Jennifer Caryn Brand Nutrition

Jennifer Brand, MPH, MS, CNS Clinical Nutritionist

Infant Nutrition (Born Full-Term at 37 Weeks Gestation or Later)

Full-term infants (39 to 40 weeks gestation1) can do a lot! They can hear, and move in response to familiar sounds like their mother’s voice. They have four states of arousal ranging from sleep to fully alert. Recognizing your infant’s state of arousal is important for being able to nurse successfully. Within hours after birth, newborns have reflexes allowing them to root, suckle and coordinate swallowing and breathing.(2)

 

The mouth of a healthy newborn provides a source of pleasure and exploring, and represents a form of early learning. Anything that interferes with the mouth at this stage, such as an extended period of respiratory support, may lead to your infant associating her mouth with discomfort and this may lead to feeding problems. From a sensorimotor perspective, the stage when infants are sensitive to food textures is also when they begin showing their speech skills.(2)

 

The development of the digestive system in infants can be confusing. An infant with soft, loose stools for example may be thought to have diarrhea. This however is typical for breastfed infants. Another source of confusion is that stomach discomfort may interfere with weight gain. It can take 6 months for the gastrointestinal tract of an infant to mature, and this time can vary depending on the infant.(2,3)

 

During the third trimester of pregnancy, the fetus swallows amniotic fluid. This stimulates the lining of the intestines to grow and mature. At birth, the digestive system of an infant is mature enough to digest fats, protein, and simple sugars. It can also absorb fats and amino acids.(2,3) Infants often have conditions that reflect how immature the gut is. These conditions may include colic, GERD (reflux), unexplained diarrhea, and constipation. Generally, these conditions do not interfere with the absorption of nutrients, and they do not interfere with your infant’s growth.(2,4)

 

Colic should be addressed by rocking, swaddling, or bathing your infant, or by other ways of calming her, by positioning the baby well for eating, or burping her to relieve gas. Colic may be caused by the mother’s diet while breastfeeding and foods that commonly cause this problem include milk, and onions, so changes in the maternal diet can be helpful. Probiotics may be helpful.(2,4,5,6)

 

Using acid blocking medications to manage digestive symptoms such as colic or reflux can lead to problems with the digestion and absorption of nutrients, an increased risk for pneumonia, infections of the gastrointestinal tract, and over time can adversely affect your infant’s growth and development, as well as her overall health and wellbeing.(2,7)

 

Diarrhea can be caused by viral and bacterial infections, food intolerances, or changes in fluid intake. Young infants have more stools each day than older infants, and have them soon after feeding. Breastfed infants tend to have soft stools, and infants fed soy formula experience more constipation. To avoid constipation ensure adequate fluid intake, and avoid medications unless they are prescribed. Using prune or other juices for their laxative effects may result in fluid imbalance and diarrhea. High fiber foods present a choking risk, so they are not recommended for constipated infants.(2) When an infant presents with diarrhea, it is recommended to feed as usual during the bout. Breast milk does not cause diarrhea (it may help prevent it), and during a bout, continuing adequate intake of breast milk or infant formula is usually sufficient for preventing dehydration.(2,8)

 

Temperament refers to your infant’s emotional reactions to new situations, activity level, and sociability. Learning your infant’s temperament may take some time, and understanding it is important for you to appropriately respond to her cues of hunger and fullness. For example, she may feed better when there is not a lot of loud noise, or when you are feeling calm as opposed to being under stress.(2)

 

Most breastfed infants, or those who get the recommended amounts of formula, meet protein requirements without the need to add foods to the diet. There are no recommendations for fat intake, however restricting dietary fat is not recommended. Cholesterol intake also should not be limited in infants because it is important for testes, ovary, and brain development. Fat is also needed to provide energy to the liver, brain, and muscles, including the heart. Full-term breastfed babies do not need to supplement fat or essential fatty acids (DHA and EPA). Essential fatty acids are required to make hormones, and for normal growth and development. Carbohydrates are also important because without enough of them, your infant’s body will use protein for energy by pulling it from her muscles, and this can interfere with proper growth and development.(2,9)

 

Infants ideally should be breastfed exclusively during the first 6 months of life, and then for an additional 6 months. For infants less than 6 months of age, no other liquids or foods are recommended in addition to breast milk (or formula). The volume taken in is not the best indicator of nutritional adequacy. Rather, focus on the growth rate and health of your infant.(2)

 

Using cow’s milk (whole, skim, reduced fat, etc.) is not recommended during infancy.(2,9) Iron deficiency anemia can be linked to early introduction of cow’s milk in infants, where calcium interferes with iron absorption in the body.(2,10)

 

