Chapter 6 Feeding Infants

6.1 Describe how to feed infants from birth to 6 months of age.

6.2 Describe how to feed infants ages 6 months to 1 year and facilitate the progression of solid
foods.
6.3 Discuss concerns and methods for feeding infants with special needs.

PART 1: Feeding Infants: The First 6 Months

A good feeding relationship is established when caregivers are responsive to infants’ feeding
cues of hunger and satiation. For example, during the first few months of life infants should be
fed on demand (Holmes, 2013). When an infant is hungry, he or she will cry. A caregiver who
responds to the infant by providing food is developing the infant’s trust, which will impact later
eating behaviors.

Through their senses of touch, sight, and smell, infants learn about the world around them.
Verbal and tactile stimulation such as holding, talking to, and smiling at an infant encourages
cognitive (or intellectual) and emotional development.

• How the infant develops both physically and cognitively is influenced by a number of
factors. From the beginning, the health of the infant’s mother during pregnancy impacts
the developing fetus.
• An undernourished mother during pregnancy can put the infant at nutritional risk during
the first few months of life and often impacts how the infant is fed.
• An infant born prematurely or an infant born with special health care needs may require
unique feeding strategies.
• Furthermore, an infant’s physical development as well as cognitive indicators throughout
the first year of life will determine the frequency of meals, the amount of food offered,
when solid foods are introduced, the type of solid foods introduced, and how the child
progresses to adult foods.

Caregivers must be reminded that infants need only breast milk or formula for the first 4–6
months of life. Breast milk and formula are the only food sources infants need because they are
specifically suited to the infant’s developing body. Due to infants’ small stomachs, they typically
consume only a low volume (2–4 ounces) of breast milk or formula at each feeding. Infants
require frequent feedings to get the calories they need. Breast milk is ideal because it is easily
and quickly digested and provides ideal proportions of essential nutrients.
Immunological and Other Health Benefits
• Colostrum, the first milk produced by the nursing mother, is rich in protective
components. These components include antibodies that help prevent illness and infection.
• After the first week, colostrum is no longer produced, but breast milk continues to
provide antibodies;
 • in addition, it contains good bacteria that promote a healthy gastrointestinal tract that can
reduce the infant’s risk of allergies and intolerances.
• Furthermore, the type of milk sugar in breast milk (called oligosaccharides) helps to
establish and promote the growth of a beneficial microbial population (Li et al., 2012),
which can lessen the risk of infection from harmful bacteria and the development of
allergies.
• Breast-fed infants, particularly those born prematurely, perform better on IQ tests
administered later in childhood and have overall improved cognitive performance than
children who do not receive breast milk in infancy.
• Breast-fed infants are less likely to have colds, ear infections, urinary tract infections,
and diarrhea.
• The CACFP provides reimbursement to programs for breast milk that is fed to infants in
a bottle, thereby reducing costs to programs that might otherwise need to purchase
formula. To support breastfeeding, the CACFP also provides reimbursement for meals
provided when the breastfeeding mother nurses the baby at the child care setting.

Breast Milk Composition

Breast milk is not a standard product. The first breast milk produced when the infant is born,
called colostrum, is pale to bright yellow in color. Mature breast milk (produced after the first
week or two) can vary in color depending on the fat content of the milk and the foods or
supplements the mother consumes. The fat in breast milk will rise to the top of the storage
container. The amount of fat varies depending on how much fore milk and hind milk is
expressed. Fore milk is the watery, nutrient-rich milk that is first released when the baby begins
to nurse. Hind milk is nutrient rich in fat and calories and is secreted at the end of nursing or
expressing breast milk. When an infant is fed from a bottle, gently shaking the bottle of breast
milk ensures that the fat is redistributed in the milk and made available to the infant.

Vitamin D
Breast milk is not a rich source of vitamin D, an important vitamin that enhances calcium
absorption and facilitates the building of strong bones and teeth. Vitamin D is produced in the
body when skin is exposed to sun. However, infants and young children who have minimum
exposure to sunlight and who are dark-skinned could be at risk for low levels of vitamin D.
Therefore, the American Academy of Pediatrics (2016) recommends providing 400 IU vitamin D
supplements for all breastfeeding infants.

