INFANT NUTRITION

NDD 10603
INFANT NUTRITION
DR. SHARIFAH WAJIHAH WAFA BTE SST WAFA
School of Nutrition and Dietetics
Faculty of Health Sciences
sharifahwajihah@unisza.edu.my
KNOWLEDGE FOR THE BENEFIT OF HUMANITY

SCHOOL OF NUTRITION AND DIETETICS . FACULTY OF HEALTH SCIENCES
TOPIC LEARNING OUTCOMES
• At the end of this lecture, the students should
be able to:
1. Identify the assessment for infant’s physical
growth.
2. Discuss the energy and nutrients needs of
infants.
3. Explain the nutrition-related problems that
affect the infants.

A newborn infant, or neonate, is a child
under 28 days of age. During these first 28
days of life, the child is at highest risk of
dying. It is thus crucial that appropriate
feeding and care are provided during this
period, both to improve the child’s chances
of survival and to lay the foundations for a
healthy life. (WHO

Course Outline
1. Birthweight and infant mortality
2. Motor and cognitive development
3. Energy and nutrient needs
4. Physical growth assessment
5. Infant feeding skills
6. Common Nutritional Problems and Concerns

Assessing Newborn Health
• Birthweight as an Outcome
– Full-term infant (37 to 42 wks)
– The average Malaysian newborn weight is around
3.2kg
– The average length of full-term babies at birth is
51 cm, although the normal range is 46 cm to 56
cm.

• Infant mortality - defined as death that occurs
within the first year
• Major cause is low birthweight (< 2500
g)
• Other leading causes include:
1) congenital malformations
2) preterm births
3) SIDS

• Combating Infant Mortality
• Factors associated with mortality:
– Social and economic status
– Access to health care
– Medical interventions
– Teenage pregnancy
– Availability of abortion services
– Failure to prevent preterm & LBW births

Source: The World Bank DataFigure 1:Mortality rate, infant (per 1,000 live births)

• Standard Newborn Growth
Assessment:
 “Appropriate for gestational
age” (AGA)
 “Small for gestational age”
(SGA) and “intrauterine
growth retardation” (IUGR)
mean newborn was <10th %
wt/age
 “Large for gestational age”
(LGA) means newborn was
>90th % wt/age

Infant Development
• Newborns:
Hear and move in response to familiar voice
CNS is immature resulting in inconsistent cues for
hunger and satiety
Strong reflexes, especially suckle and root
(reflexes are protective for newborns)

Infant Development
• Terms Related to Development:
Reflex—automatic response triggered by specific
stimulus
Rooting reflex—infant turns head toward the
cheek that is touched
Suckle—reflex causing tongue to move forward
and backward

Major Reflexes Found in Newborns

Nine Reflexes of Baby

Infant Development
1. Motor development: ability to control
voluntary muscles
• Motor development is top down— controls
head first and lower legs last
2. Muscle development from central to
peripheral
• Influences ability to feed self & the amount of
energy expended

Gross Motor Skills

Infant Development
• Critical periods
– A fixed period of time in which certain behaviors
or developments emerge
– Necessary for sequential behaviors or
developments
– If the critical period is missed, there may be
difficulty later on

Infant Development
3. Cognitive Development
• Factors that impact cognition
– Sensorimotor development
– Interactions with the environment
– Adequate energy and protein
– Stimulation of social and emotional growth
– Genetics

Sensorimotor Stage of
Development
The sensorimotor stage is divided into 6 substages:
1. Simple reflexes (Birth - 1 Month Old)
2. Primary circular reactions (1-4 Months Old
3. Secondary circular reactions( 4-8 Months Old)
4. Coordination of secondary circular reactions(8-12 Months
Old)
5. Tertiary circular reactions (12-18 Months Old)
6. Internalization of schemes(18-24 Months Old) A shift to
symbolic thinking

Development
1. Reflexes (0-1 month):
• During this substage, the child
understands the environment
purely through inborn reflexes
such as sucking and looking.

Development
2. Primary Circular Reactions
(1-4 months):
• This substage involves
coordinating sensation and new
schemas.
• For example, a child may such his
or her thumb by accident and
then later intentionally repeat the
action.
• These actions are repeated
because the infant finds them
pleasurable.

