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8 Chapter Infant Nutrition Learning Objectives After studying the materials in this chapter you should be able to:...

8 Chapter Infant Nutrition Learning Objectives After studying the materials in this chapter you should be able to: Prepared by 8.1 Examine factors that are associated with increased risk for Robyn Wong health and developmental problems in infants. 8.2 Describe guidelines and tools that can be used to identify appropriate energy and nutrient needs of infants. 8.3 Describe how to assess adequate growth in infants. 8.4 Discuss how feeding and food choices that parents make for 8.7 Identify how nutrition problems and concerns impact overall their infants can affect later health status. infant health and development. 8.5 Identify infant developmental milestones related to feeding. 8.8 Cite examples of nutritional interventions that can reduce risk for nutrition and health problems in infancy. 8.6 Describe how providers and families can access nutrition guidance for infants. CDC/Lt. Cmdr. Gary Brunette 221 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 222 Nutrition Through the Life Cycle Introduction Rapid growth during the first year of life differentiates ­infancy from all other ages.1 From birth to 6 months of age, growth occurs most rapidly than at any other period in the life cycle.2 Adequate nutrition is required for ­normal develop- ment of the brain. Infancy is a critical period for formation of the brain. During this time, the foundation for cognitive, motor, and socio-emotional skill ­development is established. These developmental skills will continue to progress through childhood and adulthood. 3 This is also the period when feeding skills and healthful eating patterns are being estab- lished. This chapter is about healthy full-term infants born at or after 37 weeks of gestation.4 These infants are expec- ted to achieve normal patterns of growth and development in their first year. Infants generally double their birth weight by 4 to 6 months of age; and triple their birth weight at one year of age (Illustration 8.1).5 Their birth length will double at the end of the first year. Head circumference is reflective of brain growth, and the weight of the newborn brain will double by 1 year of age.5 This chapter discusses how nutrition is an important component in the complex development of infants. Both biological and environmental factors interact during infant growth and development. Models about the interaction of biological and environmental factors are often incomplete. They are not always adequate for describing complex inter- actions, such as how mealtime stimulates language devel- opment and how food preferences develop during infancy. The Healthy People 2020 objectives focus on infant health target reductions in infant mortality, preterm birth Robyn Wong rates, incidence of spina bifida and neural tube defects, fetal alcohol syndrome, and other birth defects.6 Table 8.1 shows some of the infant-related 2020 objectives that are Illustration 8.1 ◗ A former very low birthweight infant tracked by public health indicators. growing and gaining well in his first year. weight. Low-birthweight (LBW) infants weigh less than Assessing Newborn Health 2500 grams; very low-birthweight (VLBW) infants weigh LO 8.1 Examine factors that are associated with less than 1500 grams. Extremely low-birthweight (ELBW) infants weigh less than 1000 grams. Birthweight and the increased risk for health and developmental problems in length of gestation are two of the most important predict- infants. ors of an infant’s survival and later health.8 Very preterm and very low-birthweight infants are at much greater risk Birthweight and Gestational Age of death and disability than infants born at term or with birth weights over 2500 grams.8 as Outcome Measures The birthweight of a newborn is one of the indicators Infant Mortality of the infant’s health status. Full-term infants, born at 37– 42 weeks gestation, usually weigh bet ween Infant mortality is one of the key indicators of the health 2500 –3800 grams (5.5–8.5 pounds). There were over of a nation. It is associated with numerous factors includ- 3.9 million births in the United States in 2013, and ing maternal health, quality and access to medical care, 89 ­p ercent of these newborns were born full term.7 Full- socioeconomic conditions, term infants with normal birth weights are generally and public health prac- full-term infants Infants born healthy, and less likely to require intensive care. Prema- tices. 8 The leading causes at or after 37 weeks gestation. ture or preterm infants are born before 37 weeks gesta- of infant mortality in the preterm infants Infants born tion and are ­classified by their gestational age and birth United States in 2011 were before 37 weeks of gestation. