Zasady żywienia zdrowych niemowląt. Zalecenia Polskiego ... · Zasady żywienia zdrowych niemowląt. Zalecenia Polskiego Towarzystwa Gastroenterologii, Hepatologii i Żywienia Dzieci

321STANDARDY MEDYCZNE/PEDIATRIA 2014 T. 11 321-338

standardy medyczne

Zasady żywienia zdrowych niemowląt.Zalecenia Polskiego Towarzystwa Gastroenterologii, Hepatologii i Żywienia Dzieci

Nutrition of healthy term infants. Recommendations of the Polish Society for Paediatric Gastroenterology, Hepatology and Nutrition

Hanna Szajewska1, Piotr Socha2, Andrea Horvath1, Anna Rybak2, Anna Dobrzańska3,

Maria Katarzyna Borszewska-Kornacka4, Alicja Chybicka5, Mieczysława Czerwionka-Sza%arska6,

Danuta Gajewska7, Ewa Helwich8, Janusz Książyk9, Hanna Mojska10, Anna Stolarczyk2,

Halina Weker11

1 Klinika Pediatrii, Warszawski Uniwersytet Medyczny; Polskie Towarzystwo Gastroenterologii, Hepatologii i Żywienia Dzieci

(PTGHiŻDz)

2 Klinika Gastroenterologii, Hepatologii i Zaburzeń Odżywiania, Instytut „Pomnik - Centrum Zdrowia Dziecka”, Warszawa;

PTGHiŻDz; Zespół Żywienia Dzieci i Młodzieży Komitetu Nauki o Żywieniu Człowieka PAN

3 Klinika Neonatologii, Patologii i Intensywnej Terapii Noworodka, Instytut „Pomnik - Centrum Zdrowia Dziecka”, Warszawa,

konsultant krajowy w dziedzinie pediatrii

4 Klinika Neonatologii i Intensywnej Terapii Noworodka, Warszawski Uniwersytet Medyczny; Polskie Towarzystwo

Neonatologiczne

5 Katedra i Klinika Transplantacji Szpiku, Onkologii i Hematologii Dziecięcej, Uniwersytet Medyczny, Wrocław; Polskie

Towarzystwo Pediatryczne

6 Katedra i Klinika Pediatrii, Alergologii i Gastroenterologii, Collegium Medicum, Bydgoszcz; konsultant krajowy w dziedzinie

gastroenterologii dziecięcej

7 Zakład Dietetyki, Szkoła Główna Gospodarstwa Wiejskiego, Warszawa; Polskie Towarzystwo Dietetyki

8 Klinika Neonatologii i Intensywnej Terapii Noworodka, Instytut Matki i Dziecka, Warszawa; konsultant krajowy w dziedzinie

neonatologii

9 Klinika Pediatrii, Żywienia i Chorób Metabolicznych, Instytut „Pomnik - Centrum Zdrowia Dziecka”, Warszawa; Polskie

Towarzystwo Żywienia Klinicznego Dzieci

10 Zakład Bezpieczeństwa Żywności, Instytut Żywności i Żywienia, Warszawa

11 Zakład Żywienia, Instytut Matki i Dziecka, Warszawa

STRESZCZENIE

Dokument, opracowany przez Sekcję Żywieniową Polskiego Towarzystwa Gastroenterologii, Hepatologii i Żywienia Dzieci, stanowi aktualizację zale-

ceń dotyczących żywienia zdrowych, urodzonych o czasie niemowląt. Przeznaczony jest dla wszystkich grup zawodowych sprawujących opiekę nad

dzieckiem do 1. roku życia. Jako metodykę opracowania przyjęto adaptację do warunków polskich istniejących wiarygodnych wytycznych stworzonych

przez towarzystwa naukowe, renomowane instytucje i zespoły ekspertów. W tym celu utworzono grupę do wyszukiwania istniejących wytycznych

i oceny ich pod kątem jakości, aktualności i możliwości przyjęcia w warunkach polskich. Przygotowana pierwsza wersja zaleceń została zrecenzowana

przez wszystkich członków interdyscyplinarnego zespołu opracowującego niniejszy dokument, przyszłych użytkowników, w tym przedstawicieli śro-

dowiska pediatrów, lekarzy rodzinnych, dietetyków, jak również decydentów opieki zdrowotnej (przedstawiciela Ministerstwa Zdrowia) oraz przedsta-

