Infant Nutrition and Newborn Health

Infant Nutrition Part 1

• Infant mortality is the number of infant deaths in the first year of life for every 1,000 live births
• Causes include birth defects, low birth weight/preterm birth, and sudden infant death syndrome (SIDS)

Newborn health

• A full-term infant is born between 37-42 weeks
• Full-term infants typically weigh between 2500-3800 grams (5 ½ to 8 ½ pounds)
• 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 based on gestational age, birthweight, length, and head circumference
• Appropriate for gestational age (AGA) falls between the 10th and 89th percentile
• Small for gestational age (SGA) is less than the 10th percentile
• Large for gestational age (LGA) is greater than the 90th percentile
• Charts show weight for age, length, and head circumference for age
• Warning signs include no increase in weight or length, continued decline, or rapid increase in weight, length, or head circumference percentile
• CDC developed growth reference charts describe how certain children grew in a particular place and time and charts for infants from birth to 36 months of age, and 2 to 20 years
• WHO developed growth standard charts that are established for children ages 0 to 5 years and describe the growth of healthy children in optimal conditions.

Infant Development

• Infant motor and cognitive development starts with head and neck control, progresses to the middle, and then legs
• Motor development moves from the center to the periphery
• Energy needs increase with movement
• Spoon feeding is appropriate when the baby can sit and has head and neck control.
• Factors impacting cognitive, motor, and socio-emotional development include severe, acute malnutrition, chronic undernutrition, iron deficiency anemia, iodine deficiency, and environmental interactions.

Assessing System Development

• Digestive system development begins in utero: the fetus swallows amniotic fluid, stimulating intestinal maturation and growth.
• At birth, healthy newborns can digest fats, proteins, and simple sugars
• Problems can include gastroesophageal reflux (GER), diarrhea, and constipation
• The infant GI tract is fully developed before birth and impacts health in later years

Feeding in Early Infancy

• Breast milk and formula can be used to feed newborns
• Exclusive breastfeeding is recommended for the first six months, continuing to one year
• Regular iron-fortified formula is recommended to 12 months.
• Cow's milk-based formulas are most similar to breast milk with a balance of protein, carbohydrates, and fat
• Soy-protein-based formulas are lactose-free and vegetarian.
• Hydrolyzed formulas are better tolerated, poorly accepted by infants, and high in cost
• Fully Hydrolyzed formulas contain amino acids and peptides (Alimentum)
• Partially Hydrolyzed formulas may still contain allergens (Nutramigen)

Development of Infant Feeding Skills

• Infants are born with innate reflexes and the ability to regulate food intake
• Eating schedule is dictated by the infant's cues
• Cluster feeding occurs most often in young infants
• Infants are born with reflexes that will prepare them to successfully. Around four to six weeks infants signal wants and needs
• Cues for feeding readiness include anticipation of eating, tight fists or reaching for a spoon, displeasure if feeding is too slow or stops, playing with food or spoon, slowing intake, turning away, refusal, or spitting out food when full
• Complementary foods can be introduced around 6 months
• Solid food is introduced via spoon, 1-2 tablespoons should be offered
• Infants can swallow pureed foods at 6 months
• Infants can swallow very soft, lumpy foods at 6-8 months
• Infants can eat soft mashed foods at 8-10 months
• Many foods are appropriate for infants 9-12 months
• Developmental readiness for drinking from a cup begins at six to eight months
• Weaning should occur at 12-18 months
• Initial portion from a cup is one to two ounces