Soy based formulas are not recommended because they contain hormone like substances that may adversely impact development, and have long-term reproductive risks.(2,11) Lactose-free and hydrolyzed formulas may be alternatives to soy for infants that are not breastfed and cannot be fed cow’s milk.(2,9)

 

Infants are born with the innate ability to regulate their energy (food) intake.(2) Learning their hunger and fullness cues can prevent under and overfeeding.(2)

 

By age 6 months, infants may be ready to eat from a spoon. If your infant is able to move her tongue from side to side without moving her head, and she can keep her head upright and sit with little support, it is time to try spoon-feeding. Other cues she may give when it comes to feeding, hunger and fullness include:(2)

 

  1. Excitedly watching the food being opened in anticipation of eating it
  2. Tight fists or reaching for the spoon to demonstrate hunger
  3. Showing agitation if the pace of feeding is too slow or if the person feeding her stops
  4. Playing with her food or spoon as she starts to get full
  5. Slowing the pace of eating or turning away from food when she is feeling full
  6. Stopping eating or spitting out food when she has had enough to eat

 

The introduction of solid food can be a challenging time for your infant, and for you. Begin offering food on a spoon in small quantities the size of 1-2 tablespoons for a meal, with one or two meals each day. The goal of offering food on a spoon to infants at 6 months of age is to help stimulate the development of mouth muscles, rather than to provide nutrition, which ideally is being done via breastfeeding.  Spoon feeding involves two new experiences for your infant in that a spoon has a different mouth feel than a breast, and the food does not feel the same as breast milk does on the tongue.(2) For tips on introducing solid foods, see “Getting Toddlers to Eat Solids and Ideas for Picky Eaters”.

 

The position of your infant during feeding is important to avoid choking, discomfort while eating, and ear infections. For the first few months, semi-upright, as your infant would be seated in a car seat or infant carrier, is recommended. Propping a bottle or placing your infant on a pillow can increase the risk for choking, and result in overfeeding. For spoon-feeding, your infant can have better control of her mouth and head if seated with good back and foot support. Sit directly in front of her when offering the spoon, and make eye contact without making her have to turn her head. Using a high chair is appropriate when your infant can sit on her own without assistance. Her hips and legs should be at about 90 degrees, and this position is important for digestion. More spitting up is likely if she is sliding down and out from under the tray of her high chair.(2)

 

Some infants may be resistant to learning new feeding skills or react to food introductions unusually. Problems like this may indicate general health or developmental difficulties. They may also indicate your child is a picky eater. For tips on navigating picky eaters, see “Getting Toddlers to Eat Solids and Ideas for Picky Eaters”, and talk to a qualified health care provider if you are concerned there are deeper issues at play.(2)

 

Weaning from your breast is recommended when your infant is 12 to 24 months of age.(2,12) If your infant is breastfed for the first year of life (as is recommended), introducing a cup for water and other fluids after 6 months of age is recommended. This is around the same time it is recommended to begin attempting spoon-feeding. Developmental readiness for a cup begins around 6 to 8 months of age. The typical portion size of fluid from a cup is about 1 to 2 ounces. Moving from a bottle to a sippy cup developmentally is not the same as moving to a regular cup. Keep in mind the same mouth skills that help your infant control liquids help encourage speech development. We want to foster this development by introducing a cup. Weaning from the breast or bottle too soon may result in a plateau in weight if your infant is not taking in enough energy (calories), and may cause constipation if she is not receiving enough fluids.(2)

 

At 6 months of age, infants go from swallowing only fluids to being able to handle pureed and soupy foods. An infant’s mouth is extremely sensitive to texture and if food with soft lumps is presented too soon, she may choke. Offering lumpy yet soft foods around 6 to 8 months of age helps to stimulate jaw movements that simulate chewing. At 8 to 10 months of age infants can chew and swallow soft, mashed foods. Mature chewing skills are not mastered until toddler age, so offering foods that require little chewing is important.(2)

 

Baby cereal is generally the first food recommended for infants at 6 months of age. Rice cereal is commonly recommended because it is easy to digest and hypoallergenic.(2,12) Note that adding baby food is not recommended to help improve your infant’s sleep as is commonly believed.(2)

 

Fruits and vegetables are also first foods for infants. It is recommended for 6 month olds, that parents introduce only one new food at a time, and to offer it over 2 to 3 days, and the purpose of this is to identify any possible negative reactions to new foods. This timing and spacing of food introductions is important, especially in families with histories of food allergies and intolerances.(2)

 

Commercial baby foods are not necessary for infants.(2) As a parent, you can prepare baby foods at home in your blender or food processor, or by mashing it with a fork. Adding salt and sugar to baby foods prepared at home decreases their nutritional quality. Preparing baby foods at home can save money, provide a wider range of foods for your infant to try, and can be more nutritious (if you do not add salt and sugar to the foods for example). Commercial baby food on the other hand is convenient.(2)

