Understanding of Infant Nutrition Needed
Most parents and caregivers have questions when it comes to feeding an infant. Often, new parents are guided by well-intended folklore or misinformation regarding this important topic. This issue of Nutrition Spotlight focuses on infant feeding the accurate, current practices that will assure parents and help ensure optimal infant nutrition.
In a recent survey conducted by the Institute of Pediatric Nutrition, researchers addressed issues related to breastfeeding, the use of iron-fortified formula, frequent spitting up, the introduction of cow's milk into the infant diet and the nutritional value of fruit juice. Mothers who responded to the survey frequently selected incorrect practices as desirable.
The article (1) concludes that "to help parents understand and learn, the information will need to be presented again and again in different ways." It is the intent of this issue of Nutrition Spotlight to revisit the important topic of feeding our youngest, and to provide information for those who educate parents about basic infant nutrition.
Source:1 Hobbie, C; Baker, S; and Bayerl. C.: "Parental Understanding of Basic Infant Nutrition: Misinformed Feeding Choices." Journal of Pediatric Health Care. 2000; 14(1): 26-31.
The ABC's of Feeding the Newborn
Feeding the Newborn
Despite what our grandmothers might say, it is impossible to "spoil" a newborn. A caregiver who is sensitive to an infant's hunger cues and provides feedings "on demand" will set the stage for optimal growth. For the first few weeks of life, this may mean nursing every couple of hours. Feeding "on demand" rather than "on schedule" allows the infant to develop a sense of security that his needs will be met and this, in turn, will foster his emotional and physical growth.
An infant can grow and thrive on either breast milk or iron-fortified infant formula. However, the current position of the American Academy of Pediatrics is " human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions." Support for this recommendation is based on mounting evidence that breastfed babies have fewer illnesses, and those that they do have are less severe. For example, infants exclusively breastfed for at least four months may experience as few as half the number of ear infections as formula fed babies. There are special antibodies and antimicrobial factors in human milk. In addition, the unique sucking technique required in breastfeeding prevents milk from pooling in the eustachian tubes which encourages bacterial growth. Lactose in breast milk also promotes growth of "good bacteria" in the gut that protects against harmful intestinal organisms such as e.coli bacteria. There is growing evidence that breastmilk may reduce the incidence of many other conditions such as diarrhea, lower respiratory infections, urinary tract infections and necrotizing enterocolitis. It also may protect against some allergies, asthma, juvenile onset insulin-dependent diabetes, Crohn's Disease, Attention Deficit Hyperactivity Disorder, and even SIDS. Most recently, studies have found that school-aged children who were breastfed as infants have much lower incidence of obesity. This could be significant in the face of our national dilemma of overweight children and adults.
Although infant formula does not have the protective antibodies of human milk, it does have all the nutrients and calories necessary to promote excellent growth and development. According to the AAP, all infant formulas should be iron-fortified. There are low iron formulas on the market, but using them without iron supplementation puts an infant at risk for anemia and even permanent cognitive and motor problems. There are circumstances when iron-fortified infant formula is the preferred feeding, as is the case when the mother may not be able to produce enough milk, or she may have a disease such as AIDS or she may be taking a medication that passes into the milk and adversely affects the infant.
Whole cow's milk is not recommended for an infant during his first year of life. The gastrointestinal tract of a young infant is not sufficiently mature and the milk can cause intestinal bleeding, dehydration, and even allergies. In an older infant, the replacement of iron-fortified infant formula with whole cow's milk ,which is naturally low in iron, may pose a problem for the infant who may not be eating sufficient amounts of iron-rich foods.
Sometimes a mother may opt to bottle feed her infant when she works outside the home. With a little planning, she can express and bottle her breastmilk for a childcare provider to feed her infant. Safe handling of formula or breastmilk is crucial as infants may be more susceptible to food borne illness while their immune systems are still developing. The basic food safety principles are the same for formula and expressed milk: everything that comes in contact with the milk should be clean, milk should be kept refrigerated prior to feeding, and all "leftover" milk should be discarded as bacteria from the baby's mouth can cause milk to spoil.
