For Healthcare Professionals only

Role of AAF in Nutritional Management of Infantile Colic
By - Danone Nutricia Academy

Key takeaways

  • Amino acid feed (AAF) is an alternative for non-exclusive breastfed infants who are suffering from severe cow’s milk allergy (CMA) and are intolerant to extensively hydrolyzed feed (eHF).1
  • In infants,AAF improvesCMA-induced colic symptoms and reduces total crying time.2
  • Long-term use of AAF is safe and shows satisfactory body growth in CMA infants.3

Infantile colic is one of the complications linked with CMA that is characterized by inconsolable crying for a longer period with irritability.3,4 Evidence suggests that hydrolyzed feed is an effective option to improve colic symptoms and promote body growth in infants with CMA.4 This article discusses the benefits of long-term amino acid feed (AAF) administration in improving colic symptoms and body growth.strong>

Impact of AAF on colic symptoms

Infantile colic affects 9-30% of newborns in the first few months of life. It is characterized by episodes of inconsolable crying, fussing, and irritability that lasts ≥ 3 hr/day, ≥ 3 days/week, and for ≥ 3 weeks. 2 Excessive gas, pullingthe legsup, and tenseabdomen are other characteristic features of colic.4 Evidence suggests that hypoallergenic maternal diet or feed may effectively improve colic symptoms in exclusively and non-exclusively breastfed infants. Though extensively hydrolyzed feed (eHF) has shown improvement in colic symptoms, few infants are intolerant to it. AAF, a feed completely free of intact protein, could be a suitable alternative for such infants.1,5

A preliminary study suggested that AAF is beneficial in improving colic symptoms in 3–7weekold infants: 2

  • AAF was well-tolerated by all infants, and symptoms improved within 1–2 days.
  • AAF reduced the daily cry time and fuss time by an average of 69% and 25%, respectively.
  • Compared to the baseline, the total time spent fussing and crying was decreased by an average of 45%.

Long-term use of AAF and growth pattern

AAF effectively improves clinical symptoms related to CMA; however, the effect is evaluated for very short-time periods (up to 6-9 months). It is essential to define the long-term effect of AAF on body growth and protein metabolism considering the changing paradigm of CMA. In this regard, a study comparing the long-term effects of AAF and extensively hydrolyzed whey feed (eHWF) on body growth and protein metabolism in infants with CMA was conducted(Figure 1).3

Figure 1. Study design N= Number of subjects; CMA: Cow’s milk allergy; AAF: Amino acid feed; eHWF: Extensively hydrolysed whey feed

Key outcomes:3
  • A similar gain in weight and increase in length was observed in the subjects of both CMA groups. At month 3, a difference in body weight and length was observed between healthy control and CMA subjects; however, the data was similar at month 6 (Table 1).
  • There was no difference observed in head circumference Z score in all three groups.

Table 1: Study subjects Z score for weight for age, length for age, and head circumference for age. (Source: Canani et al., 2016)3

Z score

Months

AAF vs HC

(P)

eHWFvs HC

(P)

AAF vs eHWF

(P)

Weight for age

0

0.046

0.003

0.456

3

0.03

0.007

0.745

6

0.494

0.448

0.560

12

0.698

0.265

0.509

Length for age

0

0.142

0.105

0.745

3

0.05

0.045

0.850

6

0.027

0.158

0.350

12

0.430

0.561

0.866

Head circumference for age

0

0.238

0.092

0.559

3

0.251

0.104

0.616

6

0.494

0.135

0.498

12

0.451

0.522

0.944

AAF: Amino acid feed; eHWF: Extensively hydrolysed whey feed; HC: Healthy controls. Bold text: Represent the difference as indicated by p value.

  • Feeds were accepted and tolerated by all patients with CMA, and protein and energy intake levels were comparable in both CMA groups (Table 2).

Table 2: Protein and energy intake levels. (Source: Canani et al., 2016)3

Months

AAF (n=21)

eHWF (n=19)

HC (n=25)

Energy intake, kcal/kg/day

0

98

96

101

3

103

97

98

6

95

95

99

12

88

90

96

Protein intake, g/kg/day

0

2.1

2.3

2.3

3

2.2

2.3

2.1

6

2.2

2.2

2.1

12

2.3

2.3

2.1

Data are reported as median; AAF: Amino acid feed; eHWF: Extensively hydrolyzed whey feed. a vs c, P=0.04, b vs c, P=0.015.

  • Protein metabolism biomarkers were within the normal range in both CMA groups. (Table 3).

Table 3: Protein metabolism biomarkers. (Source: Canani et al., 2016)3

Biomarker

Months

AAF (n=21)

eHWF (n=19)

Urea, mmol/L

0

3.1

3.8

3

3.7

4.3

Total protein, g/L

0

64.1

63

3

64.9

65.6

Albumin, g/dL

0

3.9

4.1

3

4.3

4

Retinol-binding

protein, mg/L

0

16.6

26.6

3

27.9

27.2

Insulin-like growth

factor 1, µg/L

0

56

77

3

65.5

71

Data are reported as median, AAF: Amino acid feed; eHWF: Extensively hydrolyzed whey feed

Conclusion

Long-term use of AAF is a safe option for progressive recovery of body growth in infants with CMA. Based on the severity of CMA, AAF can be prescribed to the infants to improve CMA-linked colic and other symptoms and promote overall growth.3

