1. Nutrition During Infancy and for Lactation By Jennifer Turley and Joan Thompson © 2013 Cengage

2. Introduction The physical, cognitive, and social triad during infancy – Successful growth and development Nutrition needs for the lactating mother Nutrition needs during infancy – Breast Feeding – Formula Feeding – Energy and Nutrient Needs for Baby – Baby’s First Foods Infant fitness and lifestyle management

3. Successful Growth and Development Helplessness to walking in one year. Notable developmental changes by body system. Organ/SiteDamage Circulatory System Three blood flow changes occur after birth and are mostly complete within hours after birth and totally complete within three weeks to several months. Newborns have more blood cells that are needed due to changes in respiration, therefore the liver breaks down the RBC’s to bilirubin which is normally excreted. Excess bilirubin results in jaundice or yellowish appearance and can cause brain damage. Treatment involves exposure to UV light which breaks down bilirubin in the skin.

4. Digestive System Infants can detect the smell of their mother’s milk. Taste is influenced by the mother’s diet if breast fed. Gastric pH is alkaline at birth then becomes acidic within 24 hours. Acidity then decreases for a few months. Some enzymes are equal to that of an adult (trypsin). Others are only ten to 60% of an adult (chymotrypsin, lipase, amylase). Intestines are larger than an adult and may be ‘leaky’. Endocrine System Hormonal changes occur during adolescence during puberty and again in the older adult during menopause and andropause. Integumentary System The sense of touch is fairly developed at birth. The skin is soft and elastic. Muscular System Muscular development is largely controlled by the hormones governing growth and natural physical activity. Nervous System The brain is only 25% developed (continues through childhood) and nerve fibers are not completely myelinated until age two. Reproductive System Reproductive capability develops during adolescence and then ceases in women after menopause. Respiratory System Respiration initiates at birth. During the final month of pregnancy the neonate begins breathing like motions although the lungs are filled with amniotic fluid. The birthing process causes most of the amniotic fluid to be expelled from the lungs. Skeletal System Bone matrix is increasing and mineralizing with the nutrition delivered in breast milk or infant formula. Urinary SystemIs immature until five months. By one month the kidney nephrons are mature and water balance can be maintained.

5. Successful Growth and Development Dramatic increase in body weight and length. Successful growth and development are measurable by CDC and WHO growth grids. – There are many types of grids and differences between CDC and WHO grids – Baby well check visits at 3, 6, 9, and 12 months – Tendency to follow a grid pattern – Deviation indicates a health problem and failure to thrive (FTT)

6. Successful Growth and Development Good nutrition supports cognitive development and is needed for skills acquisition Eating is a time for social maturation Sensations develop so that eating is pleasurable – Olfaction (smell) – Gustation (taste) – Mouth feel

7. The Lactating Mother Lactation is a maternal, mammalian biological process In the 1 st trimester, hormonal changes cause the breasts to enlarge, the ducts and alveoli multiply rapidly Proper nutrition supports milk production, volume, and quality Mature milk from a properly nourished lactating woman is high in fats, contains cholesterol, and is adequate in protein, carbohydrates, vitamins and minerals.

8. The Lactating Mother Breast milk composition changes 3 stages of lactogenesis – 1: 12 weeks before delivery when the breasts (mammary glands) begin to secrete colostrum. Breast size increases further as the alveoli become filled with colostrum. – 2: after birth, first fluids contain colostrum, milk comes in after 2-3 days. – 3: mature milk supply occurs, supply and demand

9. Lactation and Nutrition Needs Calories: EER + 330 Calories in 1 st 6 months of breastfeeding, + 400 2 nd 6 months Carbohydrate: 210 gm/day minimum DRI, 45- 65% of Calories ≤25% of Calories from sugars, 1.4 grams per 100 Calories fiber DRI Protein: 1.1 gm/kg to support milk production Fat: Increased EFA DRIs, 20-35% of Calories, omega-3’s support the central nervous system Vitamins, Minerals and Water: Many nutrients needed in higher amounts, 3.8 liters of water per day is the DRI