Finally, regardless of whether an infant breastfeeds or bottle feeds, she shouldn't be allowed to routinely sleep with milk in her mouth. This is because milk has a generous amount of natural sugars that can encourage bacterial growth, producing an acidic environment which can promote tooth decay. It is important to adopt this good habit before the infant's teeth erupt.
Sources: American Academy of Pediatrics, Pediatric Nutrition Handbook, 4th ed. 1998. American Academy of Pediatrics, Iron Fortification of Infant Formula, Policy Statement, 1999.
Breastfeeding Support
Breastfeeding is a learned skill for both mother and baby. Breastfeeding is sometimes unsuccessful because the mother does not have the support or resources she needs. Breastfeeding provides benefits for the entire family; it is cost-effective, efficient and healthful. Mothers with supportive, encouraging partners succeed at breastfeeding more often than those without such support. Exhaustion may contribute to the discontinuation of breastfeeding. Resting when the baby sleeps and ignoring many household chores or recruiting others to do these tasks helps reduce fatigue. Some fathers and grandparents worry about their ability to bond with the baby if the mother breastfeeds. Family members have many other ways to bond with the baby, including diapering, bathing, cuddling, rocking, singing and strolling, and, when baby is older, feeding solid foods.
In addition to information and help from family members, breastfeeding information and support networks can be found in the wider community, including books, internet sites, classes, electronic discussion groups, support groups, informal breastfeeding counselors, the baby's or mother's health care providers, and professional certified lactation consultants. Someone who has recently, or is currently, breastfeeding her own baby is usually a good ally. If someone close to you is against breastfeeding, discuss the situation ahead of time. Possibly he or she does not understand breastfeeding, or its benefits.
For working women, maternity leave provides a time to establish a good supply of milk. The longer a mother can stay home with the baby and establish breastfeeding, the easier it will be to maintain her milk supply when she returns to work. To help transition the first few weeks back to work, the mother might try starting back on a Thursday rather than a Monday. If she takes the next two Wednesdays off, she will not have to go to work more than two days in a row for the first few weeks. This schedule gives both mother and baby time to adjust to the changes. Breastfeed frequently during the evening and whenever baby wakes at night. On weekends or days off, the baby should be breastfed as often as possible.
Worksite support for nursing mothers aids breastfeeding success. Release time with supervisor's approval, lactation rooms equipped with breast pumps, and breast milk cold-storage space help women combine breastfeeding with work or school. With a fully automatic double pump, the breasts can be emptied in about ten minutes, so breast-pumping breaks do not last longer than breaks that other employees take. Mothers should express milk at the same time they would breastfeed the baby at home. A flexible work schedule, arranging opportunities to breastfeed the baby during the workday, and worksite child care programs also help breastfeeding mothers succeed. Employers benefit because employees with breastfed babies need to take fewer sick leaves, since their babies get sick much less often than do bottle-fed babies. Enabling new mothers to stay on the job also saves employers money on training replacement employees.
Also crucial to the working woman's success at breastfeeding is having a child care provider who supports her commitment to breastfeeding. Child care providers benefit from caring for breastfed babies because diaper odors are less offensive and the babies get sick less often. The baby's caregiver should be provided with written instructions on how to safely handle and store breast milk. Mothers usually breastfeed in the morning just before going to work. Caregivers should feed the baby early enough prior to the mother's return so that the baby will be ready to breastfeed when she arrives. A quiet, private breastfeeding area should be available at the caregivers' site. If the baby is very hungry just before mother's expected return, the caregiver needs to know in advance how the mother wants the baby to be pacified to wait for a full meal at the breast.