Development
3. Secondary Circular
Reactions (4-8 months):
• During this substage, the child
becomes more focused on the
world and begins to intentionally
repeat an action in order to
trigger a response in the
environment.
• For example, a child will
purposefully pick up a toy in
order to put it in his or her
mouth.

Development
4. Coordination of Reactions (8-12
months):
• During this substage, the child starts to
show clearly intentional actions.
• Children begin exploring the
environment around them and will
often imitate the observed behavior of
others.
• The understanding of objects also
begins during this time and children
begin to recognize certain objects as
having specific qualities.
• For example, a child might realize that a
rattle will make a sound when shaken.

Development
5. Tertiary Circular Reactions
(12-18 months):
• Children begin a period of trial-
and-error experimentation during
the fifth substage.
• For example, a child may try out
different sounds or actions as a
way of getting attention from a
caregiver.

Development
6. Early Representational
Thought (18-24 months):
• Children begin to develop
symbols to represent events or
objects in the world in the final
sensorimotor substage.
• During this time, children begin
to move towards understanding
the world through mental
operations rather than purely
through actions.

Infant Development
4. Digestive System Development
– Fetus swallows amniotic fluid which stimulates
intestinal maturation and growth
– At birth the healthy newborn can digest fats,
protein and simple sugars.
– Common problems include gastroesophageal
reflux (GER), diarrhea, and constipation

Infant Development
• Factors that impact rate of food passage in
colon
– Osmolarity of foods or liquids
– Colon bacterial flora
– Water and fluid balance in the body

Infant Development
• Parenting
• New parents must learn:
– Infant’s cues of hunger and satiety
– Temperament of infant
– How to respond to infant cues

Baby’s Language

Why is Nutrition Important?
• Energy of daily living
• Maintenance of all body functions
• Vital to growth and development
• Therapeutic benefits
– Healing
– Prevention

Energy and Nutrient Needs
• The recommendations for infants are from the
Dietary Reference Intakes (DRI), National Academy of
Medicine, AAP and the Academy of Nutrition and
Dietetics
– Energy needs
– Protein needs
– Fats
– Metabolic rate, calories, fats and protein—how do
they all tie together?

• Energy (Calories):
– 108 kcal/kg/day from birth to 6 months (range from 80 to
120)
– 98 kcal/kg/day from 6 to 12 months
• Factors that influence calorie needs
– Weight and growth rate
– Sleep/wake cycle
– Temperature and climate
– Physical activity
– Metabolic response to food
– Health status/recovery from illness

• Protein Needs
– 2.2 g/kg/day from birth to 6 months
– 1.6 g/kg/day from 6 to 12 months
• How much is that?
– Newborn weighing 4 kg needs 2.2 X 4 = 8.8 g protein
– 6-month-old weighing 8 kg needs 1.6 X 8 = 12.8 g protein
• Protein needs are similar to that of energy but are
also influenced by body composition

• Fat Needs
– No specific recommended intake level for infants
• Breastmilk contains about 55% calories from fat
• Infants need cholesterol for gonad and brain development
• Breast milk contains short-chain and medium-chain fatty acids
(in addition to the long-chain)
– Easier to digest and utilize than long-chain fatty acids

• Metabolic Rate, Calories, Fats and Protein
– Metabolic rate of infants is highest of any time
after birth
– The higher rate is related to rapid growth and high
proportion of muscle
– Low carbohydrate and/or energy intake results in
protein catabolism impacting growth

• Other Nutrients and Nonnutrients
– Fluoride—0.1 - 0.5 mg/d depending on age (too
much may cause tooth discoloration)
– Vitamin D—400 IU/day
– Sodium—120-200 mg/day
– Iron – 11 mg for infants 7-12 months
– Fiber—no recommendations
– Lead—None—may be toxic

Physical Growth Assessment
• Newborns grow faster than any other time of
life
• Growth reflects:
– Nutritional adequacy
– Health status
– Economic & environmental adequacy
– There is a wide range of growth =normal
– Calibrated scales & recumbent length
measurement board required for accurate
measures

• Healthy newborns double their birth weight
by age 4–6 months and triple it by 1 year.