10. Nutrition Needs during Infancy BenefitsTips for Success Infant benefits  Highly bioavailable and balanced nutrient source  Hormonal support for psychological development  Cognitive development  Strengthened immunity; possible protection against hypertension, type 1 diabetes, and allergies later in life Mother benefits  Uterus contraction  Conserves iron by preventing menses (not a reliable method of contraception)  Possible breast and ovarian cancer protection Other benefits  Cost savings from improved health and no formula purchasing  Environmentally responsible choice of non manufactured, processed, packaged, and shipped food source

11. Breast milk of formula to age 1 Breast Feeding Gold standard Bonding process Controlled by oxytocin On demand feeding Requires proper technique If baby is growing and developing as expected, then baby is getting enough breast milk Formula Nutritionally balanced off of breast milk Often cow’s milk or soy based Many contain DHA Some contain taurine Specialized formula’s made with hydrolyzed proteins to improve tolerance Reconstitute per instructions

12. Energy and Nutrient Needs for Baby Calories: EER, high Calorie need, 2-4 times more per Kg than adults Carbohydrate: 60 gm/day (0-6 mo & high lactose); 95 gm/day (7-12 mo); no DRI for fiber Protein: 1.52 gm/Kg (0-6 mo); 1.5 gm/Kg (7-12 mo); 10 EAA, underdeveloped kidney’s Fat: High intake and a DRI; 31 gm/day (0-6 mo); 30 gm/day (7-12 mo); DRIs for the EFAs, long chain omega-3 FA are health promoting

13. Vitamins: focus on vitamin K, D, B 12 Minerals: focus on iron, iodine and fluoride Energy and Nutrient Needs for Baby

14. Vitamins & Minerals Vitamin K: injection given at birth for blood clotting, sterile gut so no bacterial synthesis Vitamin D: If breast fed provide liquid supplement 400 IU/day Vitamin B 12 : A concern for breast fed infants with strict vegan mothers Iron : reserves up to age 6 mo, formula is typically fortified, introduce iron fortified cereals and other iron rich sources in time, prevent milk-anemia Iodine: critical for proper growth and development, deficiency of iodine causes irreversible brain and central nervous system damage Fluoride: for tooth formation, amount supplemented depends on water fluoridation and filtration

15. Water Need positive water balance for nutrient and waste transport, body temperature regulation, and as the medium for metabolism 75% body composition is water, by age 1 60%. 15% daily turnover from urine, feces, skin, and breath. Breast milk or infant formula replaces fluids. No need for extra water under normal circumstances. DRI: 0.7 L/day (0-6 mo); 0.8 L/day (7-12 mo)

16. Baby’s First Foods Division of Responsibility – Parent or Caregiver and Infant – Caregiver feeds infant on demand and provides scheduled healthy and appropriate foods – Baby decides how much to eat and pace Sequence of Introducing Foods – Age of first foods – Skills based progression

17. AgeGrowth & DevelopmentFeeding SkillFoods to Introduce 0-1 Month Large head with soft spot on top; May hiccup, spit up, startle easily, sneeze, and tremble at the jaw; Sleeps most the time Rooting reflex; Sucking reflex; initially swallows liquids using back of tongue Breast milk or iron- fortified infant formula every few hours on demand with cuddling 2-4 Months Lifts head briefly when lying on stomach; Smiles, coos, and gurgles; Whole body moves when lifted or touched; Deliberate communication and movement begins; Sleeps most the time Gradually begins to use front of tongue along with back of tongue; Strong extrusion reflex (tongue-thrust) to push food out Breast milk or iron- fortified infant formula every three to four hours or on demand with cuddling while alert and calm 4-6 MonthsWeight nearly doubled and growth increased three to four inches since birth; Follows objects with eyes and reaches for objects with both hands; Grasps objects with palm of hand; Puts fingers and objects in mouth; Turns over, vocalizes, sits erect with support; Sleeps six to seven hours at night and takes three to four naps per day Extrusion reflex diminishes, ability to swallow non liquid foods develops; Indicates desire for food by opening mouth and leaning forward; Opens mouth for spoon and closes lips over spoon; Swallows semi-solid food; Begins chewing action and brings hand to mouth; Indicates satiety by turning away and leaning back Continue cuddling nipple feeding from breast or bottle; Begin iron- fortified rice cereal mixed with breast or infant formula and pureed vegetables and fruits according to baby’s skills using baby spoon and offering small bites; Eats six to seven times per day

