Nutrition in Infancy

Kevin E. Carpio, MSc, RND

 Infancy
Infancy is the period from birth to one
year.
Characterized by rapid changes in physical
growth, development, and maturation of
oral, fine, and motor skills.
The weight of a newborn is a key measure
of the mother's health during pregnancy.
 Categories of Newborn Infants
Full term infant - born between 37 and 42
weeks of gestation.
Preterm infant - born before 37 weeks of
gestation
Low birth weight infant - born with a birth
weight of 2.5 kg or below.
Very low birth weight - an infant weighing <1500
g at birth.
Extremely low birthweight - an infant weighing
less than 1000 g at birth
Characteristics of a newborn infant
Based on Filipino standards, a healthy full
term infant should:
Weigh between 2.7 to 3.2 kg
Measure 48 to 50 cm in length
Head circumference averages 35 cm
Skin is moist, elastic, and not wrinkled
 Growth and Development
A. Weight and height - birth weight
doubles by 5 to 6 months and triples by
twelve months.

B. Body proportions - at birth, head is

disproportionately large, the legs are
bowed, and short.
 Growth and Development
C. Bones, muscle, and fat
Skeleton is mostly cartilage at birth;
fontanel close by age two.
Fat accumulates rapidly until nine
months of age.
At birth, water is about 75% of body
weight and 60% at one year.
 Growth and Development
D. Brain - at birth, the brain is 25% of its
adult weight and reaches 75% of adult size
age twelve to twenty four months.

E. Teething - twenty baby teeth begin to

erupt six and seven months, complete by
age three.
 Growth and Development
F. Digestion and absorption - the stomach
capacity of an infant increases from 10 to
20 ml at birth to 200 ml by one year of
age.
The digestive system of a full term
infant at birth is capable of only
digesting protein, simple CHO, and
emulsified fats.
 Growth and Development
G. Renal function - infant has a functionally
immature kidneys

H. Neuromuscular development - the infant has

a number of reflexes that work together to
permit the intake of food.
By six months of age, biting and chewing
are added to sucking.
Good closure of mouth by nine months of
age allows drinking from a cup.
Major Reflexes found in newborns
Name Response Significance

Babinski A babys toes fan out when the Perhaps a remnant

sole of the foot is stroked. of evolution from
heel to toe.
Blink A babys eyes close in response to Protects the eyes
bright light or loud noise.
Moro A baby throws its arms out and May help a baby
then inward (as if embracing) cling to its mother
in response to
loud noise

Palmar A baby grasps an object placed in Precursor to

the palm of its hand. voluntary grasping
Major Reflexes found in newborns
Name Response Significance

Rooting When a babys cheek is stroked, it Helps a baby find

turns its head toward the cheek the nipple
that was stroked and opens its
mouth
Stepping A baby who is held upright by an Precursor to
adult causes the feet to step. voluntary walking
forward begins to
step rhythmically

Sucking A baby sucks when an object is Permits feeding

placed in its mouth.
Withdrawal A baby withdraws its foot when Protects a baby
the sole is pricked with a pin. from unpleasant
stimulation.
 Motor Development
Motor development reflects an infants ability
to control voluntary muscle movement.
The development of muscle control is top-
down, meaning head control is the start, and
last comes lower legs.
Muscle development is from central to
peripheral - the infant learns to control the
shoulder and arm muscles before muscles in
the hands.
Motor development influences both the ability of the infant to feed and the amount of calories
expended in the activity
 First 1000 Days of Life
The period between conception until the
childs 2nd birthday.
Considered as the period of rapid growth
where nutrient deficiencies and poor health
can have long-term consequences on the
child.
The 1000 days comprise 270 days of
pregnancy, 365 days for the first year of life
of the child, and another 365 days for the
2nd year of life.
Why is the First 1000 days important?