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Chapter 8: Infant Nutrition 223 TAble 8.1 United States 2020 Healthy People Objectives related to infants ◗  Selected Goals in Maternal, Infant, and Child Health Baseline Target Reduce all infant deaths within 1 year 6.7 infant deaths per 1000 live births 10 percent improvement Reduce preterm births 12.7 percent of live births preterm 10 percent improvement Increase the proportion of infants who are put to sleep on 69.0 percent of infants were put to 10 percent improvement their backs sleep on their backs Reduce the proportion of breastfed newborns who receive 24.2 percent of breastfed newborns 10 percent improvement formula supplementation within the first 2 days of life Increase the proportion of infants who are ever breastfed 74.0 percent of infants 81.9 percent Increase appropriate newborn blood-spot screening and 98.3 percent of screen-positive infants 100% follow-up testing source: Healthy People.gov topics and objectives, Maternal, Infant and Child Health, online access http://www.healthypeople.gov/2020/topicsobjectives2020 congenital malformations, prematurity/low birthweight, health, education, and ­well-being of infants, children, ad- sudden infant death (SIDS), maternal complications, and olescents, and their families.14 This project has developed unintended injuries.9 exemplary health supervision guidelines, tools and mater- In 2010, the U.S. infant mortality rate was 6.1 deaths ials for practitioners working with the pediatric popula- per 1,000 live births. This ranked the United States tion. Bright Futures Nutrition is an excellent publication 26th in infant mortality among the 29 countries in the and series of tools and materials which focus on improving ­Organization for Economic Cooperation and Development the nutritional health of infants, children, adolescents, and (OECD).10 This low ranking has been attributed to the children with special health care needs.15 very high incidence of preterm births; 9.8 percent of births in the United States in 2010 were preterm—the highest rate among the 29 OECD countries.10 Newborn Growth Assessment Newborn health status is assessed by various indicators of Combating Infant Mortality growth and development taken right after birth. Indicators include gestational age, birthweight, length, and head cir- Over the past two decades in the United States, much of cumference. The designation “small for gestational age” the efforts to reduce infant mortality have focused on (SGA) indicates that the newborn’s weight, length, or head preventing preterm and low-birthweight deliveries. 8 Suc- circumference plots below the 10th percentile on the growth cessful efforts contributing to a decline in this rate in- chart. When all three measurements fall below the 10th clude improved access to specialized care for mothers and percentile, the infant is symmetrically small for gestational infants.11,12 age. Measurements above the 90th percentile are considered This is a multifaceted problem, however, also affected by: large for gestational age (LGA) and more often are noted in ◗◗ Socioeconomic level infants of diabetic mothers. Appropriate for gestational age (AGA) infants have birth measurements that plot between ◗◗ Access and availability of quality health care the 10th and the 89th percentile. SGA, AGA, and LGA ◗◗ Medical interventions such as caesarean section and are indicators of the infant’s size at birth. Another indic- induction of labor ator, intrauterine growth ◗◗ Teen pregnancy ­r estr iction (I UGR), is a infant mortality Death that ◗◗ Increased incidence of multiple births medical diagnosis identified occurs within the first year of life. ◗◗ Large differences in rates among racial/ethnic groups antenatally. The etiology of infant mortality rate The IUGR may be associated number of infant deaths for every Health O utcomes o f H igh-Risk a nd At-Risk Infants 1000 live births. with genetic factors, con- Medicaid and the Child Health Initiatives Program (CHIP) genital anomalies, infection, EPSDT The Early Periodic Screening, Detection, and provide health care coverage and contribute to improved multiple gestation, maternal Treatment Program is a part of access to quality health care for high-risk and at-risk in- nutrition, environmental Medicaid and provides routine fants.13 The Early Periodic Screening, Detection, and Treat- toxins, placental factors and checkups for low-income families. ment Program (EPSDT) is a major source of preventive and maternal vascular disease intrauterine growth routine health care for infants and children in low-income such as diabetes, chronic retardation (IUGR) Fetal families. Immunizations in infancy are another example of hyper tension, advanced undergrowth from any cause, a public health prevention-focused program. Bright Futures resulting in a disproportionality maternal age, and morbid in weight, length, or weight-for- is a collaborative project of the U.S. Department of Health obesity. IUGR is a signific- length percentiles for gestational and Human Services and the American Academy of Pedi- ant factor in perinatal mor- age. Sometimes called intrauterine atrics (AAP). The goal of Bright Futures is to improve the bidity and mortality.16 growth restriction. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 224 Nutrition Through the Life Cycle Normal Physical Growth and Development motor skills achieved during infancy.18,21 ­I llustration 8.2 depicts motor development during the first 15 months.18 There is now evidence that the rate and ­progression of It is a great source of pride for parents when their early growth is a major risk factor for ­development of cer- baby first rolls over or sits up. The development of muscle tain chronic diseases including ­coronary heart ­disease and control and coordination progresses from top down; type 2 diabetes.17 Monitoring infants’ nutritional status initiating with head control and ending with lower leg requires an understanding of their overall development. coordination and walking. 22 Muscle development also Full-term newborns have a wider range of abilities than progresses centrally to peripherally; meaning that the previously recognized; for ­example, they hear and move in infant learns to control the shoulder and arm muscles response to familiar sounds, such as their mother’s voice.18 before muscles in the hands. 