Nutritional Recommendations and Requirements During Infancy

• Infants need more energy per body weight than at any other time in life and twice as much as adults based on relative size
• Infants require 100 kcal/kg body weight
• The distribution of calories should be 40-50% fat, 7-11% protein, with the rest from carbohydrates
• Triglycerides are the major energy source in human milk. Infants need at least 30 grams of fat per day
• EPA, ARA, and DHA are essential fatty acids for infant development
• Grams/kg body weight determines protein needs which change with growth/development
• Between 0-6 months, infants need 1.5 g/kg of protein
• Between 7-12 months, infants need 1.2 g/kg or 11g/day of protein
• Glucose is imperative for development, and inadequate supply can cause growth stunting
• Vitamin D is fat-soluble
• Vitamin D is required for bone mineralization and calcium and phosphorus utilization in blood.
• Exclusively breastfed infants need supplementation of 400 IU/day in order to prevent rickets
• Infants are born with iron stores reflective of maternal stores
• By 6 months, breastfed infants should receive iron-fortified formula to avoid irreversible behavioral and brain function abnormalities
• The DRI of fluoride is 0.1 mg/day for infants younger than 6 months and 0.5 mg/day for infants 7-12 months and helps create stronger teeth but is not an essential nutrient
• Sodium is an essential mineral needed for fluid maintenance
• Requirements are 120 mg from birth to 5 months and 200 mg for 6-12 month-old based on the amount in breastmilk
• Lead toxicity can interrupt brain development, slow growth, and interfere with calcium and iron absorption
• Lead is found in water and paint, and infants can be exposed if caregivers carry home lead dust
• From 6 to 12 months, fiber may be gradually introduced until 5 g of fiber are consumed per day
• Sources of fiber include whole-grain cereals, green vegetables, and legumes

Infant Nutrition Part II

• Colic is a condition with no specific cause
• Defined as crying for more than three hours, for more than 3 days per week, and for more than 3 weeks in an otherwise healthy, well-fed infant
• Possibly helpful interventions include probiotics, breastfeeding mothers removing bananas from their diet, and consuming protein-rich foods, grapes, lemons, and potatoes.
• Diarrhea is defined as three or more loss of watery stools per day or a stool volume greater than 10 grams per kilogram body weight and constipation is changes in the frequency, size, consistency, or easy of passing stool.
• Diarrhea may result from infections, food intolerance, changes in fluid intake, or excessive fruit juice intake
• Adequate hydration is important
• Constipation is more frequent in formula-fed infants and often occurs for a short duration.
• Early childhood caries (ECC) are linked to feeding practices
• Feeding techniques to reduce caries include avoiding high-frequency consumption of sugar, limiting the use of bedtime bottles, avoiding frequent breastfeeding after the first tooth, bottle weaning between 12 and 18 months, seeing a dentist by 12 months, and brushing or wiping emerging teeth
• Lactose Intolerance is the inability to digest lactose
• Symptoms include cramps, nausea, pain, alternating diarrhea, and constipation
• Uncommon in infancy and tends to be overestimated
• Primary Lactose Intolerance has decreased ability to synthesize lactase in childhood and adulthood (“lactase nonpersistence”)
• Secondary lactose intolerance results from injury to the small intestine with commonality in infants where no lactase restriction is needed
• Congenital lactose intolerance is rare and requires lactose-free formula
• Developmental lactase deficiency occurs in preterm infants < 34 weeks gestational age where lactose is still beneficial and lactase produced soon
• Food allergies are due to the absorption of intact proteins resulting in wheezing and skin rashes and breast milk is recommend for infants
• Vegetarian diets support normal growth and development when well planned
• DHA content is lower in breast milk of vegetarian mothers vs non-vegetarian mothers
• Infants of vegan mothers should pay particular attention to protein, omega-3 essential fatty acids, iron, calcium, vitamin D and B12 intake as mothers exclusively breastfeed.

Avoidance of Allergies

• The mucosal barrier includes proteolytic enzymes (stomach and small intestine), bile acids and other enzymes, pH changes, mucus layers, tight junctions between epithelial cells, and the secretory IgA system
• In the Neonate, the mucosal barrier has high pH in stomach, leaky intestinal barrier, and an immature sIgA system
• In maturation of the mucosal barrier the immature mucosa = more permeable leading to uptake of relatively intact proteins and IgE and allergy and closure in 3-4 months

Major Food Allergens

• Milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, and soybeans are major food allergens and high-risk infants should be identified
• Intervention incudes exclusive breast-feeding for 4-6 months, hypoallergenic formulas, including potential allergens after 6 moths, and probiotics

