Chapter 8 Infant Nutrition

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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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 • http://www.youtube.com/watch?v=ULno8FAmt0c

9. Major Reflexes Found in Newborns

10. 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

11. Gross Motor Skills

12. 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

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

14. Sensorimotor Stage of Development

15. 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

16. 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

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

18. 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?

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

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

26. Physical Growth Assessment

27. Measuring Growth in Infants

28. 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

29. 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

30. Typical Daily Volumes for Young Infants Not Being Breastfed

31. How Infant Formulas Are Modified Compared to Breast Milk Breast Milk Cow’s Milk-Based Formula 9-12% calories from Protein 41-43% calories from carbs 48-50% calories from fat • 7% of calories from Protein • 38% calories from carbs • 55% 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.

32. 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

33. 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

34. 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

35. 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

36. 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 Introduction of Solid Foods

37. 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

38. 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

39. 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)

40. 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

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

42. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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