Chapter 8Infant Nutrition

Nutrition Through the Life Cycle Judith E. Brown

Key Nutrition Concept #1

• The dynamic growth experienced in infancy is the most rapid of any age. Inadequate nutrition in infancy, however, leads to consequences that may be lifelong, harming both future growth and future development.

Key Nutrition Concept #2

• Progression in feeding skills expresses important developmental steps in infancy that signal growth and nutrition status.

Key Nutrition Concept #3

• Nutrient requirements of term newborns have to be modified for preterm infants. Knowing the needs of newborn infants who are ill or smaller than normal results in greater understanding of the complex nutritional needs of all newborns and infants.

Key Nutrition Concept #4

• Changing feeding practices, such as the care of infants outside the home and the early introduction of foods, markedly affects nutritional status of infants.

Assessing Newborn Health

• Birthweight as an Outcome– Full-term infant (37 to 42 wks)

• Typical weight 2500-3800 g (5.5 to 8.5 lbs)

• Typical length 47-54 cm (18.5 to 21.5 in)

• 88% of U.S. infants are born full-term

Infant Mortality

• Infant mortality defined as death that occurs within the first year

• Major cause is low birthweight (< 2500 g)

• Other leading causes inlcude: – 1) congenital malformations,– 2) preterm births, and – 3) SIDS

Combating Infant Mortality

• Factors associated with mortality:• Social and economic status

• Access to health care

• Medical interventions

• Teenage pregnancy

• Availability of abortion services

• Failure to prevent preterm & LBW births

Resources to Combat Infant Mortality

– Resources and prevention programs to combat infant mortality

• Medicaid

• Child Health Initiatives Program (CHP)

• Early Periodic Screening, Detection, and Treatment Program (EPSDT)

• WIC and CDC (Nutrition Surveillance Program)

• Bright Futures

Assessing Newborn Health

• Standard Newborn Growth Assessment– “Appropriate for gestational age” (AGA)– “Small for gestational age” (SGA) and

“intrauterine growth retardation” (IUGR) mean newborn was <10th % wt/age

– “Large for gestational age” (LGA) means newborn was >90th % wt/age

Infant Development

• Newborns:– Hear and move in response to familiar voice– CNS is immature resulting in inconsistent cues

for hunger and satiety– Strong reflexes, especially suckle and root

(reflexes are protective for newborns)

Infant Development

• Terms Related to Development:– Reflex—automatic response triggered by

specific stimulus– Rooting reflex—infant turns head toward the

cheek that is touched– Suckle—reflex causing tongue to move forward

and backward

Major Reflexes Found in Newborns

Motor development

• Motor development: ability to control voluntary muscles

• Motor development is top down— controls head first and lower legs last

• Muscle development from central to peripheral

• Influences ability to feed self & the amount of energy expended

Gross Motor Skills

Critical Periodsof Infant Development

• A fixed period of time in which certain behaviors or developments emerge

• Necessary for sequential behaviors or developments

• If the critical period is missed, there may be difficulty later on

Cognitive Development of Infants

• Factors that impact cognition– Sensorimotor development– Adequate nutrient intake– Positive social and emotional interactions– Genetics

Sensorimotor Stage of Development

Digestive System Development of Infants

• Fetus swallows amniotic fluid which stimulates intestinal maturation and growth

• At birth the healthy newborn can digest fats, protein and simple sugars.

• Common problems include gastroesophageal reflux (GER), diarrhea, and constipation

Digestive System Development of Infants

• Factors that impact rate of food passage in GI– Osmolarity of foods or liquids– Colon bacterial flora– Water and fluid balance in the body

Parenting

• New parents must learn:– Infant’s cues of hunger and satiety– Temperament of infant – How to respond to infant cues

Energy and Nutrient Needs

• The recommendations for infants are from the Dietary Reference Intakes (DRI), National Academy of Medicine, AAP and the ADA– Caloric needs– Protein needs– Fats– Metabolic rate, calories, fats and protein—how

do they all tie together?

Energy Needs • Energy (Calories):

– 108 kcal/kg/day from birth to 6 months (range from 80 to 120)

– 98 kcal/kg/day from 6 to 12 months

• Factors that influence calorie needs

– Weight and growth rate

– Sleep/wake cycle

– Temperature and climate

– Physical activity

– Metabolic response to food

– Health status

Protein Needs

• Protein Needs– 2.2 g/kg/day from birth to 6 months– 1.6 g/kg/day from 6 to 12 months

• How much is that?– Newborn weighing 4 kg (8.8 lbs) needs 2.2 X 4 = 8.8 g

protein– 6-month-old weighing 8 kg (17.6 lbs) needs 1.6 X 8 = 12.8

g protein

• Protein needs are similar to that of energy but are also influenced by body composition

