Infancy (0-12 Months) Flashcards Preview

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  • 0-12 months
  • Highest nutrient requirement per kg
  • Direct relation between growth and nutritional status so careful assessment is required
  • Stage specific assessment tools 
    • Growth charts 
    • Length, weight and head circumferences
    • Up toage 3
    • Data recorded as percentiles 


Infancy Stage Changes

  • Dramatic changes occur
    • Babies have no head control → standing and walking
  • Period of most rapid growth
  • Changes in food and feeding abilities
    • Reflexive sucking → feeding themselves 


Growth and Maturation

  • Nutrition influences physical and psychosocial growth and development
  • Under and over nutrition detrimental
  • First 6 months critical for brain growth
  • Stage of maturation determines types of food
  • Substantial requirement of energy for growth from 0-4 months
    • Growth rate slows from 4-12 months
    • Caloric reqs/kg decrease
  • Nutritional status determined by anthropometrics
  • Bond between infant and parents, siblings, etc. is established in this stage 


Birth Weight

  • Determined by:
    • Mother's medical history
    • Nutritional status before and after preg
    • Events during preg
    • Fetal characteristics
    • Pre-preg weight
    • Weight gain during preg


Weight Changes during Infancy

  • Immediately after birth → 6-10% weight loss → regained by 10-14th day
  • Weight gain proceeds at a rapid, but decelerating, rate
  • By 4-6 months, birth weight usually doubles
  • By 1 year, BW triples
  • Rate of growth slows substantially in 2nd half of infancy 



  • Increases by 50% in first year of life
  • Average length gain is 10-12 inches
  • Some infants shift percentiles up or down on growth grids
  • Race may influence growth rate
  • AA smaller than white at birth, but they grow more rapidly during first 2 years 


Growth Assessment

  • Growth grids used to plot weight, length and head circumference
  • Physical growth is an indicator of health and nutritional status
  • Accurate measuring and recording is critical
  • Periods of growth acceleration and growth deceleration should be monitored carefully
  • Growth Charts, 2000
    • Originally based on white, mostly bottle-fed infants
    • Revised based on a more representative sample
    • Birth - 36 months
    • Wt, L, HC (for age) and wt for length 
    • Wt-ht percentile rank infant in relation to 100 others of same length 


Body Composition Changes

  • Percent water decreases in first year
  • Intracellular water increases
  • Extracellular water decreases
  • Increase in LBM and fat mass
  • Gender related differences appear
    • Females deposit a greater percentage of weight as fat than do males 


Body Proportions

  • Head proportion decreases with age
  • Torso and leg proportion increase with age


Psychosocial Development

  • Key part of overall infant development
  • Feeding is the fundamental interaction from which parent-infant relationship evolves
  • Healthy development facilitated by:
    • Parents's response to hunger should be immediate in newborn to assure baby their needs will be met
    • Close physical contact during feeding is beneficial
    • Development of trust is critical
    • Propping bottle is not safe and hinders development in first few months of life 
    • Babies generally don't feed well when they are distressed
    • Temperment of infant needs tobe considered
    • Quiet, wakeful state
    • Parent/caregiver must be cued into infants signs of hunger and satiation
    • Infant's cues rapidly change with development


Development of GI tract

  • Development influenced by
    • exposure of fetal GI to growth factors, hormones, enzymes and immunoglobulins
    • Factors in human milk, such as growth factors, hormones and enzymes 
  • Digestion requires:
    • Coordinated sucking and swallowing function
    • Gastric Emptying
    • Intestinal motility 
  • Absorption Requires:
    • Savliary, gastric, pancreatic and hepatobiliary secretions
    • Intestinal cell function
    • Expulsion of undigested waste products 


GI Function in Newborns

  • Frequent "spitting up" is normal
    • Esophageal motility decreased
    • Lower esophageal sphincter pressure is less
    • Gastric emptying delayed
    • Intestinal motility not organized
  • Stomach capacity 10-12cc increases → 200cc
  • Spitting up
    • Small amounts of milk and food
    • Not cause for alarm if infant is growing well
    • Furter evaluation warranted if:
      • Growth is inadequate
      • Pain is associated
      • Feeding aversions present
  • Small intestinal transit time slower to aid in adequate digestion and absorption of nutrients 
  • Colonic transit time quicker, which may increase risk of dehydration and electrolyte disturbances if diarrhea develops



  • Severe abdominal pain
  • Persistent, unexplained crying "Rule of Threes"
  • 10-30% infants affected
  • Affects both breast and formula fed infants
  • Most cases are outgrown 
  • Most do not respond to nutritional therapies
  • Some recent evidence associating foods with symptoms: cow's milk, egg,s peanuts, tree nuts, wheat, soy and fish 


