Feeding & Nutritional Requirements PDF

Unit (4) Feeding of Newborn and Infants General objective By the end of this lecture; the student will be able to explain the various methods of feeding newborn and infants and the principles of weaning. Specific objectives...

Unit (4) Feeding of Newborn and Infants General objective By the end of this lecture; the student will be able to explain the various methods of feeding newborn and infants and the principles of weaning. Specific objectives By the end of this lecture the student will be able to: I. Breast Feeding  Identify the nutritional requirements during infancy  Enumerate food stuffs  Identify types of infants' feeding  Define types of human breast milk  Define the proper storage of breast milk  List WHO and UNICEF breast feeding recommendations.  State the advantages of breast feeding  State Psychological impact of breast feeding  Enumerate Teaching of mothers about breast feeding  Illustrate the best position of breast feeding  List Criteria of adequate breast feeding  List Criteria of under feeding  Explain difficulties of breast feeding 51   State the ten steps for successful breast feeding II. Bottle feeding  Identify the types of formula feeding  State the disadvantages of bottle feeding  Identify types of formula  Enumerate preparation of formula  Explain techniques of feeding newborn and infant  Define five common mistakes of bottle feeding III. Weaning  Define weaning technique.  State the best time of weaning  Identify reasons of starting weaning at 4-6 months  Enumerate the principles of weaning  Explain the schedule of Weaning according to infant age per months  Identify the care during weaning  Explain the needs of caloric requirements according to developmental age. 52  Feeding of Newborn and Infants Introduction The proper time the decision of infant s’ feeding choices should be explored during antepartum period by the nurse with the parent(s). In general, there are two primary choices: human milk and commercially prepared cow’s milk -based formula. Optimal nutrition during first year of life is very important for three reasons:  Growth is proceeding very rapidly.  Cellular growth of essential organs is completed during this period.  Feeding provide time for meeting the emotional needs of infants. Nutritional requirements during infancy Calories: 100+20 cal.kg/day - One calorie is supplied by 1.5 cc. of milk (Human-cow’s). - In the second year the needs are 70cal./kg/day. Fluid: 150ml/kg/day. Food stuffs  Protein: 2gm/kg/day.  Vit. A: 4000IU/day.  Vit. C: 40 mg/day.  Vit. D: 400-800 IU/day.  Niacin: 4mg/day.  Iron: 6 mg/day.  Vit. B1: 0.4 mg. 53   Calcium: 0.5gm/day.  Vit. E.: 4 IU/day. Types of Infants' feeding  Enteral feeding  Oral: Breast feeding and bottle feeding.  Gastric: Gavage feeding and gastrostomy feeding.  Parenteral feeding  I.V. fluids.  Total parenteral nutrition. Stages of Breast Milk  Colostrum or Early Milk is produced in the late stage of pregnancy till 4 days after delivery; and is rich in antibodies.  Transitional Milk produced from day 4 – 10 is lower in protein in comparison to colostrum.  Mature milk is produced from approximately ten days after delivery until the termination of the breastfeeding. Storage of Breast Milk  Human milk can be stored at room temperature for 6-8 hours.  Expressed milk can be stored in a cooler bag with icepacks for 24hours.  It can also be kept in a freezer compartment for up to two weeks at 0 - 5°F  It can be stored in a deep freezer for about 3-12 months. 54 Types of nipple  Normal or protruded.  Bifid or divided into two parts.  Flat at the level of the skin.  Depressed below the level of the skin. Types of nipples Definition of exclusive breastfeeding is defined as no other food or drink, not even water, except breast milk (including milk expressed or from a wet nurse) for 6 months of life, but allows the infant to receive ORS, drops and syrups (vitamins, minerals and medicines) To enable mothers to establish and sustain exclusive breastfeeding, WHO and UNICEF recommend:  Initiation of breastfeeding within the first hour of life.  Breastfeeding on demand - that is, as often as the child wants, day and night for 6 months of infants’ life.  