Vitamin B12
A lack of vitamin B12 can be a concern for infants of breastfeeding mothers who are vegan
(vegetarians who do not consume any foods of animal origin, including dairy products and eggs).
Vegan mothers are encouraged to take vitamin B12 supplements
Iron
But by 6 months of age (or earlier in premature infants), an infant’s iron reserves are depleted.
Insufficient iron can negatively impact growth and cognitive development. For these reasons, at
6 months of age it is important to introduce iron-rich foods such as iron-fortified cereal to
supplement the infant’s dietary intake of iron from breast milk

Zinc
Zinc is an important mineral for growth and a well-functioning immune system. Zinc in breast
milk is easily absorbed and meets the needs of infants until about 6 months of age. The older
breastfed infant’s need for zinc can be met with zinc-fortified cereals and strained meats

Types of Infant Formula

Like breast milk, infant formula is designed to meet the nutrient needs of infants until 6 months
of age. A variety of infant formulas are available, and they may differ in the type of
carbohydrate, protein, and fat they contain.

Modified Cow’s Milk–Based Formulas

Modified cow’s milk is the most commonly used commercial formula. It is composed of cow’s
milk that has been altered to provide less protein, more fat, and carbohydrates in an easily
digested form.
Soy-Based Formulas
Hypoallergenic formulas
They contain protein that has been broken down into smaller components, making them easier to
absorb and less likely to cause an allergic response. These products were developed for children
with cow’s-milk or soy allergies and for infants who have gastrointestinal or liver disease that
result in problems with absorption.

Understanding the Feeding Relationship

On-Demand Feeding
Infants should always be fed on demand. It is not appropriate to impose a feeding schedule on
infants in a child care setting unless this has been authorized by a health care professional for
medical reasons.
Feeding Cuse
Infants are born with the instinctual ability to cry when they are hungry. However, babies cry for
a variety of reasons, and the caregiver must learn to identify the underlying reason the baby is
crying.
Signs of Hunger and Satiety
Successfully reading hunger and satiety (fullness) cues can reduce infants’ stress and enhance the
feeding relationship. Some infants who are not fed in a timely manner become overly frustrated,
and when they receive the breast or bottle they may sputter or gulp air. This can lead to gas,
stomach distention, spitting-up, and even more crying.
How Often and How Much to Feed a Baby
Babies usually develop a routine for eating that is influenced by their weight, age, whether they
receive breast milk or formula, and whether they are eating solids. In general, breast-fed
newborns tend to eat every 1½–3 hours, or about 8–12 times per day, for the first 6 weeks. By
the time they are 4–6 months old, they consume greater volumes of breast milk, and feedings
gradually decrease to five or more feedings per day (Kleinman, 2009). Newborns receiving
formula typically need 8–12 feedings per day, although some will be hungry less often because
formula takes longer to digest compared with breast milk. By 4–6 months, the number of
formula feedings decreases to 5–8 bottles per day.

Inappropriate Infant Feeding Practices

Adding Cereal to the Bottle
Putting cereal in the bottle may result in excessive caloric intake, putting the baby at risk for
overweight and obesity (American Academy of Pediatrics, 2012f) and cavities (National Institute
of Dental and Craniofacial Research & National Institutes of Health, 2011).
Mothers may not recognize cereal as a solid food and may receive pressure from grandparents or
other family members about feeding decisions.
Finishing the Bottle
Adults may encourage a baby to finish the bottle to avoid wasting formula or breast milk. This
disrupts the infant’s ability to self-regulate food intake and alters responsiveness to internal cues
of hunger and satiety, putting them at risk for developing obesity.
Using Honey in the Bottle or on the Pacifier
The inappropriate feeding practice of putting honey in a baby’s bottle can have severe outcomes.
A serious foodborne illness called infantile botulism can occur in infants as a result of
consuming honey.

Offering Alternative Milk

Milk produced by cows should not be served until a baby has reached 12 months of age.
Consuming cow’s milk can lead to iron-deficiency anemia and can cause gastrointestinal upset
and intestinal blood loss in some infants. Cow’s milk is too high in protein, sodium, and
potassium for infants, which puts stress on the kidneys. Finally, cow’s milk is not supplemented
with the vitamins and minerals that babies need.
Goat’s milk should not be used for the same reasons. Goat’s milk is very low in folic acid, which
can lead to a form of anemia (Queen Samour & King, 2012). Alternative vegetarian beverages
designed for consumption by adults, such as soy beverages, rice beverages, and other vegetarian
milk substitutes, are not acceptable for infants. These beverages may be too low in fat, and they
are not supplemented appropriately to meet the vitamin and mineral needs of infants.