Good nutrition of both the mother and the

child is an important determinant for a
child to achieve maximum growth and
development.
Studies have shown an association
between undernutrition, especially
stunting, in the early years of life and
then overnutrition and non-communicable
diseases in the childs later years.
The Intergenerational Cycle of
Malnutrition

Darnton-Hill, Nishida and James. ACC/SCN 2000.

NUTRITIONAL REQUIREMENTS IN
INFANCY
 Energy
From birth to 5 months, the female and male
infant requires around 560 and 620 kcal,
respectively.. From 6-11 months, energy needs are
630 and 720 kcal. At one year, 920 and 1000 kcal.

Recommended allowance is 120 and 110 kcal per

body weight (kg) for 0-6 and 7-12 months.

Breastmilk will adequately meet the needs of

infants below 6 months, after which
complementation with other foods become
necessary.
 Protein
The need for protein is high because of rapid
skeletal and muscle growth of early infancy.

In addition to the nine essential amino

acids, arginine is essential for infants.

The RDA is 1.5 to 2.5 grams per kg body

weight from 0 to 6 months and 1.5 to 2.0
grams from six to 12 months of age.
 Protein
Of the protein needs, 50% is used for growth in
the first 2 months and declines to 11% at 2-3
years of age.

Human milk provides the major protein source

during infancy. Its content is lower than
formula milk but is adequate for the first 6
months.
 Protein

Inadequate protein intake may be due to

poverty, excessive dilution of formula,
continuation of a regimen designed to treat
diarrhea after illness, multiple food allergies,
or extreme vegetarian patterns.
 Fats
Fat is a concentrated energy source to fuel
infants rapid growth and development.

Infants use fats to supply energy to the liver,

brain, and muscles, including the heart. Young
infants cannot tolerate fasting for long
because it quickly uses up both carbohydrate
and fat energy sources.

Human milk, cows milk, and formulas provide

approximately 50% of the energy as fat.
 Water
An infant requires 4.5 to 5.5 oz of water
per kg DBW or 10-15% body weight, or 1.5
ml per kcal food intake.

Attention should be given to the infants

need for water because of the
evaporative losses from the skin and lungs
which become higher during the hot
weather.
 Water
Water intake must be higher when solid foods
are given. Foods high in protein and electrolytes
can cause dehydration if offered without water.

Human milk and properly prepared formula will

supply adequate amounts of water.
However, when a formula is boiled, water
evaporates and solutes become
concentrated. Thus boiled milk or formulas
are not appropriate.
 Fat Soluble Vitamins
A healthy newborn is assumed to have
adequate supply of Vitamin A in the liver.
Vitamin K supplementation is given at
birth as protection against hemorrhage.
 Water Soluble Vitamins
Breastmilk provides the RDA for water
soluble vitamins if the mother's intake is
adequate.
Requirements for thiamin, riboflavin, and
niacin change in relation to energy intake.
METHODS OF FEEDING THE
INFANT
I. Breastmilk
Breastfeeding the best and most natural way
of feeding the infant

a) Substitute for breastfeeding when mother is

unwilling, sick, or dies.
b) Wet nurse a lactating woman who breastfeeds
an infant deprived of his own mothers milk.
c) Cross-nursing mothers agree with other
nursing women to baby sit with breastfeeding.
II. Artificial Feeding or Bottle Feeding

The infant is fed on formula from the

bottle.
Done when the mother is incapable of
breastfeeding.
III. Mixed Feeding
Feeding infant partially from both the breast and
the bottle.

a) Supplemental feeding bottlefeeding is substituted

for breastfeeding. Usually used when mother is
away part of the day during the feeding time.

b) Complemental feeding bottle is given after the

breast to complete the feeding. Used when the
mother does not have enough milk to satisfy the
baby.
Considerations favoring Breastfeeding

1. Nutrient composition of the milk of each

species is suited to the growth needs of its
offspring.
Considerations favoring Breastfeeding

