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Infant Nutrition and Feeding PDF
Infant Nutrition and Feeding PDF
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FNS-288
Revised March 2009
Note to the Reader on Using This Handbook
This handbook is for staff that provide participants. It is a resource for planning
nutrition education and counseling to the individual counseling sessions, group classes,
parents and guardians (termed “caregivers” in and staff in-service training sessions. Chapter
the text) of at-risk infants who participate in 8 summarizes key points taken from the whole
the Special Supplemental Nutrition Program text. Reference citations throughout the text
for Women, Infants, and Children (WIC) are cited in full at the end of each chapter. A
and the Commodity Supplemental Food list of resources is provided in the appendix
Program (CSFP). This publication provides for additional references on infant nutrition,
an overview of basic subjects related to infant food safety, and other related topics. For quick
nutrition and feeding and answers some reference to topics, refer to the detailed index at
common questions on the nutritional needs the end of this handbook.
of infants; the development of feeding skills;
breastfeeding; formula feeding; the introduction Every effort has been made to ensure the
of complementary foods; infant feeding accuracy of the information in this handbook.
practices; food selection, preparation, sanitation, The recommendations in this handbook are
and storage; oral health; vegetarian nutrition; not designed to serve as an exclusive nutrition
common gastrointestinal problems; obesity; care plan or program for all infants. It is the
and physical activity/motor skill development. responsibility of each staff person providing
nutrition education to caregivers of infants
Since this publication primarily focuses on to evaluate the appropriateness of nutrition
nutrition for the healthy full-term infant, the recommendations in the context of an infant’s
reader is advised to consult with other trained nutritional and health status, lifestyle and
health professionals or textbooks on pediatrics other factors affecting that status, and any new
or pediatric nutrition for more detailed or developments in infant nutrition. If you have a
advanced technical information on particular question or are unsure about the appropriateness
aspects of infant nutrition; assessment of an of a particular nutrition recommendation for a
infant’s nutritional status (including growth and particular infant, consult with the infant’s health
development); and nutrition care for preterm, care provider or a professional with additional
low-birth-weight or special needs infants, or those expertise in pediatric nutrition before making the
with medical conditions. Note that the term recommendation.
“health care provider” in the text refers to the
physician, dentist, nurse practitioner, registered We are interested in your comments on this
nurse, or other health professional providing handbook. Please help us by completing the
medical or dental care to the infant. READER RESPONSE on the last page of this
handbook.
This handbook can assist staff in disseminating
appropriate and accurate information to
Recommendations for feeding infants, from For additional information on the function,
infant formula to complementary foods, are based deficiency and toxicity symptoms, and major food
primarily on the DRIs. The DRIs for infants are sources of the nutrients discussed below, as well as
▘▘ EAR is the median usual intake that is estimated to meet the requirement of half of the healthy
population for age and gender. At this level of intake, half the individuals will have their nutrient
needs met. The EAR is used to establish the RDA and evaluate the diet of a population.
▘▘ RDA is the average dietary intake level sufficient to meet the nutrient requirement of nearly all
(97–98 percent) healthy individuals. If there is not enough scientific evidence to establish an EAR
and set the RDA, an AI is derived.
▘▘ AI represents an approximation of intake by a group of healthy individuals maintaining a defined
nutritional status. It is a value set as a goal for individual intake of nutrients that do not have a
RDA.
▘▘ UL is the highest level of ongoing daily intake of a nutrient that is estimated to pose no risk in the
majority of the population. ULs are not intended to be recommended levels of intake, but they
can be used as guides to limiting intakes of specific nutrients.
Males
Age (mo) Reference Weight Reference Weight Reference Length Reference Length Estimated Energy
(kg) (lb) (cm) (in) Requirements
(kcal/day)
1 4.4 9.7 54.7 21.5 472
2 5.3 11.7 58.1 22.9 567
3 6.0 13.2 60.8 23.9 572
4 6.7 14.8 63.1 24.8 548
5 7.3 16.1 65.2 25.7 596
6 7.9 17.4 67.0 26.4 645
7 8.4 18.5 68.7 27.0 668
8 8.9 19.6 70.2 27.6 710
9 9.3 20.5 71.6 28.2 746
10 9.7 21.4 73.0 28.7 793
11 10.0 22.0 74.3 29.3 817
12 10.3 22.7 75.5 29.7 844
Females
Age (mo) Reference Weight Reference Weight Reference Length Reference Length Estimated Energy
(kg) (lb) (cm) (in) Requirements
(kcal/day)
1 4.2 9.3 53.5 21.1 438
2 4.9 10.8 56.7 22.3 500
3 5.5 12.1 59.3 23.2 521
4 6.1 13.4 61.5 24.2 508
5 6.7 14.8 63.5 25.0 553
6 7.2 15.9 65.3 25.7 593
7 7.7 17.0 66.9 26.3 608
8 8.1 17.8 68.4 26.9 643
9 8.5 18.7 69.9 27.5 678
10 8.9 19.6 71.3 28.1 717
11 9.2 20.3 72.6 28.6 742
12 9.5 20.9 73.8 29.1 768
Sources Functions
An infant’s vitamin B12 stores at birth generally Folate, a water-soluble or B-vitamin, is required for
supply his or her needs for approximately 8 the following:
months. Major food sources of vitamin B12 ▘▘ Cell division
are breast milk and infant formulas. Infants ▘▘ Growth and development of healthy blood
consuming appropriate amounts of breast milk cells and
from mothers with adequate B12 stores or infant ▘▘ Formation of genetic material within every
formula receive adequate amounts of this vitamin. body cell.