Special Health Needs

  • Poor suck may indicate abnormal muscle tone or cerebral palsy
  • Stiffening and arching during feeding may be due to spasticity
  • Poor growth may indicate physical or neurological difficulties
  • Intervention and assessment by an interdisciplinary team is recommended if any of these signs exist 



  • Allow digestion and absorption of nutrients in milk
  • Infants have lower levels compared to adults
  • Infant GI tract is able to compensate for lower enzyme levels/immature pancreas
    • Salivary and gastric lipase
    • Amylase and lipase in breast milk


Caloric Requirements

  • 0-6 months → 108 kcal/kg/day (range 80-120)
  • 6-12 months → 98 kcal/kg/day
  • Based on
    • body size
    • physical growth
    • Rates of growth
  • May be overestimated
    • Breast fed infants have lower requirements than bottle fed because of more efficient absorption
  • Total daily energy requirements increase
    • kcal/kg decreases because energy/unit body size decreases
    • requirements for growth decrease
    • Requirements for activity increase as infant becomes more mobile 


Protein Requirements

  • Body protein content increases in first year
  • Requirements:
    • 1st period → 2.2 g/kg/day
    • 2nd period → 1.6 g/kg/day
  • Minimum standards for formula → 1.8 g/100 kcal formula (per AAP)
    • 9 essential AA plus cysteine and tyrosine


Fat Requirements

  • Supplies 40-50% energy for newborn so protein can be used for tissue synthesis
  • Energy from fat drops when carb-rich weaning foods introduced
    • do not introduce solids too early
    • energy from fat increases when table food introduced
  • Inadequate fat intake → growth failure 
  • Fat and cholesterol intake during infancy → long term effects on lipid metabolism 
  • EFA's necessary 
    • prevent EFAD
    • promote growth and neurological development
    • EFA's serve as precursors for LCFA's
  • AAP and FDA recommend 2.7% linoleic acid 
    • Breast milk = 3-7%


Docosahexanoic Acid (DHA)

  • Very important for brain and CNS
  • Breast milk is a good source
    • Only if the mom has been consuming sufficient DHA
  • DHA may
    • explain reported higher IQ
    • Explain reported improved visual function
    • Reduce growth rates 
    • Ratio of omega-3 to omega-6 FA may be a key factor in growth rate
    • DHA and ARA recently added to most formulas


Water Requirements

  • Higher water / kg than adults 
  • Requirements determined by:
    • water losses 
      • evaporation from skin
      • water lost in breath
      • elimination in urine and feces
    • water required for growth
    • solutes derived from diet 
  • 1.5 cc/kcal energy expenditure
    • 1st period → 165 cc/kg
    • 2nd period → 147 cc/kg
  • Excessive → water intoxication 


Renal Function

  • Newborns have "stupid kidneys"
  • Small range for maintaining water and electrolyte balance
  • Infants susceptible to dehydration
    • Limited amount of antidiuretic hormone produced by pituitary
    • Limited capacity to concentrate urine 


Vitamins and Minerals

  • Requirements influenced by:
    • GR
    • Mineralization of bone
    • Increase in bone length
    • Increase in blood vol
    • Macro intake


Ca and Phosporous

  • Breast milk content is reference point
  • Ca absorption varies considerably with source
    • Breast milk → 60%
    • Formula → 38%
  • Formula has more Ca to compensate for lower absorption rate 



  • Iron deficiency in US declined because
    • Increased breast feeding
    • Use of iron fortified formula
  • Iron deficiency → developmental problems
  • Iron needs supplied by:
    • Prenatal reserves
    • Food sources
  • Infants at risk for deficiency:
    • Premature infants
    • Rapidly growing infants
  • Absorption is highly variable
  • Exclusively breastfed infants require additional Fe after 6 months 



  • Essential in preventative dental care
  • Excess intakes → fluorosis
  • Breast milk is low in fluoride and may require infant supplement - debated
    • < 6 months → 0.1 mg/day
    • > 6 months → 0.5 mg/day
  • Formulas mixed with water reflect fluoride in water supply
  • Maternal fluoride intake does not affect breast milk 


Vitamin A

  • Excess worse than deficiency
  • Milk is good source
  • Generally no supplementation
  • Supplementation recommended for:
    • Infants/toddlers with complications of measles
    • Older infants with deficiency symptoms
    • Immunodeficiency
    • Malabsorption
    • Malnutrition 


