Chapter 3: Infancy and Toddlerhood PDF

Here's the converted markdown format of the provided document or image. ## Chapter 3: Infancy and Toddlerhood We will now turn our attention to the physical, cognitive, and socioemotional development during the first two years. Researchers have given this part of the lifespan more attention than a...

Here's the converted markdown format of the provided document or image. ## Chapter 3: Infancy and Toddlerhood We will now turn our attention to the physical, cognitive, and socioemotional development during the first two years. Researchers have given this part of the lifespan more attention than any other period, perhaps because changes during this time are so dramatic and so noticeable. We have also assumed that what happens during these years provides a foundation for one's life to come. However, it has been argued that the significance of development during these years has been overstated (Bruer, 1999). **Learning Objectives: Physical Development in Infancy and Toddlerhood** * Summarize overall physical growth during infancy * Describe the growth of the brain during infancy * Explain infant sleep * Identify newborn reflexes * Compare gross and fine motor skills * Contrast development of the senses in newborns * Describe the habituation procedure * Explain the merits of breastfeeding and when to introduce more solid foods * Discuss the nutritional concerns of marasmus and kwashiorkor **Overall Physical Growth:** The average newborn in the United States weighs about 7.5 pounds (between 5 and 10 pounds) and is about 20 inches in length. For the first few days of life, infants typically lose about 5 percent of their body weight as they eliminate waste and get used to feeding. This often goes unnoticed by most parents but can be cause for concern for those who have a smaller infant. This weight loss is temporary, however, and is followed by a rapid period of growth. By the time an infant is 4 months old, it usually doubles in weight and by one year has tripled the birth weight. By age 2, the weight has quadrupled, so we can expect that a 2-year-old should weigh between 20 and 40 pounds. The average length at one year is about 29.5 inches and at two years it is around 34.4 inches (Bloem, 2007). **Body Proportions:** Another dramatic physical change that takes place in the first several years of life is the change in body proportions. The head initially makes up about 50 percent of our entire length when we are developing in the womb. At birth, the head makes up about 25 percent of our length, and by age 25 it comprises about 20 percent our length. **Figure 3.1 Changes in Proportions** The image shows a diagram illustrating changes in body proportions during growth. The diagram displays a series of figures representing human body shapes from infancy to adulthood, arrayed from left to right demonstrating how body proportions shift. * An infant showing its larger head to body ratio on the left side of the image * An adult figure is on the right side, showing a smaller proportional head size to body ratio **The Brain in the First Two Years** Some of the most dramatic physical change that occurs during this period is in the brain. We are born with most of the brain cells that we will ever have; that is, about 85 billion neurons whose function is to store and transmit information (Huttenlocher & Dabholkar, 1997). While most of the brain's neurons are present at birth, they are not fully mature. During the next several years dendrites, or branching extensions that collect information from other neurons, will undergo a period of exuberance. Because of this proliferation of dendrites, by age two a single neuron might have thousands of dendrites. Synaptogenesis, or the formation of connections between neurons, continues from the prenatal period forming thousands of new connections during infancy and toddlerhood. This period of rapid neural growth is referred to as synaptic blooming. **Figure 3.2 Components of the Neuron** The image is a detailed diagram of a neuron, illustrating its key components. The diagram emphasizes features such as the **cell body (soma)** from which branching **dendrites** extend to receive messages from other cells. The **axon** is shown passing messages away from the cell body and covered by the **myelin sheath**, which helps speed-up neural impulses. Synaptic connections are shown at the **terminal buttons** in synaptic contact with dendrites from another neuron. The blooming period of neural growth is then followed by a period of synaptic pruning, where neural connections are reduced thereby making those that are used much stronger. It is thought that pruning causes the brain to function more efficiently, allowing for mastery of more complex skills (Kolb & Whishaw, 2011). Experience will shape which of these connections are maintained and which of these are lost. Ultimately, about 40 percent of these connections will be lost (Webb, Monk, and Nelson, 2001). Blooming occurs during the first few years of life, and pruning continues through childhood and into adolescence in various areas of the brain. Another major change occurring in the central nervous system is the development of myelin, a coating of fatty