Fat Needs

• Breastmilk contains about 55% calories from fat• Infants need cholesterol for gonad and brain

development• Breast milk contains short-chain and medium-

chain fatty acids (in addition to the long-chain)– Easier to digest and utilize than long-chain fatty

acids

Metabolic Rate, Calories, Fats and Protein

• Metabolic rate of infants is highest of any time after birth– The higher rate is related to rapid growth and

high proportion of muscle– Low carbohydrate and/or energy intake results

in protein catabolism impacting growth

Other Nutrients and Nonnutrients

– Fluoride—0.1 - 0.5 mg/d depending on age (too much may cause tooth discoloration)

– Vitamin D—400 IU/day– Sodium—120 mg/day– Fiber—no recommendations– Lead—None—may be toxic

Physical Growth Assessment

• Newborns double birthweight by 4-6 mos and triple it by 1 yr

• Growth reflects: – Nutritional adequacy– Health status – Economic & environmental adequacy

• There is a wide range of growth =normal• Calibrated scales & recumbent length measurement

board required for accurate measures

Typical Gains in Wt and Ht for Age in Infancy

• Calibrated scales & recumbent length measurement board required for accurate measures

Physical Growth Assessment

Measuring Growth in Infants

Interpretation of Growth Data

• Measures over time identify change in growth rate and need for intervention

• Warning signs:– Lack of Wt or Lt gain– Plateau in Wt, Lt or HC for > 1 month– Drop in Wt without regain in a few weeks

Feeding in Early InfancyBreast Milk and Formula

• AAP & ADA recommend exclusive breast feeding for 1st 6 months & continuation to 1 yr

• Initiate breast feeding right after birth

• Growth rate and health status indicate adequacy of milk volume

• Standard infant formula provides 20 cal/oz

• Preterm formula provides 22-24 cal/oz

Typical Daily Volumes for Young Infants Not Being

Breastfed

How Infant Formulas Are Modified Compared to Breast Milk

Breast Milk

• 7% of calories from Protein

• 38% calories from carbs

• 55% calories from fat

Cow’s Milk-Based Formula

• 9-12% calories from Protein

• 41-43% calories from carbs

• 48-50% calories from fat

Table 8.6 gives an overview of the compostion of commercially available infant formulas compared to breast milk.Table 8.7 compares various formulas to one another.

Cow’s Milk during Infancy

• Whole, reduced-fat or skim cow’s milk should not be used in infancy

• Iron-deficiency anemia linked to early introduction of cow’s milk

• Anemia linked to:– GI blood loss– Calcium & phosphorus – Displacement of iron-rich foods

Soy Protein-Based Forumla during Infancy

• Soy protein in place of milk protein should be limited in its use

• There is little scientific evidence for benefit of increase soy over milk-based

• The use of soy formula is not recommended– For managing infantile colic– Or as an advantage of cow’s milk formula for

preventing allergy in healthy at-risk infants

Development of Infant Feeding Skills

• Infants born with reflexes & food intake regulatory mechanism

• Inherent preference for sweet taste

• At 4-6 wks, reflexes fade; infant begins to purposely signal wants & needs

• Table 8.8 shows infant developmental milestones and readiness for feeding skills

Development of Infant Feeding Skills

• Cues infants may give for feeding readiness include:– Watching the food being opened in anticipation of

eating– Tight fists or reaching for spoon– Irritation if feeding too slow or stops temp.– Playing with food or spoon– Slowing intake or turning away when full– Stop eating or spit out food when full

Introduction of Solid Foods

• Food offered from spoon stimulates muscle development

• At 4-6 months, offer small portions of semisoft food on a spoon once or twice each day

Recommendations for Introduction of Solid Foods

• Infant should not be overly tired or hungry

• Use small spoon with shallow bowl

• Allow infant to open mouth & extend tongue

• Place spoon on front of tongue with gentle pressure

• Avoid scraping spoon on infant’s gums

• Pace feeding to allow infant to swallow

• First meals may be 5-6 spoons over 10 minutes

The Importance of Infant Feeding Position

• Improper positioning may cause choking, discomfort, and ear infections

• Position young bottle-fed infants in a semi-upright

• Spoon-feeding should be with infant seated with back and feet supported

• Adults feeding infants should be directly in front of infant making eye contact

Preparing for Drinking from a Cup

• Offer water or juice from cup after 6 months

• Wean to a cup at 12 to 24 months

• First portion from cup is 1-2 oz

• Early weaning may result in plateau in weight (due to reduced calories) and/or constipation (from low fluid intake)

Preparing for Drinking from a Cup

• Changing from a bottle to a covered “sippy” cup with a small spout is not the same developmental step as weaning to an open cup

• Open cup drinking skills also encourage speech development

Food Texture and Development

“They say fingers were made before forks and hands before knives.”

