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Chapter 8
Infant 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:
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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 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
Cognitive Development of
Infants
• Factors that impact cognition
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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 mediumchain 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 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 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
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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 semiupright
• 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
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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
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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
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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
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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