References:

  1. Meyer R, Groetch M, Venter C. When should infants with cow's milk protein allergy use an amino acid formula? A practical guide. The Journal of Allergy and Clinical Immunology: In Practice. 2018 Mar 1;6(2):383-99.
  2. Estep DC, Kulczycki Jr A. Treatment of infant colic with amino acid‐based infant formula: a preliminary study. Acta Paediatrica. 2000 Jan;89(1):22-7.
  3. Canani RB, Nocerino R, Frediani T, Lucarelli S, Di Scala C, Varin E, Leone L, Muraro A, Agostoni C. Amino Acid–based Formula in Cow's Milk Allergy: Long-term Effects on Body Growth and Protein Metabolism. Journal of pediatric gastroenterology and nutrition. 2017 Apr 1;64(4):632-8.
  4. Al Dhaheri W, Diksic D, Ben-Shoshan M. IgE-mediated cow milk allergy and infantile colic: diagnostic and management challenges. Case Reports. 2013 Feb 7;2013:bcr2012007182.
  5. Nocerino R, Pezzella V, Cosenza L, Amoroso A, Di Scala C, Amato F, Iacono G, Canani RB. The controversial role of food allergy in infantile colic: evidence and clinical management. Nutrients. 2015 Mar;7(3).

IMPORTANT NOTICE: MOTHER’S MILK IS BEST FOR YOUR BABY

The World Health Organization (WHO)* has recommended that pregnant women and new mothers be informed of the benefi¬ts and superiority of breast-feeding, in particular, the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for and maintenance of lactation, with special emphasis on the importance of the well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle feeding or other foods and drinks should be discouraged since it will have a negative effect on breast-feeding. Similarly, mothers should be warned of the diffi¬culty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and ¬financial implications of her decision. For example, if a baby is exclusively bottle-fed, more than one can (500g) per week will be needed, so the family circumstances and cost should be kept in mind. Mother should be reminded that breast milk is not only the best but also the most economical food for babies. If a decision to use infant formula is taken, it is important to give instruction on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can lead to illness.

*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981.

Importance of Breastfeeding:

Immediately after delivery, breast milk is yellowish and sticky. This milk is called colostrum, which is secreted during the fi¬rst week of delivery. Colostrum is more nutritious than mature milk because it contains more protein, more anti-infective properties which are of great importance for the infant's defense against dangerous neonatal infections. It also contains higher levels of, Vitamin 'A', (ii) breast miIk- A) is, a complete and balanced food and provides all the nutrients needed by the infant [for the ¬first six months of life] (B) has anti-infective properties that protect the infants from infection in the early months (C) is always available; (D) needs no utensils or water (which might, carry germs) or fuel for its preparation, (iii) breastfeeding is much cheaper than feeding infant milk substitutes as the cost of the extra food needed by the mother is negligible compared to the cost of feeding infant milk substitutes, (iv) mothers who breast-feed usually have longer periods of infertility after child birth than non-lactators; (b) details of management of breast feeding, as under:- (i) breast-feeding- (A) immediately after delivery enables the contraction of the womb and helps the mother to regain her ¬figure quickly; (B) is successful when the infant suckles frequently and the mother wanting to breast-feed is confi¬dent in her ability to do so (ii) in order to promote and support breast-feeding the mother’s natural desire to breast feed should always be encouraged by giving, where needed, practical advice and making sure that she has the support of her relatives. (iii) adequate care for the breast and nipples should be taken during pregnancy. (iv) it is also necessary to put the infant to the breast as soon as possible after delivery, (v) let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called "rooming-in"); (vi) give the infant colostrum as it is rich in many nutrients and anti-infective factors protecting the infants from infections during the few days of its birth; (vii) the practice of discarding colostrum and giving sugar water, honey water, butter or other concoctions instead of colostrum should be very strongly discouraged; (viii) let the infants suckle on demand; (ix) every effort should be made to breast-feed the infants whenever they cry; (x) mother should keep her body and clothes and that of the infant always neat and clean. Breast-feeding is the best form of nutrition for babies and provides many benefi¬ts to babies and mothers. It is important that, in preparation for and during breast-feeding, you eat a healthy, balanced diet. Combined breast and bottle-feeding in the ¬first weeks of life may reduce the supply of your own breast-milk and reversing the decision not to breast-feed is dif¬ficult. Always consult your Healthcare Professional for advice about feeding your baby. The social and fi¬nancial implications of using infant formula should be considered. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. If you use infant formula, you should follow manufacturer's instructions for use carefully - failure to follow the instructions may make your baby ill.

IMPORTANT NOTICE

Breast milk is best for babies. At Danone, we support breast feeding and believe that breast milk is the best food for babies as the sole source of nutrition for the first 6 months of life and is recommended to be continued until 2 years with the introduction of appropriate complementary foods after 6 months of age.

IMPORTANT NOTICE: Breastfeeding is the best for babies and a healthy diet / maternal nutrition is important when breastfeeding. A decision not to breastfeed can be difficult to reverse. Infant formula is suitable from birth when babies are not breastfed. It is recommended that all formula milks be used on the advice of a doctor, midwife, health visitor, public health nurse, dietitian, pharmacist, or other professional responsible for maternal and child-care and the financial implications should be considered. All preparation and feeding instructions should be followed carefully as inappropriate preparation could lead to health hazards. this is the same as the above – does this need to be included

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