tissues around the axon of the neuron (Carlson, 2014). Myelin helps insulate the nerve cell and speed the rate of transmission of impulses from one cell to another. This enhances the building of neural pathways and improves coordination and control of movement and thought processes. The development of myelin continues into adolescence but is most dramatic during the first several years of life. The infant brain grows very fast. At birth the brain is about 250 grams (half a pound) and by one year it is already 750 grams (Eliot, 1999). Comparing to adult size, the newborn brain is approximately 33% of adult size at birth, and in just 90 days, it is already at 55% of adult size (Holland et al., 2014). Most of the neural activity is occurring in the cortex or the thin outer covering of the brain involved in voluntary activity and thinking. The cortex is divided into two hemispheres, and each hemisphere is divided into four lobes, each separated by folds known as fissures. If we look at the cortex starting at the front of the brain and moving over the top (see Figure 3.3), we see first the frontal lobe (behind the forehead), which is responsible primarily for thinking, planning, memory, and judgment. Following the frontal lobe is the parietal lobe, which extends from the middle to the back of the skull and which is responsible primarily for processing information about touch. Next is the occipital lobe, at the very back of the skull, which processes visual information. Finally, in front of the occipital lobe, between the ears, is the temporal lobe, which is responsible for hearing and language (Jarrett, 2015). **Figure 3.3 The Two Hemispheres** The image shows two views of a human brain representing the left and right hemispheres divided into sections. Each section of the brain is labeled and colored to represent different functions. * Parietal, occipital, frontal, temporal. * Labeled connectors point to the auditory cortex and the visual cortex. * Includes cerebellum and labels related to the auditory cortex. The brain is divided into two hemispheres (left and right), each of which has four lobes (temporal, frontal, occipital, and parietal). Furthermore, there are specific cortical areas that control different processes. Although the brain grows rapidly during infancy, specific brain regions do not mature at the same rate. Primary motor areas develop earlier than primary sensory areas, and the prefrontal cortex, that is located behind the forehead, is the least developed (Giedd, 2015). As the prefrontal cortex matures, the child is increasingly able to regulate or control emotions, to plan activities, strategize, and have better judgment. This is not fully accomplished in infancy and toddlerhood, but continues throughout childhood, adolescence and into adulthood. **Lateralization** is the process in which different functions become localized primarily on one side of the brain. For example, in most adults the left hemisphere is more active than the right during language production, while the reverse pattern is observed during tasks involving visuospatial abilities (Springer & Deutsch, 1993). This process develops over time, however, structural asymmetries between the hemispheres have been reported even in fetuses (Chi, Dooling, & Gilles, 1997; Kasprian et al., 2011) and infants (Dubois et al., 2009). Lastly, **neuroplasticity** refers to the brain's ability to change, both physically and chemically, to enhance its adaptability to environmental change and compensate for injury. The control of some specific bodily functions, such as movement, vision, and hearing, is performed in specified areas of the cortex, and if these areas are damaged, the individual will likely lose the ability to perform the corresponding function. The brain's neurons have a remarkable capacity to reorganize and extend themselves to carry out these particular functions in response to the needs of the organism, and to repair any damage. As a result, the brain constantly creates new neural communication routes and rewires existing ones. Both environmental experiences, such as stimulation and events within a person's body, such as hormones and genes, affect the brain's plasticity. So too does age. Adult brains demonstrate neuroplasticity, but they are influenced less extensively than those of infants (Kolb & Fantie, 1989; Kolb & Whishaw, 2011). **Infant Sleep** **Figure 3.4** The image shows a baby sleeping on its back. A newborn typically sleeps approximately 16.5 hours per 24-hour period. This is usually polyphasic sleep in that the infant is accumulating the 16.5 hours over several sleep periods throughout the day (Salkind, 2005). The infant is averaging 15 hours per 24-hour period by one month, and 14 hours by 6 months. By the time children turn two, they are averaging closer to 10 hours per 24 hours. Additionally, the average newborn will spend close to 50% of the sleep time in the Rapid Eye Movement (REM) phase, which decreases to 25% to 30% in childhood. **Sudden Unexpected Infant Deaths (SUID):** Each year in the United States, there are about 3,500 Sudden Unexpected Infant Deaths (SUID). These deaths occur among infants less than one-year-old and have no immediately obvious cause (CDC, 