Vitamin D

  • Necessary for bones - works with Ca, P and protein
  • Requirements dependent on amount of exposure to sunlight
  • AAP recommends 400 IU/day for breastfed infants (starting in first few days of life)
  • Sun exposure:
    • 1/2 hr/week (diaper)
    • 2 hr/week (clothing, no hat)
  • Formula kids don't need sun exposure



  • Weakening of bones
    • Diminished Ca absorption → hypocalcemia
    • Usually result of Vit D deficiency
    • Can lead to seizures
  • Increase incidence (3 fold) in past decade
  • AA more susceptible 


Vitamin K

  • Infants have low K stores at birth
  • Risk for hemorrhagic disease of newborns (2-10 days after birth)
  • Breast fed infants at greater risk
  • Since 1961, AAP recommends prophylactic dose (IM) of Vit K at birth
  • IM dose more effective than oral


Vit/Min Summary

Full-term breastfed infants receive adequate, except:

  • K → IM shot
  • D → sun exposure
  • Fluoride
  • Iron (after 6 months and if mother is deficient)
  • B12 if mother is vegan → okay if mom takes supplements

Full term formula receive adequate, except:

  • K
  • Fluoride, depending on water source


Development of Oral Structure/Function

  • Physical and motor maturation affects:
    • Form of oral structure
    • method by which infant extracts milk from nipple
  • Neonate prepared at birth to suck and swallow
  • Newborns suck instinctively
  • 2-3 week old infants suckle
  • Older learn mature sucking


Newborn "Eating"

  • At birth, tongue is disproportionately large compared to lower jaw
  • When mouth is closed, upper and lower jaw do not align
  • Tip of tongue lies between upper and lower jaw



  • Earliest feeding skill
  • Reflexive movement of tongue
  • Breast and bottle suckling are similar 
  • Negative pressure created when nipple is in mouth
  • Lower jaw and tongue qork together to remove milk
  • Nipple held in position, close to junction of the hard and soft palate
  • Larynx is elevated so liquid passes around it


Mature Sucking

  • Differs from suckling in the mechanism of liquid movement in oral cavity and swallowing
  • Tonsils and lymphoid tissue important in swallowing
  • Not a continuous process
  • Swallowing movement interrupts the sucking and breathing



  • Coordination of the oral structures to:
    • Propel milk to the pharynx and esophagus
    • Keep airway open and food away
    • Back portion of soft palate raised toward roof of mouth


Mature Feeding

  • Oral cavity larger
  • Tongue no longer fills mouth
  • Elongated tongue can be protruded to receive and pass solids between gum pads and erupting teeth for mastification
  • Characterized by separate movements of lips, tongue, gum pads or teeth 


Feeding: 1-3 Months

  • Rooting reflex → stroking perioral skin (cheeks and lips) causes infant to turn toward stimulus
  • Rooting and suckling can be elicited when infant hungry but absent when satiated
  • Tongue moves in up and down motion
  • neonate assumes tonic position, head to one side and arms fisted 


Feeding: 4-6 months

  • Tongue movement back and forth
  • Rooting fades
  • Spoon feeding feasible
  • Infant can draw in lower lip as spoon is removed
  • Tonic neck position fades
  • Head at midline position during feeding
  • Hands close over bottle
  • Palmer squeeze/grasping objects


Feeding: 7-9 months

  • Chewing
  • Up and down movementof jaws
  • normal gag reflex developing 
  • Hand to mouth coordination
  • Sitting posture
  • Finger feeding
  • Can hold bottle alone
  • Pincer grasp


Feeding: 10-12 Months

  • Biting nipples, spoons, crunchy foods
  • Grasps bottle, foods
  • Drinking from cup that is held
  • Uses tongue to lick food morsels off lower lip
  • Refined finger feeding 


Infant Formulas

  • Higher nutrient content than breast milk
  • Lower bioavailability
  • Continue to adjust as we learn more about optimal feeding for infants
  • Classified by source and form of protein
  • Possible future additions to formula:
    • Antiallergenic factors
    • Immunity-enhancing antibodies/antigens
    • Growth-promoting factors
    • Biologically active factors that increase absorption


Modified Cow's Milk Formulas

  • Feeding of choice when breastmilk not used - stopped at one year old 
  • Regulated by FDA through Infant Formula Act
  • Heat-treated nonfat milk
  • Butterfat replaced with vegetable oil
    • Mimics FA profile of human milk
    • Increases EFA content
  • Lactose = major carb
  • Vits and mins added in amounts large enough to compensate or lower bioavilability
  • Fortified with low or high levels of Fe
  • True intolerance to Fe-fortified formula rare
    • Use of formula recommended to prevent anemia