Growth of Infants at Risk/Special Health Care Needs

• Growth reflects the nutritional status of most infants and can be determined through growth charts, biochemical indicators, body composition, and head circumference
• Nutritional Status can be determined through evidence-based practice treatment guidelines and medication assessment
• Growth in preterm infants can be measured using Fenton preterm growth charts and Olsen intrauterine growth charts

Energy and Nutrient Needs for Preterm Infants

• Preterm infants and infants with special health care needs/developmental delay requires varied energy needs
• Increased calories for infections, fever, difficult breathing, temperature regulation, and recovery from surgery compared with decreased calories for Spina Bifida or Down syndrome
• Hydrolyzed protein or single amino acid-based formulas are preferred for Protein
• 45-55% Fats with no low-fat diets
• Medium-chain triglycerides (MCT) are routinely used, do not require bile for absorption, and a routine source of fat in preterm infant formula
• Higher iron needs for preterm infants which are provided by human-milk fortifiers, as well as additional calories and nutrients
• Sick babies are fed enternally with Gavage, gastrostomy, and jejunostomy or parentally with intravenous feeding
• Soy formulas are not recommended for preterm infants < 1800 g due to the challenges of lethargy, low tolerance of volume, stress responses

Feeding Problems

• 40-45% of VLBW infants encounter feeding problems
• An infant born at 32 weeks gestation are ready for complementary foods at 8 months
• Feeding problem interventions include frequent growth assessment, monitor fluid and food intake, adjust frequency, volume, or concentration, adjust feeding time, assess feeding position, increase nutrient density, parent education, observe infant-caregiver interactions, consider developmental abilities
• Infants who were born preterm or with special health care needs qualify for nutrition-related services and program
• Includes early intervention programs funded through the IDEA, Early Head Start, WIC, AND State Children with Special Health Care Needs programs

Toddler and Preschooler Nutrition

• Toddlers are 1-3 years old and experience a rapid increase in gross and fine motor skills
• Preschool-age children are 3-5 years old experiencing increased autonomy, broader social circumstances and have increasing language skills and expanding behavior control

Normal Growth and Development

• Newborns from birth to twelve months
• Average infant triples birthweight
• Toddlers experience an average gain of 8 ounces a month, growing 0.4 inches
• Preschoolers experience an average gain of 4.4 pounds a year, growing 2.75 inches
• Appropriate weight for height after 2 years old is assessed with BMI
• WHO growth charts are intended for use in children up to age 2
• CDC growth charts are intended for children ages 2-19

Physical and Cognitive Development

• Toddlers expand physical and developmental skills
• Crawling upstairs at 15 months
• Running stiffly at 18 months
• Walking up stairs one foot at a time and jumping in place at 24 months
• Alternating feet going up stairs at 30 months
• Riding a tricycle at 36 months
• Cognitive development of toddlers means toddlers often "orbit" around parents

Development of Feeding Skills

• Toddlers make transitions from self-centered to more interactive
• Toddlers expand their vocabulary
• Terible two temper tantrums
• Toddlers develop feeding skills
• Bottle weaning at 9-10 months
• Completely weaned at 12-14 months
• Refined pincer grasp at 12 months
• Use tongue to clean lips with well-developed rotary chewing at 18-24 months
• Adult supervision to prevent choking
• Toddlers have rituals in feeding
• May have strong preferences and dislikes and food jabs
• Serve new foods with familiar foods
• Toddlers imitate the eating behavior of others
• Toddlers slowing growth results in decreased appetite
• Toddler-sized portions average one tablespoon per year of age
• Establish regular but flexible meal and snack times
• Preschoolers' cognitive development demonstrates magical thinking and egocentrism, learning to set limits, begin cooperative and organized play, expansion of vocabulary to over 2000 words, speaking in complete sentences
• Preschoolers demonstrate feeding skills
• Can use a fork, spoon, and cup
• Eating is less messy
• Foods should be cut into bite-size pieces
• Adult supervision is imperative
• Preschoolers appetite is related to growth and they should be involved in meal selection and preparation, having innate ability to control energy intake
• This entails children adjusting caloric intake to meet caloric needs, avoid telling the child to “clean your plate", and healthful eating habits
• Preschoolers like preference for familiar foods