Similar caloric value - breast milk and formula

milk
Cows milk has more protein than human milk.
Most of this protein is casein.
Human milk has more whey.
Fatty acids in human milk are more medium
chain and less saturated.
Lipase in human milk contributes greatly to the
hydrolysis of milk triglycerides.
Considerations favoring Breastfeeding

Human milk contains less calcium than cows milk

but that calcium is more easily absorbed.
Iron in human milk is better absorbed than the
iron in cows milk
Human milk contains more linoleic acid.
Thiamin and Vitamin C in human milk is
completely available to the infant.
Vitamin A and Vitamin E levels in human milk is
greater than that of cows milk
Considerations favoring Breastfeeding

2. For the few days after birth, colostrum is

secreted by the mammary glands.
Compared to mature milk, colostrum has
the following qualities:

More protein, beta carotene, vitamin A

Less fat
Higher sodium, potassium, chloride
Contributes to immunity
Considerations favoring Breastfeeding

3. It contains factors that provide protection

against certain bacteriologic infections,
diarrhea, and otitis media.

IgA: immunoglobulin breast milk; protect infants

gut from infections.
Lactoferrin: deprives bacteria of iron thus slowing
their growth
Peroxidases: weaken bacterial cell membrane
Lysozymes: destroys cell membrances of bacteria
Lactobacillus bifidus: enhanced by breastmilk and
interferes with growth of infections.
Considerations favoring Breastfeeding

4. Allergic reactions to human milk are rare.

Cows milk proteins (betaglobulin and

albumin) are common allergens in humans.
IgA in breastmilk: promotes closure of the gut
and decrease permeability of allergens.
Considerations favoring Breastfeeding

5. Economical in terms of time needed for

preparation.

6. Breastmilk is always available,

convenient, and dependable.

7. No danger of contamination since

preparation is not needed.
Considerations favoring Breastfeeding

8. The closeness between mother and infant

during breastfeeding promotes attachment and
bonding.
Unang Yakap
Rooming in after parturition
Considerations favoring Breastfeeding

9. Maternal benefit factors:

Secretion of oxytocin during lactation causes
uterine contractions and involution of uterus.
Delays onset of another pregnancy: Prolactin
which stimulates milk production represses the
synthesis of ovarian hormones.
Lactation Amenorrhea Method (LAM)
Promotes natural weight loss
Considerations favoring Breastfeeding

10. Extraction of milk from breast is harder than

bottle thus infants jaw becomes more developed
and teeth are less crowded.

11. Less colic and lower sudden infant death have

been reported among breastfed infants.

12. Enhances intelligence. Evidence shows that

fatty acids found in breastmilk can increase the
intelligence quotient (IQ) of babies up to 7 points,
leading to better performance in school or at
work later in life.
 Consequence of non-exclusive
breastfeeding
Babies who are not exclusively breastfed may
not be able to achieve their full potential for
physical growth and cognitive development, and
are exposed to short- and long-term health
risks.

Infant formula increases babies risk to

infections, allergies, digestive problems, as well
as obesity, cancers, diabetes and heart diseases
later in life.
 Consequence of non-exclusive
breastfeeding
Formula-fed infants are shown to have lower IQs
compared to breastfed infants and may
experience iron-deficiency anemia, which is also
related to impaired cognitive development.

If a mother did not breastfeed her infant, it

increases her risk to being overweight and obese
and predisposes her to having diabetes, certain
types of cancer (breast, ovarian and uterine)
and cardiovascular diseases.
 Consequence of non-exclusive
breastfeeding
Mixed feeding can decrease breastmilk
production since breastmilk supply is
driven by feeding cues of the baby.