Soy Protein Formula

  • Soy protein with added methionine 
  • Safe and nutritionally equivalent to cow's milk
  • Generally not needed for most infants 
  • Indicated for:
    • Vegetarian families
    • Galactosemia (can't convert galactose → lactose)
    • Hereditary lactase deficiency
  • Not recommended for:
    • Preterm infants → not adequate for bone mineralization 
    • Cow's milk protein-induced enterocolitis
      • infants allergic to cow's milk often develop allergy to soy
      • May need casein hydrolysates formula
    • Infants with acute gasteroenteritis
    • Prevention of colic or allergy


Casein Hydrolysate Formulas

  • Proteins hydrolyzed to small peptides and AA
  • Most are lactose free
  • Contain MCT
  • Strong taste like throw up
  • Expensive
  • Developed for infants who can't tolerate other formulas or have severe milk protein allergies 


Unmodified Animal Milk

  • Unmodified cow or goat milk not recommended for first year of life
  • Increased risk of anemia
  • High renal solute load
  • Lower levels of Fe, EFA's, Vit E, Zinc, and Folate
  • Lower level of fat absorption
  • Whey:Casein ratio
    • Cow's milk: 20% whey and 80% casein
    • Breast milk: 60% whey and 40% casein
  • Whey protein
    • better tolerated, less spitting up and softer stools
    • protein remaining after curd and cream removed
  • Casein
    • Predominant
    • Forms a tough, hard to digest curd in stomach
  • Can cause GI blood loss 


Follow Up Formulas

  • Developed for older infants and toddlers
  • Offer no advantage when weaning foods are chosen carefully
  • Contain higher levels of proteins and minerals (fe) than cow's milk
  • May offer advantage if child eats poor quality diet 


Substitute or Imitation Milk

  • Should not be used for infants
  • Can cause severe malnutrition
  • Developed by the FDA as nutritionally equivalent to cow's milk based on content of 15 nutrients
  • Does not contain all nutrients
  • Can pose significant nutritional problem for infants with no other source of nutrients in diet 


Formula Preparation

  • Standard provides 20 kcal/oz
  • Liquid concentrate prepared by mixing with equal amounts of water
  • Ready to feed avilable in different sizes
    • 4-32 oz
  • Powdered formulas prepared by mixing water
  • All types provide appropriate nutrients and solute load when properly prepared
  • Errors with prep can be dangerous
  • Guidance in prep recommended
  • Feeding dilute formula can cause:
    • Malnutrition
    • Water intoxication
    • Hyponatremia
    • Irritability
    • Coma
  • Feeding concentrated formula cause:
    • Hypernatremia
    • Dehydration
    • Tetany
    • Obesity
    • Fever
    • Infection



  • No longer recommended
  • Water supply should be safe
  • Clean technique should be utilized
    • Careful handwashing
    • Thorough washing and rinsing of all equipment
    • Covering and refrigerating all opened cans
    • Discarding leftover milk after feeding
    • Microwaving bottle strongly discouraged 


Developmental Approach to Instant Feeding

  • Addition of semisolid food occurs in 2nd half
  • Developmental readiness for solids may include a critical period for accepting solids
  • Most infants are developmentally ready for semi-solid at 4-6 months
  • Most infants learn to chew around 6-7 months
  • At this point, they are ready to consume "food"


Transitional Phase


  • From pureed → chopped occurs at 6-12 months
    • If delayed, child may have trouble with acceptance
    • Should be introduced one at a time
  • Choice of foods should facilitate manipulation in mouth
  • Avoid foods with potential choking risk
  • Family foods can be added at end of first year
  • Transition to cup at 6-8 months
  • Inappropriate pressure may result in feeding problems
  • Feed when infant shows signs of hunger
  • Food is not a reward or bribe
  • Intervals between feeding may vary
  • Formula fed infants may have greater intervals than breast fed
  • Over and under feeding should be avoided 
  • Newborns like sugar
  • Repeated exposure may be needed to accept new food
  • Loving and nuturing environment → sense of security and trust
  • Breast fed > formula fed infants in accepting new foods
  • Force feeding is counter productive 


Hunger/Satiety Cues

  • 0-3 months
    • Hunger: fusses, cries, mouths nipple
    • Full: draws away, falls asleep
  • 4-6 months
    • Hunger: actively approaches breast, bottle or spoon
    • Full: releases nipple, fusses, cries, attentive to environment
  • 7-9 months
    • Hunger: vocalizes eagerness for feeding
    • Full: clothes mouth tightly, shakes head
  • 10-12 months
    • Hunger: points or touches spoon
    • Full: hands bottle/cup back to feeder


