Infant Mortality and Newborn Health

Infant Mortality

• Infant mortality rate is an estimate of infant deaths during the first year per 1,000 live births
• Infant mortality rate is an indicator of a nation's health and well-being
• The U.S. ranks 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)
• The infant mortality rate reported in the United States was 5.96 per 1,000 live births in 2014
• Nutrition is a key factor in infant mortality

Assessing Newborn Health

• Birthweight and gestational age are outcome measures for newborn health
• A full-term infant is born between 37 to 42 weeks, weighing 2500-3800 grams (5 1/2 to 8 1/2 pounds)
• Preterm infants are born before 37 weeks
• Low birthweight is under 2500 grams
• Very low birthweight is under 1500 grams
• Extremely low birthweight is under 1000 grams

Newborn Growth Assessment

• Newborn growth assessment considers gestational age, birthweight, length, and head circumference
• Appropriate for gestational age (AGA) is between the 10th to 89th percentile
• Small for gestational age (SGA) is less than the 10th percentile
• Large for gestational age (LGA) is greater than the 90th percentile
• Intrauterine growth retardation (IUGR) is also considered

Interpretation of Growth Data

• Growth charts show weight for age and length
• Growth charts show length and head circumference for age
• Warning signs in growth data include no increase in weight or length
• Continued decline or rapid increase in weight, length, or head circumference percentile are also warning signs

Tracking and Interpreting Data

• Two types of growth charts are available
• The Growth Reference Charts are developed by the CDC
• The CDC charts describe how children grew in a specific place and time
• The CDC charts are for infants from birth to 36 months, and children ages 2 to 20 years
• Growth Standard Charts are developed by the WHO
• The WHO charts are established for children ages 0 to 5 years
• The WHO charts describe growth of healthy children in optimal conditions

Cognitive Development

• Cognitive, motor, and socio-emotional development is impacted by several factors
• Factors impacting development include severe, acute malnutrition
• Chronic undernutrition
• Iron deficiency anemia
• Iodine deficiency
• Environmental interactions

Digestive System Development

• The fetus swallows amniotic fluid which stimulates intestinal maturation and growth
• Healthy newborns can digest fats, protein, and simple sugars at birth
• Common digestive problems include gastroesophageal reflux (GER), diarrhea, and constipation
• The infant Gl tract is fully developed around 6 months
• The gut microbiome develops before birth and impacts health in later years
• Breastfeeding impacts the microbiome
• Gl issues can impact overall gut health and the microbiome

Infancy and Dietary Intake

• A newborn's stomach capacity on day 1 approximates a shooter marble, about 5-7 mL
• The stomach capacity on day 3 approximates a ping pong ball, about 22-27 mL
• A baby's stomach capacity on day 10 approximates an extra-large chicken egg, about 60-81 mL

Feeding in Early Infancy

• Exclusive breastfeeding is recommended for the first six months, continuing to one year
• Infant formulas are manufactured to closely resemble human milk
• Numerous components of human milk cannot be replicated in formula
• Growth and health status are better indicators of dietary adequacy than volume of breast milk or formula alone

Formula Types

• Regular formula is iron-fortified for 12 months
• Regular formula may be cow's milk-based
• Regular formula may also be soy-protein based
• Hydrolyzed formulas are also available

Cow's Milk-Based Formula

• The American Academy of Pediatrics (AAP) recommends iron-fortified cow milk formula if breastfeeding is not an option
• Cow's milk-based formula is most similar to breast milk
• It has a good balance of protein, carbohydrates, and fat

Soy Based Formulas

• Soy based formulas are lactose-free and vegetarian
• Soy formulas are supplemented to try to match human milk and cow's milk-based formulas
• The American Academy of Pediatrics published information on soy-based formulas in Pediatrics 2008

Hydrolyzed Formulas

• Hydrolyzed formulas have better Gl tolerance
• Infants may have poor acceptance of hydrolyzed formulas due to a bitter taste
• Hydrolyzed formulas are high cost
• Hydrolyzed formulas are recommended if an allergy is confirmed
• Fully hydrolyzed formulas contain amino acids and peptides, e.g., Alimentum
• Partially hydrolyzed formulas may still contain the allergen, e.g., Nutramigen