18. 6-8 Months Gains in weight and height are less rapid, appetite decreases; Teething occurs; Sits alone; Stands up with help; Takes three naps per day Able to feed self with fingers; Bites off food; Chews with rotary motion; Develops pincher (finger to thumb) grasp; Begins to drink from cup; Joins family meals Continue cuddling nipple feeding from breast or bottle; Begin wheat-free dry cereal, mashed vegetables, fruits, plain baby food meats, unsweetened 100% fruit juices from cup; Spoon feed thick/lumpy foods; Introduce sippy cup 8-10 Months Sits unsupported and crawls; Explores objects with hands, eyes, and mouth; Takes two naps per day Begins to hold own bottle; Curves lips around cup; Reaches for and grasps food and spoon; Chewing improves Continue cuddling nipple feeding from breast or bottle but at snack time only beginning around nine months; Begin breads, cereals, crackers, yogurt, soft chopped cooked vegetables and fruits, finely cut meats and fish, casseroles, cheese, eggs, and mashed cooked legumes from the table with hands, fingers, and/or spoon 10-12 Months By twelve months has tripled birth weight, increased length by 50%, and begins to walk unassisted; Grasps and releases objects with fingers; Takes one to two naps per day Chewing and cup drinking improves. Finger feeds and masters spoon but still spills some food; By 12 months engages in family time eating with self-feeding; Is offered scheduled meals and snacks Continue cuddling nipple feeding from breast or bottle but at snack time only; Add variety and increase portion sizes; At 12 months offer all soft non-choking risk foods at the family table; May switch from breast milk or formula to whole pasteurized milk; Full transition from bottle to sippy cup with weaning

19. Inappropriate Foods, Beverages, and Feeding Methods Feed based on the baby’s skills Baby’s bottle: avoid microwaving and BPA plastic bottles Formula preparation: watering down formula can cause FTT and hyponatremia. Other: Don’t mix with cereal and put in a bottle, Don’t jiggle the nipple to speed up the feeding, don’t put baby to bed alone with a bottle to self-feed, Do hold baby while feeding Avoid choking risk foods: popcorn, peanuts, hotdogs, hard candy, and whole grapes Limit fruit juice once OK to feed

20. Inappropriate Foods, Beverages, and Feeding Methods Pay attention to allergy signs and symptoms, don’t introduce foods too early No honey or corn syrup, clostridium botulinum risk Don’t force child to clean plate, avoid putting too much food on child plate, don’t allow grazing, don’t let child get too hungry Model appropriate eating patterns and manners. Offer nutritious foods to support baby’s nutritional needs best

21. Food Assistance Programs Women, Infants, Children (WIC) – Supplemental foods, health care referrals, and nutrition education – Pregnant, breastfeeding, and non-breastfeeding postpartum women, and infants and children up to age five The Supplemental Nutrition Assistance Program (SNAP) – Modern day food stamp program

22. Infant Fitness and Lifestyle Management An active baby is a healthy and happy baby. During awake times and as developmental skills progress, infants do enjoy physical activity Caregiver activities and stimulation at first, then infant can engage in activities based on skills Provide safe age-appropriate fitness opportunities on a regular daily schedule

23. Summary Successful growth and development requires adequate nutrition and cognitive and social stimulation. Expected infant growth is monitored using a variety of anthropometric growth grids. Feeding the infant through the first year of life includes providing breast milk or formula. Solid foods may be introduced sometime between four and six months; one food at a time and the least allergy risk foods introduced first. When feeding, the principles incorporated in the division of responsibility should be adopted and appropriate feeding and fitness practices should be established. References for this presentation are the same as those for this topic found in module 7 of the textbook