The Parent-Infant Feeding Relationship
Positive interaction between parent, or caregiver, and infant during feeding is essential to the child's well-being. The feeding relationship can affect the infant's food acceptance, nutritional status, growth and the way he feels about himself and the world. (1)
Many nutrition professionals and developmental experts have studied the importance of the interactions that take place between parent and child during feeding. None has more clearly defined the role of each than Ellyn Satter, a registered dietitian and licensed social worker who works closely with families to address feeding concerns. Satter identifies the parent's responsibility as what the infant or child is offered to eat. It is, however, the child's responsibility for how much of it he eats. Since the responsibility is shared, according to Satter, the parent has to be accepting of the child's abilities and limitations in feeding, as well as responsive to the cues or messages the child gives that let the parent know what, when, and how much the child wants to eat.
During feeding, both the infant and the caregiver receive satisfaction and pleasure. The baby is pleased because hunger is satisfied, and the parent is pleased because the needs of the infant or child are met. Infants learn to trust the parent to feed them, and a positive relationship develops as feeding proceeds successfully. (2)
Infants may reflect parental concern and anxieties by becoming upset and not eating well. This may in turn increase the anxiety of the parent or caregiver. It is important to remember that a relaxed, warm relationship between parent and infant during feeding will help result in optimal nutrition as well as a sound foundation for trust and self-esteem.
What can be done to establish and encourage a positive feeding relationship? The parent in a successful feeding situation will become very skilled at recognizing the infant cues, and the infant will trust that those signals will be heeded. Parents must learn to recognize both hunger and satiation of hunger in infants and be willing to accept the child's expressions of satisfaction, resisting the urge to control the amount of food the child takes.
In summary, Satter outlines some effective skills to help ensure a positive feeding relationship with an infant. These include:
1. Satter, E. Child of Mine: Feeding With Love and Good Sense. Bull Publishing, 1991. 2. Pipes, PL; Trahms, CM. Nutrition in Infancy and Childhood. 5th ed. Mosby, 1993.
Introducing Solid Foods to Your Baby
There are no hard and fast rules about when to add solid foods to a baby's diet, and guiding thought through the years has changed radically. It is currently recommended that the feeding of semisolid foods be delayed until the infant displays a swallowing pattern beyond reflexive or basic sucking abilities. This usually becomes evident at approximately four to six months of age.
When the time is right to start an infant on solid foods, the caregiver will notice signs that indicate baby is ready, including baby's increased sitting up, drooling, and hands beginning to go to the mouth. These developmental markers indicate that now, or very soon, is the right time to introduce semisolid foods usually iron-fortified cereals for infants, and typically rice cereal is an appropriate first choice.
Why is infant rice cereal a good first semisolid food? There are several reasons. First of all, infant cereals are iron-fortified and baby needs iron added to the diet somewhere around month four to six. Another reason supporting cereal for first food is that it is easy to control the texture and thickness. Initially, baby will best tolerate a smooth, semi-liquid texture; later, baby's more advanced skills will allow serving a thicker, more textured cereal. Rice is chosen because it is considered least allergenic of the cereal grains. It is important to introduce grains, and ultimately, all foods, one at a time, to ensure there are no allergic reactions to the new food.
It appears to make little difference whether fruits or vegetables are introduced next. Some pediatricians recommend beginning with vegetables, to be sure these flavors are well-accepted before the sweeter fruits are offered. New foods should be added one at a time, with three or four days between each introduction to allow observation of baby's tolerance of each new food.
The main goal in adding vegetables and fruits is to gradually shift baby's primary source of vitamins A and C to solid foods and, eventually, away from formula or breastmilk. The parent or caregiver may start with pureed fresh or frozen cooked vegetables, or they may decide to buy commercial baby food. If the parent chooses to prepare their own baby foods, it is important to leave the seasoning out. For this reason, canned vegetables should be avoided for baby food - they have added sodium that baby doesn't need.
