NATIONAL PROGRAM OPTIMIZATION OF FEEDING CHILDREN OF THE FIRST YEAR OF LIFE IN THE RUSSIAN FEDERATION
Approved at the XVI Congress of pediatricians of Russia
(February 2009)
Moscow
Union of pediatricians of Russia
2011
EXCERPT
11. POWER IN carbohydrate intolerance
Violations of the hydrolysis and absorption of carbohydrates manifest similar symptoms so-called "fermentation" "sour" or "osmotic" diarrhea, due to the same development mechanisms.
The clinical symptoms of intolerance to carbohydrates
- frequent (8-10 times a day or more) liquid, foam chair with large water stain and sour smell;
- bloating, rumbling (flatulence), abdominal pain (cramps);
- Availability carbohydrates in feces (0.25 g% in children 1 year of age);
- acidic chair reaction (pH below 5.5);
- possible development of dehydration;
- rarely - the development of severe malnutrition
In the absence or lack of activity of enzyme involved in the hydrolysis of a carbohydrate The absorbed and not remaining disaccharides in the intestinal lumen and / or monosaccharides having a high osmotic activity, facilitate the exit of water and electrolytes in intestinal lumen (osmotic diarrhea), stimulate the motility of the upper gastrointestinal tract, causing excess carbohydrates enters the thick intestine. In the colon, they are fermented by intestinal microflora actively with the formation of organic acids, hydrogen gas, methane, carbon dioxide and water, causing flatulence, colic, enhanced peristalsis and accelerates the passage of the chyme intestines. The pH of intestinal contents is changed to the acid side. Disruption of the normal chemical composition of intestinal contents may contribute to the development of dysbiosis.
lactase deficiency (ICD-10 E73) Is the most frequent form of disaccharidase deficiency develops as a result of the reduction or complete absence of the enzyme lactase-phlorizin hydrolase in the enterocytes of the small intestine mucous membrane. This enzyme belongs to the most vulnerable enzymes of the small intestine. It is surfactant, and its concentration is much lower than that of other enzymes wall digestion. In prematurity (28 to 34 week gestation) lactase activity is only 30% of its level in term infants. Maximum enzyme activity was observed at the age of 2-4 months.
Clinic
Severity of clinical symptoms caused by IL with the total degree of reduction in enzyme activity, the amount of received dietary lactose, the character of the intestinal microflora, as well as individual sensitivity to pain to stretching gases intestine.
Distinguish primary FN associated with congenital enzymatic deficiency and secondary LN which develops due to damage enterocyte in infectious, inflammatory, autoimmune disease of the intestine, as well as lactose intolerance in the syndrome of "short gut. "
Most pediatricians often meet hypolactasia children of the first months of life.
Clinical symptoms (flatulence, colic, diarrhea) appear at the child usually March 6 weeks of age, which is apparently due to the increase of the volume of milk or formula. The history of these children, as a rule, there are indications of complicated course of pregnancy and childbirth (hypoxia), And in the immediate family often identified symptoms LN adult type. In infants with signs of hypoxic CNS lesions sometimes observed the so-called "locking" form lactase deficiencyWhich is characterized by the absence of independent stool in the presence of liquid stool and other symptoms listed above. Usually most of the symptoms in children stoped by 5 to 6 months (the time of weaning) and will not be traced, so this type of lactose intolerance is difficult to attribute to the primary.
diet therapy
The approach to treatment should be differentiated depending on the nature
feeding (natural or artificial), the degree of enzyme deficiency (alaktaziya, hypolactasia) genesis fermentopathy (primary or secondary) Table. 35.
Table 35. Driving correction lactase insufficiency in children in the first year of life
When breastfeeding |
When artificial feeding |
the most complete and dlitelnoesohranenie breast milk in the baby's diet |
partial or complete replacement for milk formula or Low-lactose-free mixture according to the tolerance to lactose and nature of comorbidity |
appointment of enzymes: lactase or lactase Baby | |
the ineffectiveness (maintaining expressed anxiety, colic, dehydration symptoms, lack of weight gain) - the partial replacement of breast milk lactose free dairy mix 1/3 2/3 volume of each feeding |
In primary alaktazii newborns which is extremely rare, the child immediately and fully translated into feeding lactose free formula.
When hypolactasia when the child is breastfed reduction in the amount of breast milk is not desirable. The best option is the use of lactase preparations ( "Lactase baby» (National Enzyme Company, USA, 1 capsule of 700 units (7 mg), 1 is assigned to the capsule feeding. Dose of enzyme preparation is mixed with 20 30 mL (1/3 volume feeding) expressed milk and baby desoldering before breast-feeding.