22 , 23 Motor development States of arousal describe sleep and awake states in in- influences both the ability of the infant to feed and the fants, and affect the way they respond at any given time. amount of energy expended in the activity. An example They provide a framework for parents and caregivers to of how motor development affects feeding is the ability observe, understand, and interact with their infants. For to sit in a high chair. When an infant has achieved head infants, states of arousal allow them to control the type and trunk control, sitting balance, and fading of certain and amount of input they receive from their ­environments. reflexes such as tongue thrust, oral feeding can be initi- These states include quiet sleep, active sleep, drowsy, quiet ated. 23 As motor skills continue to progress, daily energy alert, active alert and crying.19 needs increase because of higher energy expenditure. In- Organs and organ systems developed in utero con- fants who are crawling or starting to walk will expend tinue to increase in size and complexity during infancy. more energy in physical activity than younger infants The newborn’s central nervous system is immature; who are not yet rolling over. the neurons in the brain are less organized compared to those of the older infant. 20 As a result, the newborn Critical Periods gives inconsistent or subtle cues of hunger and other needs, compared to the cues given at a later age. The fact The concept of critical period is based on a fixed time that newborns can root, suckle, and coordinate suck- period when certain behaviors emerge. Piaget’s stages ing, swallowing, and breathing within hours of birth of cognitive development and Erickson’s psychological shows that feeding is directed by reflexes and the cent- stages of development are examples of theories of de- ral nervous system.18,21 Newborn reflexes are protective. velopment st at i ng t h at These reflexes later fade as they are replaced by more there are time periods or root reflex Action that occurs if purposeful movements during the first few months of life windows of development, one cheek is touched, resulting in (see Table 8.2.).18,21,22 when certain skills must the infant’s head turning toward be learned in order for that cheek and the infant opening his mouth. subsequent lea r n i ng to Motor Development occur. A critical period 21 suckle A reflexive movement of the tongue moving forward and Motor development reflects an infant’s ability to control for the development of backward; earliest feeding skill. voluntary muscle movement. There are several models for oral feeding skills may ex- reflex An automatic describing infant development, but none provides a com- plain some later feeding (unlearned) response that is plete description and explanation of the rapid ­advances in problems in infancy. 23 In a triggered by a specific stimulus. TAble 8.2 Major reflexes found in newborns ◗  Name Response Significance Babinski Baby’s toes fan out when the sole of the foot is stroked. Perhaps a remnant of evolution from heel to toe Blink Baby’s eyes close in response to bright light or loud noise. Protects the eyes Moro Baby throws arms out and then inward (as if embracing). May help a baby cling to the mother in response to loud noise or when baby’s head falls Palmar Baby grasps an object placed in the palm of his or her hand. Precursor to voluntary grasping Rooting When a baby’s cheek is stroked, baby turns head toward Helps a baby find the nipple the cheek that was stroked and opens mouth. Stepping Baby is held upright by an adult and is then moved. Precursor to voluntary walking forward; begins to step rhythmically Sucking Baby sucks when an object is placed in mouth. Permits feeding Withdrawal Baby withdraws foot when the sole is pricked with a pin. Protects a baby from unpleasant stimulation source: From KAIL/CAVANAUGH. Human Development, 2nd ed. © 2000 Cengage Learning Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Chapter 8: Infant Nutrition 225 Fetal posture 0 months Chin up Chest up Reach and miss Sit with support Sit on lap; 1 month 2 month 3 month 4 month grasp object 5 month Sit on high chair; Sit alone Stand with help Stand holding Creep Walk when led grasp dangling object 7 months 8 months furniture 10 months 11 months 6 months 9 months Pull to stand Climb stair steps Stand alone Walk alone by furniture 13 months 14 months 15 months 12 months Illustration 8.2 ◗ Gross motor skills. Based on Shirley, 1931, and Bayley, 1969. source: From KAIL/CAVANAUGH. Human Development, 2E. © 2000 Cengage Learning healthy newborn, the mouth is a source of oral pleasure growth retardation and linear growth retardation or and exploring, an important form of early learning. An stunting), iron deficiency anemia, and iodine deficiency. 3 infant on prolonged respiratory support may not asso- The baby’s interactions with the environment stimulate ciate oral sensations and stimulation with pleasure, but the developing brain, which is now seen as structuring instead with discomfort. The critical period for develop- the nervous system in the long term (see Illustration 8.3 ing positive associations with oral sensations, stimula- on p. 230). 3 Research has shown that access to adequate tion, and feeding may have adversely been affected. After energy and protein alone may not be sufficient for max- discharge, this infant may become a reluctant feeder and imizing brain maturation without simultaneously provid- have difficulty learning to enjoy eating and mealtimes. ing psycho-social stimulation. 