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 1.21.4 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)
14
prevalence (%)
12
10
8
overweight°
obese'
6
4
2
0
never
breastfed
breastfed
< 2 mos
3-5mos
6-12mos
>12 mos
breastfeeding duration (months)
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)
14
prevalence %
12
prevalence of
overweight°
10
8
6
4
2
0
never
breastfed
breastfed
<1 mos
1-3 mos
4-6 mos
7-9 mos
>9 mos
breastfeeding duration (months)
°Overweight was BMI>95th percentile for age and sex
Hypothesis of Programming of IGF-I axis
Breastfeeding versus formula feeding
During breastfeeding
________________
During childhood
and adulthood
_________________
↓ Linear growth √
↑ height – stature (√)
↓ IGF-I levels
↑ IGF-I levels
√
( √)
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)
30
p<0.001
25
20
% 15
10
5
0
< 1mo
2-3 mo
4-6 mo
7-9 mo
> 9 mo
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
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 widerange 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 ?
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
IGF-I Levels
According to Feeding
Insulin Secretion
According to Feeding
60
160
140
40
Higher Protein
Formula
30
Lower Protein
Formula
Breastfed
20
10
0
C-peptide: creatinine (ng/mL)
Plasma IGF-I (ng/mL)
50
120
100
Higher Protein
Formula
80
Lower Protein
Formula
60
Breastfed
40
20
0
6 Months
Socha P, et al. Am J Clin Nutr. 2011.
6 Months
DHA in forebrain
in 34 infants
up to 2 years
EPA
LC-PUFA supply: short-term effects from trials in
the complementary feeding period
Complementary
feeding
period
enriched formulas
or eggs in previously
breastfed infants
 Visual acuity at 12
months:
positive effects
from 3 studies
Limited sample size justified by the end-points 
DHA status, changes of VEP parameters
LC-PUFA in
PKU infants
through a specific
product
 Visual acuity at 12 months:
no direct effects,
visual acuity associated
with DHA status
irrespective of the type of diet
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
“antigenic” effect?
• 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
Ziegler EE, NNWS 60, 2007: 185-199
• Signficant negative associations of iron status with
cow’s milk consumption at 9 and 12 months of age
when > 460 ml/day
Thorsdottir I, Eur J Clin Nutr 2003; 57:505
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”