QUALE LATTE PER IL TUO BAMBINO Carlo Agostoni Dipartimento di Scienze Cliniche e di Comunità IRCCS Policlinico Cà Granda Università 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= n=115 n=88n=46n=3 Madsen AL, et al. Growth Hormone IGF Res. 2011;21: In all infants recorded different daily intakes of cow’s milk, infant formula and meat

Fasting Insulin at 9 Months and Number of Breastfeedings SKOT Cohort P= n=115 n=88n=46n=3 Madsen AL, et al. Diabet Med. 2010;27:

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

Breastfeeding and prevalence of overweight° in over adolescents aged 9-14 years. (adapted from Gillmann et al, JAMA 2001:285: ) °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 On average across the European Union, life expectancy at birth for the three-year period 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 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 - NUTRITION Carlo Agostoni Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico University 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 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 France Italy Denmark Rolland-Cachera et al. Acta Paed 1999; 88:365

Protein/obesity association Author Prot% Age Observation: P (obesity, BMI) Rolland-Cachera 1995 > yrs 8 yrs <0.05 Int J Obes Rel Dis 19:573 Scaglioni yr 5 yrs <0.05 Int J Obes Rel Dis 24:777 Dorosty ms Adiposity Rebound NS Pediatrics 105: 1115 Hoppe ,F, 14,M 9ms 10yrs NS Am J Clin Nutr 79:494 Scaglioni y 8yrs NS Acta Paediatrica 93:1596

LARN PROTEINE AR e PRI Anni kg AR g/d PRI g/d En%* M, 3.7F M, 4.3F M, 5.4F 11-14M M 11-14F F 15-17M M 15-17F F *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

FORMULA TYPE AND PROTEIN INTAKE g/d (SD)En% TimeHPLPP EFSA 2012 PRI g/d T1 14 (3) 119 (1) m f T6  10 9 T12  T18  T24  T2 16 (2) 119 (1) T3 17 (3) 1110 (1) T4 18 (3) 1111 (2) T5 21 (5) 1313 (2) T6 24 (5) 1415 (4) T7 28 (6) 1520 (5) T8 30 (7) 1522 (6) T9 30 (7) 1524 (7) T12 35 (9) 1529 (8) (9) T18 42(12) (10) T24 45(12) 1645 (13) (11) 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

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

TimeHPLP EFSA 2013 AR M F BF T (118) (110) T2563. (117)559.2 (113) T (116)588.9 (118) T (113)632.3 (116) T (115)678.8 (131) T6 * (140)* * (147)* T (143)765.7 (153) T (155)810.2 (162) T (155)837.8 (188) T (184) a (176) a (224) b T (223) (223)988.8 (195) T (240) (253) (222) FORMULA TYPE AND ENERGY INTAKE k cal/day

TimeHPLP EFSA 2013 AR M F BF T (118) (110) T2563. (117)559.2 (113) T (116)588.9 (118) T (113)632.3 (116) T (115)678.8 (131) T6 * (140)* * (147)* T (143)765.7 (153) T (155)810.2 (162) T (155)837.8 (188) T (184) a (176) a (224) b T (223) (223)988.8 (195) T (240) (253) (222) FORMULA TYPE AND ENERGY INTAKE k cal/day Circa 20% energia in più dell’AR raccomandato

T1 T2 T3 T4 T5 T6 T7 T8 T9 T12 T24

Energy costs of fat and protein deposition in the human infant Am 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, kJ/g, or 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

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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