Infancy (0-12 Months) Flashcards
1
Q
Infancy
A
- 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
2
Q
Infancy Stage Changes
A
- 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
3
Q
Growth and Maturation
A
- 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
4
Q
Birth Weight
A
- Determined by:
- Mother’s medical history
- Nutritional status before and after preg
- Events during preg
- Fetal characteristics
- Pre-preg weight
- Weight gain during preg
5
Q
Weight Changes during Infancy
A
- 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
6
Q
Length
A
- 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
7
Q
Growth Assessment
A
- 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
8
Q
Body Composition Changes
A
- 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
9
Q
Body Proportions
A
- Head proportion decreases with age
- Torso and leg proportion increase with age
10
Q
Psychosocial Development
A
- 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
11
Q
Development of GI tract
A
- 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
12
Q
GI Function in Newborns
A
- 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
13
Q
Colic
A
- 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
14
Q
Special Health Needs
A
- 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
15
Q
Enzymes
A
- 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
16
Q
Caloric Requirements
A
- 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
17
Q
Protein Requirements
A
- 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
18
Q
Fat Requirements
A
- 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%
19
Q
Docosahexanoic Acid (DHA)
A
- 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
20
Q
Water Requirements
A
- 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
- water losses
-
1.5 cc/kcal energy expenditure
- 1st period → 165 cc/kg
- 2nd period → 147 cc/kg
- Excessive → water intoxication
21
Q
Renal Function
A
- 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
22
Q
Vitamins and Minerals
A
- Requirements influenced by:
- GR
- Mineralization of bone
- Increase in bone length
- Increase in blood vol
- Macro intake
23
Q
Ca and Phosporous
A
- 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
24
Q
Iron
A
- 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 **
25
Fluoride
* 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
26
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
27
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
28
Rickets
* 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
29
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
30
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
31
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**
32
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
33
Suckling
* 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
34
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
35
Swallowing
* 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
36
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
37
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
38
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
39
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
40
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
41
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
42
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
43
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
44
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
45
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
46
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
47
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
48
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
49
Sterilization
* 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
50
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"
51
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
52
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
53
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
54
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
55
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
56
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
57
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
58
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
59
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
60
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 **
61
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
62
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**
63
Preterm Calories
* **120 kcal/kg** (95-180 kcal/kg)
* Aim for **at least 15 g weight gain/day**
64
Preterm Protein
3-4 g/kg
65
Catch up growth
* **\>23** weeks: provide **one year**
* VLBW or ELBW: provide 3 years