24 Feeding issues that may occur in preterm infants and in- Improving the nutritional status of infants can pos- fants with special health care needs will be discussed in itively affect their environment-related experiences and Chapter 9. stimulation. Undernourished infants may frequently be ill and subsequently irritable, fussy, tired, and withdrawn. Caregivers may experience more difficulty when feeding Cognitive Development these infants. A decrease in their activity level may occur Risk factors for poor cognitive, motor, and ­socio-emotional and alter their ability to explore their environment and in- development include: severe, acute malnutrition (very low teract with their caregivers, and poor brain development weight for length), chronic undernutrition ­(intrauterine may result.3 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 226 Nutrition Through the Life Cycle Digestive System Development do not usually interfere with the ability of the intestinal villi to absorb nutrients, and typically do not hinder growth. 27 Many factors influence the rate of food passage through the “Now good digestion wait on appetite, colon and the gastrointestinal discomfort seen in infants. and health on both.” These include: —William Shakespeare, Macbeth ◗◗ Osmolarity of foods or liquids (which affects how much water is drawn into the intestine) A healthy digestive system is necessary to support adequate ◗◗ Bacterial flora in the colon nutrition. Parents may worry about gastrointestinal prob- ◗◗ Water and fluid balance in the body lems, in part because of misinformation about nutrition in infancy. 25 An infant passing soft, loose stools may be Parenting thought to have diarrhea if parents do not know that these are typical stools for breastfed infants. Parents may feel that their infant’s gastrointestinal discomfort may affect “A babe in the house is a well-spring and interfere with weight gain, even though growth has of pleasure.” been progressing well. It takes up to 6 months for the in- —Martin Farquhar Tupper, On Education fant gastrointestinal tract to mature, and the time required is variable among infants.14,26 During the third trimester, the fetus swallows amniotic Even though the newborn is fluid, and this stimulates the lining of the intestine to grow able to breastfeed or bottle gastroesophageal reflux and mature. At birth, the healthy newborn’s digestive sys- feed soon after birth, skills (GER) Movement of the stomach contents backward into tem is sufficiently mature to digest fats, protein, and simple of new pa rents develop the esophagus due to stomach sugars and to absorb fats and amino acids. Although slowly. The parents’ ability muscle contractions. The condition healthy newborns do not have the same levels of digest- to recognize and respond to may require treatment depending ive enzymes or rate of gastric emptying as older infants, infant cues of hunger and on its duration and degree. the gut is functional at birth. 26 After birth and through satiety improves over time. osmolarity Measure of the early infancy, the coordination of peristalsis within the Table 8.3 highlights some number of particles in a solution, gastrointestinal tract improves. which predicts the tendency of of the hunger and satiety the particles to move from high to Infants may have conditions that reflect the immatur- cues observed at varying low concentration. Osmolarity is a ity of the gut, such as colic, gastroesophageal reflux (GER), ages during the first year of factor in many systems, such as in unexplained diarrhea, and constipation. 27 Such conditions life. New parents are also fluid and electrolyte balance. TAble 8.3 Infant hunger and satiety cues ◗  Infant’s Approximate Age Hunger Cues Satiety (Fullness) Cues Birth through 5 months Wakes and tosses Seals lips together Sucks on fist Turns head away Cries or fusses Decreases or stops sucking Opens mouth while feeding to indicate Spits out the nipple or falls asleep when full wanting more 4 through 6 months Cries or fusses Decreases rate of sucking or stops sucking when full Smiles, gazes at caregiver or coos during Spits out the nipple feeding to indicate wanting more Turns head away Moves head toward spoon or tries to May be distracted or pay more attention to swipe food towards mouth surroundings 5 through 9 months Reaches for spoon or food Eating slows down Points to food Pushes food away 8 through 11 months Reaches for food Eating slows down Points to food Clenches mouth shut or pushes food away Gets excited when food is presented 10 through 12 months Expresses desire for specific food with Expresses desire for specific food with words or sounds words or sounds Shakes head to say “no more” source: Infant Nutrition and Feeding: A Guide for Use in the WIC and CSF Programs. United States Department of Agriculture, Food and Nutrition Service, Special Supplemental Program for Women, Infants and Children (WIC), 2009. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Chapter 8: Infant Nutrition 227 learning about the temperament of their infants. Infant ◗◗ Weight temperament related to feeding includes emotionality, ◗◗ Growth rate activity, attention span and persistence, reaction to food, ◗◗ Sleep/wake cycle and soothability. 28 Infants also have variable eating styles, ◗◗ Temperature and climate which can be seen in their reaction to foods, predictability ◗◗ Physical activity of appetite, and distractability at mealtime. The infant’s temperament and eating style might be related to potential ◗◗ Metabolic response to food feeding problems and risk for obesity in childhood. 