Complementary foods such as meat, egg yolks,
and dairy products provide this vitamin later in
infancy as well.
Reflexive responses important for successful feeding As infants mature, they gain the skills necessary
during early infancy are described as follows:1 to progress from eating strained complementary
foods from a spoon to feeding themselves finger
foods and eventually begin to feed themselves
▘▘ Rooting reflex – When an infant’s oral area with a spoon (see Chapter 5 for more information
(corners of the mouth, upper and lower lip, regarding complementary foods). This acquisition
cheek, and chin) is touched by an object, he of skills follows a sequential pattern that is
reacts. The infant turns in the direction of the similar in most infants. However, each infant
object and opens his or her mouth. This reflex is unique. As shown in Figure 1, page 42, it
allows the infant to locate the source of food is normal for infants to develop the skills and
(i.e. seek out and grasp a nipple). This reflex is abilities needed for feeding progression at their
seen from birth to about 4 months. own rates. Caregivers must carefully observe and
•• Suck/swallow reflex •• Poor control of head, neck, •• Swallows liquids but pushes most Hunger cues:
•• Tongue thrust reflex trunk solid objects from the mouth •• Wakes and tosses
•• Up-and-down munching •• Sits with support •• Takes in a spoonful of pureed or Hunger cues:
movement •• Good head control strained food and swallows •• Cries or fusses
•• Transfers food from front to back •• Uses whole hand to grasp without choking •• Smiles, gazes at caregiver, or coos
of tongue to swallow objects (palmer grasp) •• Drinks small amounts from cup during feeding to indicate wanting
•• Draws in upper or lower lip as •• Recognizes spoon and when held by another person, more
spoon is removed from mouth holds mouth open as with spilling •• Moves head toward spoon or
4 months
•• Tongue thrust and rooting spoon approaches tries to swipe food towards mouth
through
reflexes begin to disappear
6 months Satiety cues:
•• Gag reflex diminishes •• Decreases rate of sucking or
•• Opens mouth when sees spoon stops sucking when full
approaching •• Spits out the nipple
•• Turns head away
•• May be distracted or pay attention
to surroundings more
•• Begins to control the position of •• Begins to sit alone unsupported •• Begins to eat mashed foods Hunger cues:
food in the mouth •• Follows food with eyes •• Eats from a spoon easily •• Reaches for spoon or food
•• Up-and-down munching •• Transfers food from one hand •• Drinks from a cup with some spilling •• Points to food
5 months movement to the other •• Begins to feed self with hands Satiety cues:
through •• Positions food between jaws •• Tries to grasp foods such as •• Eating slows down
9 months for chewing toast, crackers, and teething •• Clenches mouth shut or pushes
biscuits with all fingers and pull food away
them into the palm.
Infant’s Mouth Patterns Hand and Body Skills Feeding Skills or Abilities Hunger and Satiety (Fullness) Cues
Aproximate Age
•• Moves food from side to side in •• Sits alone easily •• Begins to eat ground or finely Hunger cues:
mouth •• Transfers objects from hand to chopped food and small pieces of •• Reaches for food
•• Begins to use jaw and tongue to mouth soft food •• Points to food
mash food •• Begins to use thumb and index •• Begins to experiment with spoon but •• Gets excited when food is
8 months
•• Begins to curve lips around rim finger to pick up objects (pincer prefers to feed self with hands presented
through
of cup grasp) •• Drinks from a cup with less spilling
11 months Satiety cues:
•• Begins to chew in rotary pattern •• Feeds self finger foods •• Eating slows down
(diagonal movement of the jaw •• Plays with spoon at mealtimes, •• Pushes food away
as food is moved to the side or but does not spoon- feed yet
center of the mouth)
•• Rotary chewing (diagonal •• Feeds self easily with fingers •• Begins to eat chopped food and Hunger cues:
movement of the jaw as food is •• Begins to put spoon in mouth small pieces of soft, cooked table •• Expresses desire for specific food with
moved to the side or center of •• Dips spoon in food rather than food words or sounds
the mouth) scooping •• Begins spoon-feeding self with help Satiety cues:
10 months •• Demands to spoon-feed self •• Bites through a variety of textures
through •• Shakes head to say “no more
•• Begins to hold cup with two
12 months hands
•• Drinks from a straw
•• Good eye-hand-mouth
coordination
5 months through 9 months • Reaches for spoon or food • Eating slows down
• Points to food • Pushes food away
10 months through 12 months • Expresses desire for • Expresses desire for specific food
specific food with words or with words or sounds
sounds • Shakes head to say “no more”
In some instances, social and financial problems ▘▘ The Early Periodic Screening, Diagnosis, and
within a household may cause anxiety with Treatment Program (EPSDT) for additional
detrimental effects on the interaction and assessment, counseling, and follow-up services.
feeding relationship between caregiver and
infant. This can lead to failure to thrive in an See page 47, Figure 2: Desired Outcomes for
infant. If you perceive that a caregiver is not the Infant and the Role of the Family in the
recognizing an infant’s feeding cues, responds to Feeding Relationship, and Satter’s work (1986
them inappropriately, or cannot feed the infant and 1987),4,5 for more information regarding
properly, the infant and caregiver should be the feeding relationship. See Bright Futures in
referred to: Practice: Nutrition (2002)9 for more information
concerning feeding cues.
