Infant Feeding Practices: Guide & Considerations

Infant Mortality

• Infant mortality rate estimates the number of infant deaths within the first year of life for every 1,000 live births
• This rate serves as an indicator of a nation's health and well-being
• The U.S. is ranked below other wealthy countries in infant mortality
• The top three causes of infant mortality are birth defects, low birth weight/preterm births, and sudden infant death syndrome (SIDS)
• In 2014, the infant mortality rate in the United States was 5.96 per 1,000 live births
• Nutrition is a key factor in infant mortality

Assessing Newborn Health

• Birthweight and gestational age are used as outcome measures for newborn health
• A full-term infant is born between 37 to 42 weeks, weighing between 2500-3800 grams (5 1/2 to 8 1/2 pounds)
• Preterm infants are born before 37 weeks
• Low birthweight is defined as under 2500 grams
• Very low birthweight is defined as under 1500 grams
• Extremely low birthweight is defined as under 1000 grams
• Newborn growth is assessed using gestational age, birthweight, length, and head circumference
• Appropriate for gestational age (AGA) infants fall between the 10th to 89th percentile
• Small for gestational age (SGA) infants are below the 10th percentile
• Large for gestational age (LGA) infants are above the 90th percentile.
• Intrauterine growth retardation (IUGR) can also impact newborn health
• Growth data charts show weight for age and length, as well as length and head circumference for age
• Warning signs include no increase in weight or length and a continued decline or rapid increase in weight, length, or head circumference percentile
• There are two types of growth charts: Growth Reference Charts and Growth Standard Charts
• The Growth Reference Charts, developed by the CDC, describe how children grew in a specific place and time, with charts available for infants from birth to 36 months and for ages 2 to 20 years
• The Growth Standard Charts, developed by the WHO, are established for children ages 0 to 5 years and describe the growth of healthy children under optimal conditions

Major Reflexes of Newborns

• Babinski reflex: toes fan out when the sole of the foot is stroked
• Blink reflex: eyes close in response to bright light or loud noise, protects eyes
• Moro reflex: throws arms out and then inward as if embracing, may help the baby cling to the mother
• Palmar reflex: grasps an object placed in the palm of his or her hand; Precursor to voluntary grasping
• Rooting: turns head toward the cheek that was stroked and opens mouth, helps a baby find the nipple
• Stepping: stepping motions when held upright by an adult and moved
• Sucking: sucks when an object is placed in the mouth, permits feeding
• Withdrawal: withdraws foot when the sole is pricked with a pin, Protects a baby from unpleasant stimulation

Infant Development

• Motor and cognitive development occurs as infants gain control of their head and neck, then middle, followed by the legs
• Motor development tends to move from center to peripheral
• Energy needs increase with increased movement
• Spoon feeding is appropriate once the baby can sit and has head and neck control
• Cognitive development is impacted by severe, acute malnutrition, chronic undernutrition, iron deficiency anemia, iodine deficiency, and environmental interactions
• The fetus swallows amniotic fluid, stimulating intestinal maturation and growth
• At birth, healthy newborns can digest fats, protein, and simple sugars
• Common digestive problems include gastroesophageal reflux (GER), diarrhea, and constipation
• The infant GI tract is fully developed around 6 months
• The gut microbiome develops before birth and impacts health in later years, breastfeeding impacts microbiome
• GI issues impacts overall gut health/microbiome

Infancy and Dietary Intake

• Stomach capacity of a newborn on day 1 is about the size of a shooter marble (5-7 mL)
• Stomach capacity on day 3 is about the size of a ping pong ball (22-27 mL)
• Stomach capacity on day 10 is about the size of an extra-large chicken egg (60-81 mL)
• Exclusive breastfeeding is recommended for the first six months, with continuation to one year
• Infant formulas are manufactured to closely resemble human milk but numerous components cannot be replicated
• Growth and health status are better indicators of dietary adequacy than volume of breast milk or formula alone
• Regular formulas are iron-fortified for 12 months and are either cow's milk-based or soy-protein based
• Hydrolyzed formulas are available

Types of Formula

• American Academy of Pediatrics (AAP) recommends iron-fortified cow milk formula if breastfeeding is not an option
• Cow milk formula is most similar to breast milk, with a good balance of protein, carbohydrates, and fat
• Soy-based formulas are lactose-free and vegetarian
• Supplementation is used to match human milk & cow's milk-based formulas
• Hydrolyzed formulas have better GI tolerance but poorer acceptance by infants due to the bitter taste and higher cost
• Hydrolyzed formulas are recommended if an allergy is confirmed
• Fully hydrolyzed formulas contain amino acids and peptides like in Alimentum
• Partially hydrolyzed formulas, like Nutramigen, may still contain the allergen