PART 2: Feeding Infants: 6 Months to the First Birthday

Between 6 and 12 months of age, babies’ bodies and diets undergo a significant transformation.
The maturation of the gastrointestinal tract allows the infant’s diet to evolve from the exclusive
intake of liquids to the consumption of adult-like solid foods. Babies are gradually exposed to a
myriad of aromas, flavors, and textures that come with the introduction of complementary foods.

2-1 Introducing Complementary Foods

As infants grow, their need for additional vitamins and minerals requires the introduction of
additional foods and beverages. Introducing solids too early can result in
• Increased risk for choking, eczema, and food allergies.
• It may displace the valuable nutrients found in breast milk and formula, thus interfering
with proper growth.
• It is associated with an increased risk of developing obesity
The “window of opportunity” for introducing complementary foods and advancing flavors and
textures occurs somewhere between 4 and 6 months of age through 10 months of age. Infants
who are exposed to a variety of foods and textures are more accepting of new textures and new
foods compared with those infants who are not. For example, offering a baby puréed commercial
infant bananas first, then well-mashed ripe bananas, and finally ripe bananas cut up into ¼-inch
pieces is an example of a progression of textures.

2-2 Linking Developmental Skills to Feedings

Transitioning from liquids to puréed solids, from puréed solids to textured foods, and then to the
self-feeding of table foods are all eating achievements linked to developmental milestones.
• They know to turn reflexively toward the breast or bottle when their mouth or cheek is
brushed by the nipple (rooting reflex)
• They begin to suck when something touches the roof of their mouth (sucking reflex).
• When the lips are touched, the tongue comes out of the mouth (tongue thrust reflex).
• These reflexes help to ensure that infants can latch onto a bottle or breast.
• In addition, infants possess a gag reflex, which is activated when food is placed in the
back of the mouth and results in the ejection of the food.

The transition through textures should coincide with infants’ developmental progress from being
able to keep food in their mouth, moving it around with their tongues, and then using an up-and-
down chewing motion. Initial signs of readiness include the ability to sit with support and to
indicate hunger by opening the mouth and leaning in or to indicate fullness by closing the mouth
and leaning away.
2-3 Avoid Introducing Fruit Juice Early
• Fruit juice should not be offered to infants before 12 months of age because it can replace
other foods, including breast milk or formula.
• If juice is given to babies after they reach 12 months of age, it should be 100% juice.
 • Excess juice intake can increase the risk for excessive weight gain and dental caries, and
it can lead to diarrhea, gas, abdominal distention, and diaper rash.
• Once solids are introduced to the diet or when days are hot, water can be offered to
infants
2-4 Avoiding Lead in Baby Foods
found that lead was detected in 20% of baby food samples. Lead was found in 89% of grape
juice, 67% of mixed fruit juice, and 55% of apple juice samples. To avoid lead, the American
Academy of Pediatrics recommends that children eat a variety of fruits and vegetables to
minimize risks from single foods.
2-5 Understanding How to Feed Solids to Infants
Feed babies at a pace that is comfortable for them. When feeding infants solid foods, consider
the following practical recommendations:
• The teacher’s hands should be washed before preparing and serving the meal, and the
infant’s hands should be washed before eating.
• Teachers should have space identified for feeding infants that includes high chairs with
removable trays that can be easily sanitized.
• Babies should have specifically assigned and labeled high chairs.
• Babies should be placed in a high chair when fed unless they have special needs or
disabilities. Sitting up straight with feet supported promotes proper swallowing and helps
reduce the risk of choking.
• Teachers should use plastic-coated baby spoons and have extra spoons available to allow
the infant to hold his or her own spoon while feeding.
• Food should be placed on the tip of the spoon to make it easier to access and swallow and
begin by mixing a small amount of cereal into breast milk or formula and gradually
increase texture.
• Teachers should always prepare food in a small bowl for serving. Don’t feed babies
directly from a jar because this will contaminate the baby food.
• Do not force children to finish food in the bowl. Stop feeding when the infant shows
signs of being full.
• Teachers should always supervise the baby in the high chair. Never leave the baby
unattended.
• Teachers need to remember babies have small stomachs and, therefore, require small but
frequent meals and snacks.
2-6 Reducing the Risk of Choking