▘▘ A health care provider for advice
▘▘ Resources offering help with parenting skills
▘▘ A specialist or other services for psychosocia1
evaluation or
Family
Educational/Attitudinal Behavioral Health
•• Bonds with the infant •• Meets the infant’s nutrition •• Maintains good health
•• Enjoys feeding the infant needs
•• Understands the infant’s •• Responds to infant’s hunger
nutrition needs and satiety cues
•• Acquires a sense of •• Holds the infant when
competence in meeting the breastfeeding or bottle feeding
infant’s needs and maintains eye contact
•• Understands the importance •• Talks to the infant during
of a healthy lifestyle, including feeding
healthy eating behaviors and •• Provides a pleasant eating
regular physical activity, to environment
promote short-term and long- •• Uses nutrition programs and
term health food resources if needed
•• Seeks help when problems
occur
Story M, Holt K, Sofka D, eds. 2000. Bright Futures in Practice: Nutrition. Arlington, VA: National Center for
Education in Maternal and Child Health.
1. Morris SE, Klein MD. Pre-Feeding Skills. 2nd ed. USA: Therapy Skill Builders, 2000.
2. Carruth BR, Skinner JD. Feeding behaviors and other motor development in healthy children
(2-24 months). Journal of the American College of Nutrition 2002; 21(2):88-96.
3. Carruth BR, Ziegler P, Gordon A, Hendricks K. Developmental Milestones and Self-
Feeding Behaviors in Infants and Toddlers. Journal of the American Dietetic Association 2004;
104(1):S51-S56.
4. Satter E. The feeding relationship. Journal of the American Dietetic Association 1986;
86:352-356.
5. Satter E. How to Get Your Kid to Eat...But Not Too Much. Boulder, CO: Bull Publishing
Company, 1987.
6. Birch LL, Fisher JO. Appetite and eating behavior in children. Pediatric Clinics of North America
1995; 42(4):931-953.
7. Butte NF, Cobb K, Graney L, Heird WC, Rickard KA. The Start Healthy Feeding Guidelines for
Infants and Toddlers. Journal of the American Dietetic Association 2004;104:442-454.
8. Blum-Kemelor DM. Feeding Infants: A Guide for Use in the Child Nutrition Programs
Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service; 2001.
9. Story M, Holt K, Sofka D. Bright Futures in Practice: Nutrition. 2nd ed. Arlington, VA:
National Center for Education in Maternal and Child Health. 2002.
Figure courtesy of Amy Spangler, R.N., M.N., I.B.C.L.C., Amy Spangler’s Breastfeeding,
A Parent’s Guide, 7th ed., 2000.
Figure courtesy of Amy Spangler, RN, MN, IBCLC, Amy Spangler’s Breastfeeding, A Parent’s Guide, 7th ed., 2000.
initial days following birth. It offers the following the mother; the mother will have less blood
advantages for mother and infant: 18, 20, 21 loss because the infant’s sucking causes the
uterus to contract.
▘▘ Nutrition high in protein and low in fat that
is easily digested by the newborn infant; Mothers should not express any colostrum from
▘▘ Antibodies, primarily secretory their breasts before their infant’s birth because
immunoglobulin A (sIgA), which protect the the pumping of the breasts may stimulate uterine
infant’s immune system by identifying and contractions, risking premature delivery. All
destroying foreign objects such as bacteria and the available colostrum should be saved for the
viruses; and infant.20
▘▘ Postpartum uterine contractions stimulated in
Relactation
A mother who has mostly or totally weaned and
then decides she wants to resume breastfeeding
for reasons such as her infant is intolerant
to infant formula, can consult with a person
trained in lactation management for assistance.
Relactation is rebuilding a birth mother’s milk
supply after it has been reduced or dried up. Refer
the mother to a WIC breastfeeding expert or
lactation expert for assistance with relactation.
4 Put the bottles, nipples, caps, and rings in a pot 10 Refrigerate until feeding time. Use within
and cover with water. Put the pot over heat, bring 48 hours. Do not leave formula
to a boil, and boil for 5 minutes. Remove at room temperature. To warm
with sanitized tongs, allow the items to bottle, hold under running
cool, and air dry. warm water. Do not
microwave bottles. If
formula is left in the can,
aby Gabe
cover and refrigerate open
B
8/14/98
B
4:30 p.m. aby Tony
Baby Jose
Baby Jane
8/2/98
8:30 a.m. 8/12/98
10:30 a.m.
can until needed. Use
Baby Eva
within 48 hours.
8/12/98
2:30 p.m. 8/19/98
5
12:00 p.m.
Do not microwave
12:00 p.m.
bottles.
1 Wash your hands, arms, and under your 8 Attach nipple and ring to the bottle and
nails, very well with soap and warm
SHAKE WELL. Feed prepared formula
water. Rinse thoroughly. Clean and
immediately.
sanitize your workspace.
2 Wash bottles and nipples, using bottle 9 If more than one bottle is prepared,
and nipple brushes, and caps, rings, and put a clean nipple right side up on
preparation utensils in hot soapy water each bottle and cover with a nipple
before using. Rinse thoroughly. Baby Jane Baby Tony cap. Label each bottle with the baby’s
name and the date and time that it was
8/12/98 8/11/98
2:30 p.m. 4:30 p.m.
prepared.
microwave bottles.
