Barbara Robinson, MPH, RD, CNSC

Johnson and Wales University

Length of gestation, mothers prepregnancy weight, health and size of the

placenta influence infants birth weight

After birth, the infants growth is influenced

by genetics and nourishment

Infancy

Rapid growth:
~9 in. in first year

Fetal growth
factors- like
hormones

Childhood

Slow but steady growth

(2-3 in./year)

Growth hormone

Adolescence

Pubertal growth spurt peak velocity:

Boys: ~4.5 in./yr
Girls: ~3 in./yr

Sex hormones
(testosterone and
estrogen) + growth
hormone
4

Infants adjust intake to meet energy needs

Sensitivity to hunger and satiety cues

Monitor gains in weight and length over time

Formula-fed infants consume more kcals than

breast-fed infants

Higher per kg weight than for adults because

of rapid growth DRI: 1.5g/kg/day

Recommendations based on composition of

human milk

Human milk or infant formula; supplemental

protein sources beginning age 4~6 months

40-50% of calories

Essential fatty acids (EFA) in human milk vs.

infant formula: linoleic and linolenic acids
EFA requirement: > 3% of total kcals

Long-chain polyunsaturated fatty acids;

visual acuity and neural development.
Arachidonic and Docosahexaenoic acids
(ARA,DHA)
7

Maternal reserves gone in term infants by 4 mos.

Infant iron deficiency common

effects

cognitive

Supplement w/ iron-fortified cereal

or fortified formula by 4 to 6 months

AAP: Revised recs: feed

meat earlier: by 5-7 mos.

Mineral Requirements
Calcium: more is retained from breast
milk than from infant formula
(bioavailability)
Zinc: Like Iron, is found in meats
Infants often deficient
Standard MVI does not contain minerals

Food of choice for infants

Appropriate energy & nutrients

Contains immune factors

Helps prevents diarrhea and otitis media

(exceptions)

Allergies to human milk protein are rare-caveat: mothers diet

DHA

Attachment and bonding

Maternal health benefits

10

Secretory immunoglobulin A: an antibody that plays a

critical role in mucosal immunity

Lactoferrin fights against GI infections:

Limits availability of iron in the
intestine for bacteria to feed on

Lysozymes: Exert strong influence on type of bacteria

which inhabit the intestinal tract

Lactobacillus bifidus: Helps make B vitamins, and

inhibits growth of bacteria, including more pathogenic
colon bacteria, such as salmonella.
11

DHA levels of breast milk vary with the

diet of the breastfeeding mother.

In a Danish study, eating fish/fish oil

increased the amount of DHA in breast milk.

The milk of Nigerian women, whose diet

is rich in nuts, has a high omega-3 fat
content.

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Benefits: cognitive development, gi immunity

prevention of asthma and overweight- maybe

AAP supports exclusive breast-feeding for 6

months and breast-feeding plus solid foods for
the next 6 months

New research on allergy prevention might lead

to change in recommendations

13

Protein: type affects digestibility:

~60:40 ratio of whey to casein
~20:80 ratio of whey to casein for cows milk
Whey forms softer curd, is digested more
quickly, more easily empties out of stomach
~7% of calories from protein less than formula

Lactose content
Essential fatty acids (EFAs), cholesterol, lipase
Renal solute load (RSL) (protein, sodium, potassium)

14

Based on cows milk protein

Cow milk protein is heat treated
Soy alternatives not used as often as previously

Regulated by FDA through the Infant Formula

Act, 1985

Decrease in anemia with use of iron-fortified

formulas
15

Cows milk and imitation milks not

recommended before age 1 year (caveat)

16

Cereal fortified w/ electrolytically reduced iron

Jars for fruits and vegetables provide

carbohydrates and vitamins A and C?

http://
www.nydailynews.com/life-style/health/baby-food
-grocery-store-good-infants-recommended-daily-s
upply-minerals-study-article-1.1066099

17

Issues with mixed foods and desserts

Home-prepared infant food: avoid added

salt and sugar under age ~ 10 months

Value of flavors in foods- spices, etc.