23,28 ◗◗ Health status and recovery from illness A healthy parent–infant feeding relationship involves responsive parenting. Parental skills that support healthful ­feeding and eating Protein Needs in infancy include: T he recom mended protein intake for infants from ◗◗ Responding early and appropriately to the infant’s birth to 6 months of age is 1.52 grams per kilogram ­hunger and satiety cues body weight, and 1.2 grams per kilogram from 7 to ◗◗ Recognizing the infant’s developmental abilities and 12 months of age. 30 Protein requirements of infants are feeding skills affected by age, growth, illness, and adequacy of other ◗◗ Balancing the infant’s need for assistance with nutrients in the diet. 31 Essential amino acids require- ­encouragement of age-appropriate feeding skills ments for healthy infants remain the same throughout ◗◗ Allowing the infant to initiate and guide feeding the first year of life. 30 interactions15 Infants from birth to 6 months of age who are breastfed or who consume appropriate amounts of infant formula will obtain adequate protein. Infants may exceed protein Energy and Nutrient Needs recommendations if they consume excessive formula or if protein sources such as infant cereal are added to bottles LO 8.2 Describe guidelines and tools that can be used of formula. Excessive or inadequate protein intake can res- to identify appropriate energy and nutrient needs of ult with incorrect mixing of formula. infants. Well-researched nutrient and energy recommendations Fat Needs have been established by the Food and Nutrition Board, Institute of Medicine, and the National Academies of Fat is an essential component in the diets of infants. It Sciences. The DRIs have identified age-specific recom- provides essential fatty acids, is a concentrated source of mendations for energy and for macro and micronutrients energy, and facilitates the absorption of fat-soluble vitam- for healthy infants from 0 to 6 months and from 7 to ins. Fat is especially important in infancy and early child- 12 months of age. The American Academy of Pediatrics hood because it is essential for neurological development (AAP) and the Academy of Nutrition and Dietetics provide and brain function. 32 guidelines and position papers related to infant health, Infants are at higher risk for essential fatty acid defi- ­nutrition and feeding. ciency related to their rapid growth rate and higher re- The 2014 Dietary Guidelines for Americans provide quirements for polyunsaturated fatty acids. They also have ­r e com mend at ion s for he a lt h f u l e at i ng a nd phys - limited stores of body fat. 33 Restrictions of fat and dietary ical activity for individuals starting at 2 years of age. cholesterol are not recommended in infancy. These guidelines do not provide recommendations for The Adequate Intake for fat is 31 grams for infants infants. 29 0–6 months of age and 30 grams for infants 7–12 months of age. 30 Fat contributes approximately half of the calories in breast milk 2,34 and 40 to 50 percent of calories in infant Energy Needs formulas. 35 The percentage of fat in the diet will decrease The energy needs of infants are higher per kilogram of as the infant accepts complementary foods, since most of body weight than at any other time of life. The range these foods are low in fat. in energy requirements for individual infants is broad, Infants use fats to supply energy to the liver, brain, and ranging from 80 to 120 calories per kg of body weight. 30 muscles, including the heart. The fact that infants have The average energy needs of infants in the first 6 months high energy needs compared to those of older children of life is 108 cal per kg body weight, based on growth means that infants use fats more regularly for generating in breastfed infants. From 6 to 12 months of age, the energy. Young infants cannot tolerate fasting for long be- average energy need is 98 cal/kg. 30 Factors that account cause it quickly uses up both carbohydrate and fat energy for the range of energy needs of infants include the sources. This effect of fasting explains in part why young following: infants cannot sleep through the night. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 228 Nutrition Through the Life Cycle Fats in food provide the essential fatty acids, linoleic The DRI for fluoride is 0.1 mg daily for infants less than acid (LA) and alpha-linolenic acid (ALA), and polyunsat- 6 months of age, and 0.5 mg daily for infants 7–12 months urated fatty acids, including docohexaenoic acid (DHA) old.40 Most infants who live in areas with fluoridated water and arachidonic acid (ARA). Essential fatty acids are sub- do not need additional fluoride. Supplemental fluoride is strates for hormones, steroids, endocrine, and neuroactive recommended for breastfed and formula-fed infants resid- compounds. DHA is a major fatty acid in brain and retinal ing in communities where fluoride concentration in the phospholipids.32 water is low; beginning at 6 months of age. 36 Vitamin D Vitamin D is a key nutrient in the diets of in- Metabolic Rate, Energy, Fats, and fants. It has an essential role in bone mineralization and Protein—How Do They All Tie Together? calcium and phosphorus homeostasis, and regulates genes The metabolic rate of infants is the highest of any period associated with immune response and cellular growth.41 after birth.14 The higher rate is primarily related to infants’ There are two forms: vitamin D2 (ergocalciferol), which rapid growth rate and high proportion of muscle. The is from plants and fungi, and vitamin D3 ­(cholecalciferol), usual body fuel for metabolism is glucose. When sufficient which is synthesized in the skin during exposure to glucose is available, growth will typically progress. When ­sunlight. Vitamin D3 also is found in fatty fish like s­ almon glucose from carbohydrates is limited, amino acids will be and mackerel. The Adequate Intake (AI) for vitamin D converted into glucose for generating energy and are less is 400 international units (IU) for infants. Breast milk is available for growth. The conversion of amino acids into low in vitamin D at 22 IU per