Premature Initiation of Solids


  • Can be detrimental
  • Immature kidneys can't handle large osmolar load of protein and electrolyts
  • Digestion of some fats, proteins and carbs is compormised
  • May intorduce solids before 4 months
  • Most parents who introduce too early think that solids will keep kids sleeping longer through the night
  • Choking 
  • Aspiration
  • Respiratory illness
  • Food allergies
  • Immunologic diseases
  • Excess weight gain


Serving Size

  • Very important part
  • At one year, babies eat 1/3 to 1/2 the amount an adult normally consumes
  • Offering a tablespoon of each food is a good size to start with
  • Allow the child to ask for more if they are still hungry


Commerical Infant Foods

  • Convenient and easy to transport
  • Infant cereals
    • First food added
    • Ready to serve
    • Fortified with Fe
  • Fruits/Veggies
    • Second food group added
    • Provides carbs
    • As many veggies as possible first → then fruit 
    • Variable amounts of Vit A and C
    • Several have added sugars, which is bad
    • Milk and wheat added to many veggies
    • Excessive juice intake can be risk for dental caries
      • Never give juice in a bottle
      • intake limited to 4 oz/day
  • Meat and Combination foods
    • Prepared with water only
    • Strained meats have highest caloric density
    • Excellent source of protein and Fe
    • Combination dinners:
      • high in water
      • Lower in protein and nutrients
      • Individual ingredients should be tolerated before provided in a mixed meal
  • Desserts
    • Nutrient composition varies
    • All contain sugar and modified corn starch or tapioca
    • Should be used in moderation, if at all


Home Prep of Infant Foods

  • Goals:
    • Food safety
    • Preservation of nutrients
  • Food carefully selected
  • Wash hands and utensils
  • Little to no salt and sugar
  • Minimum water 
  • Texture can vary
  • Future meals can be frozen in single portions 
    • Thaw in refrigerator
  • Age and type of table foods offered varies with culture
  • Infant and family's diet similar at one year
  • Wider variety of foods
  • Less expensive, more time consuming
  • More concentrated nutrients because less water
  • Control over quality 


Dietary Guidelines

  • Guidelines for older infants similar to those of a dults
  • Moderation
  • Avoid low nutrient dense foods
  • Avoid excessive sugar
  • Whole fat dairy until age 2
  • Adequate intakes of fiber
    • ~5 g/day
    • 1/2 c of fruit, 1/2 c veggies or 1/2 c infant cereal


Safety Issues

  • Solid food should be easily masticated
  • Choking and aspiration can occur
  • Honey → not recommended for infants under one year due to botulism spores 
  • Mercury in Fish
  • Microwaving → potentially dangers and uneven heating of food can cause burns 


Baby Bottle Tooth Decay

  • Caries between 1-3 years
  • Involves upper, front teeth most severely
  • Cause not entirely understood 
  • Presence of carb in mouth along with baceria → fermentation of carb → production of acids → demineralization of tooth structure
  • Risk associated with:
    • Lack of fluoridated water
    • Ethnicity, maternal dental health
    • Late weaning
    • Going to bed with a bottle
  • Secondary teeth also at risk
  • Prevention:
    • Stressing importance of primary teeth
    • Early use of cups
    • Avoiding bottle in bed
    • Fluoridated water or fluoride supplement at 6 months


Chronic Disease and Infant Diet

  • Obesity
    • May be related to formula feeding
    • May be related to early introduction of solids
    • Obese infants → obese adults
  • At risk for Diabetes
    • Breastfeeding recommended for full 1st year
    • Avoidance of cow's milk protein during 1st year
    • Delayed introduction to food 


Food Allergies

  • Breastfeeding beneficial
  • Avoid premature introduction of solids
  • National Institute of Allergy and Infectious Disease
    • No conclusive evidence to suggest delayed intorduction of allergenic foods is helpful 


Preterm Babies

  • < 34 weeks gestation 
    • Different growth charts, same cut points
      • SGA <10th
      • LGA >90th
  • Correction for Gestational Age
    • Accounts for number of weeks early 
    • 25 weeker (15 weeks early) → at 5 months (20 weeks old) would be considered 5 weeks old 


Preterm Calories

  • 120 kcal/kg (95-180 kcal/kg)
  • Aim for at least 15 g weight gain/day


Preterm Protein

3-4 g/kg


Catch up growth

  • >23 weeks: provide one year
  • VLBW or ELBW: provide 3 years