Il latte nel divezzamento Carlo Agostoni Dipartimento di Scienze Materno-Infantili IRCCS Policlinico Cà Granda Università 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) sovrappeso : BMI> 90o percentile per età e sesso obesità: 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) °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 (√) 8

Taveras EM et al 2004; 114: e577

A high percentage of breastfeeds among all milk feeds accumulated during 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) p<0.001 JAMA 2002; 287:2365

n-3 PUFA, enhance hepatic fatty acid oxidation and inhibit fatty acid synthesis and VLDL secretion by regulating gene expression PUFA (DHA) contro of hepatic metabolic processes Chem Phys Lipids 2008;153:3    

3) permanent effects on the regulation of cellular aging 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? GLOBAL STANDARD FOR THE COMPOSITION OF INFANT FORMULAS JPGN 2005; 41: 584-99 Quale “riferimento” usare?  Riferimento: non la composizione biochimica del latte materno ma la crescita ed i marker biochimici e funzionali dell’allattato al seno

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 forebrain in 34 infants up to 2 years EPA

LC-PUFA supply: short-term effects from trials in the complementary feeding period  Visual acuity at 12 months: positive effects from 3 studies enriched formulas or eggs in previously breastfed infants Complementary feeding period Limited sample size justified by the end-points  DHA status, changes of VEP parameters  Visual acuity at 12 months: no direct effects, visual acuity associated with DHA status irrespective of the type of diet LC-PUFA in PKU infants through a specific product

Cow’s milk and iron 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 “antigenic” effect? Ziegler EE, NNWS 60, 2007: 185-199 Thorsdottir I, Eur J Clin Nutr 2003; 57:505

Whole cow’s milk as main source of milk : not before 12 months JPGN 2008; 46: 99-110 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)

Limited sample size! Iron-sensitive subjects emerging in smaller studies?

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 nutrienti MANCANO evidenze “funzionali”