Factors That Affect Dietary Intake

• Decreased nutrition needs and appetite between 2-5 years old
• Diets need to lack variety
• High activity level with low stomach capacity
• Food jabs and food aversions
• Food jag is a condition in which an individual consumes the same food, prepared the same way, consistently
• Food aversion is a strong dislike leading to refusal to eat certain foods
• Food neophobia is the reluctance to eat new foods
• Media influence
• Food advertising drives children’s consumer behavior through created expectations, positive feelings during purchase, entertaining dimension of advert, and no ability to see persuasive nature
• The feeding relationship has division of responsibility in feeding young children, decreasing parental pressure
• Parents determine food, where, when and child determines how much to eat
• Obesogenic environments come from lact of time, lack of neighborhood safety, limited knowledge of portion size/cooking methods/healthy foods, perceived cost of healthy options, and picky family eaters

Nutrition Recommendations and Requirements

• Carbohydate is the primary energy source with fiber as a key component, making up 45-65%
• Protein is important for muscle maintenance, growth, and hormone production in toddler/preschool years and is higher quality from animal protein
• Toddlers need 1.1 g/kg of body weigh daily
• Preschoolers need 0.95 g/kg of body weigh daily
• Fat builds nerve tissue and hormones, helping the body absorb fat-soluble vitamins, insulates and protects the body, and contributes to satiety
• Excessive consumption of fat leads to weight gain, heart disease, high blood pressure, and diabetes
• Make up 30-35% of total caloric intake for children ages 1-3 and 25-35% of total caloric intake for children ages 4+
• Calcium and Vitamin D build bone and aid in calcium absorption and mineralization and prevent rickets
• Iron is a component of hemoglobin and myoglobin
• Toddlers need 7 mg of iron daily
• Children 4-5 years need 10 mg of iron daily
• A sign of iron deficiency includes serum ferritin levels in blood
• Iron-deficiency anemia is a prevalent problem in young children
• May cause cognitive development and behavioral disturbances
• Diagnosed by hematocrit and/or hemoglobin concentration

Diagnosis of Iron Deficiency Anemia

• Between 1-2 years hemoglobin is less than 11.0 g/dl and hematocrit less than 32.9%
• Between 2-5 years hemoglobin is less than 11.1 g/dl and hematocrit less than 33%

Prevention and Treatment of Iron Deficiency

• Preventive measures include supplementing with 1mg/kg of iron for breastfed infants by 4 months
• Formula does not need supplementation
• Infants at risk should be tested 9-12 months, 6 months later, and annually aged 2-5 years
• Treat with supplementation of 3-6 mg/kg of body weight for at least 3 months
• Avoide dairy 1 hour before and after supplementation, aided with absorption of Vitamin C

Common Nutrition Problems

• Dental caries are caused by bedtime bottles with milk or juice, streptococcus mutans, and stick carbs and can be prevented with fluoride
• Constipation is hard/dry stool associated with painful bowel movements and is caused by stool holding or a low-fiber diet and can be prevented by adequate fiber/fluid
• Elevated blood lead levels cause low IQ and impair physical, behavioral, and motor abilities and high levels decrease growth
• Vegetarian diet guidelines include providing 3 meals and 2-3 snacks with protein and omega-3 fatty acids. Avoid excessive bulky foods, and include energy-dense foods, Ensure an adequate intake of calcium, zinc, iron and vitamins D and B12

Conditions and Interventions

• Overweight and obesity in toddlers and preschoolers can be assessed at BMI

CDC Growth Chart Interpretation

• BMIs can classify children
• 95th percentile - obese
• 85th-95th percentile - overweight
• 5th percentile - underweight

Overweight Children

• Taller
• Advanced bone age
• Earlier sexual maturity
• May have increased levels of lipids, hypertension, elevated liver enzymes, and decreased glucose tolerance

Determinants of Pediatric Obesity

• Prenatal - higher maternal prepregnancy BMI and excess maternal gestations weight gain
• Breast vs formula feeding type consumed
• Type of complementary diet and if early solid feeding, increased intake of infant nutrient, and imbalances in infant gut microbiome

