QUALE LATTE PER IL TUO BAMBINO
Carlo Agostoni
Dipartimento di Scienze
Cliniche e di Comunità
IRCCS Policlinico Cà Granda
Università degli Studi di Milano
Il latte nel divezzamento (e oltre)
Quale latte?
• Latte materno
• Formule
• Latte vaccino
LATTE MATERNO 
24 mesi e anche oltre se la mamma o il bambino lo desiderano
WHO
IGF-I at 9 Months and Number of Breastfeedings
SKOT Cohort
In all infants recorded different daily intakes of cow’s milk, infant formula and meat
P=0.0006
n=115
n=88
n=46
n=3
4
Madsen AL, et al. Growth Hormone IGF Res. 2011;21:199-204.
Fasting Insulin at 9 Months and Number of Breastfeedings
SKOT Cohort
P=0.0015
n=115
n=88
n=46
n=3
5
Madsen AL, et al. Diabet Med. 2010;27:1350-1357.
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
Taveras EM et al 2004; 114: e577
Life expectancy at birth in EU member states has increased by over 6
years between 1980 and 2010. On average across the European Union,
life expectancy at birth for the three-year period 2008-10 was 75.3 years
for men and 81.7 years for women.
Most European countries have reduced tobacco consumption via public
awareness campaigns, advertising bans and increased taxation
Alcohol consumption has also fallen in many European countries.
In the European Union, 52% of the adult population is now overweight
and 17% is obese. The obesity rate has doubled since 1990 in many
European countries. Obesity tends to be more common among
disadvantaged social groups, and especially women
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)
Ljung K et al
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
Elementi chiave delle formule
1. Proteine (quantità e qualità)
2. Grassi (quantità e qualità  acido
linolenico, acido docosaesaenoico)
3. Qualità carboidrati (digeribili/non
digeribili)
4. Minerali e micronutrienti (ferro, zinco,
calcio, Vitamina D), altri composti
“funzionali”
Is Cows' Milk Harmful
for a Child's Health ?
Key-note lecture - NUTRITION
Carlo Agostoni
Fondazione IRCCS Cà Granda
Ospedale Maggiore Policlinico
University of Milan, Italy
CHAIR PERSON: Dominique Turck, Lille, France
Conclusions: Cow’s Milk harmful?
• Negative effects on iron status up to 9-12 months,
then no negative effects if adequately complemented
with iron enriched foods
• Lactose intolerance  easily managed
• Allergy to WCM proteins may be transient. Atopics
may independently be at risk of poor growth
• A cause-effect relationship with T1D is not
established, and the same for ASDs
• Cow’s milk stimulates IGF-1 and may affect linear
growth , but associations with non-communicable
diseases is still not convincing
Conclusions: Cow’s Milk Safety
•
•
•
•
From 12 months of life onwards
Up to around 500 mL per day
250 mL in lactose intolerants
Fat-reduced milks after 24-36 months on
individual basis
Reports of nutrient intakes in European
Countries in the 8-24 mos period
Country age(mos) Pg/kg P %
•
•
•
•
Spain
France
Italy
Denmark
9
10
12
12-36
4.4
4.3
5.1
3.3
15.7
15.6
19.5
15
Lip%
26.4
27.1
30.5
28
Cho%
58
57
50
57
Rolland-Cachera et al. Acta Paed 1999; 88:365
Protein/obesity association
Author
Rolland-Cachera 1995
Prot% Age Observation:
>14.8
2 yrs
22
1yr
14
18ms
(obesity, BMI)
8 yrs
P
<0.05
Int J Obes Rel Dis 19:573
Scaglioni 2000
5 yrs
<0.05
Int J Obes Rel Dis 24:777
Dorosty 2000
Adiposity Rebound
NS
Pediatrics 105: 1115
Hoppe 2004
13,F, 14,M 9ms
10yrs
NS
8yrs
NS
Am J Clin Nutr 79:494
Scaglioni 2004
Acta Paediatrica 93:1596
14
1y
LARN 2012- PROTEINE AR e PRI
Anni
kg
AR g/d
0.5-0.99
1-3
4-6
7-10
11-14M
11-14F
15-17M
15-17F
8.6
13.7
20.6
31.4
49.7
50.7
66.6
55.7
9
11
16
25
39
39
50
40
PRI g/d En%*
11
14
19
31
48
48
62
50
-4M, 3.7F
4.1M, 4.3F
5M, 5.4F
5.7M
6.5F
6.25M
6.3F
*En%  calcolata come AR (fabbisogno medio) proteine vs
mediana (kcal/die) fabbisogno energetico per LAF
Come ridurre le proteine ?