Bottlefeeding increases the risk for

childhood obesity due to bottle emptying
and improper appetite regulation.
UNANG YAKAP:
ESSENTIAL NEWBORN
CARE PROTOCOL (DOH)
Early initiation of breastfeeding is part of the Essential
Newborn Care Protocol adopted by the Department of Health
in 2009. The four key elements of the protocol are:

1. Immediate and thorough drying up of the newborn for

30-60 seconds warms the newborn and stimulates
breathing.
2. Early skin-to-skin contact between newborn and mother
and delayed washing for at least 6 hours prevents
hypothermia, infection and hypoglycemia.
3. Properly timed cord clamping and cutting prevents the
newborn from having anemia and protects against anemia
4. Early initiation of breastfeeding within the first hour after
birth and continuous non-separation of the newborn from
the mother to defend the newborn against infections.
 Procedures for Breastfeeding
1. If the mother and baby are physically
able; first feeding is within an hour after
birth; the sucking reflex is strongest
20-30 minutes after birth.
2. The sooner the newborn is put to the
breast, the better the chance for
lactation to succeed and colostrum to be
taken.
 Procedures for Breastfeeding
3. Prepare the breasts for breastfeeding as
early as pregnancy by imitating the
sucking action of the infant. (eg. pulling
and stretching the nipples)
4. Keep nipples clean by washing with
boiled water before and after each
nursing.
5. Mother and baby should be comfortable
either lying or sitting down.
 Procedures for Breastfeeding
6. Touch the area around the mouth with
the nipple
7. Nurse each time to alternate breasts
8. Practice flexible on demand feeding
 Failure of Infants to Thrive on
Breastfeeding
1. Causes inherent to the infant:
Poor suckling, infrequent feeding, structural
abnormality
Low net intake due to malabsorption,
infections
High energy requirement because of diseases
or when infant is SGA
 Failure of Infants to Thrive on
Breastfeeding
2. Causes inherent to the mother:
Poor milk production due to poor diet,
illness, effects of drugs, fatigue
Poor let down reflex due to psychological or
emotional factors
BREASTFEEDING SUBSTITUTES
 Requirements for a satisfactory
artificial feeding
Sufficient infants energy needs
Sufficient protein, carbohydrates, minerals,
vitamins, and water for growth and regulating
body functions
Absence of harmful bacteria; proper technique
of preparation
Easy digestibility
Proper temperature
Type and amount of formula should be
individually prescribed for the infant
 Milk Formula
A mixture of milk, water, and some of
carbohydrates in appropriate proportions
to meet the nutritional requirements of
the infants.

Designed to simulate human milk and is

prepared in the most sterile manner
possible to render itself safe to infants.
 Methods of Sterilization
1. Standard aseptic method
2. Terminal sterilization
 Standard Aseptic Method
All equipment used are sterilized by steam
or by boiling for 5 minutes
Measure the required amount of sugar, milk,
and water
Mix the formula well and boil for 3 minutes,
stirring constantly.
Allow to cool and pour into sterilized
bottles.
Cool in running water.
 Terminal Method
All equipment used are washed
Formula is prepared and poured before
sterilizing the bottles
Nipples are applied to the bottles and a cap or
cover is placed over the nipple that will permit
exposure of the nipple to the steam
The filled up bottle is placed in the sterilizer to
be boiled for 15-25 minutes
After sterilization, the nipple cover is sealed
tight and untouched until feeding time.
 Techniques in Bottle Feeding
Warm nursing bottle
Test temperature of milk formula by shaking a
few drops of milk on the inside part of the
wrist.
Mother should sit in a comfortable chair holding
the baby in a semi-erect position just like in
breastfeeding.
Baby should finish feeding in 15-20 minutes;
otherwise check holes of nipples if baby feeds
too slow or too fast.
Burp the baby after each feeding to expel
swallowed air.
 How to tell if baby is being fed
adequately

Baby is satisfied after 15 - 20 minutes of feeding.