Interpretation of Growth Data
• Measures over time identify change in growth
rate and need for intervention
• Warning signs:
– Lack of Weight or Length gain
– Plateau in Weight, Length or head circumference
for > 1 month
– Drop in Weight without regain in a few weeks

Feeding in Early Infancy
• Breast Milk and Formula
– recommend exclusive breast feeding for 1st 6
months & continuation to 1 yr
– Initiate breast feeding right after birth
– Growth rate and health status indicate adequacy
of milk volume
– Standard infant formula provides 20 cal/fl oz
– Preterm formula provides 22-24 cal/fl oz

How Infant Formulas Are Modified
Compared to Breast Milk
Breast Milk
• 7% of calories from Protein
• 38% calories from carbs
• 55% calories from fat
Cow’s Milk-Based Formula
• 9-12% calories from Protein
• 41-43% calories from carbs
• 48-50% calories from fat

Cow’s Milk during Infancy
• Whole, reduced-fat or skim
cow’s milk should not be
used in infancy
• Iron-deficiency anemia
linked to early introduction
of cow’s milk
• Anemia linked to:
– GI blood loss
– Low absorption of calcium &
phosphorus
– Displacement of iron-rich
foods

Soy Protein-Based Formula During Infancy
• Soy protein in place of milk
protein should be limited in
its use
• The use of soy formula is
not recommended
– For managing infantile colic
– Lactose free and hydrolyzed
formulas are better for
infants unable to breastfeed
or be fed cow’s milk formulas

Development of Infant Feeding Skills
• Infants born with
reflexes & food intake
regulatory mechanism
• Inherent preference for
sweet taste
• At 4-6 wks, reflexes
fade; infant begins to
purposely signal wants
& needs

Development of Infant Feeding Skills
• Cues infants may give for feeding readiness include:
– Watching the food being opened in anticipation of eating
– Tight fists or reaching for spoon
– Irritation if feeding too slow or stops temporarily
– Playing with food or spoon
– Slowing intake or turning away when full
– Stop eating or spit out food when full

Introduction of Solid Foods
• Food offered from
spoon stimulates
mouth muscle
development
• At 6 months, offer small
portions of semisoft
food on a spoon once
or twice each day

Recommendations for Introduction of
Solid Foods
• Infant should not be overly tired or hungry
• Use small spoon with shallow bowl
• Allow infant to open mouth & extend tongue
• Place spoon on front of tongue with gentle pressure
• Avoid scraping spoon on infant’s gums
• Pace feeding to allow infant to swallow
• First meals may be 5-6 spoons over 10 minutes

The Importance of Infant
Feeding Position
• Improper positioning may cause choking, discomfort,
and ear infections
• Position young bottle-fed infants in a semi-upright
position
• Spoon-feeding should be with infant seated with
back and feet supported
• Adults feeding infants should be directly in front of
infant making eye contact

Preparing for Drinking from a Cup
• Offer water or juice from cup
after 6 months
• Wean to a cup at 12 to 24
months
• First portion from cup is 1-2 oz
• Early weaning may result in
plateau in weight (due to
reduced calories) and/or
constipation (from low fluid
intake)

Preparing for Drinking from a Cup
• Changing from a bottle to a covered “sippy”
cup with a small spout is not the same
developmental step as weaning to an open
cup
• Open cup drinking skills also encourage
speech development

“They say fingers were
made before forks and
hands before knives.”
Jonathan Swift

Food Texture and Development
• Can swallow pureed foods at 6 months
• Early introduction of lumpy foods may cause
choking
• Can swallow very soft, lumpy foods at 6-8
months
• By 8-10 months, can eat soft mashed foods

First Foods
• 6 months—iron-fortified baby
cereal
– Rice cereal is hypoallergenic
• 6 months—fruits and vegetables
• Only one new food over 2-3 days
• Commercial baby foods are not
necessary but do provide sanitary
and convenient choices
• 9-12 months soft table foods

Water
• Breast milk or formula provide adequate water for
healthy infants up to 6 months
• All forms of fluids contribute to water intake
• Additional plain water needed in hot, humid climates
• Dehydration is common in infants

