Introduction to Infant Feeding: Growth and Assessment

1. Introduction to Infant Feeding: Growth and Assessment

2. Growth

3. Fetal Growth from 25-40 weeks GA • Weight increases 4-fold • Length and OFC increase 2-fold

4. Determinants of fetal growth • Genetics • Maternal/paternal genes, race, sex estimated to account for 20% of variance in birth weight • Environmental factors

5. Body Composition • BMI and percentage of body weight made up of fat increase rapidly during the first months of life • Fat accounts for 0.5% of body weight at the fifth month of fetal growth and 16% at term. • 3rd trimester: increase from 1-3% of body weight to 10-16% of body weight at term • After birth, fat accumulates rapidly until approximately 9 months of age

6. Minerals • Two-thirds of mineral content of full-term newborn is accummulated in the last trimester of pregnancy.

8. Energy Reserves

9. Maternal health Nutrition Glucose, fatty acids, amino acids for tissue deposition and fuel for oxidative purposes Ability of maternal-placental system to transfer nutrients to fetus Endocrine environment E.g. LGA infant: glucose-insulin-growth factors Environmental factors

10. GROWTH IN FIRST 12 MONTHS • From birth to 1 year of age, normal human infants triple their weight and increase their length by 50%. • Growth in the first 4 months of life is the fastest of the whole lifespan - birthweight usually doubles by 4 months • 4-8 months is a time of transition to slower growth • By 8 months growth patterns more like those of 2 year old than those of newborn.

11. Weight Gain in Grams per Day in One Month Increments - Girls Guo et al., J Peds. 1991

12. Weight Gain in Grams per Day in One Month Increments - Boys Guo et al., J Peds. 1991

13. Body Composition • BMI and percentage of body weight made up of fat increase rapidly during the first months of life • Fat accounts for 0.5% of body weight at the fifth month of fetal growth and 16% at term. • After birth, fat accumulates rapidly until approximately 9 months of age

14. Individual Growth Patterns • Weight and length at term appear to be primarily determined by nongenetic maternal factors • Birth weigh and birth length weakly correlate with subsequent weight and length values

15. Individual Growth Patterns, cont. • African American males and females are smaller than whites at birth, but they grow more rapidly during the first 2 years • Patterns of growth in breastfed infants are different from formula fed infants

16. Rates of gain for breastfed and formula fed infants during early months of life generally have been found to be similar although some reports have demonstrated greater gains by breastfed infants and others have shown greater gains by formula fed infants

17. Weight gain of Breast fed vs bottle fedinfants: 8-112 days of age (g/d) Nelson et al Early Human Development 19:223 1989

18. Factors to Consider • Characteristics • Nutrient needs • Goals • Growth expectations • Outcomes that Impact growth and nutritional needs

19. Assessment

20. Assessment • Screening identifies nutritional risk • Nutrition Assessment • Uses information gathered in screening • Adds more in depth, comprehensive data • Interprets data • Develops care plan • Reassess

21. Assessment • Screening identifies nutritional risk • Nutrition Assessment • Uses information gathered in screening • Adds more in depth, comprehensive data • Interprets data • Develops care plan • Reassess

22. Nutrition Screening: Purpose • To identify individuals who appear to have or be at risk for nutrition problems • To identify individuals who require further assessment or evaluation

23. Screening: Definition • Process of identifying characteristics known to be associated with nutrition problems • ASPEN, Nutri in Clin Practice 1996 (5):217-228 • Simplest level of nutritional care (level 1) • Baer et al, J Am Diet Assoc 1997 (10) S2:107-115

24. Goals of Nutrition Assessment • To collect information necessary to document adequacy of nutritional status or identify deficits • To develop a nutritional care plan that is realistic and within family context • To establish an appropriate plan for monitoring and/or reassessment

25. Information Collected • Growth • Dietary • Medical history • Diagnosis • Feeding and developmental information • Psychosocial and environmental information • Clinical information and appearance (hair, skin, nails, eyes) • Other (anthropometrics, laboratory)

26. Linking information collected with: Goals/expectations Reference data/standards Evidence individual Asking questions Interpretation

27. Challenges Nutrient needs influenced by: genetics, activity, body composition, medical conditions and medications Alterations in growth and measures of growth genetics, body composition, physical limitations

28. Challenges • Information • Availability, sufficiency, accuracy • Interpretation • Goals, expectation, “does it make sense” • Questions • What are goals and expectations, “does it make sense”

29. Challenges: Recommendations for populations v.s individual • Considerations • Growth in infancy • Physiology of infancy • GI • Renal • Infant Development • Nutrient requirements * Recommendations • Milk based feedings/Infant formulas • Timing of complementary foods • What are families actually doing? • Specific issues of safety and oral health

30. Challenges • Identification of etiology • Weighing risk vs benefit • Supportive of: • Family • Individual • Development/temperament

31. Growth Assessment

32. Growth Concerns • Underweight • Short stature • Overweight

33. A variety of growth references were developed and and used in the U.S. since the early 1900’s

34. Stuart/Meredith Growth Charts (1946-76) Caucasian, Boston/Iowa city, small sample size NCHS growth charts (1976-1978) NCHS AAP/MCHB study group Used cross sectional data from NHES, NHANES, and FELs (infant) CDC produced normalized version 1978 WHO recommended international use Growth references: timeline

35. Growth reference timeline: continued • 2000 CDC growth charts: revision of NCHS growth charts • 2006 WHO released new international growth standards

36. Assessment of Growth • Growth Charts • CDC/NCHS • http://www.cdc.gov/growthcharts/ • World Health Organization • http://www.who.int/childgrowth/en • Specialized growth charts • Patterns, rates, velocity

37. NCHS growth charts: Concerns • Infant data: Fels study • Primarily formula fed • Underrepresented groups: largely caucasian, middle class • Intervals of measurements (q3 months from 3-36 months) may not define dynamic patterns during rapid growth phases • Statistical smoothing proceedures

38. CDC Growth charts: 2000 • Based on 5 cross sectional nationally representative surveys between 1963 and 1995 • Included more breastfed infants

39. CDC/NCHS Growth Charts • Data from previous NCHS charts came from private study of primarily white, formula-fed, middle-class infants from southwestern Ohio before 1975 • Newer charts have more representative data (some breastfeed and ethnic diversity) from NHANES and use more sophisticated smoothing techniques • 16 new charts provided by gender and age

40. CDC Growth Charts (compared to older NCHS • Standardized data collection methods • Expanded sample • Exclusions • VLBW infants • NHANES III weight data for >6 year olds

41. CDC Growth Charts (compared to older NCHS • Standardized data collection methods • Expanded sample • Exclusions • VLBW infants • NHANES III weight data for >6 year olds

42. CDC/NCHS Growth Charts • Clinical charts for infancy for girls and boys: • weight • length • weight for length • OFC • Choice between outer limits at 3rd and 97th or 5th and 95th percentiles

44. Adam

45. Adam

46. Carl

48. WHO Child Growth Standards • Released new growth standards April 2006 • Assumed that infants and children between birth and 5 years grow similarly when needs are met. • Concerns for CDC charts included: • Frequency of growth measures during dynamic periods of infant growth • Statistical methods

49. WHO growth charts • Data from Brazil, Ghana, India, Norway, Oman and USA • Multiethnic, affluent • Exclusive breastfeeding to 4 months • Solids according to recommendations 6 months • Continued breastfeeding to 12 months