Efficacy increases if expressed milk with lactase is left to ferment for 15 minutes, and the processing lactase total volume of milk. Perhaps the use of "Lactase» (Enzyme Lactase company Nature's Way Products, Inc, United States, 1 capsule of 3450 units., Since 1/4 of the capsule in the feeding).
With the ineffectiveness of using an enzyme (which is usually observed in patients with severe reduction of lactase activity) resorting to a reduction of lactose load by replacing 1/3 to 2/3 of the volume of each feeding lactose free dairy mixture (Table. 36), after which the baby to finish feeding human milk. Lactose-free mixture is introduced into the diet gradually, at each feeding, leading for 3 to 5 days before the required number, is judged by what reduction of bloating, resumption of normal consistency of stools and stool frequency, a decrease in excretion in the feces of carbohydrates, enhance pH feces. Typically the volume of lactose-free product is 30 to 60 ml per feeding.
Table 36. The chemical composition and energy content of low-lactose and lactose-free milk mixtures (100 ml of a ready mix)
The product's name |
The company, country of origin |
ingredients |
Energy value, kcal |
|||
proteins |
fats |
carbohydrates |
||||
Total |
lactose |
|||||
lactose free mixture | ||||||
Nutrilak lactose-free |
Nutritek Group, Russia |
1,6 |
3,5 |
7,3 |
0 |
66,3 |
NAS lactose-free |
Nestle, Switzerland |
1,7 |
3,3 |
7,6 |
0 |
67 |
Enfamil Laktofri |
Mead Johnson, USA |
1,42 |
3,7 |
7,2 |
||
Low-mix | ||||||
Nutrilak low-lactose |
Nutritek, Russia |
1,6 |
3,5 |
7,3 |
0,9 |
66,3 |
Nutrilon low-lactose |
Nutricia, The Netherlands |
1,4 |
3,6 |
7,1 |
1,33 |
66 |
Humana-LP |
Humana, Germany |
1,8 |
2,0 |
9,2 |
1,1 |
62 |
Humana MCT-LP + |
Humana, Germany |
1,9 |
2,0 |
8,9 |
0,5 |
61 |
at artificial feeding should choose low-lactose mixture with the amount of lactose that transports the patient, preventing the appearance of clinical symptoms and increase the excretion of carbohydrates in feces. Low-mixture, introducing it in each feeding, are gradually replacing the infant formula. Small amounts of lactose entering the colon, are a natural prebiotic, necessary for the proper formation of the microflora. Lactose is also the only source of galactose, which is formed at its cleavage. Galactose is used for the synthesis of galactolipids including cerebrosides, which are necessary for the formation of the central nervous system and myelination of nerve fibers, as well as for the synthesis of mucopolysaccharides (hyaluronic acid) included in the vitreous, and synovial liquid.
feeding dishes children first year of life with no LN prepared with milk, and at the low or lactose free mixture, which receives the child. With 4-4.5 months of age are assigned fruit purees industrial or baked apple. The first main lure (5 to 4.5 months). Is advisable to assign porridge (rice, corn, buckwheat) or mashed vegetables with structurally unstable plant fiber (cauliflower, zucchini, pumpkin, carrot) supplemented with vegetable oil. After 2 weeks, administered meat purees. Fruit juice (diluted with water 1: 1) is introduced into the diet such children later, usually during the second half of life. Children can use the second half of dairy products, where the lactose content is insignificant - the washed curd from the whey, butter, hard cheese.
In primary (constitutional) lactase deficiency low-lactose diet is appointed for life.
In secondary hypolactasia lactase deficiency symptoms are transient. Therefore, upon reaching the underlying disease remission after 1 diet 3 months should extend gradually introducing lactose infant formula, under the control of clinical symptoms (diarrhea, flatulence) and carbohydrates with excretion feces.
Congenital sucrase-isomaltase insufficiency is a rare disease among Europeans and is inherited in an autosomal recessive manner. Lack of the enzyme is not a life-threatening condition. It appears for the first time with the introduction of sucrose in the diet of a child (fruit juice, puree, sugar water or tea) at least - starch and dextrin (porridge, mashed potatoes) as a heavy "carbohydrate" diarrhea with crises dehydration. With age, children often acquire the ability to carry an increasing amount of dextrin, starch and sucrose without increasing enzyme activity, which is associated with increased mucosal absorptive surface shell. Often, patients develop an aversion to sweet dishes, fruit, starchy foods, then there is the self-regulation of sucrose entering the child's body.
