes@nal • Pueden tener indicación en niños con alta carga atópica familiar
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Formulas An@rreflujo (AR)
• Formulas a las cuales se les ha agregado un espesante que habitualmente es Cereal de Arroz, cuyo efecto principal es enlentecer el vaciamiento gástrico, Poseen mayor densidad Calórica
• Uso cosmé@co
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Formulas para Alergia a Leche de Vaca
• Definición • AAP: fórmulas terapéu
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Formulas Extensamente Hidrolizadas
• Primera línea de tratamiento. • Fuente proteica basada en suero y/o caseína de leche de vaca.
• Proceso de prediges@ón mediante hidrólisis enzimá@ca, tratamiento térmico y ultrafiltración.
• Pép@dos de PM
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Fórmulas extensamente hidrolizadas
FORMULA KCAL/100 ML
PROT (GR/100 ML)
CHO (GR/100 ML)
GRASAS TOTALES (GR/100 ML)
ACEITES VEGETALES
LACTOSA OSM (mOsmol/L)
DILUCIÓN OTROS
NUTRILON PEPTI JUNIOR
66 1,8 6,8 3,5 Palma, canola, girasol
no 190 12,8% 85% prot de suero – 15% aa libres
ALTHERA 67 1,7 7,3 3,4 Oleina de palma, maravilla, canola, coco
si 251 13,2% Base caseina 80% pep@dos – 20% aa libres
HUMANA AT1
69 1,8 7,4 3,6 Coco, girasol, soya, palma
no 185 14,1% 80% prot suero – 20% caseina
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Formulas Aminoacidicas
• Primera línea en presentaciones severas. • Sinté@cas en base aa libres de origen vegetal • CHO: maltodextrina • Grasas: aceites vegetales • For@ficadas
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Fórmulas aminoacídicas
FORMULA KCAL/100 ML
PROT (GR/100 ML)
CHO (GR/100 ML)
GRASAS TOTALES (GR/100 ML)
ACEITES VEGETALES
LACTOSA OSM (mOsmol/L)
DILUCIÓN OTROS
NEOCATE LCP
67 1,8 7,2 3,4 Coco, canola, maravilla
no 340 13,8% 33%MCT
NEOCATE ADVANCE
100 2,5 15 3,5 no 520 15% 35% MCT
ELECARE 68 2,1 7,3 3,2 Cártamo, soya, ácido oleico
no 350 15,6% 33% MCT
AMINOMED
63 1,8 6,8 3,2 Canola, girasol, palma
no 330 13% 10% MCT
COMIDAGEN PLUS
101 3,1 14,8 3,4 Palma, canola y girasol
no 23%
ALFAMINO 76 2,06 8,6 3,6 Canola, maravilla, palma
no 313 15,3% 24% MCT
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Usos alterna@vos
• Síndrome de Intes@no Corto • Malabsorción de Grasas • Gastroenteropa@as Eosinofilicas
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Conclusiones
• La leche humana es el alimento ideal para en lactante, la AAP recomienda LM exclusiva los 6 primeros meses de vida
• La OMS recomienda Lactancia Humana los 2 primeros años de vida
• El uso de formulas infan@les posee indicaciones precisas
• El uso de formulas “Confort “ no @ene evidencia cienlfica