2019). The three commonly reported types of SUID are: * **Sudden Infant Death Syndrome (SIDS):** SIDS is identified when the death of a healthy infant occurs suddenly and unexpectedly, and medical and forensic investigation findings (including an autopsy) are inconclusive. SIDS is the leading cause of death in infants 1 to 12 months old, and approximately 1,400 infants died of SIDS in 2017 (CDC, 2019). Because SIDS is diagnosed when no other cause of death can be determined, possible causes of SIDS are regularly researched. One leading hypothesis suggests that infants who die from SIDS have abnormalities in the area of the brainstem responsible for regulating breathing (Weekes-Shackelford & Shackelford, 2005). * **Unknown Cause:** The sudden death of an infant less than one year of age that cannot be explained because a thorough investigation was not conducted, and cause of death could not be determined. In 2017, 1300 infants died from unknown causes (CDC, 2019). * **Accidental Suffocation and Strangulation in Bed:** Reasons for accidental suffocation include: Suffocation by soft bedding, another person rolling on top of or against the infant while sleeping, an infant being wedged between two objects such as a mattress and wall, and strangulation such as when an infant's head and neck become caught between crib railings. In 2017, 900 infants died from accidental suffocation and strangulation. **Figure 3.5** lists the 2017 percentages of infants who died based on each of the three types. **Figure 3.5 Breakdown of Sudden Unexpected Infant Death by Cause, 2017** The pie chart illustrates the breakdown of Sudden Unexpected Infant Death by Cause in 2017. 38% of the deaths fall under the category "Sudden infant death syndrome(SIDS)", followed by 36% attributable to "Unknown cause", and 26% to "Accidental suffocation and strangulation in bed". As can be seen in the next graph (Figure 3.6), the combined SUID death rate declined considerably following the release of the American Academy of Pediatrics safe sleep recommendations in 1992, which advocated that infants be placed for sleep on their backs (nonprone position). These recommendations were followed by a major Back to Sleep Campaign in 1994. However, accidental suffocation and strangulation in bed mortality rates remained unchanged until the late 1990s. In 1998 death rates from accidental suffocation and strangulation in bed actually started to increase, and they reached the highest rate at 24.6 deaths per 100,000 live births in 2017 (CDC, 2019). **Figure 3.6 Trends in Sudden Unexpected Infant Death by Cause, 1990-2017** The line graph illustrates the trends in Sudden Unexpected Infant Death by Cause between the years 1990 and 2017. Deaths are measured per 100,000 Live Births. * Combined SUID rate begins at high death-rate in 1990 then drops below and remains relatively steady. * Sudden infant death syndrome parallels the Combined SUID rate. * Unknown Cause trends horizontally after a significant decrease in late 90's. * Accidental suffocation and strangulation remains low at 20 until 2000 in which the rate gradually increases through 2017. **Figure 3.7** The image depicts a mother and child sleeping together, with the child's face nestled close to the mother's face. Should infants be sharing the bed with parents? Colvin, Collie-Akers, Schunn and Moon (2014) analyzed a total of 8207 deaths from 24 states during 2004–2012 that were contained in the National Center for the Review and Prevention of Child Deaths Case Reporting System, a database of death reports from state child death review teams. The results indicated that younger victims (0-3 months) were more likely to die by bed-sharing and sleeping in an adult bed/on a person. A higher percentage of older victims (4 months to 364 days) rolled into objects in the sleep environment and changed position from side/back to prone. Carpenter et al. (2013) compared infants who died of SIDS with a matched control and found that infants younger than three months old who slept in bed with a parent were five times more likely to die of SIDS compared to babies who slept separately from the parents but were still in the same room. They concluded that bed sharing, even when the parents do not smoke or take alcohol or drugs, increases the risk of SIDS. However, when combined with parental smoking and maternal alcohol consumption and/or drug use, risks associated with bed sharing greatly increased. The two studies discussed above were based on American statistics. What about the rest of the world? Co-sleeping occurs in many cultures, primarily because of a more collectivist perspective that encourages a close parent-child bond and interdependent relationship (Morelli, Rogoff, Oppenheim, & Goldsmith, 1992). In countries where co-sleeping is common, however, parents and infants typically sleep on floor mats and other hard surfaces which minimize the suffocation that can occur with bedding (Nelson, Schiefenhoevel, & Haimerl, 2000). **From Reflexes to Voluntary Movements** **Table 3.1 Some Common Infant Reflexes** Given the descriptions, Here's a markdown table. | Reflex | Description | Image | | :------- | :-------------------------------------------------------------------------------------------------------------------------------------------------------------- | :---------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Sucking | Suck on anything that touches the lips | A baby sucking. | | Rooting | Turning the head when the cheek is touched | Image of a baby turning its head | | Grasp | Fingers automatically grip anything that touches the palm of the hand | Image of a baby grasping a finger | | Babinski | (Description) The toes will fan out and curl when the sole of the foot is stroked from heel to toe | a foot where stimulation of the sole yields an upward fanning of the toes upward along with dorsiflexion of the foot. This test is used to evaluate lesions of the motor cortex | | Moro | A sudden noise or loss of support to the head and neck will cause infants to spread out their arms and legs then quickly contract the limbs inward | A baby spreads out its arms and legs out abruptly | | Tonic Neck | When lying on the back with the head to one side infants will extend the arm and leg on that side while flexing the limbs on the opposite side (looks like a fencer pose). | A baby exhibiting the tonic reflex. The arm on which the head is turned towards extends while the opposite arm flexes | | Stepping | Legs move in stepping like motion when feet touch a smooth surface | Bottom of a baby's feet stepping in shallow steps. Newborns are equipped with a number of reflexes (see Table 3.1) which are involuntary movements in response to stimulation. Some of the more common reflexes, such as the sucking reflex and rooting reflex, are important to feeding. The grasping and stepping reflexes are eventually replaced by more voluntary behaviors. Within the first few months of life these reflexes disappear, while other reflexes, such as the eye-blink, swallowing, sneezing, gagging, and withdrawal reflex stay with us as they continue to serve important functions. Reflexes offer pediatricians insight into the maturation and health of the nervous system. Reflexes that persist longer than they should can impede normal development (Berne, 2006). In preterm infants and those with neurological impairments, some of these reflexes may be absent at birth. Once present, they may persist longer than in a neurologically healthy infant (El-Dib, Massaro, Glass & Aly, 2012). **Motor Development** Motor development occurs in an orderly sequence as infants move from reflexive reactions (e.g., sucking and rooting) to more advanced motor functioning. As mentioned during the prenatal section, development occurs according to the Cephalocaudal (from head to tail) and Proximodistal (from the midline outward) principles. For instance, babies first learn to hold their heads up, then to sit with assistance, then to sit unassisted, followed later by crawling, pulling up, cruising or walking while holding on to something, and then unassisted walking (Eisenberg, Murkoff, & Hathaway, 1989). As motor skills develop, there are certain developmental milestones that young children should achieve. For each milestone there is an average age, as well as a range of ages in which the milestone should be reached. An example of a developmental milestone is a baby holding up its head. Babies on average are able to hold up their head at 6 weeks old, and 90% of babies achieve this between 3 weeks and 4 months old. On average, most babies sit alone at 7 months old. Sitting involves both coordination and muscle strength, and 90% of babies achieve this milestone between 5 and 9 months old. If the child is displaying delays on several milestones, that is reason for concern, and the parent or caregiver should discuss this with the child's pediatrician. Developmental delays can be identified and addressed through early intervention. **Figure 3.8** The image shows a close-up photograph of an infant grasping a finger with their hand. **Motor Skills** refer to our ability to move our bodies and manipulate objects. Fine motor skills focus on the muscles in our fingers, toes, and eyes, and enable coordination of small actions (e.g., grasping a toy, writing with a pencil, and using a spoon). Newborns cannot grasp objects voluntarily but do wave their arms toward objects of interest. At about 4 months of age, the infant is able to reach for an object, first with both arms and within a few weeks, with only one arm. At this age grasping an object involves the use of the fingers and palm, but no thumbs. This is known as the **Palmer Grasp**. The use of the thumb comes at about 9 months of of age when the infant is able to grasp an object using the forefinger and thumb. Now the infant uses a **Pincer Grasp**, and this ability greatly enhances the ability to control and manipulate an object and infants take great delight in this newfound ability. They may spend hours picking up small objects from the floor and placing them in containers. By 9 months, an infant can also watch a moving object, reach for it as it approaches, and grab it. Gross motor skills focus on large muscle groups that control our head, torso, arms and legs and involve larger movements (e.g., balancing, running, and jumping). These skills begin to develop first. Examples include moving to bring the chin up when lying on the stomach, moving