When planning meals for infants, it is imperative to consider whether the food prepared might
pose a choking risk. All foods offered to an infant should be cut into pieces no larger than ¼ inch
in diameter. Because infants are new eaters and are developing oral motor skills at different
rates, teachers should continually monitor and evaluate their chewing and swallowing skills.
Food items used for teething can pose a risk too. For example, chicken bones, raw carrots, frozen
bananas, bagels, and whole apples are not recommended.
• Slippery round or circular foods, such as grapes and cooked carrots.
• Easy-to-inhale foods such as sunflower seeds, peanuts, raisins, popcorn, and corn kernels.
• Sticky, chewy foods such as peanut butter, fruit leathers, and gummy candy.
• Firm food that can wedge in the throat such as hot dogs, whole bananas, and bagels.
• Hard, dry foods such as pretzels and chips.
Likewise, medications for teething pain should not be applied before meals because gums,
mouth, and throat can become numb. This can make swallowing more difficult. Teachers should
sit and eat with infants at mealtimes to ensure safety.

2-7 Infants Learning About Food and Eating

Eating is a learning process. Infants learn about food if they are allowed to explore it. This
involves looking, touching, poking, squishing, smelling, and tasting food. Through these
explorations, infants are learning how to move food in their mouth, to chew, and to swallow.
Allowing babies to self-feed is also a learning experience.

PART 3: Feeding Infants with Special Health Care Needs

Feeding problems are defined by the American Academy of Pediatrics as developmental
disorders related to the mouth (Kleinman, 2009). Feeding problems related to the swallowing
process are identified in infants who have difficulty consuming liquids and who cough or choke
during meals. Infants who gag on foods that need to be chewed and have a strong preference for
smooth or crunchy foods but have no problems with liquids also show symptoms of a feeding
problem.
Feeding problems can be either sensory or motor based (Kleinman, 2009). For example, some
babies may have issues with oral sensitivity. Infants with oral hyposensitivity have less feeling in
the mouth, and therefore are less conscious of where food is once it is placed inside their mouths.
Oral hypersensitivity, on the other hand, describes a condition in which infants are overly aware
of foods placed in or near their mouths. For these babies, food brought near or into the mouth can
cause a gag or bite-down reflex. These conditions can make mealtimes challenging for both baby
and caregiver (Yang, Lucas, & Feucht, 2010). Babies with oral motor delays may have
difficulties chewing due to weak jaw muscles. They also may have problems moving food
around in the mouth due to uncoordinated tongue movement, which can result in choking,
gagging, and labored eating.

Feeding Premature Infants

Premature infants, defined as infants who are born before 37 weeks of gestation, may have
special feeding needs. Premature infants should receive breast milk, if possible. Compared with
formula, breast milk offers immunological protection and improved developmental outcomes. In
premature infants (but not necessarily near-term infants), expressed breast milk can be fortified
with special milk fortifiers to meet the higher protein, vitamin, and mineral requirements of
growth.
The child care setting should have a written policy that requires a prescription from the health
care provider with a clearly written recipe. As the infant develops, teachers should rely on the
guidance of the family and their health care provider on when to introduce solid foods for
premature infants. As a rule, the introduction of solids for these infants should be based on
developmental readiness, which may need to be based on the baby’s due date or corrected age as
opposed to date of birth. A baby’s corrected age is the number of weeks the baby was born early
subtracted from his or her current age in weeks. For example, an infant who enters a child care
setting when he is 3 months old but was 3 weeks premature would have a corrected age of 9
weeks of age.

Feeding Infants with Cleft Lip and Cleft Palate

Cleft lip and cleft palate are birth defects of the lip and mouth that contribute to particularly
complex swallowing problems. During the first few weeks of pregnancy, the sides of the lip and
mouth begin developing and eventually come together. In some cases, the sides of the mouth or
lips do not fuse properly, creating a cleft palate or cleft lip or both. A cleft lip is generally not
problematic for babies because they can still suck and swallow. A cleft palate, however, consists
of an opening in the roof of the mouth. Babies born with a cleft palate may not be able to suck
successfully and are at increased risk of poor intake (Academy of Nutrition and Dietetics, 2012).
The use of special bottles can allow breast milk or formula to be squeezed into the infant’s
mouth. Elongated nipples can also be used to help with sucking and swallowing.
A cleft lip is surgically closed at about 6 weeks to 3 months of age, and a cleft palate is repaired
at about 9–12 months; therefore, caregivers should make sure infants are well nourished prior to
surgery