liter.42 Standard infant for- glucose is a more dynamic process in infants in compar- mulas are manufactured to contain 400 IU per liter. ison to adults. The breakdown of amino acids for use as The AAP recommends that all breastfed and p ­ artially energy occurs during illness in adults, but it can occur breastfed infants receive 400 IU of vitamin D daily. daily in fast-growing infants. Circulating amino acids in ­Formula-fed infants who are consuming less than one liter the blood from ingested foods will be used for glucose pro- of infant formula daily should receive 400 IU of vitamin D duction, and if these are not sufficient, the body will re- daily.43 Vitamin D needs during lactation are discussed in lease amino acids from muscles. This process of breaking Chapter 6. down body protein to generate energy is known as cata- bolism. If catabolism continues for an extended duration, Sodium Sodium is a major component of extracellu- it can contribute to growth faltering in infants. lar fluid and an important regulator of fluid balance. The Adequate Intake (AI) for sodium is 120 mg for 0- to 6-month-old infants and 370 mg for 7- to 12-month-old Other Nutrient and Non-Nutrient Needs infants. The sodium content in breast milk was used as Fluoride Fluoride is a naturally occurring mineral com- the basis for establishing sodium requirements for infants. pound that can contribute to the prevention and reduction Infant formula is supplemented with sodium to match the of dental caries. When ingested during the time that teeth amount contained in breast milk.44 Generally, infants do are developing the fluoride will be deposited on tooth sur- not have difficulty with maintenance of body fluids and faces. The maximum reduction in dental caries will be electrolytes, even though they may not show thirst as a achieved when fluoride is provided systemically while teeth separate signal from hunger. Young infants do not sweat are developing and topically after teeth are present in the as much as older children, so losses from sweating are not mouth. Fluoride helps to reduce tooth decay by decreasing usually problematic. Illnesses such as diarrhea or vomiting the solubility of tooth enamel, decreasing the production cause the loss of fluid and sodium and increase the risk of acid by oral bacteria, and by supporting further remin- of dehydration. Infants do not need salt added to foods to eralization. Dental caries are the most common chronic maintain adequate sodium intake. disease of childhood.36 Infants can obtain fluoride from fluoridated water, Iron Infants are at risk for iron deficiency because of rapid bottled water with added fluoride, and from fluoride sup- growth in the first year. From 4 to 12 months of age, an plements. Fluoride content in breast milk is low. 37 infant’s blood volume will double.45 Those with lower iron Water fluoridation has been shown to reduce caries in stores at birth or low intakes of dietary iron are also at risk. primary teeth of children by as much as 60 percent. 38 In Iron deficiency anemia in infancy is associated with short- 2012, 74.6 percent of the U.S. population on public ­water and long-term consequences, including poor cognitive and systems had access to fluoridated water. 39 Community motor development. These infants have been reported with ­w ater fluoridation is one of the objectives in Healthy socio-emotional impairments including being more wary, People 2020, with desired outcome that 79.6 percent of hesitant, solemn, unhappy, and more closely keeping with people on public water systems receive water that has the their mothers.46 Newborns at risk for iron deficiency include optimal level of fluoride recommended for preventing infants of diabetic mothers, growth-restricted (IUGR) new- tooth decay.6 borns, and preterm infants.47 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Chapter 8: Infant Nutrition 229 Young infants have iron levels that ref lect their Accurate growth measurements and interpretation mother’s health during late pregnancy and delivery. In- of growth rates are important components in evalu- fants born at term generally have adequate iron stores that ating an infant’s nutritional status. Use of calibrated will last through 4–6 months of age.45 According to the infant scales, recumbent measuring boards, and non- Institute of Medicine, healthy-term infants 0–6 months of stretch head circumference tapes improves measurement age need 0.27 mg of iron each day. This AI recommenda- accuracy. tion was based on the iron content of breast milk, and the Standardized methods should be utilized when meas- average breast milk intake of infants at this age. The RDA uring growth; these require practice and consistency. for older infants 7–12 months of age increases to 11 mg Equipment used to measure infants differs from equip- daily related to depletion of their iron stores 4–6 months ment for measuring older children. The scale bed must be after birth.48 To assure that preterm, full term, and older long enough to allow the infant to lie down or sit. Length infants have sufficient iron regardless of the method of is measured with the infant lying down with head and feeding, the AAP recommends initiation of supplemental feet touching the measuring board at right angles. Posi- iron for exclusively breastfed infants starting at 4 months tioning the baby quickly and carefully is a skill needed of age.49 for accurate measurement of recumbent length. Cloth- ing, hair ornaments, and excessive movement of the in- Lead Although lead is not a nutrient, it can be associated fant while on the scale will affect measurement accuracy. with iron and calcium status during infancy. Children’s ­I llustration 8.4 shows weight, length and head circumfer- blood lead levels increase most rapidly at 6–12 months ence measurements obtained with recommended measur- of age, and peak at 18–24 months of age. 50 Elevated ing equipment. blood lead levels have a neurotoxic effect on infants and young children, and are associated with intellectual and ­behavioral functioning impairments. 