the chest up, and rocking back and forth on hands and knees. But it also includes exploring an object with one's feet as many babies do as early as 8 weeks of age if seated in a carrier or other device that frees the hips. This may be easier than reaching for an object with the hands, which requires much more practice (Berk, 2007). Sometimes an infant will try to move toward an object while crawling and surprisingly move backward because of the greater amount of strength in the arms than in the legs. **Sensory Capacities** Throughout much of history, the newborn was considered a passive, disorganized being who possessed minimal abilities. William James, an early psychologist, had described the newborn's world as "a blooming, buzzing confusion," (Shaffer, 1985). However, current research techniques have demonstrated just how developed the newborn is with especially organized sensory and perceptual abilities. **Vision:** The womb is a dark environment void of visual stimulation. Consequently, vision is one of the most poorly developed senses at birth, and time is needed to build those neural pathways between the eyes and the brain (American Optometric Association \[AOA], 2019). Newborns typically cannot see further than 8 to 10 inches away from their faces (AOA, 2019). An 8-week old's vision is 20/300. This means an object 20 feet away from an infant has the same clarity as an object 300 feet away from an adult with normal vision. By 3-months visual acuity has sharpened to 20/200, which would allow them the see the letter E at the top of a standard eye chart (Hamer, 2016). As a result, the world looks blurry to young infants (Johnson & deHaan, 2015). Why is visual acuity so poor in the infant? The fovea, which is the central field of vision in the retina and allows us to see sharp detail, is not fully developed at birth, and does not start to reach adult levels of development until 15 months (Li & Ding, 2017). Even by 45 months some of the sensory neurons (cones) of the fovea are still not fully grown. Can babies see color? Young infants can perceive color, but the colors need to be very pure forms of basic colors, such as vivid red or green rather than weaker pastel shades. Most studies report that babies can see the full spectrum of colors by five months of age (AOA, 2019). Newborn infants prefer and orient to face-like stimuli more than they do other patterned stimuli (Farroni et al., 2005). They also prefer images of faces that are upright and not scrambled (Chien, 2011). Infants also quickly learn to distinguish the face of their mother from faces of other women (Bartrip, Morton, & De Schonen, 2001). When viewing a person's face, one-month olds fixate on the outer edges of the face rather than the eyes, nose, or mouth, and two-month olds gaze more at the inner features, especially the eyes (Hainline, 1978). Researchers have examined the development of attention and tracking in the visual system and have found the following for young infants: * One-month-olds have difficulty disengaging their attention and can spend several minutes fixedly gazing at a stimulus (Johnson & deHaan, 2015). * Aslin (1981) found that when tracking an object visually, the eye movements of newborns and one-month olds are not smooth but saccadic, that is step-like jerky movements. Aslin also found their eye movements lag behind the object's motion. This means young infants do not anticipate the trajectory of the object. By two months of age, their eye movements are becoming smoother, but they still lag behind the motion of the object and will not achieve this until about three to four months of age (Johnson & deHaan, 2015). * Newborns also orient more to the visual field toward the side of the head, than to the visual field on either side of the nose (Lewis, Maurer, & Milewski, 1979). By two to three months, stimuli in both fields are now equally attended to (Johnson & deHaan, 2015). **Binocular vision**, which requires input from both eyes, is evident around the third month and continues to develop during the first six months (Atkinson & Braddick, 2003). By six months infants can perceive depth perception in pictures as well (Sen, Yonas, & Knill, 2001). Infants who have experience crawling and exploring will pay greater attention to visual cues of depth and modify their actions accordingly (Berk, 2007). **Hearing:** The infant's sense of hearing is very keen at birth, and the ability to hear is evidenced as soon as the seventh month of prenatal development. Newborns prefer their mother's voices over another female when speaking the same material (DeCasper & Fifer, 1980). Additionally, they will register in utero specific information heard from their mother's voice. DeCasper and Spence (1986) tested 16 infants (average age of 55.8 hours) whose mothers had previously read to them prenatally. The mothers read several passages to their fetuses, including the first 28 paragraphs of the Cat in the Hat, beginning when they were 7 months pregnant. The fetuses had been exposed to the stories an average of 67 times or 3.5 hours. When the experimental infants were tested, the target stories (previously heard) were more reinforcing than the novel story as measured by their rate of