Falls asleep right away after each feeding and
sleeps for about 3 - 4 hours.
Gains weight satisfactorily, (i.e. about
kilogram every month for the first six (6) months
such that birth weight will be doubled by about
the sixth (6th) month, and tripled by the first
year).
Urinates about six (6) times a day (wetness test).
 Problems associated with artificial
feeding
Colic - characterized by acute abdominal
pain from muscular spasms near the colon

Regurgitation - expulsion of gastric contents

Overfeeding - weight gain of an ounce or

more per day; infant is disturbed and
irritable in the first two hours after feeding.
 Problems associated with artificial
feeding
Underfeeding - baby cries after feeding and
has inadequate weight gain

Overdilution - addition of more water to

extend milk supply. May lead to
undernutrition

Contamination - formula is not sterilized

properly
Philippine Code of Marketing Breastmilk
Substitutes (Executive Order 51, 1986)
National Code of Marketing Breastmilk
Substitutes, Breastmilk Supplement, and
Related products
Aim is to contribute the provision of safe
and adequate nutrition for infants through
the protection and promotion of
breastfeeding and ensuring the use of
proper breastmilk substitutes when
necessary.
Philippine Code of Marketing Breastmilk
Substitutes (EO 51, 1986)
The Code applies to the marketing and to
related practices of the products below:
Breastmilk substitutes such as infant
formula
Other milk products, food beverages,
and bottle-fed complementary foods
when represented as partial or total
replacement of breastmilk
Feeding bottles and teats
COMPLEMENTARY FEEDING
 Complementary Feeding
Complementary feeding is recommended
by WHO to be initiated at 6 months, while
continuing breastfeeding up to two years
and beyond.

Weaning: previously, weaning connotes

changing breastmilk to other milk
substitutes. Currently, weaning means to
accustom to foods other than breastmilk or
milk formula.
 Complementary Feeding
Sooner or later, foods other than milk are
added to an infants diet. The introduction of
solid foods is influenced by:

1. Nutrition
2. Physiological readiness
Secretion of enzymes for digestion of starch
and unemulsified fats
Gastric acidity is increased
Maturity of kidney function
3. Physical readiness
 Complementary Feeding
Complementary feeding has four
elements:
1.Timing
2.Adequacy of amount
3.Safety
4.Active or responsive feeding
 I.Timing
The introduction of complementary foods
should be properly timed, at 6 months,
because at this age the baby is ready to
receive food as evidenced by progression
of his/her developmental skills
 When the infant is physically and
physiologically capable of handling solid
foods, the sequence and timing of giving
foods is influenced by his nutritional
needs

1. Cereals the first solid food given to the

baby; usually given at 6 months. Must be
well cooked, well strained. Breastmilk or
formula may be added to the cereal.
2. Fruits mashed ripe bananas, ripe papaya,
mango may be given at 6 months but consistency
may be coarser as the baby begins to chew.

3. Vegetables cooked very soft, mashed, or

passed through a sieve; added to the babys diet
at 7 months. Carrots, malunggay, sayote,
potatoes, pechay, kangkong.

4. Eggs egg yolk may be given at 7 months,

whole egg at 11 months.
5. Munggo and other dried beans cooked
very soft and strained. May be given at 6
months.

6. Meat, fish, poultry strained or chopped

very finely. May be given at 6 months.

7. Other foods custards, simple puddings,

plain ice cream, plain gulaman, or jello may
be given to babies 8 months or older.
 II. Adequacy of amount
The infant should receive a variety and
adequate amounts of foods to provide
sufficient energy, protein and other
nutrients to meet the needs for growth
and development.
 II. Adequacy of amount
In addition to breastmilk, the diet should include
adequate amounts of four or more of these seven food
groups:
1) grains, roots and tubers
2) legumes and nuts
3) dairy products
4) meat, fish, poultry, liver/organ meats
5) eggs
6) vitamin A-rich vegetables and fruits
7) other fruits and vegetables every day.