No use of bottles, teats, or pacifiers. Advantages of breast feeding 55  Advantages to the mother 1- Economic and no needs of preparation. 2- Emotional satisfaction. 3- Helps involution of the uterus and prevent of postpartum hemorrhage. 4- Birth spacing. 5- Regain their normal weight faster. 6- Lower incidence of cancer breast and cancer ovary. Advantages to the infant 1. Human milk is warm, ready, sterile, and available all times and perfectly balanced in element of nutrition. 2. It is more easily digested than cow’s milk. 3. Breast-fed infants have greater immunity to certain childhood diseases. 4. Infants are less likely to have gastro-intestinal disorders, anemia and Vit deficiency. 5. Infants are less likely to acquire infection in homes where cleanliness is difficult to attain. 6. Infant is secure through constant contact with his mother. Psychological impact of breast feeding  Breast-feeding establishes a close bond between mother and baby.  Breast-feeding positively influence the quality of mother-child interaction.  Development of sense of trust.  Mothers are taught to talk, sing, and touch their babies while providing breast-feeding. Technique of breast feeding  Breast should be cleansed every day. 56   Mother’s clothes should not be tight over the breast and clean.  The mother should wash hand thoroughly before nursing her infant.  The infant should be hungry, dry and warm.  The mother should be in comfortable position either in sitting or lying position (support feet in sitting position).  Proper positioning of infant that stimulate "rooting reflex" and ―latch on".  Duration of each feeding.  When nursing is completed, the infant should be placed in a crib on his right side or in prone position to facilitate emptying of the stomach. Best position of breast feeding Lying down position Football position Cradle position Holding position Latch – on Australian Hold Position C Hold Position Criteria of adequate breast feeding 1- Baby feeds at least 8 times/24hrs. 57  2- Baby is calm and satisfied after feeding. 3- Baby sleeps well 2 - 4 hrs. after feeding. 4- Normal bowel motion with no constipation. 5- Baby urinates 6 or more times/day. 6- Weight gain 20 - 30 grams/day. Criteria of underfeeding 1- Weight gains slow and irregular. 2- Decrease amount and frequency of urination. 3- Baby always unsatisfied and crying after feeding. 4- Sleeplessness or very short sleep. 5- Constipation and hunger stool. 6- Air swallowing leading to colic and vomiting. Criteria of overfeeding 1. Vomiting especially after feeding and crying due to colic and flatulence 2. Overweight infants 3. Diarrhea with large bulky stools 4. Polyuria and sore buttocks 5. Excessive sweating Difficulties of breast feeding A- Difficulties related to the newborn: 1- Prematurity  Give the expressed breast milk to infant by a dropper or gavage (by a nurse) or by cup.  Mothers can increase the frequency of feeding up to every 2 hours. They should wake the baby for feeding. 58  2- Congenital malformation in the heart and GIT  Cardiac disorders may weaken the infant so that nursing is too exhausting.  Mother may pump her breasts and maintain the sick infant on breast milk given by a fine tube, which passes from a container (cup or bottle) to the baby’s mouth, while the baby’s suckling. 3- Breast-milk jaundice  Although breast-feeding is sometimes associated with jaundice for the infant it is not contraindication to breast-feeding. It occurs after 1st week of delivery. It is characterized by drop in the level of unconjugated bilirubin in blood in response to withholding breast-feeding for one day.  Some mothers excrete a substance in their milk that interferes with bilirubin metabolism resulting in jaundice. If bilirubin level reaches 15-16 mg/100 ml the physician may suggest interruption of nursing for 1-2 days as a diagnostic test. Breast-feeding then is resumed without problems. It usually subsides after a week or two without any treatment. Factors that may lead to breast feeding problems  Lack of mother’s knowledge.  Improper attachment of baby to breast.  Separation of mother and baby.  Overburdened by work.  Psychological factors a. Anxiety. b. Concern about nipple shape and size. c. Misbelieves about colostrum and her own milk (Not enough, deficient or diluted milk). B- Difficulties related to the mothers’ breast 59   Nipple Trauma.  