sucking. However, for control infants, the target stories were not more reinforcing than the novel story indicating that the experimental infants had heard them before. **Figure 3.9** The image shows a baby holding a book. An infant can distinguish between very similar sounds as early as one month after birth and can distinguish between a familiar and non-familiar voice even earlier. Infants are especially sensitive to the frequencies of sounds in human speech and prefer the exaggeration of infant- directed speech, which will be discussed later. Additionally, infants are innately ready to respond to the sounds of any language, but between six and nine months they show preference for listening to their native language (Jusczyk, Cutler, & Redanz, 1993). Their ability to distinguish the sounds that are not in the language around them diminishes rapidly (Cheour-Luhtanen, et al., 1995). **Touch and Pain:** Immediately after birth, a newborn is sensitive to touch and temperature, and is also highly sensitive to pain, responding with crying and cardiovascular responses (Balaban & Reisenauer, 2013). Newborns who are circumcised, which is the surgical removal of the foreskin of the penis, without anesthesia experience pain as demonstrated by increased blood pressure, increased heart rate, decreased oxygen in the blood, and a surge of stress hormones (United States National Library of Medicine, 2016). Research has demonstrated that infants who were circumcised without anesthesia experienced more pain and fear during routine childhood vaccines. Fortunately, today many local pain killers are currently used during circumcision. **Figure 3.10** The image shows a baby sticking his tongue out. **Taste and Smell:** Studies of taste and smell demonstrate that babies respond with different facial expressions, suggesting that certain preferences are innate. Newborns can distinguish between sour, bitter, sweet, and salty flavors and show a preference for sweet flavors. Newborns also prefer the smell of their mothers. An infant only 6 days old is significantly more likely to turn toward its own mother's breast pad than to the breast pad of another baby's mother (Porter, Makin, Davis, & Christensen, 1992), and within hours of birth an infant also shows a preference for the face of its own mother (Bushnell, 2001; Bushnell, Sai, & Mullin, 1989). **Intermodality:** Infants seem to be born with the ability to perceive the world in an intermodal way; that is, through stimulation from more than one sensory modality. For example, infants who sucked on a pacifier with either a smooth or textured surface preferred to look at a corresponding (smooth or textured) visual model of the pacifier. By 4 months, infants can match lip movements with speech sounds and can match other audiovisual events. Sensory processes are certainly affected by the infant's developing motor abilities (Hyvärinen, Walthes, Jacob, Nottingham Chapin, & Leonhardt, 2014). Reaching, crawling, and other actions allow the infant to see, touch, and organize his or her experiences in new ways. **How are Infants Tested:** Habituation procedures, that is measuring decreased responsiveness to a stimulus after repeated presentations, have increasingly been used to evaluate infants to study the development of perceptual and memory skills. Phelps (2005) describes a habituation procedure used when measuring the rate of the sucking reflex. Researchers first measure the initial baseline rate of sucking to a pacifier equipped with transducers that measure muscle contractions. Next, an auditory stimulus is presented, such as a human voice uttering a speech sound such as “da.” The rate of sucking will typically increase with the new sound, but then decrease to baseline levels as “da” is repeatedly presented, showing habituation. If the sound “ma” was then presented, the rate of sucking would again increase, demonstrating that the infant can discriminate between these two stimuli. Additionally, the speed or efficiency with which infants show habituation has been shown to predict outcomes in behaviors, such as language acquisition and verbal and nonverbal intelligence. Infants who show difficulty during habituation, or habituate at slower than normal rates, have been found to be at an increased risk for significant developmental delays. Infants with Down syndrome, teratogen-exposed infants, malnourished infants, and premature infants have all been studied. Researchers have found that at the age of 16 months, high-risk infants show rates of habituation comparable to newborn infants (Phelps, 2005). **Nutrition** **Breast milk** is considered the ideal diet for newborns. Colostrum, the first breast milk produced during pregnancy and just after birth has been described as “liquid gold" (United States Department of Health and Human Services (USDHHS), 2011). It is very rich in nutrients and antibodies. Breast milk changes by the third to fifth day after birth, becoming much thinner, but containing just the right amount of fat, sugar, water, and proteins to support overall physical and neurological development. For most babies, breast milk is also easier to digest than formula. Formula fed infants experience more diarrhea and upset stomachs. The absence