8/2/98 Baby Jose
8/12/98
pot over heat, bring to a boil, and boil
Baby Jane 8:30 a.m.
8/12/98 Baby Eva 10:30 a.m.
2:30 p.m. 8/19/98
6 Remove plastic lid; wash lid with soap 12 Make sure that no water or other liquid
and clean water and dry it. Write date gets into the can of powder. Cover
on outside of plastic lid. Wash the top of opened can tightly and store in a cool
the can with soap and water, rinse well, dry place (not in the refrigerator). Use
and dry. Wash the can opener with soap within 4 weeks after opening to assure
and hot water. Open the can and remove freshness.
scoop. Make sure that the scoop is
totally dry before scooping out powdered
formula. Only use the scoop that comes
with the formula can.
Ground/
Finely Chopped
Chopped
Spoon Feeding
Cup Feeding
Self Feeding/
Feeding Finger Foods
Special Note: represents the age range when most infants are developmentally ready to begin
consuming complementary foods. The American Academy of Pediatrics Section on Breastfeeding
recommends exclusive breastfeeding for the first 6 months of life. The AAP Committee on Nutrition
recommends that, in developed countries, complementary foods may be introduced between ages
4 and 6 months. This is a population-based recommendation, and the timing of introduction of
complementary foods for an individual infant may differ from this recommendation.
** Complementary foods include infant cereal, vegetables, fruits, meat, and other protein-rich foods
modified to a texture appropriate (e.g., strained, pureed, chopped, etc.) for the infant’s developmental
readiness. See Figure 1 for more guidance on feeding skills and infant development.
Fruit Juice The AAP has concluded that fruit juice offers no
In recent years, fruit juice has become a popular nutritional benefit for infants less than 6 months
beverage to offer infants because it tastes good and no benefit over whole fruits for infants older
and infants readily accept it. Although fruit juices than 6 months. However, 100 percent fruit juice
contain carbohydrates, may contain vitamin C, or reconstituted juice can be consumed as part of
and are a source of fluid they have potentially a well-balanced.21
detrimental effects.
Guidelines on Introducing Fruit Juice
Infants who drink excessive amounts of fruit juice
from a bottle or cup may: If fruit juices are introduced, caregivers should
adhere to the following recommendations: 1, 21
▘▘ Consume an inadequate quantity of breast
milk, infant formula, or other nutritious
foods;20 ▘▘ Wait to introduce fruit juices until the infant
▘▘ Develop gastrointestinal symptoms, such as is 6 months or older.
diarrhea, abdominal pain, or bloating, from ▘▘ Use 100 percent fruit juice.
consuming an excessive amount of certain ▘▘ Never feed infants unpasteurized juice.
juices, i.e., fruit juices containing a significant ▘▘ Introduce new fruit juices one at a time
amount of sorbitol, a naturally occurring and not sooner than about 7 days apart,
carbohydrate. Juices containing sorbitol and observe the infant for adverse reactions.
include prune, pear, cherry, peach, and Introduce mixed fruit juice only after the
apple juice; infant has tried all the juices in the mixture.
▘▘ Develop malnutrition and short statue; and21 ▘▘ Avoid offering fruit juice in a bottle or spill-
▘▘ Develop dental caries. proof cup (sippy cup) that can easily be
carried around by the infant.
▘▘ Avoid offering fruit juice at nap or bedtime.
Vegetables and Fruits That May Infants can be offered well-cooked strained or
Cause Choking pureed lean beef, pork, lamb, veal, chicken,
turkey, liver, boneless finfish (fish other than
Due to the risk of choking, it is best to avoid feeding shellfish), egg yolk, legumes, tofu, sliced or grated
infants these vegetables and fruits: mild cheese, yogurt, or cottage cheese.
▘▘ Raw vegetables (including green peas, string
beans, celery, carrot, etc.);
▘▘ Cooked or raw whole corn kernels;
Visit the Food and Drug Administration’s Food Safety Website www.cfsan.fda.gov or the Environmental Protection
112 Agency’s
I N F A N T Fish
N U T R IAdvisory E E D I N G www.epa.gov/ost/fish for a listing of mercury levels in fish.
T I O N A N D FWebsite
Grain Products That May Cause Choking Sweetened Foods and Sweeteners
Due to the risk of choking, it is best to avoid feeding Sweeteners (e.g., sugar, syrups) eaten alone or
infants these grain products: added to foods provide additional kilocalories
▘▘ Cookies or granola bars; to the diet and, as fermentable carbohydrates,
▘▘ Potato/corn chips, pretzels, and similar snack promote the development of tooth decay.
foods; Sweetened foods may be higher in sugar and
▘▘ Crackers or breads with seeds, nut pieces, or fat and lower in key nutrients than other more
whole grain kernels such as wheat berries; and nutritious foods, such as plain fruit. Plain fruit
▘▘ Whole kernels of cooked rice, barley, wheat, is a good choice as a dessert for an infant. Advise
or other grains. caregivers to avoid feeding infants:
▘▘ Small enough for them to pick up and Honey, including that used in cooking or baking
▘▘ Soft enough for them to chew on. or as found in processed foods (e.g., yogurt with
honey, honey graham crackers), should not be
Appropriate finger foods include: cooked fed to infants under 12 months of age.2 Honey
macaroni or noodles, small pieces of bread, is sometimes contaminated with Clostridium
small pieces of soft, ripe peeled fruit or soft botulinum spores. Foods made with honey that in
cooked vegetables, small slices of mild cheese, the preparation process are not heated to a certain
crackers, or teething biscuits. This is a messy temperature, may still contain viable spores.
