1. Chapter 8 Infant Nutrition
Nutrition Through the Life Cycle
Judith E. Brown

2. 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.

3. Key Nutrition Concept #2
Progression in feeding skills expresses important developmental steps in infancy that signal growth and nutrition status.

4. 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.

5. 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.

6. Assessing Newborn Health
Birthweight as an Outcome
Full-term infant (37 to 42 wks)
Typical weight g (5.5 to 8.5 lbs)
Typical length cm (18.5 to 21.5 in)
88% of U.S. infants are born full-term

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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

13. Major Reflexes Found in Newborns

14. 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

15. Gross Motor Skills

16. Critical Periods of 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

17. Cognitive Development of Infants
Factors that impact cognition
Sensorimotor development
Adequate nutrient intake
Positive social and emotional interactions
Genetics

18. Sensorimotor Stage of Development
Illustration 8.2 Sensorimotor stage of development.

19. 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

20. 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

21. Parenting New parents must learn: Infant’s cues of hunger and satiety
Temperament of infant
How to respond to infant cues

22. 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?

23. 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

24. Protein Needs Protein Needs How much is that?
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

25. 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

26. 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

27. Other Nutrients and Nonnutrients
Fluoride— 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

28. 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

29. Typical Gains in Wt and Ht for Age in Infancy
Calibrated scales & recumbent length measurement board required for accurate measures

30. Physical Growth Assessment

31. Measuring Growth in Infants

32. 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

33. Feeding in Early Infancy Breast 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 cal/oz

34. Typical Daily Volumes for Young Infants Not Being Breastfed

35. How Infant Formulas Are Modified Compared to Breast Milk
Cow’s Milk-Based Formula
7% of calories from Protein
38% calories from carbs
55% calories from fat
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.

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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)

44. 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

45. Food Texture and Development
“They say fingers were made before forks and hands before knives.”
Jonathan Swift

46. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. How 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

54. 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

55. 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

56. 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

57. Common Nutritional Problems and Concerns
Failure to thrive (FTT)
Colic
Iron-deficiency anemia
Constipation
Dental caries
Food allergies

58. 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

59. Common Nutritional Problems and Concerns

60. 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

61. 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

62. 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

63. Diarrhea and Constipation
To avoid constipation assure adequate fluids
Diarrhea may be a serious problem-continue to feed the usual diet during diarrhea

64. 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

65. 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

66. 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

67. 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

68. Vegetarian Diets
Infants receiving well-planned vegetarian diets grow normally
Breastfed vegan infants need supplements
Vitamin D
Vitamin B12
Possibly iron and zinc

69. 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