322 STANDARDY MEDYCZNE/PEDIATRIA 2014 T. 11 321-338

standardy medyczne

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W.1A!(%.(? .<"#("%.!"#%,#( >.G!, #5)(-& ,#%,.( #(

wicieli rodziców/opiekunów. W wyniku konsultacji opracowana została ostateczna postać zaleceń. Częścią dokumentu jest skrócony schemat żywienia

przeznaczony do codziennego użytku przez rodziców/opiekunów dziecka. Kolejna aktualizacja planowana jest nie później niż po 3. latach od publikacji

obecnych zaleceń. Standardy Medyczne/Pediatria 2014 T. 11 321-338

SŁOWA KLUCZOWE: DZIECI NIEMOWLĘTA ŻYWIENIE KARMIENIE PIERSIĄ KARMIENIE SZTUCZNE POKARMY UZUPEŁNIAJĄCE

ABSTRACT

The document, developed by the Committee on Nutrition of the Polish Society for Paediatric Gastroenterology, Hepatology and Nutrition, is an update

of recommendations for feeding healthy term infants. The document is intended for use by all health care providers involved in caring for a child up

to 1 year of age. Evidence for the recommendations was obtained by adapting trustworthy guidelines developed by scienti=c societies, renowned

institutions, and expert organizations. For this purpose, a working group was established that searched for and retrieved guidelines and other relevant

documents and then assessed their quality, content, and applicability to the Polish setting. A draft of the document was sent to all co-authors and future

users, including pediatricians, family physicians, dieticians, health care decision makers (representatives of the Ministry of Health), and representatives

of the parents/guardians, for review and further comments. All critical feedback was considered and changes were incorporated as necessary. Part of

this document is a short summary of infant feeding for everyday use by parents/guardians. An update of current recommendations is planned for no

later than 3 years from now. Standardy Medyczne/Pediatria 2014 T. 11 321-338

KEY WORDS: CHILDREN INFANTS BREASTFEEDING FORMULA FEEDING COMPLEMENTARY FEEDING


standardy medyczne

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standardy medyczne

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Żywienie sztuczne

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standardy medyczne

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standardy medyczne

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Tabela 3. Umiejętności w zakresie karmienia i przykładowe pokarmy podawane w pierwszych 12-24 miesiącach życia34

WIEK (MIESIĄCE) UMIEJĘTNOŚCI RODZAJ POKARMÓW PRZYKŁADY POKARMÓW*

0-6 Ssanie i połykanie Płyny Mleko matki/mleko mody=kowane

4-7

Początkowe „mielenie” językiem, silny odruch ssania, cofanie się odruchu wymiotnego do tylnej części języka

Gładkie purée

Mleko j.w.Gotowane miksowane warzywa (np. marchew) lub owoce (np. banan), mięso lub purée ziemniaczane, kaszki

7-12

Oczyszczanie łyżki wargami, gryzienie, żucie, ruchy języka na boki, rozwój drobnej motoryki umożliwiający samodzielne karmienie

Zwiększona różnorodność rozdrob-nionych lub posiekanych pokar-mów, produkty podawane do rączki, pokarmy z rodzinnego stołu

Mleko j.w.Zmielone mięso, rozgniecione gotowane warzywa i owoce, posiekane surowe warzywa i owoce (np. banan, melon, pomidor), kasze, pieczywo

12-24 Żucie, stabilizacja żuchwy Pokarmy z rodzinnego stołu

Mleko j.w.Wszystkie produkty i pokarmy z rodzin-nego stołu, przy założeniu prowadzenia zbilansowanej, zdrowej diety

*Mleko podawane jest z piersi, butelki ze smokiem lub otwartego kubka. Pozostałe pokarmy podajemy łyżeczką

Tabela 2. Kolejność wprowadzania pokarmów o różnej konsystencji zalecana przez WHO38

WIEK DZIECKA KONSYSTENCJA POKARMU

6-8 miesięcyPoczątek: gęsta kasza, owsianka, dokładnie rozdrobnione produkty (gładkie purée)Następnie: rozdrobnione produkty z rodzinnego stołu (papki/purée z grudkami)

9-11 miesięcy Drobno posiekane lub rozdrobnione pokarmy oraz miękkie produkty podawane do rączki

12-23 miesięcy Produkty z rodzinnego stołu, posiekane lub rozdrobnione w miarę potrzeby


standardy medyczne

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Uwagi dotyczące wybranych produktów w żywieniu niemowląt

Produkty o właściwościach alergizujących ]+.*?1#( 1#<%)"%.!"%&!B( <.%&!B/( !"&( ):Hc%,)%#( :+) .<".%,#(:)*.+'H (:)7#%!1.4%,#(?!"?4.1A!&!B(+"#!"& ,G!,#( 7+ .4#( ".:)R,#5.( %,#:)-A<.%&'( +#.*-

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EKNO.