of antibodies in formula often results in a higher rate of ear infections and respiratory infections. Children who are breastfed have lower rates of childhood leukemia, asthma, obesity, type 1 and 2 diabetes, and a lower risk of SIDS. **Figure 3.11** The Image shows baby being breast fed. The USDHHS recommends that mothers breast feed their infants until at least 6 months of age, and that breast milk be used in the diet throughout the first year or two. Several recent studies have reported that it is not just babies that benefit from breastfeeding. Breastfeeding stimulates contractions in the uterus to help it regain its normal size, and women who breastfeed are more likely to space their pregnancies further apart. Mothers who breastfeed are at lower risk of developing breast cancer (Islami et al., 2015), especially among higher risk racial and ethnic groups (Islami et al., 2015; Redondo et al., 2012). Women who breastfeed have lower rates of ovarian cancer (Titus-Ernstoff, Rees, Terry, & Cramer, 2010), reduced risk for developing Type 2 diabetes (Schwarz et al., 2010; Gunderson, et al., 2015), and rheumatoid arthritis (Karlson, Mandl, Hankinson, & Grodstein, 2004). In most studies these benefits have been seen in women who breastfeed longer than 6 months. Current rates of breastfeeding indicate that 83.2% of mothers have breastfed their infants at some point (CDC, 2018). However, most mothers who breastfeed in the United States stop breastfeeding exclusively at about 6-8 weeks, often in order to return to work outside the home (USDHHS, 2011). Mothers can certainly continue to provide breast milk to their babies by expressing and freezing the milk to be bottle fed at a later time or by being available to their infants at feeding time. However, some mothers find that after the initial encouragement they receive in the hospital to breastfeed, the outside world is less supportive of such efforts. Some workplaces support breastfeeding mothers by providing flexible schedules and welcoming infants, but many do not. In addition, not all women may be able to breastfeed. Women with HIV are routinely discouraged from breastfeeding as the infection may pass to the infant. Similarly, women who are taking certain medications or undergoing radiation treatment may be told not to breastfeed (USDHHS, 2011). **Figure 3.12** The image shows a graphic comparing the costs of exclusive breastfeeding with the costs of formula feeding. It says that exclusive breastfeeding costs $375 per year and formula feeding costs between $1,500 and $3,000 per year. Besides the nutritional benefits of breastfeeding, breast milk is free. Anyone who has priced formula recently can appreciate this added incentive to breastfeeding. Prices for a year's worth of formula and feeding supplies can cost between \$1,500 and \$3000 per year (Los Angles County Department of Public Health, 2019). In addition to the formula, costs include bottles, nipples, sterilizers, and other supplies. One early argument given to promote the practice of breastfeeding was that it promoted bonding and healthy emotional development for infants. However, this does not seem to be the case. Breastfed and bottle-fed infants adjust equally well emotionally (Ferguson & Woodward, 1999). This is good news for mothers who may be unable to breastfeed for a variety of reasons and for fathers who might feel left out. **When to Introduce More Solid Foods:** Solid foods should not be introduced until the infant is ready. According to The Clemson University Cooperative Extension (2014), some things to look for include that the infant: * can sit up without needing support * can hold its head up without wobbling * shows interest in foods others are eating * is still hungry after being breastfed or formula fed * is able to move foods from the front to the back of the mouth * is able to turn away when they have had enough For many infants who are 4 to 6 months of age, breast milk or formula can be supplemented with more solid foods. The first semi-solid foods that are introduced are iron-fortified infant cereals mixed with breast milk or formula. Typically rice, oatmeal, and barley cereals are offered as a number of infants are sensitive to more wheat-based cereals. Finger foods such as toast squares, cooked vegetable strips, or peeled soft fruit can be introduced by 10-12 months. New foods should be introduced one at a time, and the new food should be fed for a few days in a row to allow the baby time to adjust to the new food. This also allows parents time to assess if the child has a food allergy. Foods that have multiple ingredients should be avoided until parents have assessed how the child responds to each ingredient separately. Foods that are sticky (such as peanut butter or taffy), cut into large chunks (such as cheese and harder meats), and firm and round (such as hard candies, grapes, or cherry tomatoes) should be avoided as they are a choking hazard. Honey and corn syrup should be avoided as these often contain botulism spores. In children under 12 months, this can lead to death (Clemson University Cooperative Extension, 2014). **Global Considerations and Malnutrition** Children in developing countries and countries experiencing the