Water
• Pedialyte or sports drinks provide electrolytes but
lower in calories than formula or breast milk
• Limit juice
• AAP recommends juice is not needed to meet the
fluid needs before the age of 6 months
• Avoid colas and tea

How Much Food is Enough for
Infants?
• Infants vary in temperament
• Crying or fussiness may be interpreted as hunger
resulting in overfeeding
• First foods may appear to be rejected due to
immature tongue movement

How Much Food is Enough for
Infants?
• Infants learn food preferences based on experiences
with foods
• Flavor of breast milk influenced by mother’s diet
• Genetic predisposition to sweet taste
• Food preference from infancy sets stage for lifelong
food habits

Common Nutritional Problems and
Concerns
• Failure to thrive,
• Colic,
• Iron-deficiency anemia,
• Constipation,
• Dental caries, and
• Food allergies

Concerns
• Failure to thrive (FTT)
– Inadequate weight or height gain
– Energy deficit is suspected
• Organic FTT:
– Inadequate weight or height gain resulting from a health problem,
such as iron-deficiency anemia or a cardiac or genetic disease.
• Nonorganic FTT:
– Inadequate weight or height gain without an identifiable biological
cause, so that an environmental cause is suspected (maternal
depression, mental illness, alcohol or drug abuse in the home, feeding
delegated to siblings or others unable to respond to the infant, and
overdilution of formula)

Concerns
• Colic - the sudden onset of irritability, fussiness or
crying
– Episodes may appear at the same time each day
– Disappear at 3rd or 4th month
– Cause unknown but associated with GI upset, infant
feeding practices

Concerns
• Iron-deficiency Anemia
– Less common in infants than in toddlers
– Iron stores in the infant reflect the iron stores of the
mother
– More common in low-income families
– Breastfed infants may be given iron supplements and iron-
fortified cereals at 6 months
– Iron-fortified versus “Low-iron” formula

Concerns
• Diarrhea and Constipation
– Infants typically have 2-6 stools per day
• Causes of diarrhea & constipation:
– Viral and bacterial infections
– Food intolerance
– Changes in fluid intake
• To avoid constipation assure adequate fluids
• Continue to feed the usual diet during diarrhea

Concerns
• Prevention of Baby Bottle Caries and Ear Infections
– Are linked to feeding practices
– Risk for ear infections is also correlated with excessive use
of a baby bottle as a bedtime practice, as a result of the
feeding position.
– Feeding techniques to reduce caries and ear infections
• Limit use of bedtime bottle
• Offer juice in cup
• Only give water bottles at bedtime
• Examine and clean emerging teeth

Concerns
• Food Allergies and Intolerances
– About 6-8% of children < 4 yrs have allergies
– Absorption of intact proteins causes allergic
reactions
– Common symptoms are wheezing or skin rashes
– Treatment may consist of formula with hydrolyzed
proteins

Concerns
• Lactose Intolerance
– Inability to digest the disaccharide lactose
– Characterized by cramps, nausea and pain and
alternating diarrhea and constipation
– Lactose intolerance in uncommon and tends to be
overestimated

Key Points
1. Infants born full-term and preterm infants born between 34
weeks and 38 weeks of gestation are the same in their
milestones of growth, development, and feeding in the first
year of life.
2. The ability of infants to feed and eat is based on
developmental skills that show readiness for the next step;
parents learn to read the signals of readiness from their
infants over time.
3. Energy and nutrient needs of infants are modulated by
individual differences in sleep/wake cycle, exposure to
temperatures, and state of health, among other factors

Key Points
4. The priority is energy needs first; protein and carbohydrates
will be converted to meet energy needs if sufficient calories
are not consumed, slowing growth over time.
5. Growth as weight, length, and head circumference accretion
is monitored and interpreted over the first year.
6. Introduction of solid foods is also a developmental stage for
parents in learning to read signs of hunger, fullness, and food
preferences in their infants and to know safe food choices.

Key Points
7. Common nutrition problems in the first year such as failure
to thrive, colic, iron deficiency anemia, and baby bottle caries
are usually solved by combining parent educational,
nutritional, and medical approaches.

THANK YOU

INFANT NUTRITION

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