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standardy medyczne

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standardy medyczne

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4A7(STabela 4VC(

PIŚMIENNICTWO1 Domellöf M, Braegger C, Campoy C i wsp.; ESPGHAN Committee on Nutrition. Iron

requirements of infants and toddlers. J Pediatr Gastroenterol Nutr 2014;58:119-

129.

2 Barker DJ, Bagby SP, Hanson MA. Mechanisms of disease: in utero programming in

the pathogenesis of hypertension. Nat Clin Pract Nephrol 2006;2:700-707.

3 Stolarczyk A, Szott K, Socha P. Ocena sposobu żywienia niemowląt w wieku 6 i 12

m. ż. w populacji polskiej w odniesieniu do zaleceń Schematu Żywienia Niemow-

ląt z 2007 roku. Standardy Medyczne Pediatria 2012;9:545-551.

4 Dobrzańska A, Czerwionka-SzaQarska M, Kunachowicz H i wsp. Zalecenia doty-

czące żywienia dzieci zdrowych w pierwszym roku życia, opracowane przez Ze-

spół Ekspertów powołany przez Konsultanta Krajowego ds. Pediatrii. Standardy

Medyczne Pediatria 2007;4:197-202.

5 Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Re-

duction in Children and Adolescents; National Heart, Lung, and Blood Institute.

Expert panel on integrated guidelines for cardiovascular health and risk reduction

in children and adolescents: summary report. Pediatrics 2011;128(S5):213-256.

6 Braegger C, Campoy C, Colomb V i wsp.; ESPGHAN Committee on Nutrition. Vita-

min D in the healthy European paediatric population. J Pediatr Gastroenterol Nutr

2013;56:692-701.

7 Braegger C, Chmielewska A, Decsi T i wsp.; ESPGHAN Committee on Nutrition.

Supplementation of infant formula with probiotics and/or prebiotics: a systema-

tic review and comment by the ESPGHAN committee on nutrition. J Pediatr Ga-

stroenterol Nutr 2011;52:238-250.

prof. dr hab. n. med. Hanna Szajewska

Klinika Pediatrii Warszawski Uniwersytet Medyczny 01-184 Warszawa, Działdowska 1

[email protected]


standardy medyczne

Tab

ela

4. S

chem

at ż

ywie

nia

dzi

eci w

1. r

.ż.

WIE

K (m

.ż.)

LIC

ZB

AP

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A D

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(ml)

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ON

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EN

CJA

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Y P

OK

AR

MÓ

W2

17

11

0

Ssan

ie, p

oły

kan

ie

Kar

mie

nie

pie

rsią

lu

b m

leki

em

mo

dy=

kow

anym

1

Płyn

y

M

leko

mat

ki lu

b m

leko

mo

dy=

kow

ane

2-4

61

20

-14

0

5-6

51

50

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0

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ątko

we

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nia

-n

ie p

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rmó

w ję

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em

Siln

y o

dru

ch s

san

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anie

jed

zen

ia

z u

st z

a p

om

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kcja

prz

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ust

prz

y zb

liżan

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e

4

po

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mik

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p. m

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ce (n

p. j

abłk

o, b

anan

), m

ięso

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o lu

b p

ure

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bez

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Pr

od

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y zb

ożo

we

w m

ałyc

h il

ośc

iach

nie

wcz

eśn

iej n

iż

w 5

. m.ż

., n

ie p

óźn

iej n

iż w

6. m

.ż. (

np

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za z

bo

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Wo

da

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ku c

ukr

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o 1

50 m

l n

a d

ob

ę (p

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ja li

czo

na

z ilo

ścią

sp

oży

tych

ow

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w)

7-8

51

70

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0

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bie

ran

ie w

arg

ami

po

karm

u z

łyże

czki

R

ozw

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oo

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um

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ne

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nyc

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w

Pro

du

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łki m

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od

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wan

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rob

no

po

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so, r

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arzy

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row

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e=r

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po

12.

m.ż

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9-1

24

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90

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a lic

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ów

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ielk

ość

po

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1 C

elem

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któ

reg

o n

ależ

y d

ążyć

jest

wył

ączn

e ka

rmie

nie

pie

rsią

prz

ez p

ierw

szyc

h 6

mie

sięc

y ży

cia

2 M

leko

po

daw

ane

jest

z p

iers

i, b

ute

lki z

e sm

oki

em lu

b o

twar

teg

o k

ub

ka. P

ozo

stał

e p

oka

rmy

po

daj

emy

łyże

czką

3 M

ałe

ilośc

i mle

ka k

row

ieg

o m

ożn

a za

sto

sow

ać d

o p

rzyg

oto

wan

ia p

oka

rmó

w u

zup

ełn

iają

cych

, ale

nie

po

win

no

być

on

o s

toso

wan

e ja

ko g

łów

ny

pro

du

kt m

lecz

ny

prz

ed 1

2. m

.ż.