Obstructed lactiferous  Inverted Nipples. Duct.  Engorgement.  Mastitis.  Candidiasis / Thrush.  Breast Abscess. Problems of breast feeding 1- Nipple trauma or painful nipple Definition Tenderness and soreness of the nipple are usually the result of trauma and irritation from poor feeding technique or improper hygienic care. Management  Apply moist heat and massage before feedings (3-5minutes).  Begin each feeding on the least involved side.  Frequent, short feedings (2-2.5 hours), not less.  Proper positioning, attachment, and removal technique.  Apply small amount of breast milk to areola after feeding and let dry.  Air/sun exposure.  Avoid engorgement.  Mild analgesic 30 minutes before feeding.  Avoid irritating substances.  Treatment for candidacies.  Dermatitis treatment.  Supportive bra 60  2- Inverted nipples Definition Inverted nipples are rare and some postnatal measures may be helpful in order to facilitate breast-feeding. Causes Persistence of original invagination of managing dimples. Management  Breast shells.  Breast pump.  Pre-nursing nipple stimulation.  Side-sitting position.  Avoid bottle, nipples and pacifiers 3- Breast engorgement Definition It is an accumulation of increased amount of blood and other body fluids as well as milk in the breasts. 61  Breast engorgement Management  Apply moist warm packs to the involved breast 2-3 minutes before each feeding.  Massage and hand express or pump to relieve areolar engorgement before feeding to facilitate attachment.  Cold packs after feeding.  Stress reduction, relaxation techniques.  Neck and back massage.  Mild analgesic. 4- Candidiasis / Thrush Definition Persistent sore nipple may be caused by candida albicans, also called monilia or thrush. 62 Management for mother  Apply medication to nipple after every feeding for 14 days.  Keep area dry: expose nipples to air or sun and use a fresh bra liner every feeding.  Wash clothes and other articles that come into contact with breasts in very hot water.  Wash hands well, especially after changing infant’s diaper. Management for infant  Apply oral medication directly to affected areas for 14 days.  Boil articles that come in contact with infant’s mouth for 20 minutes daily.  Treat diaper rash until healing is complete. 5- Obstructed lactiferous duct Definition It results in a tender area or painful lump in the breast. Causes Milk stasis secondary to:  Infrequent nursing.  Incomplete emptying.  Local pressure. Management  Massage prior to and during nursing.  Proper positioning, attachment, and removal techniques.  More Moist warm packs to area before nursing.  Frequent nursing.  Check fit of clothing. 63  6- Mastitis Definition It is an infection of breast tissue surrounding the milk ducts by staphylococcus aureus Symptoms A tender reddened area of the breast accompanied by: Fever, chills, headache, generalized achiness. Management  Don’t discontinue nursing except in systemic illness  Nurse more frequently (2-2.5 hours).  Offer baby involved breast first.  Proper positioning, attachment, and removal technique.  Moist warm packs (3-5 minutes).  Bed rest for 24 hours.  Mild analgesic.  Antibiotic for prevention as a current treatment of 10 days of (amoxicillin or cephalexin started 24 hours after onset of symptoms.  Drink fluid to satisfy thirst (fever). 64  7- Breast abscess Causes Delayed or inadequate treatment of mastitis leads to breast abscess Management  Antibiotics.  Incision and drainage.  Warm packs.  Breast-feed from affected side if the incision is away from the areola or express breast milk until healing is complete.  Rest. Contraindication of breastfeeding Maternal chemotherapy Active tuberculosis not under treatment in mother HIV in mother Galactosemia in infant Maternal herpes simplex lesion on a breast Maternal substance abuses as cocaine and marijuana Mothers receiving diagnostic or radioactive isotopes The role of breast-feeding support group  Emphasize to mothers the benefits of breast-feeding.  Teach mothers the correct technique for successful breast-feeding.  Listen to mothers and give sympathy.  Give advice on how to ensure continuity by proper diet, exercise, rest, fluid intake, breast care, clothing and bathing.  