51 There is a negative Interpretation of Growth Data correlation between blood lead levels and blood calcium A comparison of the WHO growth charts and the CDC and iron levels. growth charts is shown in Table 8.4. Both sets of growth Infants may inadvertently be exposed to environmental charts show: sources of lead. Lead may be a contaminant in water from lead pipes, particularly if the house was built before ◗◗ Weight for age 1950. Older homes may contain lead-based paints that ◗◗ Length for age taste sweet to infants. The American Academy of Pediat- ◗◗ Weight for length rics recommends screening children at risk beginning at ◗◗ Head circumference for age 9–12 months of age. 53 The 2006 W HO growth charts include charts for the age range of 0 –24 months for each gender. 54 The Growth Assessment W HO growth charts are based on longitudinal and cross-­s ectional data of infants who were exclusively or LO 8.3 Describe how to assess adequate growth in ­predominantly breastfed, and living in urban, ­middle-class infants. communities in Brazil, Ghana, Oman, Norway, India, Physical growth is defined as the increase in the mass of and Davis, California. These growth charts show how body tissues that occurs in genetically determined rates, infants and children should grow under ideal conditions patterns, and ages as a healthy infant grows into adult- and environments. The European Society for Pediatric hood.5 Adequate nutrition and physical activity are needed ­G astroeneterology, Hepatology and Nutrition repor- to achieve optimal growth and maturation. In most nor- ted that the patterns of linear growth were remarkably mal, healthy infants, growth and maturation progress with few, if any, problems. 5 TAble 8.4 Accurately measuring growth in infants ◗  Frequent measurements of weight, length, and head cir- To Avoid Measurement Errors cumference during infancy will facilitate early identifica- Use measuring equipment that was recently calibrated. tion of potential problems such as slow or excessive weight Confirm that the scale is on zero before starting. gain or slow linear growth. There is a wide range of ap- Weigh the infant nude or wearing a dry diaper. propriate growth patterns in infancy. Healthy infants may Confirm the position of the infant for length measurements: have brief periods when their weight gain is slower or more Head position—the infant’s eyes are looking straight up rapid than at other times. Slight variations in growth rate and the head is in midline, touching the head board. may result from illness, inappropriate feeding routine, or Neither hips nor knees are bent. family disruption. The overall growth pattern is import- Heel is measured with foot flat against the foot board. ant, and each assessment is compared to the overall health Head circumference measure is at the widest part of the head. assessment. © Cengage Learning 2014 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 230 Nutrition Through the Life Cycle SUBSTAGES DURING THE SENSORIMOTOR STAGE OF DEVELOPMENT Substage Age Accomplishment Example (months) 1 0–1 Reflexes become coordinated. Sucking a nipple 2 1–4 Primary circular reactions appear Thumb sucking —an infant’s first learned reactions to the world. 3 4–8 Secondary circular reactions Shaking a toy to hear a rattle emerge, allowing infants to explore the world of objects. 4 8–12 Means–end sequencing of Moving an obstacle to reach schemes is seen, marking the a toy onset of intentional behavior. 5 12–18 Tertiary circular reactions Shaking different toys to develop, allowing children to hear the sounds they make experiment. 6 18–24 Symbolic processing is revealed Eating pretend food in language, gestures, and with a pretend fork pretend play. Illustration 8.3 ◗ Sensorimotor stage of development. source: From KAIL/CAVANAUGH. Human Development, 2E. © 2000 Cengage Learning Robyn Wong Robyn Wong Robyn Wong Illustration 8.4 ◗ Infant measurements taken with ­recumbent length board, digital scale and head ­circumference tape. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Chapter 8: Infant Nutrition 231 TAble 8.5 Comparing infant growth in CDC and WHO growth charts ◗  Basis CDC 2000 WHO 2011 Geography and sample size U.S. selected sites with 5,000 measurements Worldwide six selected sites with 19,000 measurements Concept Descriptive reference reflecting past: “How infants Prescriptive optimal standard: have grown” “How infants should grow” Feeding Method 66% formula fed and 33% breastfed for 3 months All breastfed at least 4 months Time covered Birth to 36 months Birth to 24 months Low weight for age in 12 months Higher prevalence Lower prevalence High weight for length up to 12 months Higher prevalence Lower prevalence © Cengage Learning 2014 consistent between the different countries and ethnic Infant formulas are manufactured to closely resemble groups. 55 In late 2010, the CDC and the AAP recommend human milk; however, there are numerous compon- use of the WHO growth charts for 0- to 24-month-old ents that cannot be replicated in commercial formula. infants and children (Table 8.5). Sample WHO growth Examples include immunoglobulins, lactoferrin, and charts with plotted ­infant measurements are found in lysozyme. See Chapter 6 to review the benefits of breast- Chapter 9. feeding and breast milk. Table 8.6 provides a comparison Warning signs of growth difficulties include: no of the various types of infant formula and indications for ­increase in weight or length; and a continued decline or their use. 57 In the United States the manufacture of in- rapid increase in weight, length, or head circumference fant formula is closely regulated by the Food and Drug percentile.15 Head circumference increases are reflective Administration through the Infant Formula Act of 1980 of brain growth. 