Development of Infant Feeding Skills

• Infants are born with innate reflexes and the ability to regulate food intake
• An infant's 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 coordinate sucking, swallowing, and breathing
• Infants have an inherent preference for sweet tastes
• Around four to six weeks, reflexes fade and infants begin to purposely signal wants and needs

Cues for Feeding Readiness

• Watching food being opened in anticipation of eating
• Tight fists or reaching for spoon
• Displeasure if feeding is too slow or stops temporarily
• Playing with food or spoon
• Slowing intake, turning away, refusal, or spitting out food when full

Introduction of Complementary Foods

• Complementary foods are 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
• A total of 1–2 tablespoons should be offered

Complementary Feeding

• Infants can swallow pureed foods at six months
• At 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 for Feeding

• Infants should not be overly tired or hungry during feeding
• Use a small spoon with a shallow bowl
• Allow the infant's 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 volume

The Importance of Infant Feeding Position

• Improper positioning may cause choking, discomfort, and ear infections
• Young bottle-fed infants should be in a semi-upright position
• Spoon-feeding should be with infant seated with back and feet supported
• Adults feeding infants should be directly in front of the infant making eye contact
• Developmental readiness for drinking from a cup begins at six to eight months
• Wean to a cup at 12 to 18 months
• The first portion from a cup is typically one to two ounces
• A drop in total fluids consumed may result in constipation

Infant Fluids

• Breast milk or formula provide adequate water for healthy infants the first six months
• Fluid needs during illness are a concern because dehydration is a common response to illness in infancy
• Juice is not needed to meet fluid needs Influence of food preferences on feeding behavior
• 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 and Requirements

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

Energy Needs

• Infants need more energy per bodyweight than at any other time during life
• Relative to size, infant energy needs are twice that of an adult
• Most infants require 100 kcal/kg body weight
• Energy needs change with age
• Distribution of calories in infancy should be 40–50% from fat, 7–11% from protein, with the remainder from carbohydrates
• Fat in the diet is essential to meet needs

Lipids

• Triglycerides are the major energy source in human milk
• Infants need at least 30 grams of fat per day
• Human milk provides essential fatty acids, including ARA, EPA, and DHA

Protein

• Protein needs are determined as grams/kg body weight
• Protein needs change with growth and development
• Infants 0-6 months need 1.5 g/kg of protein per day
• Infants 7-12 months need 1.2g/kg or 11g/day of protein

Carbohydrates

• Glucose is imperative for proper growth and development
• Without adequate glucose supply, growth stunting can occur

Vitamin D

• Vitamin D is fat soluble
• Required for bone mineralization and proper calcium and phosphorus utilization in blood
• Exclusively breastfed infants need a vitamin D supplement of 400 IU/day
• Vitamin D deficiency can lead to rickets

Iron

• Infants are born with iron stores reflective of maternal stores
• 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

• Fluoride is not an essential nutrient
• It helps to create stronger teeth
• DRI for infants is 0.1 mg/day for infants younger than 6 months
• DRI is 0.5 mg/day for infants 7–12 months
• Special circumstances may require fluoride supplementation

Sodium

• Sodium is an essential mineral
• Needed for fluid maintenance
• Requirements are 120 mg from birth to 5 months
• Requirements are 200 mg for 6- to 12-month-olds
• Sodium requirements are based on the amount of sodium found in breastmilk

Lead

• Lead toxicity can interrupt brain development and slow growth
• Lead also interferes with calcium and iron absorption
• Lead can be found in water and paint
• Infants can be exposed if caregivers carry home lead dust

Fiber

• From 6 months to 12 months, fiber-containing foods may be gradually introduced to infants
• Infants should consume 5 g/day of fiber
• Sources of fiber for infants include whole-grain cereals, green vegetables, and legumes

Water

• Water needs for infants are typically met via breastmilk/formula
• Excessive water intake can be harmful
• Infants should be monitored for dehydration