Prevention of Related Disorders

• Prevention of over weight and Obesity is done through limiting sweet beverages, encouraging fruits and vegetables, eating daily breakfast, limiting television and screen time, restricting portions/limiting restaurants and fast foods

Management of obesity

• Management begins with
• Prevention
• Structured weight management
• Comprehensive/Multidisciplinary intervention
• Tertiary care
• Nutrition and prevention of cardiovascular disease aims to limit saturated fat, cholesterol, and trans fat for children 1-18
• Aim to get 25-35% of calories from fat during these years
• For children with hyper lipidemia, limit saturated fat to less than 7% and less than 200mg cholesterol

Overweight Goals

• For overweight (85%-95% BMI): weight maintenance, or a slow weight gain until achieve less than 85%
• For obese (95%-98% BMI): weight maintenance, or weight loss less than 1 BI/month until less than 85%
• For BMI 99%: weight loss less than 2BI/week until less than 85% at least, weight maintenance

Health Care Needs

• A child with special health care needs is a child
• Who does not see, hear, or walk
• Who does not reach the appropriate developmental milestones
• Suffers from cognitive, physical, language and speech, psychological or self-helping skills
• Has a physical or mental condition with a high probability of delay
• Shows signs of down syndrome
• The child is then considered eligible for EIP which is a case of developmental delay

Nutrition Needs of of Toddlers and Preschoolers Under Medical Care

• Chronic conditions indicate DRIs are a starting point for protein, vitamin, and mineral needs
• Consider if condition causes increased or decreased caloric intake which may lead to obesity or underweight
• Measure growth, food/nutrient intake, eating skill, and possible diagnosis
• Assess growth via growth charts developed specifically to track low birth weight, special head/body growth charts
• Feeding problems can be related not only to diet, texture, and intake amount but to
• Low interest in health, length of meal times, and/or food refusal
• Behavioral conditions such as ASD/ADHD
• Disorders of fluid and neuromuscular control

Nutrition Related Conditions

• Failure to thrive due to declines in growth or digestive/neurological/breathing issues
• Toddler diarrhea due to fruit juice
• Celiac, Autism, Muscle Coordination, and Pulmonary conditions
• May require restrictions of certain foods, alterations to diet, and/or supplemental feeding

Child and Preadolescent Nutrition

• Middle childhood is 5-10 years
• Preadolescence is 9-11 years for girls and 10-12 years for boys

Normal Growth and Development

• Genetics and Hormones
• growth and development are due to all the combined efforts of genetics, hormones, and nutrition
• Genetics determine height and body size
• Hormones from endocrine/pituitary systems are directed by genes

Growth Considerations

• Growth velocity slows down during school age
• Monitor
• Adiposity rebound may occur
• “Mid-growth spurt” can occur between 4-8 years
• Growth needs energy from sufficient macro and micro nutrients
• Needs different per stage

Early and Middle Development

• Physiological development
• Muscular strength, motor coordination, and stamina increase
• More complex patter movements
• Body fat decreases
• Cognitive development
• Increases self efficacy
• Shifts Magical thinking, egocentrism and learning
• Develops self and family/peer roles

Develop Eating Habits

• Eating habits are influenced by others
• family
• snacking
• Outside contact with media and dieters

Energy Needs

• Energy
• Varies on activity. gender, and body comp
• Calculated via EER
• Protein 0.95 g/kg

Factors Impacting Dietary Intake

• Food choices
• Limited accessibility
• Diet and habits are a source of personal identity
• Peer influence

Marketing

• Marketing
• Over 1/3 of kids are overweight
• There are some efforts for marketing regulation occurring

Recommendation for physical activity

Helps with multiple systems and habits

• 60 mins of exercise or activity recommended

Sports

• Organised sports can lead to lower overweight in kids
• Requires a variety of exercises

Oral Health

• Oral health requires regular, twice-daily brushing, fluoride levels, good levels of calcium and vitamin D, and limitations to sugary foods

School Age Ailments

• Can be caused by inactive life
• Includes heart issues, excess weight, puberty development, high pressure, cancer
• Needs healthy eating and activity to avoid