stage, but allowing infants to feed themselves is When consumed by an infant, these spores can
very important to their development of feeding produce a toxin that may cause infant botulism,
skills. Using a highchair or booster seat with a foodborne illness that can result in death. The
a removable tray that can be washed easily or gastrointestinal tract of infants cannot destroy
covering the area under the infant’s seat with these spores (older children and adults can destroy
newspaper or a plastic mat will help manage the the small amount of spores in honey). Corn syrup
mess. and other syrups currently on the market are not
sources of Clostridium botulinum spores and are
Caregivers should be alerted to the risk of infants not associated with infant botulism; however,
choking and instructed to closely supervise they are not appropriate for infant consumption.
infants while eating. See pages 124–125 regarding
choking prevention. By about 10 to 12 months,
most healthy, full-term infants are able to feed
themselves chopped foods from the table with
their fingers unassisted.
Tooth decay is the most common chronic The nutrients necessary for proper tooth
childhood disease. It is the most common development include protein and the minerals
chronic infectious disease that does not respond calcium, phosphorus, and fluoride. Protein
to antibiotics and does not heal itself. Good provides the foundation for the teeth and the
nutrition, use of proper feeding techniques, minerals are deposited in this foundation to
and careful attention to keeping the mouth and form a hard tooth structure. Fluoride, when
teeth clean are all important for assuring that an incorporated during tooth development and after
infant develops and maintains healthy, strong the teeth erupt, makes tooth enamel significantly
teeth. Infants from low-income families whose more resistant to the acid attack that produces
mothers have low educational levels and who eat dental caries. Thus, a nutritionally adequate
sugar-containing foods have been shown to be diet, along with adequate fluoride, is important
32 times more likely to have dental caries at age for both the development and maintenance of
3.1 Similarly, statistics from the United States healthy, strong teeth. Yet, even if a nutritious diet
Government Accountability Office indicate that is consumed, as soon as any of the primary teeth
children from low-income families are 5 times begin to appear, they can decay under certain
more likely to have untreated tooth decay and conditions.
experience 12 times more activity restricted
days due to dental problems than children from Dental Caries (Tooth Decay)
higher-income families. This section reviews
tooth development, dental caries, early childhood Three variables contribute to the development of
caries, dental care for infants, and teething. dental caries – susceptible teeth, specific bacteria
Refer to pages 26–27 for information regarding in the mouth, and fermentable carbohydrates
fluoride supplementation for infants, as related to (sugars and starches). Tooth decay begins when
preventive dental care. fermentable carbohydrates from food or beverages
are metabolized to organic acids by bacteria,
Tooth Development primarily Streptococcus mutans (S. mutans), in
the mouth. The S. mutans bacteria that normally
The primary teeth and many permanent teeth live in the mouth adhere to the tooth surfaces
begin forming inside the jawbones before birth. and form dental plaque, the sticky, colorless
The primary teeth, which erupt over the first material that accumulates around and between
2½ years of the infant’s life, are important as are the teeth and gums and in the pits and grooves
the permanent teeth that follow. The primary of the chewing surfaces of the teeth. The sticky
teeth are critical for chewing and eating food, plaque enables the bacteria and the acids they
normal development of the jaw bones and produce to remain on the tooth surface instead of
muscles, proper placement of the permanent being washed away by saliva. The longer plaque is
teeth, the appearance of the face, and proper allowed to stay undisturbed on the tooth surfaces,
speech development. The first primary teeth to the greater is the likelihood that the bacteria will
Photographs below show teeth with mild to severe cases of early caries
Photographs courtesy of: Dr. Norman Tinoff, DDS, MS, Professor, University of Connecticut Health Center, School of
Dental Medicine, Department of Pediatric Dentistry, Farmington, Connecticut
Up to one fifth of all infants experience colic in Use of ordinary beverages to treat diarrhea
the first few months of life. Colic is described may actually worsen the condition and lead to
as prolonged, inconsolable crying that appears further dehydration.25 In most cases of acute
to be related to stomach pain and discomfort diarrhea, and clearly when dehydration is not
(infants may pull their legs up in pain) often in present, continued feeding of the infant’s usual
the late afternoon or early evening.6 It usually diet is the most appropriate treatment.25 This
develops between 2 to 6 weeks of age and may is true whether the infant’s usual intake is breast
continue until the infant is 3 to 4 months old. milk, milk-based infant formula, soy-based
Formula-fed infants seem to experience colic infant formula, or any of these milks along with
more often than breastfed infants; the cause of complementary foods. Caregivers should consult
colic is unknown. A systematic review of a variety with the infant's health care provider about the
of therapies used to manage colic indicates no treatment of diarrhea and not self-treat diarrhea
clearly effective treatments.23 Some evidence by feeding ordinary beverages such as carbonated
indicates that breastfed infants may benefit from beverages, sport drinks, fruit juice, tea, or chicken
breastfeeding mothers eliminating milk products broth.
Reprinted with permission from Patrick K, Spear B, Holt K, Sofka D. Bright Futures in Practice: Physical Activity.