 

Portion sizes for infants should be based on their appetite, keeping in mind their innate ability to control how much food they eat based on their cues of hunger and fullness.(2) Also keep in mind that commercially prepared products such as fruits with added tapioca or baby food desserts and snack foods are not recommended for most infants. Many new parents inadvertently select foods such as these for their infants based on their own likes and dislikes, rather than on the needs of the infant. Regular applesauce, yogurt, soft cooked green beans and mashed potatoes, are examples of foods that can be eaten by infants, as well as other family members once the infant reaches 9 to 12 months of age, making food preparation for your family easier and more streamlined.(2)

 

Examples of foods that present a choking risk include hot dog pieces, hard candy, jelly beans, peanuts and other nuts, chunks of nut butters, whole grapes, uncut stringy meat, sausage, sticky foods (marshmallows, gum, gummy candies), hard fruits or vegetables like raw apples and raw green beans.(2)

 

For the first 6 months, breast milk or formula provides enough water for your infant. All forms of fluid contribute to meeting the water needs of your infant. Replacing infant formula or breast milk with juice, sports drinks, soda or tea contributes to lower quality dietary intake and is not recommended.(2,12)

 

Infants have a limited ability to signal thirst, especially when they are sick. Vomiting and diarrhea can lead to dehydration quickly. Over the counter remedies (like Pedialyte and Gatorade) can easily become overused. Juices are not needed to meet fluid needs. Juice and other sugar containing beverages are not recommended for use before 6 months of age. They increase the risk for overweight and obesity later in life, and they should never be used at bedtime in a bottle because sugar in the mouth can easily lead to the formation of cavities.(2,13,14) Juices can be used after one year of age, and are not recommended for use prior to this time. Juice should be offered in a cup (if it is offered) and never in a bottle. Limiting juice at this stage is important so that it does not become a habit later in life. It is an unnecessary source of added dietary sugar. Excessive use of a baby bottle at bedtime can lead to cavities and ear infections so limit use of bottles as part of your bedtime routine.(2,14,15) Again, offer juice in a cup and not in a bottle, and if offering a bottle for sleep, only fill it with water. Make sure to clean baby teeth to prevent the formation of cavities.(2)

 

During your infant’s first few months of life, the oral need to suck can be easily confused with hunger. Also, not all signs of infant discomfort are related to hunger. A crying baby does not always want or need food. Infants may want to be held, changed, or calmed by movement or touch. Overfeeding is often the result as parents try to comfort their infant, and overfeeding is less likely to occur with breastfeeding compared to formula feeding.(2)

 

Infants typically move their tongue forward and backward. During their first attempts at spoon-feeding this may appear as if your infant is rejecting the food. It may look like your infant is spitting out her food but rather she is learning to swallow. If choking occurs, it may be due to the position of the spoon on the tongue, and not due to dislike of the food being offered. The mouth is very sensitive, particularly toward the back, and if the spoon is placed there, it can cause a gagging reaction, which has nothing to do with the taste of the food.(2)

 

Infants learn food preferences based on their food experiences.(2,16) Breastfed infants can be exposed to a wider variety of tastes within breast milk compared to infants who are formula fed. What the mother eats flavors her breast milk. Breastfed babies may have a quicker acceptance of new foods after the first year of life because of this. There is a genetic predisposition toward sweet tastes(17) and against bitter foods, which can affect food preferences. Lifelong habits are born out of food preferences developed in infancy, so it is important to incorporate a variety of flavors into your infant’s nutritional regimen.(2)

 

The immune system of infants develops over the first few years of life.(18) While breastfeeding, the mother’s immune system may pass some immunity to the infant.(19) Adverse reactions to foods are more common in infants than in children. The most common allergic reactions are respiratory and skin problems (wheezing and skin rashes).(2) You can lower your infant’s risk for food allergy or intolerance by breastfeeding. In families with known food allergies and intolerances, you can lower your infant’s risk by postponing the introduction of foods that are commonly known as allergens, such as peanuts, wheat, eggs, milk, nuts, sesame, fish, and various fruits and vegetables.(2,20) Otherwise, restriction of foods is not recommended because doing so can increase the risk for nutritional inadequacy and reinforce behaviors like rejection of foods, and limiting variety. Breast milk is recommended for infants that are at risk for allergies, soy is not recommended. Also consider the role of environmental allergens in your infant’s symptoms. Often dust and grasses are to blame rather than foods.(2)

 

Recognizing an infant’s needs and responding to them appropriately is important. Infants that are offered only a limited variety of foods without much interaction during mealtime may refuse to eat as a way to get attention, and infants who learn to manipulate the behavior of adults will become even more successful at this when they become toddlers.(2)

 

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References:

  1. The American College of Obstetricians and Gynecologists. ACOG. OB-Gyns Redefine Meaning of “Term Pregnancy.” Published October 22, 2013. Available from: https://www.acog.org/About-ACOG/News-Room/News-Releases/2013/Ob-Gyns-Redefine-Meaning-of-Term-Pregnancy. Accessed January 2, 2018.
  2. Brown J. Nutrition through the Life cycle 4th ed. Belmont, CA: Wadsworth; 2011.
  3. Abrahamse E, Minekus M, van Aken GA, et al. Development of the Digestive System—Experimental Challenges and Approaches of Infant Lipid Digestion. Food Digestion. 2012;3(1-3):63-77. doi:10.1007/s13228-012-0025-x.
  4. Gelfand AA. Infant Colic. Seminars in pediatric neurology. 2016;23(1):79-82. doi:10.1016/j.spen.2015.08.003.
  5. Anabrees J, Indrio F, Paes B, AlFaleh K. Probiotics for infantile colic: a systematic review. BMC Pediatrics. 2013;13:186. doi:10.1186/1471-2431-13-186.
  6. De Weerth C, Fuentes S, de Vos WM. Crying in infants: On the possible role of intestinal microbiota in the development of colic. Gut Microbes. 2013;4(5):416-421. doi:10.4161/gmic.26041.
  7. Slaughter JL, Stenger MR, Reagan PB, Jadcherla SR. Neonatal H2-Receptor Antagonist and Proton Pump Inhibitor Treatment at US Children’s Hospitals. The Journal of pediatrics. 2016;174:63-70.e3. doi:10.1016/j.jpeds.2016.03.059.
  8. Turin CG, Ochoa TJ. The Role of Maternal Breast Milk in Preventing Infantile Diarrhea in the Developing World. Current tropical medicine reports. 2014;1(2):97-105. doi:10.1007/s40475-014-0015-x.
  9. Raiten DJ, Raghavan R, Porter A, Obbagy JE, Spahn JM. Executive summary: evaluating the evidence base to support the inclusion of infants and children from birth to 24 mo of age in the Dietary Guidelines for Americans—“the B-24 Project.” The American Journal of Clinical Nutrition. 2014;99(3):663S-691S. doi:10.3945/ajcn.113.072140.
  10. Burke RM, Leon JS, Suchdev PS. Identification, Prevention and Treatment of Iron Deficiency during the First 1000 Days. Nutrients. 2014;6(10):4093-4114. doi:10.3390/nu6104093.
  11. Westmark CJ. Soy-Based Therapeutic Baby Formulas: Testable Hypotheses Regarding the Pros and Cons. Frontiers in Nutrition. 2016;3:59. doi:10.3389/fnut.2016.00059.
  12. Centers for Disease Control and Prevention. Breastfeeding. Last updated June 16, 2015. Available from: https://www.cdc.gov/breastfeeding/faq/. Accessed January 2, 2018.
  13. Sonneville KR, Long MW, Rifas-Shiman SL, Kleinman K, Gillman MW, Taveras EM. Juice and water intake in infancy and later beverage intake and adiposity: Could juice be a gateway drink? Obesity (Silver Spring, Md). 2015;23(1):170-176. doi:10.1002/oby.20927.
  14. Avila WM, Pordeus IA, Paiva SM, Martins CC. Breast and Bottle Feeding as Risk Factors for Dental Caries: A Systematic Review and Meta-Analysis. Clifford T, ed. PLoS ONE. 2015;10(11):e0142922. doi:10.1371/journal.pone.0142922.
  15. Ear infections. Paediatrics & Child Health. 2009;14(7):465-466.
  16. Moding KJ, Birch LL, Stifter CA. Infant temperament and feeding history predict infants’ responses to novel foods. Appetite. 2014;83:218-225. doi:10.1016/j.appet.2014.08.030.
  17. Mennella JA, Bobowski NK, Reed DR. The Development of Sweet Taste: From Biology to Hedonics. Reviews in endocrine & metabolic disorders. 2016;17(2):171-178. doi:10.1007/s11154-016-9360-5.
  18. Simon AK, Hollander GA, McMichael A. Evolution of the immune system in humans from infancy to old age. Proceedings of the Royal Society B: Biological Sciences. 2015;282(1821):20143085. doi:10.1098/rspb.2014.3085.
  19. Hanson LA. Breastfeeding Provides Passive and Likely Long-Lasting Active Immunity. Annals of Allergy, Asthma & Immunology. 1998;81(6):523-534. doi.org/10.1016/S1081-1206(10)62704-4.
  20. Valenta R, Hochwallner H, Linhart B, Pahr S. Food Allergies: The Basics. Gastroenterology. 2015;148(6):1120-1131.e4. doi:10.1053/j.gastro.2015.02.006.