Emphasize the role of the father. 65   Emphasize gender issues with respect to equality of care, rearing and education.  Raise the awareness about the importance of birth spacing.  Arrange for close contact of mothers with their premature babies.  Teach mothers how to express their milk.  Convince mothers that even if the expressed amount is small, it is nutritionally adequate for her baby’s.  Use no bottles, teats or pacifiers as this can cause babies to develop nipple confusion.  Once the baby is capable of nutritive suckling the mother should be guided on breast feeding.  Place the baby clinging with skin to skin on the mother using (kangaroo method) for low birth weight.  Repeated periodical stimulation is required during feeding.  Prolactin stimulates the initiation and maintenance of breast-feeding.  Correct mothers’ misconception. Ten steps for successful breast feeding 1- Have a written breast-feeding policy that is routinely communicated to the health care staff. 2- Train all health care staff necessary to implement this policy. 3- Inform all pregnant women about the benefits and management of breast-feeding. 4- Help mothers initiate breast-feeding within half-hour of birth. 5- Show mothers how to breast-feed, and how to maintain lactation even if they should be separated from their baby. 66  6- Give newborn babies no food or milk other than breast milk unless medically indicated. 7- Practice rooming in allows mothers and babies to remain together 24 hours a day. 8- Encourage breast-feeding on demand. 9- Give no artificial teats or pacifiers to breast-feeding babies. 10- Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic. Bottle feeding Introduction Breast feeding is the best method of feeding for all newborn and infants, even premature infants, there is no real substitute for breast milk. But if it is not possible, formula feeding is indicated. Three types of formula feeding a- Complementary feeding Each feed, the breast is given first until it is emptied then formula is given to complete the feed. b- Supplementary feeding Formula is given to substitute one or more feeds, where some feeds are completely breast milk and others are completely formula or bottle. C- Substitutive No breast-feeding is given and the infant is fed on formula only. This indicated in the following cases death of the mother, institutions, and any Contraindication to breast-feeding. 67 Disadvantages of bottle feeding 1- Disadvantage related to formula preparation a. Starvation: Infant might have diluted formula, where mothers do not put enough milk powder to water as a result of their ignorance or the expensiveness of milk powder. Thus, marasmus often occurs to those infants. b. Infection: Pathogenic microorganisms grow quickly in milk when not refrigerated. It also grows quickly in warm and dirty feeding bottles. To kill these microorganisms, boil the bottles and all the equipment used in formula preparation for 15 minutes. 2- Disadvantage related to the nature and the technique of bottle feeding a. Difficulty to digest: the casein in cow’s milk is responsible for the hard big curds formed in the infant’s stomach, which interferes with digestion of milk, unless it is modified. b. Emotional defect due to loss of maternal and infant attachment c. Aspiration specially when the infant sleep with bottle feeding d. Otitis media may occur if the infant lies flat and suck e. Continuous pooling of formula in the infants’ mouth may lead to dental caries when the teeth erupt. Types of formula These contain more protein and iron and less fat than the humanized milk. 1) Liquid milks  fresh milk  Raw fresh cow, buffalo and goat milk.  Pasteurized milk (to kill some bacteria and modifies the casein curds). 68   Ultra-pasteurized, especially packed milk which can be kept for several weeks. 2) Dried milk  Dried milks are prepared by evaporating water from fluid milk.  Each 100ml of fluid fresh milk is transformed to 12.5gm of powder.  The advantages of dried milk are  Dried milk is sterile, highly soluble.  Constant in its composition.  Can be modified to meet the needs of newborns and infants in health and disease. Types of dried milk 1- Dried whole milk  This is simply dried milk.  