5 Atypical rates of head circumference and its amendments in 1986. In 2014, the FDA updated growth (notable slowing or rapid increase) will warrant these quality control and safety regulations to include close follow-up by the infant’s primary care physician. manufacturer testing of formula products for nutrient composition and presence of any harmful pathogens, and demonstration that their products support normal phys- Feeding in Early Infancy ical growth in infants. 59 There are frequent changes made in formula composition and product lines by manufac- LO 8.4 Discuss how feeding and food choices that turers. There are standard cow-milk based and soy-based parents make for their infants can affect later health infant formulas, and types such as “­o rganic,” “hypo- status. allergenic,” “for spit up or reflux,” “reduced lactose,” and “follow-up.” Table 8.6 lists different types of infant “Food is the first enjoyment of life.” formulas and indications for their use.60 —Lin Yutan, The Importance of Living Growth and health status of an infant are better indic- ators of dietary adequacy than the volume of breast milk or formula alone. It is optimal for infants to continue breastfeeding through the first year of life. If breastfeed- Breast Milk and Formula ing is discontinued prior to one year of age, infants will The AAP and the Academy of Nutrition and Dietetics need to be transitioned to infant formula. Formula-fed (AND) recommend that optimal nutrition for infants be infants need to remain on formula through the first year provided by exclusive breastfeeding for the first 6 months of life. Routine formulas for full-term infants provide of life and continuation of breastfeeding for the second 20 calories per ounce when prepared as directed. Premature 6 months. 56,57 Breastfeeding is a key public health strategy post-discharge formulas provide higher energy typically for improving infant health and reducing morbidity and at 22 or 24 calories per mortality in the first 12 months.15 ounce. Some health pro- The benefits of breastfeeding and composition of viders recommend further sensorimotor An early learning system in which the infant’s senses breast milk are well described in Chapter 6. Nutrient increasing the caloric density and motor skills provide input to ­recommendations for young infants were established based of formula for some ­infants, the central nervous system. on intakes of exclusively breastfed infants. No additional such as those with volume hypoallergenic Foods or ­f luids or foods are needed for infants prior to 6 months restrictions or increased products that have a low risk of of age. 58 ­energy needs. promoting food or other allergies. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 232 Nutrition Through the Life Cycle TAble 8.6 Infant formulas: Types and indications for use ◗  Formula Type Indications for Use Product Examples Standard cow milk–based Healthy term infants 0–12 months of age Bright Beginnings formula Most commonly used formula Enfamil Premium Similac Advance Generic store brands Symptoms of intolerance Term infants with fussiness or spit up Enfamil Gentlease Contains partially hydrolyzed protein and reduced lactose Similac Sensitive Some have added rice starch Enfamil AR Similac for Spit-Up Partially hydrolyzed protein Not considered hypoallergenic Gerber Good Start Not for use with allergic condition or disease Enfamil Gentlease Can be considered for spitting up or fussiness Similac Total Comfort Soy-based Vegetarian diet Bright Beginnings Soy Galactosemia Enfamil Prosobee Hereditary lactase deficiency Good Start Soy Similac Isomil Not recommended for preterm infants Generic store brands Premature post discharge For preterm infants transitioning home Bright Beginnings Neocare Higher in energy, protein and micronutrients than standard term formula Enfamil Enfacare Usual concentration: 22 cal/oz but can be mixed to higher concentrations Similac Neosure Extensively hydrolyzed protein Hypoallergenic Nutramigen Intolerance to cow milk protein, soy protein Pregestimil Significant malabsorption Similac Alimentum Amino Acid based Extreme protein hypersensitivity Elecare Neocate Infant Pur Amino source: adapted from Corkins MR (ed.) Pediatric Nutrition Support Handbook, American Society for Parenteral and Enteral Nutrition, 2011. © Cengage Learning 2014 Cow Milk In early infancy, self-regulation of feeding is mediated by the pleasure of the sensation of fullness. Inherent prefer- The American Academy of Pediatrics and the Academy of ences are in place for a sweet taste, which is also a pleas- Nutrition and Dietetics Pediatric Practice Group recom- urable sensation. After the first 4 to 6 weeks, reflexes fade mend that whole cow milk, skim milk, and reduced-fat and infants learn to purposely signal wants and needs. milk not be used in infancy. 61,62 Iron-deficiency anemia However, it is not until much later—about age 3—that has been linked to early introduction of whole cow’s milk. children can verbalize that they are hungry. In between Low iron availability may result from gastrointestinal reflexes fading and advancing verbal skills, children’s blood loss or the lack of other iron-rich foods.61 ­appetites and food intakes are regulated by