Development of Infant Feeding Skills

• Infants are born with innate reflexes and ability to regulate food intake
• The eating schedule should be dictated by the infant
• Cluster feeding may occur and is most common during the evening and in young infants
• Infants are born with reflexes that prepare them to feed successfully
• Infants need to coordinate sucking, swallowing, and breathing
• Infants have an inherent preference for sweet tastes
• At four to six weeks, reflexes fade and the infant begins to signal wants and needs
• Cues for feeding readiness include watching food being opened, tight fists or reaching for spoon, displeasure if feeding is too slow, playing with food or spoon, and slowing intake when full

Introduction of Complementary Foods

• Introduction of complementary foods is typically appropriate around 6 months
• Signs of readiness include moving the tongue from side to side, keeping the head upright, and sitting with little support
• Solids should be offered via spoon, with a total of 1-2 tablespoons offered
• Infants can swallow pureed foods at six months
• From six to eight months, infants can swallow very soft, lumpy foods
• By eight to ten months, infants can eat soft mashed foods
• Many foods are appropriate for infants who are nine to 12 months of age
• Recommendations: The infant should not be overly tired or hungry
• Use a small spoon with a shallow bowl
• Allow the mouth to open and tongue to extend
• Place the spoon on the front of the tongue with slight downward pressure
• Avoid scraping the spoon on the infant's gums
• Pace feeding to allow the infant to swallow
• First meals may be in small volumes

Infant Feeding Positions

• Improper positioning may cause choking, discomfort, and ear infections
• Young bottle-fed infants should be positioned in a semi-upright position
• Spoon-feeding should be with the infant seated with back and feet supported
• Adults feeding infants should be directly in front of the infant making eye contact
• Developmental readiness for a cup begins at six to eight months
• Infants may wean to a cup at 12 to 18 months
• The first portion from the cup is typically one to two ounces
• A drop in total fluids consumed may result in constipation
• Breast milk or formula provide adequate water for healthy infants the first six months
• Fluid needs during illness are of concern because dehydration is a common response to illness in infancy
• Juice is not needed to meet fluid needs
• Infants have been exposed to flavors while in utero
• The flavor of breast milk is influenced by the mother's diet
• Infants have a genetic, unlearned preference for sweet and salty tastes, and rejection of sour and bitter tastes

Nutritional Recommendations

• Human milk is the gold standard for nutrient content
• Intake guidelines for infants are research based
• Organizations create recommendations based on research, including:
  • The Academy of Pediatrics
  • The National Academy of Medicine (develops Dietary Reference Intakes [DRIs])
  • The Academy of Nutrition and Dietetics
  • The European Society of Pediatric Gastroenterology, Hepatology, Nutrition Committee on Nutrition

Nutritional Requirements

• Infants need more energy per bodyweight than any other time during life
• Relative to size, needs are twice that of an adult
• Most infants require 100 kcal/kg body weight, and needs change with age
• Calorie distribution in infancy should be 40-50% from fat, 7-11% from protein, and the remainder from carbohydrates
• Fat in the diet is essential to meet the needs of the baby
• Infants need at least 30 grams of fat per day ·Human milk provides essential fatty acids such as ARA, EPA, and DHA
• Protein needs are met by 1.5 g/kg from 0-6 months, and 1.2g/kg or 11g/day from 7-12 months
• Glucose is imperative for proper growth/development and without adequate supply, growth stunting can occur
• Exclusively breastfed infants need vitamin D supplementation with 400 IU/day
• Vitamin D deficiency can lead to rickets
• By 6 months, a breastfed infant needs an additional iron source
• Formula-fed infants should receive iron fortified formula
• Iron deficiency can cause irreversible behavioral and brain function abnormalities
• Fluoride is not an essential nutrient but helps to create stronger teeth
• The DRI is 0.1 mg/day for infants younger than 6 months, and 0.5 mg/day for infants 7–12 months
• Special circumstances may require fluoride supplementation
• Sodium is an essential mineral needed for fluid maintenance
• Requirements are: 120 mg from birth to 5 months, and 200 mg for 6- to 12-month-olds, and is based on the amount of sodium found in breastmilk
• Lead toxicity can interrupt brain development, slow growth, and interfere with calcium and iron absorption
• Lead can be found in water and paint, and infants can be exposed if caregivers carry home lead dust
• From 6 months to 12 months, fiber-containing foods may be gradually introduced to infants until they consume 5 g of fiber per day
• Fiber sources include whole-grain cereals, green vegetables, and legumes
• Water needs are typically met via breastmilk/formula, but excessive intake can be harmful and infants should be monitored for dehydration

Explore best practices for infant feeding, including when to introduce cups, appropriate food textures, and potential issues like dehydration. This guide covers developmental milestones and feeding methods to ensure positive feeding experiences and optimal nutrition for infants. Learn about important considerations for spoon-feeding and juice intake.