After reconstitution, it is exactly similar in composition to cow’s milk.  It cannot be used for feeding young infants unless modified. E.g.: Nido, Cornation, Francelait, La Frizan. 2- Modified cow’s milk formulas  Reducing casein amount and replacing it by soluble protein.  Milk fat is replaced by a mixture of milk and vegetable fat to increase its unsaturated fatty acids content.  Lactose is increased to 7%.  Reducing the amount of ash.  Iron and vitamins are added.  However, modified milk can’t be compared to human milk from the biological point of view. E.g.: American milk:Similac, Similac with iron, SMA, S26, Enfamil. 69 3- Modified special formulas  Many milk formulas are modified to suit certain metabolic errors or diseases states.  These formulas may be based on cow’s milk, other mammal’s milk or on vegetable ingredients, E.g.: Lactose free milk (Isomil A1 110). 4- Acidified milk  Acidified milks were thought to have an advantage in facilitating digestion and absorption. They include:  Full-Cream Acidified Milk: It contains 4% lactose, 0.4% lactic acid e.g. Pelargon, Bebelac Z18 Acidified.  Half-Cream Acidified Milk: It contains 1.5% fat, 4% lactose & 0.4 lactic acid e.g. Prodieton, Bebelac Z9 Acidified. Preparation of Formula 1) According to fluid requirements  To estimate the amount of fluid required per day for an infant (150 ml/kg body weight). This is equivalent to the amount of isocaloric milk needed for the infant.  The calculated amount is then divided by number of feeds. Volume in cc/feed = 150cc x baby weight (in kg) Total no. of feeds 2) According to infant’s weight Volume in cc/feed = weight in grams 36 70 3) According to caloric requirement  To estimate the calories required by an infant in 24 hours (100-120 calories/ kg body weight).  Calculate the number of ounces the infants needs /24 hours (remember the ounce contains 20 calories).  Since ounces are mass, they should be transformed into volume (one ounce = 30cc). Therefore, calculate the total volume needed by the infant in 24 hours. Then, divided the amount by number of feeding to obtain the 3. According to caloric requirement volume/feed. Examples: formula for an infant weighing 4 kg Number of calories required /24 hrs= 100 x 4 = 400 calories No. of ounces infant needs / 24 hour = Total caloric requirement/24 hours 400 = = 20 Ounces 20 20 Volume in cc / feed = 20 x 30 = 100 ml 6  Average number of feeding/24hours Age Average numbers of feeding in 24 hours Birth – 1 week 8-10 1 week – 1 month 6-8 1 month – 3 month 5-6 3 months – 7 months 4-5 7 months – 9 months 3-4 9 months – 10 months 3 71 Reconstitute the dried milk  Liquid cow’s milk is reduced to 1/ 8 of its volume. Therefore, to reconstitute it we dilute 1: 8 with water (one-gram powder should be added to 8 gm of water).  The scoop (measure) utilized for European milks equals 4gm of powder. So, it should be diluted in 30ml of water. But the American scoop is larger in size. It contains 8 gm; therefore, it should be diluted in 60 ml of wat Techniques of feeding newborn and infant 1- Obtain the formula bottle from the refrigerator and warm it up. 2- Check the patency of the nipple. 3- Ensure safe newborn/ infant’s positioning. 4- Feed the newborn/ infant. 5- Burping the newborn/ infant. 6- Discard the unused portion of formula. Five common mistakes in bottle feeding 1- Leaving the child with the feeding bottle unattended. 2- Too large or too narrow hole in the teat. 3- Use of any available bottle. 4- Over diluted feed. 5- Frequent crying of baby because of underfeeding. Feeding of preterm infants  Enteral  Oral: Breast feeding and bottle feeding.  Gastric: Gavage feeding and gastrostomy feeding.  Parenteral  I.V fluids.  Total parenteral nutrition. 72 Feeding of pre-term infants  The nurse should assess the Preterm health condition to choose the appropriate method for premature feeding (pre-term’s weight, gestational age, sucking and swallowing reflexes, respiratory condition and patency of gastrointestinal tract.  If the Preterm infant has a patent GIT (no obstruction) and no respiratory distress and suckling and swallowing reflexes are developed and coordinated, weighing more than 1800gm and the gestational age usually 34 weeks or more, he/ she can be fed through oral feeding (either breast or bottle).  