How to give complementary feeding

Introduce only one new food at a time;

allow the infant to become familiar with
one food before trying another.
It is best to give new foods at the
beginning of the feeding when the babys
appetite is still good.
Give small amounts of food; teaspoonful
or less at the beginning.
 Use a thin or soft consistency when starting
solid foods. Gradually the consistency can be
made more solid when the infant learn to push
the food back.
You can put the food in the middle of his
tongue with a small spoon
Never force the infant to eat more than he
takes willingly.
Foods should only be slightly seasoned.
When baby is able to chew, gradually subsitute
finely chopped vegetables, fruits, and meat.
 If after several trials the baby still refuses
to eat a particular food, omit it for a
week and try again; if the child refuses
the food again, omit and give substitute.
If baby refuses to take some foods, mix
them with other foods he likes well.
Variety in foods is important
Dont show any dislike for the food you
are giving to the baby.
 Amount of Complementary Food
Needed
Start at 6 months of age with small
amounts of food and increase the quantity
as the child gets older while maintaining
breastfeeding.

6-8 months: 200 calories

9-11 months: 300 calories
12-23 months: 550 calories
Meal Frequency and Energy Density

Increase the number of times that the

child is fed as the child gets older.
6-8 months: 2-3 times/ day
9-11 months : 3-4 times/day
12-24 months: 3-4 times/day with
additional nutritious snacks 1-2 times/day
 III. Safety
Complementary foods should be prepared
and stored hygienically and the infant
should be fed with clean hands using
clean utensils.
 IV. Responsive Feeding
Complementary foods should be given upon
the childs signals of appetite and satiety.
The caregiver should actively encourage the
child to consume food using fingers, spoon or
self- feeding.
The baby should be fed slowly and patiently.
Feeding times should be periods of learning
and love, and distractions should be
minimized.
 IV. Responsive Feeding
1. Feed infants directly and assist older children
when they feed themselves, being sensitive
to hunger and satiety cues.
2. Feed slowly and patiently, and encourage
children to eat, but do not force them.
3. If children refuse many foods, experiment
with different combinations, taste, textures,
and methods of encouragement.
4. Minimize distractions during meals.
5. Talk to children with direct eye to eye
contact feeding times are period of love
and learning.
 Food Consistency
Infants can eat pureed, mashed, and semi
solid foods beginning at six months.
By 8 months, most infants can feed finger
foods.
By 12 months, most infants can eat the same
types of foods eaten by the family. Avoid foods
that may cause choking or items that have a
shape that may cause them to be lodged in
the trachea (nuts, raw carrots, grapes, etc)
Feeding During and After Illness
Increase fluid intake during illness,
including frequent breastfeeding, and
encourage the child to eat soft, varied,
appetizing, favorite meals.

After illness, give food more often and

encourage the child to eat more.
Risks of Early Complementary Feeding

Reduce breastmilk production or intake.

Contribute to higher rates of infant
mortality and morbidity.
Interfere with iron absorption.
Increase the risk of mothers being
pregnant.
Risk of Late Complementary Feeding

Late introduction (at 7 or 8 months)

exposes the child to increased risk for
being stunted, underweight and/or
wasted.
May lead to malnutrition
 Criteria of Adequate Nutrition
An adequately nourished infant:

1. Has steady weight gain and height;

2. Has firm, fill flesh, bright eyes, and
pinkish cheeks and nails;
3. Is happy and active when awake;
4. Sleeps well;
5. Has normal elimination.
 References
Brown, J. (2011). Nutrition Through the Life Cycle.
(2nd ed). California: Wadsworth Cengage Learning.

Claudio, V., et al. (2004). Basic Nutrition for

Filipinos. (5th ed). Manila: Merriam Webster
Publishing, Inc.

Orense, C., Barba, C., Tuazon, A. (2009).

Fundamentals in Nutrition in Public Health and the
Life Stages. (2nd ed). Nutritionist Dietitians
Association of the Philippines Foundation.
THANK YOU!