Any damage to the gut epithelium can lead to a secondary deficiency of this enzyme (infectious enteritis, giardiasis, celiac disease, radiation enteritis), but the activity of the enzyme does not fall before the extremely low level, as is the case with the primary failure.
diet therapy
The basis for diet therapy for this condition is the elimination of sucrose and, sometimes, reduced amount of starch and dextrins in the diet. In primary (congenital) sucrase-isomaltase deficiency children usually tolerate lactose, the secondary (postinfection) - not transferred, i.e. they formed concomitant disaccharidase failure. Therefore, when choosing a child with a mixture of primary sucrase-izomaltaznoy failure preferably as long as possible the preservation of breast feeding, in the absence thereof should be administered with infant formula lactose carbohydrate component.
Children with lack of sucrase-isomaltase not carry fruits, berries, vegetables, juices with high sucrose (peaches, apricots, tangerines, oranges, melons, onions, beets, carrots, etc.), as well as foods that are rich in starch (cereal, potato, bread, jelly and et al.). Introduction feeding is recommended to start with mashed vegetables, substantially free of sucrose and starch (Table. 37).
Table 37. Vegetables and fruits containing the minimum amount of sucrose and starch
The main carbohydrates - fructose |
The main carbohydrate is glucose |
|
- cauliflower - broccoli - Brussels sprouts - spinach - salad - beans - sorrel - green pea |
- tomatoes - lemons - cherry - cranberry - sea buckthorn |
Sweeten foods can be glucose or fructose. In the second year of life it is usually possible to expand the diet by introducing a small amount of starch-containing foods (vegetables, cereals, potatoes).
at secondary intolerance to sucrose duration of its elimination depends on the severity of the underlying disease and treatment progress. Deficiency carbohydrates compensate recommended parenteral and / or enteral administration of glucose solutions. Period elimination sucrose, unlike lactose, less extensive and may be limited to 10-15 days.
starch intolerance can occur in premature infants during the first six months of life, in which the activity of pancreatic amylase physiologically reduced, as well as exocrine pancreatic insufficiency, so they do not shown
assignment of mixtures comprising starch carbohydrate component in the composition.
at congenital (primary) malabsorption of glucose - galactose there is a defect in the transport systems of the brush border of the enterocytes, the activity of disaccharidases and hydrolysis of carbohydrates are not violated. This rare pathology is inherited in an autosomal retsesssivnomu type; It manifested by profuse diarrhea and dehydration after the first feeding of the newborn. Substitution on lactose-free milk and dairy mixture has no effect.
The only monosaccharide capable absorbed in the small intestine, is fructose.
The drug of choice is the transfer of the child to total parenteral nutrition. On the background of parenteral nutrition feeding begin dosing with 2.5% fructose solution, the concentration of which in the absence of diarrhea is increased to 7 to 8%. Next administered protein source (protein preparation or meat purees), fat (vegetable oil or fat emulsion, from 1 of 2 drops). In the future expansion of the diet is carried out at the expense of mashed fructose-containing vegetables. Prognosis with total malabsorption glucose-galactose very serious. Surviving children with partial deficiency of glucose-galactose transport system suffer from chronic diarrhea and lag behind in physical development.
acquired intolerance to monosaccharides It manifested severe chronic diarrhea with delayed physical development. It may be accompanied during the severe intestinal infections in children during the first months of life with poor premorbid background, occur due to the atrophy of the villi of the intestinal mucosa of celiac disease, cow's milk protein intolerance, protein-calorie failure. Diarrhea in a child is reduced, when he is hungry, and resumes when increasing the volume of oral feeding. Characteristic is the low pH and high concentration of glucose and galactose in the feces. Lactose-free and dairy-free therapy is ineffective mixtures.
Acquired intolerance to monosaccharides is a transient state, however, has a total character: not absorbed glucose, galactose, fructose, also violated the hydrolysis of di- and polysaccharides. Oral rehydration standard solutions ineffective because they contain glucose. Condition of the patient requires transfer to total parenteral nutrition.
Introduction of glucose orally start cautiously with 2.5% solution on the background of stable condition and absence of diarrhea, with a gradual increase in the solution concentration. When 5% glucose mixture was well tolerated, parenteral nutrition can be stopped. Introduction of higher glucose concentrations, the starch may again cause diarrhea that require re-discharge. Upon reaching the good tolerability glucose, dextrin, sucrose, starch solutions are introduced gradually, starting with 3-5% concentration, fruit puree, juices, diluted with water 1: 1, and no sooner than 1-2 months can try to enter the infant formula with a moderately reduced concentration lactose.
Materials for this chapter are also provided: Ph.D. EA Roslavtseva