If sucking is poor and the gestational age is less than 34 weeks or/ and there is mild distress (respiratory rate more than 60/min) and weight less than 1500gm feed the preterm infant through gastric feeding (Nasogastric/gavage feeding).  If there is tracheo-esophageal fistula, the preterm infant must be fed through Gastrostomy feeding until repair is complete.  If there is gastro-esophageal reflux disease, the preterm infant is fed through transpyloric feeding.  Regardless of the route of nutrition, the nurse must feed the preterm infant within 2 hours after delivery, either enteral or parenteral, especially low birth weight infants. Early feeding will reduce the possibility for hypoglycemia, dehydration, hyperbilirubinemia and it will increase the survival rate. 73  Weaning Definition  It is a gradual addition of solid foods to the infant’s diet according to individual infant’s capacity and gradual diminution of breast or artificial feeding in frequency and/or quantity.  Time of weaning: after the infant have 6 months of age Reasons for starting weaning after the age of 6 months 1- This is the time where breast-feeding become inadequate to meet the child nutritional needs. 2- Enzymes necessary to digest the complex structure of solid food are developed. 3- Biting is an accomplishment that becomes possible at about 6 months of age. 4- It is a good chance for child to learn independency by using cup and spoon to feed himself. 5- To accustom the infant to chew and swallow solid food. Principles of weaning  Start weaning when the child is free from any disease particularly from any G.I.T. troubles.  Don’t start in summer.  One-food item is introduced at intervals of 4-7 days to allow for identification of food allergies.  New foods are fed in small amounts.  Food should not be mixed in the bottle and feed through a nipple with a large hole.  Don’t wait too long to introduce solid food. 74   Offer new food while baby is hungry.  Never force the infant to take a new food.  Vegetables and non-sweetened food may be introduced before sweetened food. Schedule of Weaning according to infant age per months  By 6th – 8th months  Eggs: give the egg yolk first and then egg white as it may cause some allergic manifestation.  Iron-rich pureed meats, fruits, and vegetables, soft cooked vegetables as green peas, carrots, sweet potatoes, squash, applesauce, pears, bananas, and peaches  By 8th – 12th months: offer finger foods in small amounts as  Beans (skinned or mashed), ground meat, chicken liver, fish, rabbit, soft cooked vegetables, washed and peeled fruit.  Mixed food containing 2 or 3 different foods as rice and vegetable or rice, vegetable and ground chicken. This is a more balanced diet than if each is used alone.  Desserts as custard pudding or jelly should be added later or better after the first 18 months.  After the first year a little butter could be added to the infant diet.  It is better to avoid fried food until the 2nd year.  The key to healthy weaning is gradual  Replace one feeding at a time.  It is easiest to begin by stopping the feeding your baby wants the least, or seems most distracted or least interested in. E.g.: Instead of breastfeeding mid-morning, take baby to the park, read a book, or have a snack or drink from a spoon or cup. 75   Gradually, feedings can be replaced one at a time. Wait between a few days and two weeks before replacing another nursing time to allow your baby to get used to this change and to prevent yourself from having overfull breasts.  The weaning method of ―don’t offer, don’t refuse‖ often works best for most mothers and babies. Basically, this means that you do not offer your baby your breast for one feeding at a time. However, if your baby is interested in breastfeeding at the feeding you are trying to replace, you do not refuse him the feeding. NB: Weaning does not mean refusing to let baby nurse, it means gradually releasing your baby from breastfeeding and adding new food.  Try to limit situations that encourage breastfeeding. E.g.: Avoid sitting in the rocking chair you always sit in to nurse, but be open to breastfeeding during baby’s needful periods of the day.  Expect nap nursing and night nursing sessions to be the last to end.  