As the baby develops and matures, the texture of the food he eats needs to change to keep up with his skills. When the infant is attempting to "chew" and manipulate the food, it is probably a good time developmentally to introduce fork-mashed cooked or even diced vegetables and fruits. Although baby foods are nutritious, they do not keep pace with the infant's development.
When the infant can tolerate food texture and variety somewhere around the age of seven to ten months, she is ready for foods from the table, including finely chopped meats, poultry and fish. As baby gradually decreases the amount of formula or breastmilk and increases solid food intake, it is important to include meat or other high-protein, iron rich foods. Introducing meat can be a challenge, because baby's few teeth aren't necessarily the ones that are needed to chew meat. Some foods, like hamburger, fish, or tender poultry will work well; others will need to be ground or cut in 1/8 inch pieces. After cutting or grinding, you will probably need to add a little moisture broth, milk, or low-fat gravy.
Finger foods are important to an infant's development by the age of nine months or so. A baby this age is developing a more precise grip using the thumb and forefinger. Caregivers will want to include appropriate finger foods to encourage developing motor skills. These foods could include cooked vegetable strips, potato, carrot, peas, green or waxed beans, zucchini; soft toast, rice, noodles or macaroni, peeled soft fruit wedges or slices; and soft, tender pieces of cooked meat, poultry or fish.
By ten months or so, baby is probably ready for eggs, unless there is a history of egg allergy in the family. By this age, baby is past the high-risk period for this allergy. If there is a family history of food allergies, be sure to discuss them with a physician before adding those foods to your baby's diet.
At one year of age, the baby may be eating many of the foods the family eats. It is still a good idea to continue the iron-fortified infant cereal, until age 18 months. As teeth increase in number, the texture and crispness of foods can safely increase in a young child's diet. For amounts to serve a one-year-old child, see the chart on the outside page of this newsletter.
Sources: Feeding Our Youngest newsletters, Kansas State University Agricultural Experiment Station and Cooperative Extension Service, Manhattan, KS. 1998. Pipes, PL and Trahms, CM.. Nutrition in Infancy and Childhood, 5th ed. Mosby, 1993.
When to Wean
Weaning is the process of gradually replacing breast or bottle feedings with the introduction of solid foods and drinking from a cup. It affects mother and baby both physically and emotionally.
The cup is usually introduced with a little breast milk or iron-fortified formula. Babies enjoy the sound of their teeth on the rim of the cup and they will swallow more and more liquid as days go by. It is recommended to offer fruit juice solely from a cup because juice is a concentrated sweet.
At approximately six months of age, even before the first tooth appears, most infants make chewing movements with their gums. Developmentally, this baby is ready to begin soft solid foods, and needs the challenge of advanced textures. In addition to this sign, there are several other signs that indicate when a baby is ready to begin weaning and eating solid foods:
There is not a unique rule or perfect time for weaning a baby. After six to eight months, a baby needs less formula or breast milk as she gets more nutrients and calories from other foods. As the baby is being weaned away gradually from an exclusively fluid diet, the foods needed must change to meet his physical, emotional and nutritional growth.
Sources: Satter, E. Child of Mine-Feeding with Love and Good Sense. Bull Publishing Co. 1991 Feeding Our Youngest, Kansas State University, 1998 Pipes, PL and Trahms, CM. Nutrition in Infancy and Childhood. 5th ed. Mosby, 1993.
Interested in Making Baby Food at Home?
Recommended Guidelines for Children Just Beginning to Eat Solid Food
At 12 months of age, your baby should be receiving at least these amounts every day:
Milk 16-24 ounces whole milk
Fruits and vegetables 4 servings, each 1-2 Tbsp.
-vitamin C source: 3 ounces daily
-vitamin A source: 3 times weekly
Breads and cereals 4 servings daily, each about 1/4 the adult serving size
Meats, poultry, fish, eggs 2 servings
daily, each about 1/2 ounce