(m.ż

. - m

iesi

ąc ż

ycia

)

Ro

dzi

c/o

pie

ku

n d

ecyd

uje

CO

dzi

ecko

zje

, KIE

DY

I JA

K je

dze

nie

będ

zie

po

dan

e. D

ziec

ko d

ecyd

uje

CZ

Y p

osi

łek

zje

i IL

E z

je.


standardy medyczne

8 ESPGHAN Committee on Nutrition, Agostoni C, Braegger C, Decsi T i wsp. Bre-

ast-feeding: A commentary by the ESPGHAN Committee on Nutrition. J Pediatr

Gastroenterol Nutr 2009;49:112-125.

9 Agostoni C, Decsi T, Fewtrell M I wsp.; ESPGHAN Committee on Nutrition. Com-

plementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J

Pediatr Gastroenterol Nutr 2008;46:99-110.

10 AAP Committee on Nutrition. Pediatric Nutrition Handbook, 6th Edition. 2013

11 Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics

2012;129:827-841.

12 EFSA Panel on Dietetic Products, Nutrition and Allergies. Scienti=c opinion on

nutrient requirements and dietary intakes of infants and young children in the

European Union. EFSA Journal 2013;11:3408.

13 Jarosz M. (red). Normy żywienia dla populacji polskiej-nowelizacja. Instytut

Żywności i Żywienia 2012.

14 Dyrektywa Komisji 2013/46/UE z dnia 28 sierpnia 2013 r. zmieniająca dyrekty-

wę _2006/141/WE w odniesieniu do wymogów dotyczących białek, odnoszą-

cych się _do preparatów do początkowego żywienia niemowląt i preparatów

do dalszego żywienia niemowląt. Dziennik Urzędowy Unii Europejskiej.

15 Commission Directive 2006/141/EC of 22 December 2006 on infant formu-

lae and follow-on formulae and amending Directive 1999/21/EC Text with

EEA relevance. http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=CE-

LEX:32006L0141:EN:NOT

16 Tijhuis MJ, Doets EL, Noordegraaf-Schouten V. Extensive literature search and

review as preparatory work for the evaluation of the essential composition of

infant and follow-on formulae and growing-up milk. www.efsa.europa.eu/en/

supporting/doc/551e.pdf

17 Michaelsen KF, Greer FR. Protein needs early in life and long-term health. Am J

Clin Nutr 2014;99:718-722.

18 Koletzko B, von Kries R, Closa R i wsp.; European Childhood Obesity Trial Study

Group. Lower protein in infant formula is associated with lower weight up to

age 2 y: a randomized clinical trial. Am J Clin Nutr 2009;89:1836-1845.

19 Food and Agriculture Organization of the United Nations (FAO). 2001. Health

and Nutritional Properties of Probiotics in Food including Powder Milk with

Live Lactic Acid Bacteria, www.who.int/foodsafety/publications/fs_manage-

ment/en/probiotics.pdf

20 Thomas DW, Greer FR; American Academy of Pediatrics Committee on Nutrition;

American Academy of Pediatrics Section on Gastroenterology, Hepatology,

and Nutrition. Probiotics and prebiotics in pediatrics. Pediatrics 2010;126:1217-

1231.

21 EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA). Lipil® and visu-

al development - Scienti=c substantiation of a health claim related to Lipil® and

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Nowoczesny żel opatrunkowyna wszystkie rodzaje ran

Skaleczenia Zadrapania

Otarcia i pęknięcia skóry Oparzenia

LECZENIE RAN

Dwukrotnie przyspiesza gojenie ran*

Działa przeciwbólowo!

anDwukrotnie przyspiesza gojenie ranra* Hinman CD, Maibach H, Winter GD.Effect of air exposure and occlusion on experimental human skin wounds.Nature. 1963; 200:377–8.

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Zasady żywienia zdrowych niemowląt. Zalecenia Polskiego ... · Zasady żywienia zdrowych niemowląt. Zalecenia Polskiego Towarzystwa Gastroenterologii, Hepatologii i Żywienia Dzieci