Before ending breastfeeding, bedtime, you should have a bedtime routine or nap routine as quieting activities (reading bedtime stories; a back rub and a lullaby; or a healthy snack, bath, and pajamas)  It is often helpful to have dad or another caregiver fulfill these evening routines so baby does not think of breastfeeding; this also allows important contact time between father and child. NB: as you develop playful interactions instead of breastfeeding, your child will slowly learn to be content with them and prefer them as a substitute to breastfeeding.  Be prepared to breastfeed more often again if the infant has behavior chances as tantrums, anger, or sadness which may result from rapid weaning or if the child ill, upset, or experiencing new situations. At these times, breastfeeding for comfort is required. 76 Care during weaning 1- Cleanliness: Instruct mothers to wash their hands and baby’s hands when he begins to feed himself. Cooked food should be covered to protect it from the flies and dust. Utensils used in the preparation of food and feeding should be clean and washed before and after use. 2- Consistency: Weaning food must be made into a form and texture that is soft and easily digestible for a young child. Don’t use mixer / blender in preparation of vegetable soup as it transfers it into a liquid form unsuitable for training babies on swallowing of semi-solid food. 3- Bulkiness: because the infant has a small stomach, he shouldn’t be given bulky food with high percentage of water (as rice). So, it is better to give small amount of these foods. 4- Frequency of meals: young infant should be fed 4-5 times daily, in their own bowel or plate (so mother can see the amount taken by child). The caloric requirement according to each child's developmental stage Feeding of toddler: (1- 3 years)  The toddler age group needs 1200 calories/day. The primary aim in dietary management of these children is to accustom them to chopped food and remove all strained food from the diet.  The basic food remains the same. The only difference is the consistency of each food and size of serving is governed by the child’s activity, rate of growth, body structure and the food habits he begins to initiate. Feeding of preschool child: (3-6 years) He needs 1500-1600 calories daily. The basic food for preschool continues as the main stay in the diet. Children of this age group need and enjoy serving to them in shapes and sizes. They can pick up and examine (e.g. raw carrot straws). 77 Feeding of school child: (6-12 years) He needs 2000-2500 calories daily. The basic food continues to be used in about the same manner although the size of serving must be increased. Instructions about feeding of young children. 1- Serve in very small amounts; encourage asking for second helping. 2- Serve attractively. 3- Give older child some freedom to choose food and to eat in his own way. 4- Don’t allow drinking all milk first. 5- Don’t withhold food for punishment. 6- Don’t hurry child. 7- Don’t insist that a child ―eat all this ―before he can have any of that. 8- Spices have no nutritional value and shouldn’t be added to children’s food. 9- Ingredient used in the preparation of weaning food is not expensive. 10- By 8-12 months, infant should be trained to drink from cup. 11- By 12-14 months, the child may be taught to use spoon. By 2 years, child can be taught to spoon-feed himself. 12- Opened containers of baby's food should be covered and stored in a refrigerator for no longer than 2 days. 13- The use of fork is not recommended before the age of 3 years. 14- Do:  Give praise usually at the end of the meal.  Establish good relationship with child.  Provide learning experiences. 78 Things to be avoided 1- Food that causes chocking as nuts, fruits with seeds, etc… 2- Food that produces allergy as fresh milk, fish, tomato, etc…. 3- Artificial colors and flavors foods. 4- Salted food might cause hypertension. 5- Junk food as sweets, candies that deprive the child from taking more nutritious food and encourage the desire for sweets. 6- Highly spiced and fatty food. 7- Honey, in some region, as it may be contaminated with clostridium botulism spores. 8- Cow’s milk for infant under age 1 year, because is difficult to be digested. 79