− Jonathan Swift

Food Texture and Development

• Can swallow pureed foods at 4-6 months

• Early introduction of lumpy foods may cause choking

• Can swallow very soft, lumpy foods at 6-8 months

• By 8-10 months, can eat soft mashed foods

First Foods

• 6 months—iron-fortified baby cereal– Rice cereal is hypoallergenic

• 6 months—fruits and vegetables• Only one new food over 2-3 days• Commercial baby foods are not necessary but do

provide sanitary and convenient choices• 9-12 months soft table foods

Inappropriate and Unsafe Food Choices

• Foods that choke infants– Popcorn

– Peanuts

– Raisins, whole grapes

– Stringy meats

– Gum & gummy-textured candy, hard candy or jelly beans

– Hot dogs

– Hard fruits or vegetables

Water

• Breast milk or formula provide adquate water for healthy infants up to 6 months.

• All forms of fluids contribute to water intake

• Additional plain water needed in hot, humid climates

• Dehydration is common in infants

Water

• Pedialyte or sports drinks provide electrolytes but lower in calories than formula or breast milk

• Limit juice – AAP recommends juice is not needed to meet

the fluid needs before the age of 6 months

• Avoid colas and tea

How Much Food is Enough for Infants?

• Infants vary in temperament

• Crying or fussiness may be interpreted as hunger resulting in overfeeding

• First foods may appear to be rejected due to immature tongue movement

How Infants Learn Food Preferences

• Infants learn food preferences

• Flavor of breast milk influenced by mother’s diet

• Genetic predisposition to sweet taste

• Food preference from infancy sets stage for lifelong food habits

Nutrition Guidance

• Guidance materials are available– WIC program– Bright Future in Practice

• Infant feeding recommendations from nutrition education materials are sampled in Table 8.9

Nutrition Guidance

• Infants and exercise– Adult exercise and fitness do not apply to

infants

• Stimulating environment is recommended to allow infants to explore and move as a part of their developmental milestones

Nutrition Guidance

• Supplements for infants– Fluoride—for breastfed infants or if in any area

with no fluoridated water– Iron—if mother was anemic – Vitamin B12—for vegans– Vitamin D—needed if low sun exposure or

exclusively breastfed

Common Nutritional Problems and Concerns

• Failure to thrive (FTT)

• Colic

• Iron-deficiency anemia

• Constipation

• Dental caries

• Food allergies

Common Nutritional Problems and Concerns

• Failure to thrive (FTT) – Inadequate wt or lt gain– Organic—diagnosed medical illness– Nonorganic—not based on medical diagnosis

• Intervention for FTT– May be complex and involve a team approach

including the registered dietitian

Common Nutritional Problems and Concerns

Colic

• The sudden onset of irritability, fussiness or crying

• Episodes may appear at the same time each day

• Disappear at 3rd or 4th

• Cause unknown but associated with GI upset, infant feeding practices

Iron-deficiency Anemia

• Less common in infants than in toddlers• Irons stores in the infant reflect the iron stores of

the mother• More common in low-income families• Breastfed infants may be given iron supplements

and iron-fortified cereals at 4-6 months• Iron-fortified versus “Low-iron” formula

Diarrhea and Constipation

• Infants typically have 2-6 stools per day

• Causes of diarrhea & constipation:– Viral and bacterial infections– Food intolerance– Changes in fluid intake

Diarrhea and Constipation

• To avoid constipation assure adequate fluids

• Diarrhea may be a serious problem-continue to feed the usual diet during diarrhea

Prevention of Baby Bottle Caries and Ear Infections

• Caries and ear infections linked to feeding practices

• Feeding techniques to reduce caries and ear infections– Limit use of bedtime bottle– Offer juice in cup– Only give water bottles at bedtime– Examine and clean emerging teeth

Food Allergies and Intolerances

• About 6-8% of children < 4 yrs have allergies

• Absorption of intact proteins causes allergic reactions

• Common symptoms are wheezing or skin rashes

• Treatment may consist of formula with hydrolyzed proteins

Lactose Intolerance

• Inability to digest the disaccharide lactose

• Characterized by cramps, nausea and pain and alternating diarrhea and constipation

• Lactose intolerance in uncommon and tends to be overestimated

• Many infants “outgrow” lactose intolerance

Cross-Cultural Considerations

• Baby foods do not reflect ethnic diversity

• Some cultural practices are harmful; others are harmless or helpful

• Cultural considerations may impact willingness to participate in assistance programs

Vegetarian Diets

• Infants receiving well-planned vegetarian diets grow normally

• Breastfed vegan infants need supplements– Vitamin D– Vitamin B12– Possibly iron and zinc

Nutrition Intervention for Risk Reduction

• Early Head Start Program– Works with families at risk such as drug abuse,

infants with disabilities, or teenage mothers

• Model program: newborn screening– Phenylketonuria, galactosemia,

hypothyroidism, or sickle-cell anemia