Arlington, VA: National Center for Education in Maternal and Child Health, 2001.
Age Carbohy- Fat n-6 PUFA n-3 PUFA Protein Vitamin A Vitamin D Vitamin E Vitamin K
drate (grams/day) (grams/day) (grams/day) (grams/day) (µg RAE) (µg[IU] (α-tocoperol) (µg)
(grams/day) (mg)
RDA
UL 600 µg 25 (1,000) ND ND
preformed
EAR 9.9
(1.1/kg)
EAR
RDA
UL ND ND ND ND ND ND ND ND ND
EAR
UL ND ND ND ND ND ND ND ND ND
1–3 years AI
UL 400 ND ND 10 30 mg as 300 ND ND ND
pyroxidine
Age Calcium Chromium Copper Fluoride Iodine (µg) Iron (mg) Magne- Man- Phos Selenium Zinc (mg)
(µg) (µg) (mg) sium ganese phorous (µg)
(mg) (mg) (mg)
210 0.2 200 0.01 110 0.27 30 0.003 100 15 2.0
EAR
RDA
UL ND ND ND 0.7 ND 40 ND ND ND 45 4
RDA 11 3
UL ND ND 0.9 ND 40 ND ND ND 60 5
1. World Health Organization. Physical Status: The Use and Interpretation of Anthropometry.
Geneva: World Health Organization, 1995. WHO Technical Report Series 854.
2. American Academy of Pediatrics. Pediatric Nutrition Handbook. 4th ed. Elk Grove Village, IL:
American Academy of Pediatrics. 1998;4:168–169.
3. Kuczmarski RJ, Ogden C, Grummer-Strawn LM, et al. CDC Growth Charts: United States.
Hyattsville,MD: U.S. Department of Health and Human Services, 2000. NCHS Advance Data
Report No. 314.
4. Himes JH, Dietz WH. Guidelines for overweight in adolescent preventive services:
Recommendations from an expert committee. American Journal of Clinical Nutrition
1994;59:307–316.
5. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert committee recommendations.
Pediatrics 1998;102(3):E29.
6. Nelhaus G. Head circumference from birth to eighteen years: Practical composite international and
interracial graphs. Pediatrics 1968;41:106–114.
7. WIC CDC Growth Charts may be viewed, downloaded, and printed in Adobe Acrobat from the
WIC Works Resource System (WIC Works).
8. Adapted from http://www.cdc.gov/nccdphp/dnpa/growthcharts/00binaries/growthchart.pdf
CM
MY
CY
CMY
Available at http://www.nal.usda.gov/wicworks
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2002).
http://www.cdc.gov/growthcharts WIC Makes A Difference
Available at http://www.nal.usda.gov/wicworks
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2002).
http://www.cdc.gov/growthcharts WIC Makes A Difference
CM
MY
CY
CMY
Available at http://www.nal.usda.gov/wicworks
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2002).
http://www.cdc.gov/growthcharts WIC Makes A Difference
Available at http://www.nal.usda.gov/wicworks
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2002).
http://www.cdc.gov/growthcharts WIC Makes A Difference
Essential for biosynthesis of Pernicious anemia; neurologic Infant formula, breast milk,
Vitamin B12 nucleic acids and nucleoproteins; deterioration meat, fish, poultry, cheese,
red blood cell maturation; involved egg yolk, liver
(Cobalamin, with folate metabolism; central
Cyanocobalamin) nervous system metabolism
Essential in the biosynthesis of Poor growth; megaloblastic ane- Masking of B12 deficiency symp- Breast milk; infant formula;
nucleic acids; necessary for the mia (concurrent deficiency of vi- toms in those with pernicious ane- liver; green leafy vegetables;
Folacin normal maturation of red blood tamin B12 should be suspected); mia not receiving cyanocobalamin legumes; whole-grain breads,
cells impaired cellular immunity cereals, and fortified or en-
(Folate) riched grain products; legumes;
oranges; cantaloupe; lean beef
Aids in the synthesis and break- Microcytic anemia; Sensory neuropathy with progres- Breast milk; infant formula;
down of amino acids and unsatu- convulsions; irritability sive ataxia; photosensitivity liver; meat; whole-grain breads,
Pyridoxine rated fatty acids from essential cereals, or other grain products;
fatty acids; essential for conver- legumes; potatoes
(Vitamin B6) sion of tryptophan to niacin; es-
sential for normal growth
Combines with phosphorus to Beriberi, neuritis, edema, Breast milk; infant formula; lean
form thiamin pyrophosphate (TPP) cardiac failure pork; wheat germ; whole-grain
Thiamin necessary for metabolism of pro- and enriched breads, cere-
tein, carbohydrate, and fat; essen- als, and other grain products;
(Vitamin B1) tial for growth, normal appetite, legumes; potatoes
191
192
Nutrient Function Deficiency Symptoms Toxicity Symptoms Major Food Sources
Essential for growth; plays Photophobia, cheilosis, glossi- Breast milk; infant formula,
enzymatic role in tissue respira- tis, corneal vascularization, poor meat; dairy products; egg yolk;
Riboflavin tion and acts as a transporter of growth legumes; green vegetables;
hydrogen ions; synthesis of FMN whole-grain breads, cereals,
(Vitamin B2)
and FAD and fortified or enriched grain
products
Part of the enzyme system for Pellegra: dermatitis, diarrhea, Transient due to the vasodilat- Breast milk; infant formula;