http://pediatrics.about.com/cs/agesstages/
a/nine_months.htm
18

Early

feeding patterns: Initially every 2

hours
By 2-4 months : 4 ounces every 4 hours
and no night feed
Satiety

Cues

Development

of feeding skills:
Palmer and pincer grasp
Up and down munching at 4-6
months
Rotary chewing at 7-9 months
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20
20

Addition of foods:
Solids, Complementary foods, Spoon feedings,
Beikost ("foods other than milk or formula), Infant foods

Weaning breast or bottle to cup

Preventing caries (cavities)

Feeding older infants: type of food, serving size,

forced feeding, environment
21

Weight

Length

Head Circumference

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OK135S065

24

Low weight and normal height =

acute nutritional deficiency
Low height for age = chronic
nutritional deficiency
Wasting vs. stunting
25

Inadequate growth or
Failure to ThriveFTT
(malnutrition)
Weight < 3rd percentile for age or
crossing downward two percentiles on
the growth chart within six months or
less
26

Growth failure
Developmental delay
Decreased cognitive ability

Apathy, irritability (learning, eating)

Decreased strength and physical ab

27

To compensate: need to promote

accelerated growth velocity
increased calories and
protein for anabolism
increased micronutrients such as
calcium (bone), iron, (blood
volume) zinc (DNA synthesis)

28

Inadequate food intake in

absence of disease
Due to economic and/or social
deprivation
Homes deficient in love, warmth,
enjoyment and stimulus
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Secondary
Due

Malnutrition

to disease or disability

30

Impaired ability to ingest:

chewing or swallowing
Impaired digestion/absorption
Chronic illness
31

Normative data is available and should be

utilized.

Data is only useful when accurately

obtained using recommended methodology

Successive measures of weight and height

plotted on a growth curve have far more
value than a single measure

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Premature Infants:
Chronological Age -Number of Weeks
Premature = Corrected Age
Down Syndrome
Turner Syndrome
35

36

Recumbent length: measured for first 3

years on a length board

Standing height on stadiometer

thereafter

37

38

o Supplement all
o infants w/ 400 iu Vit D
o Breast feed to 12 months
o After breastmilk, iron-fortified
formula
o Iron-enriched foods by (4-6 mos)

39

Offer meats earlier

Infants < 6months dont need water, juice
No low fat milk < age two.
Limit juice to 4- 6 ounces- offer only in
cup, not bottle

40

http://www.colbertnation.com/the-colbert-r
eport-videos/371019/january-13-2011/though
t-for-food---fruit-pouch--doritos-ad---sup
er-big-gulp

41

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Vitamin D: Supplements recommended

for ALL infants, especially those
with dark skin and esp. premature infants

AAP increased recommendation to 400

Vitamin K: Hemorrhagic disease of the newborn;

preventive injection at birth for all newborns

43

INFANT CASE STUDY

44

Breast-feeding:
1. Exposes infants to variety of
flavors that reflect maternal diet

2. Allows infant to choose own

portion sizes
45

Casein hydrolysates
Nutramigen
Pregestimil
Alimentum

Amino Acid-Based
Neocate
Elecare
Nutramigen AA

46

 Takes
But

up some of childs time and attention

keeps its place as one important area in life

Food

preferences are
a learned behavior:

Children are able to accept a wide variety of

foods with familiarity being a major
determinant of food preferences. Satter

Birch, L. Development of food acceptance.Dev.Psych. 1990:26:515

47

Eating is a Learned Behavior

Learning what to eat is a developmental

process and occurs in context of a family
environment

Eating : activity that is repeated over and over

again

Feeding behaviors and

preferences are shaped
through this repetition
48

 During

the early years, families

establish feeding and parenting
patterns that persist through the
childs growing up years.

49

Adults are responsible for

what, when and where a
child eats, but ultimately,
the child is responsible for
how much and whether
he/she eats at all
50

51

 Parents

are a childs first teachers

Window of opportunity in development of

infant and child food preferences
Effective parenting in early years :
positive impact later on

52

Food preferences repetition

Child initially dislikes healthy foods? Parent should
not be discouraged!
Continue to offer healthy food in context of pleasant
feeding experience

higher number of food exposures necessary in

children aged 4 to 5 years than in children
aged 2 years
54

Can Parents Take Advantage of This?