• Latte vaccino 500 mL (o equivalente)  circa
3.5 g/dL 18 g proteine  72 kcal
• Latte “formula”  1.5 g dL  circa 7.5 g
proteine  30 kcal
• In una dieta giornaliera intorno a 1000 kcal il
bambino (con 500 mL di prodotto) passerebbe
da circa 45 g proteine (180 kcal, 18% energia)
a circa 35 grammi proteine (140 kcal, 14%
energia)
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
FORMULA TYPE AND PROTEIN INTAKE g/d (SD)En%
Time
HP
14 (3) 11
T1
16 (2) 11
T2
LP
P
EFSA 2012 PRI g/d
m f
T6  10 9
T12  12 11
T18  12 11
T24 12 12
9 (1) 7
0.001
9 (1) 7
0.001
T3
T4
T5
T6
17 (3) 11
10 (1) 7
0.001
18 (3) 11
11 (2) 7
0.001
21 (5) 13
13 (2) 7
0.001
24 (5) 14
15 (4) 8
0.001
T7
T8
T9
28 (6) 15
20 (5) 10
0.001
30 (7) 15
22 (6) 11
0.001
30 (7) 15
24 (7)11
0.001
T12
35 (9) 15
29 (8)13
0.001
31 (9) 14
T18
T24
42(12) 16 42 (12) 16
0.626
39 (10) 15 0.004 0.013
45(12) 16 45 (13) 16
0.679
43 (11) 16 0.025 0.073
BF
P vs HP P vs LP
0.001
0.028
Energy and nutrient content per 100 ml of different milk based products
for young children (modified from Nutrition Committee, Germany, 2011)
Changing protein requirements in relation to different energy intakes:
example in young adults
2.9%
5.3%
6.9%
Nutrient:energy
ratio requirement
depends upon the
activity level of
the individuals in a
population
29
LARN
1120
1382
mediana
LARN
1040
1346
REE, resting energy expenditure predicted with the equations of
Henry (2005) using body mass and height.
FORMULA TYPE AND ENERGY INTAKE kcal/day
Time
HP
LP
T1
T2
T3
509.9 (118)
563. (117)
595.7 (116)
512.46 (110)
559.2 (113)
588.9 (118)
T4
T5
T6
T7
631.1 (113)
667.0 (115)
700.9 (140)*
754.4 (143)
632.3 (116)
678.8 (131)
726.6 (147)*
765.7 (153)
T8
T9
791.4 (155)
814.8 (155)
810.2 (162)
837.8 (188)
T12
T18
891.5 (184)a
1043.3 (223)
881.9 (176)a
1045.1 (223)
T24
1119.7 (240)
1112.6 (253)
EFSA 2013 AR
M
F
636
661
688
777
1028
573
599
625
712
946
BF
792.5(224)b
988.8 (195)
1079.4 (222)
FORMULA TYPE AND ENERGY INTAKE kcal/day
Time
HP
LP
T1
T2
T3
509.9 (118)
563. (117)
595.7 (116)
512.46 (110)
559.2 (113)
588.9 (118)
T4
T5
T6
T7
631.1 (113)
667.0 (115)
700.9 (140)*
754.4 (143)
632.3 (116)
678.8 (131)
726.6 (147)*
765.7 (153)
T8
T9
791.4 (155)
814.8 (155)
810.2 (162)
837.8 (188)
T12
T18
891.5 (184)a
1043.3 (223)
881.9 (176)a
1045.1 (223)
T24
1119.7 (240)
1112.6 (253)
EFSA 2013 AR
M
F
BF
Circa 20%
energia in più
dell’AR raccomandato
636
661
688
777
1028
573
599
625
712
946
792.5(224)b
988.8 (195)
1079.4 (222)
Z- score of caloric intake per Countries
0,6
z-score kcal
0,4
GE
0,2
BE
0
IT
-0,2
PL
-0,4
ES
-0,6
-0,8
T1
T2
T3
T4
T5
T6
time
T7
T8
T9
T12 T24
Energy costs of fat and protein deposition in the human infant
Am J Clin Nutr 1988; 48:951
Total energy requirement for deposition  1.17 kJ/kJ (kcal/kcal)
deposited for fat (ie, 1 kJ deposited and 0.17 kJ expended for
deposition, and 2.38 kJ/kJ (kcal/kcal) for protein.
The metabolizable-energy requirement for weight gain during infancy
was calculated (range, 12.2-25.1 kJ/g, or 2.9-6.0 kcal/g; means, 18.7
kJ/g, or 4.5 kcal/g) from the energy costs of fat and protein deposition
and published information on changes in body composition during
the first year of life.
Energy expended by low birth weight infants in the deposition of
protein and fat.
Pediatr Res 1997 ;41:584
Using multiple regression analysis of energy expenditure against protein
stored, and metabolizable energy, the energy expended in the deposition
of protein was calculated to be 5.5 kcal/g +/- 1.1 kcal/g (SE) and the
energy cost of fat deposited was 1.6 kcal/g +/- 0.3 kcal/g (SE).
Ghisolfi et al, Public Health Nutr, 2013; 16:524
AGE  17 (GUM) – 19 (CM) months
961 + 33
967 + 18
46
Quando introdurre il latte vaccino ?
• Non prima del dodicesimo mese  latte materno fino ad un
anno, anche più a lungo
• Dopo il 12° mese può essere introdotto il latte vaccino
(limitare la quantità?)
• Tra il 12° ed il 36° mese una formula di crescita - GUMpuò migliorare il bilancio dei nutrienti  effetti funzionali
non noti, mancano dati “diretti” su parametri ematici
ATTENZIONE al bilancio energetico nel suo complesso 
puo’ vanificare ogni altro tentativo di riequilibrio
qualitativo e quantitativo