oxidation, energy release; nec- dementia ing effects of niacin (does not meat; poultry; fish; whole-grain
Helps regulate acid-base equi- Muscle weakness; decreased Breast milk; infant formula;
librium and osmotic pressure of intestinal tone and distension; fruits especially orange juice,
body fluids; influences muscle cardiac arrhythmias; respiratory bananas, and dried fruits;
activity, especially cardiac failure yogurt; potatoes; meat; fish;
Potassium muscle poultry; soy products;
vegetables
Age Breast Milk or Infant Grain Products Juices Vegetables Fruits Protein-Rich Foods
Formula
Birth–4 Months Breast: None
8–12+ feedings
Iron-Fortified Infant
Formula:
14–42 ounces
(~108 kcal/kg body
weight)
4–6 Months Breast: Iron-fortified infant None Plain strained Plain strained or Plain strained or
5 or more feedings cereals or enriched or pureed cooked pureed fresh or pureed protein-rich
hot cereals vegetables cooked fruits foods such as meats,
Iron-Fortified Infant (1–2 Tbsp) (1–2 Tbsp) (1–2 Tbsp) egg yolk, and legumes
Formula: may be introduced
26–39 ounces if an additional food
(~108 kcal/kg body source of iron is
weight) needed
The American Academy of Pediatrics (AAP) Section on Breastfeeding recommends exclusive breastfeeding for the first 6
months of life. The AAP Committee on Nutrition recommends that, in developed countries, complementary foods may be
introduced between ages 4 and 6 months. This is a population-based recommendation, and the timing of introduction of
complementary foods for an individual infant may differ from this recommendation.
6–8 Months Breast: Iron fortified infant 100 percent pasteur- Plain strained Plain strained or Plain strained or
3–5 feedings cereals or enriched ized fruit or vegetable or pureed cooked pureed fresh or pureed protein-rich
hot cereals juice (2–4 ounces) vegetables cooked fruits foods such as meats,
Iron-Fortified Infant (4–6 Tbsp) (3–4 Tbsp) (3–4 Tbsp) egg yolk, and legumes
Formula: * J uice offers no (1–2 Tbsp)
24–32 ounces Dry toast, small piec- nutritional benefit
(~98 kcal/kg body es of crackers, or dry over whole fruits
weight) breakfast cereals and and vegetables. If
other grain products offered, it should be
(4–6 Tbsp) in a cup.
Comments • By about 12 to 14 • Examples of other • Avoid feeding soda, • It is not necessary • Do not add sugar or • Avoid fried meats,
months, try to wean grain products fruit punches, ades, to add salt, sugar, syrups to fruits. gravies, sauces, pro-
entirely off the include zwieback, and drinks, gelatin oil, butter, other cessed meats (e.g.,
bottle and onto a bread, noodles, water, coffee, or fats, or seasonings. • Never add honey to hot dogs, luncheon
cup. mashed rice, corn tea. fruit or any foods. meats, bacon, and
grits, and soft torti- • Avoid foods that sausage).
• An infant’s health lla pieces. may cause choking. • Remove seeds and
care provider may pits from fruits. • Check carefully for
recommend feeding • Avoid wheat cereals bones (especially in
a small amount of until 8 months. • Avoid foods that fish).
sterile water (~4 to may cause choking
8 ounces per day) • Do not add sugar or • Do not feed any
in a cup when com- syrups to cereal. shellfish, peanut
plementary foods butter, whole eggs,
are introduced. • Never add honey to or egg whites before
cereal or any foods. 1 year of age.
Bibliography
• Nevin-Folino NL, editor. Pediatric Manual of Clinical Dietetics. 2nd ed. Chicago, IL: American Dietetic Association, 2003.
• Kleinman RE, editor. Pediatric Nutrition Handbook. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2004.
• Samour PQ, King K, editors. Handbook of Pediatric Nutrition. 3rd ed. Sudbury, MA: Jones and Bartlett Publishers, Inc., 2005.
Appendix E: Activities for Infants
Food Safety and Inspection Service Protects consumers by ensuring that meat, poultry, and egg
U.S. Department of Agriculture products are safe, wholesome, and accurately
Washington, DC 20250 labeled. Provides resource materials on food safety.
Operates the USDA Meat and Poultry Hotline (MPH).
(MPH) Hotline Toll-free phone: 1-800-535-4555
TTY: 1-800-256-7072
Web site: http://www.fsis.usda.gov/
Centers for Disease Control and Prevention Develops and applies disease prevention and control, envi-
1600 Clifton Rd. ronmental health, and health promotion and education ac-
Atlanta, GA 30333 tivities. The National Center for Chronic Disease Prevention
and Health Promotion publishes pediatric growth charts as
well as information on using and interpreting growth data.
Toll-free phone: 1-800-311-3435
Web site: http://www.cdc.gov
Food and Drug Administration Promotes and protects the public’s health by ensuring that
Center for Food Safety and Applied Nutrition the nation’s food supply is safe, sanitary, wholesome, and
200 C Street, S.W. honestly labeled, and that cosmetic products are safe and
Washington, DC 20204 properly labeled.