No

guarantee a child will like a given food

But, early, consistent exposure to a variety of

healthy foods appears to be a critical factor in

fostering preference
Take home message: Promote and expose the

child to healthy eating in the EARLY stages of

development
Birch and Marlin, 1982
55

Parental modeling:
Siblings/peers/parents = role models
encourage tasting new foods

Protective Factors: eating 6+ family dinners

per week, eating breakfast (all age groups)

REMEMBER: children are unable to eat

foods not available to them!

Rosenkranz, Richard R Model of the home food environment

and childhood obesity. Nutrition Reviews. Vol. 66(3). (2008):
56

 When

given the option, the child

often choose the LESS healthy one
Examples:
Apple vs. apple Pop Tart
Milk vs. soda
Yogurt vs. jello
low fat popcorn vs. potato chips
Baked Sweet potato vs. french fries
57

Antecedents to eating behaviors in

childhood
More food exposures needed at 4-5 yrs of
age than at 2 yrs of age:
Younger children are more likely to accept new flavors
Birch and Marlin, 1982. I dont like it, I never tried it:effects of exposure on two
year old childrens food preferences. Appetite, 353-360.

2002 study: 8 year-old children preferred the

same foods that they liked at age 4:
Suggests food preferences are more difficult to change as
children become older- durability
Skinner, Carruth, Bounds and Zeigler, 2002.58

Toddlers have poor eating habits

Study
9-11

population: 3,000 1-2 year olds

mos. of age: 9% daily french fries

19-24

mos.: 20% daily french fries

~30%

of children < 24 mos: no fruits or

vegs

Devaney, B et al. Feeding infants and toddlers study.

J.AM.Diet.Assoc. 2004:104:1 S-8-79.
59

60

 17%

had juice before 6 mos.

>30%

of kids 15 24 mos had a sugary fruit

drink each day and ~ 10% had soda

Children

aged 1-2 years require about 950

calories/day.

Median

intake was found to be 1,220 calories

Devaney, B, et al. Feeding Infants and Toddlers Study. JADA.

2004:104:1, S-8-79.

61

1. Authoritative: sensitivity, emotional warmth,

involvement and expectations for self control and
discipline

Give and take between parent and child: higher academic

achievement, increased self-regulatory ability, more
adaptable

2. Authoritarian: high demands for self-control, low levels

of sensitivity, minimal emotional support

Associated with poorer outcomes

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Permissive: low expectations for selfcontrol/discipline, high sensitivity/warmth

Children more self-confident but lower
levels of self-control

3.

4. Neglectful: low expectations for selfcontrol/discipline, low sensitivity/warmth

Unfavorable child outcomes, higher rates
of depression/smoking/poor school
achievement

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A combination of sensitivity and

expectations for self-control seem to
create an optimal environment for children
with respect to limiting overweight risk

Parent-child cooperation and parental

warmth increased childrens ability to
regulate negative emotions

Encourage listening to internal hunger

cues and promote natural desire to
exercise

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6% < 3 yrs.; up to 90% in some Head Start

Programs
AAP : know local fluoride concentrations
Varying recommendations for
6 mos 3 yr
3-6 yr
6 yr. 16 yr.
No fluoride < 6 mos.

Baby bottle tooth decay: prolonged contact of

bottle nipple to mouth, liquid pools behind
teeth. Discourage walking around or falling to
sleep with bottle.

Can occur with any liquid that has any type of

sugar including breastmilk, formula or juice
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Fluoride

Recommended dietary fluoride supplement* for age

Fluoride concentration in community drinking water

<0.3 ppm

0.30.6 ppm

>0.6 ppm

Age
06 months

None

None

None

6 months3 years

0.25 mg/day

None

None

36 years

0.50 mg/day

0.25 mg/day

None

616 years

1.0 mg/day

0.50 mg/day

None

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The use of foods and liquids (with consideration of types of foods,

feeding environment, and portion sizes served) to support
nourishment and developmental progress
sets the stage for lifelong food habits.

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Thank you!

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