Toll-free phone: 1-888-SAFEFOOD
Web sites: http://www.cfsan.fda.gov/list.html
http://www.foodsafety.gov/ (this is a gateway web site that
provides links to selected government food safety-related
information)
U.S. Department of Agriculture Provides resource materials on infant nutrition and food
National Agricultural Library (NAL) safety. NAL sponsors:
10301 Baltimore Blvd., Room 304 – Food and Nutrition Information Center (FNIC) (collects and
Beltsville, MD 20705-2351 disseminates information about food and nutrition).
Phone: (301) 504-5414
Web site: http://www.nal.usda.gov/fnic
–N
utrition.gov (serves as a gateway to reliable information
on nutrition, healthy eating, physical activity, and food
safety for consumers from across the federal government)
Web site: http://www.nutrition.gov/
U. S. Environmental Protection Agency (EPA) Provides information on water safety and recommendations
Ariel Rios Building for consumption of foods susceptible to contamination with
1200 Pennsylvania Avenue, N.W. hazardous materials such as mercury or lead.
Washington, DC 20460 Web site: http://www.epa.gov
U.S. Consumer Product Safety Commission (CPSC) Protects the public from unreasonable risks of injury or
4330 East West Highway death from many types of consumer products including
Bethesda, MD 20814 baby and children’s products.
Toll-free phone hotline: 1-800-638-2772
TTY Hotline: 1-800-638-8270
Web site: http://www.cpsc.gov
Free copies of CPSC’s “Sleep Safe/Play Safe” campaign
brochures and posters, in English and Spanish, are
available through the web site or by writing to
CPSC, Washington, DC 20207.
U.S. Government Bookstore Offers for sale official Government books, periodicals, post-
732 North Capitol Street, NW ers, pamphlets, forms, and subscription services in many
Washington, DC 20401 subject categories, including nutrition, childhood, health
care, and safety.
Phone: 1-866-512-1800
Web site: http://bookstore.gpo.gov/
American Dietetic Association (ADA) Source of materials and information on infant nutrition,
216 W. Jackson Blvd. food safety, and other nutrition topics.
Suite 800 ADA’s National Center for Nutrition and Dietetics (NCND)
Chicago, IL 60606 Information Line offers the public direct access to objec-
tive, credible food and nutrition information from registered
dietitians.
Toll-free phone: 1-800-877-1600
Web site: http://www.eatright.org/
American Academy of Pediatric Dentistry (AAPD) Source for oral health policies, clinical guidelines related to
211 East Chicago Avenue, Suite 700 oral health for infants and children, and parent education
Chicago, IL 60611 brochures.
Phone: (312) 337-2169
Web site: http://www.aapd.org
International Lactation Consultants Association (ILCA) Source of education, resources and materials on breast-
1500 Sunday Drive, Suite 102 feeding and lactation consultants.
Raleigh, NC 27607 Phone: (919) 861-5577
Web site: http://www.ilca.org
La Leche League International (LLLI) Provides resources for both breastfeeding mothers and
1400 N. Meacham Road professionals. Includes information on how to find local LLLI
Schaumburg, IL 60173 leaders or groups.
Phone: (847) 519-7730
Toll-free phone: 1-800- LALECHE
Web site: http://www.llli.org/
Institute of Medicine of the National Academies Serves as an independent adviser to the nation to improve
500 Fifth Street, NW health, providing advice that is unbiased, based on evi-
Washington, DC 20001 dence, and grounded in science. Periodically updates and
publishes the Dietary Reference Intakes.
Phone: (202) 334-2052
Web site: http://www.iom.edu/
American Red Cross National Headquarters Provides health and safety training to the public and emer-
2025 E Street, NW gency social services to U.S. military members and their
Washington, DC 20006 families. Your local chapter provides pamphlets, posters,
and classes in emergency techniques for first aid, prevent-
ing choking, and cardiopulmonary resuscitation (CPR).
Phone: (202) 303-4498
Web site: http://www.redcross.org/
Partnership for Food Safety Education Sponsors “Fight BAC!” Campaign; source of information on
50 F Street, NW, 6th Floor food safety.
Washington, DC 20001 Phone: (202) 220-0651
Web site: http://www.fightbac.org
We thank Beth Leonberg MS, RD, CSP, FADA, CNSD, LDN (Nutrition Outcomes, LLC)
for her major contribution to the revision of this handbook.
Kay Olson-Fischer RD, IBCLC Amy Spangler, MN, RN, IBCLC for providing
Public Health/ WIC the illustrations from her book, Breastfeeding: A
Bloomington MN Parent’s Guide on pages 54 and 56.
Poppy Strode, MS, MPH, RD Dr. Norman Tinanoff for providing the images
California Department of Health Services WIC demonstrating examples of healthy teeth and early
Branch childhood caries on page 135.
Sacramento, CA
The President’s Council on Physical Fitness
Judy A. Sundquist, MPH, RD and Sports for providing the figures from the
Children’s Medical Services publication Kids In Action: Fitness for Children,
Sacramento, CA Birth to Age Five on page 197 in the Appendix.
Z
Zinc, see Minerals
Development of Infant
Feeding Skills
Breastfeeding
Complementary Foods
Special Concerns in
Infant Feeding
Physical Activity in Infancy
Appendix
Resources
If this publication was revised, what changes would you suggest? Please include any other comments on this
handbook.
Title__________________________________________________________________________
Organization/Program____________________________________________________________
City and State __________________________________________________________________
INFANT NUTRITION AND FEEDING 1