Introduction to Infant Nutrition

Framework– Growth and Assessment– Nutrient needs– Formula and Breast milk– Feeding development and relationship– Non milk feedings

Population v.s. individual

Goals and Objectives

Optimal growth and development Individual health Population Health Prevention and Chronic Illness

Population vs individual

AAP Guidelines DRI’s Bright Futures Start Healthy Feeding

Guidelines

Needs Guidelines Recommendations education

Recommendations/guidelines

DRI: Dietary Reference Intakes– AI– UL– EER

AAP Bright Futures Start Healthy feeding guidelines

DRI: Dietary Reference Intakes

– periodically revised recommendations (or guidelines) of the National Academy of Sciences

– quantitative estimates of nutrient intakes for planning and assessing diets for healthy people

AI: Adequate Intake UL: Tolerable Upper

Intake Level EER: Estimated Energy

Requirement

Infant Feeding Practices Study II

Fein, Sara B. et al Pediatrics Vol 122 October 2008 (Supplement)

– Data from nationally distributed consumer opinion panel of 500000 households

– Mothers of healthy term and late preterm infants– N= 4902 pregnant women, ~2000 continued

through infants first year

Infant Feeding Practices Study II

83% of survey respondents initiated breastfeeding

Declined to 50% at 6 months and 24% at 12 months

52% of breastfed infants received some formula in the hospital

40% received infant cereal at 4 months

Infant Feeding Practices Study II

Majority of formula feeding mothers did not receive instruction on formula preparation or storage from a health professional (73-77%)

30% did not read safe use instrcutions on package label

55% did not wash hands before bottle prep, 32% did not wash bottle nipples between use, 35% heated bottles in microwave, and 6% did not always discard formula left standing > 2 hours

Infant Feeding Practices Study II

At 6 months of age 18% of term breastfed and mixed fed infants had not received infant cereal or meat in the previous 7 days. 58% received <2 daily servings and did not receive oral supplements >3X per week

Screening, Assessment, Education

Information Collected

Growth Dietary Medical history Diagnosis Feeding and developmental information Psychosocial and environmental information Clinical information and appearance (hair, skin, nails, eyes) Other (anthropometrics, laboratory)

Nutrition Screening: Purpose

To identify individuals who appear to have or be at risk for nutrition problems

To identify individuals who require further assessment or evaluation

Identify risk and education needs for prevention of nutritional problems

Screening: Definition

Process of identifying characteristics known to be associated with nutrition problems

– ASPEN, Nutri in Clin Practice 1996 (5):217-228

Simplest level of nutritional care (level 1)

– Baer et al, J Am Diet Assoc 1997 (10) S2:107-115

Assessment

Screening identifies nutritional risk Nutrition Assessment

– Uses information gathered in screening– Adds more in depth, comprehensive data– Interprets data– Develops care plan– Reassess

Goals of Nutrition Assessment

To collect information necessary to document adequacy of nutritional status, identify deficits, and determine etiology of any identifiable problems

To develop a nutritional care plan that is realistic and within family context

To establish an appropriate plan for monitoring and/or reassessment

Assessment Process

Linking information collected with:

– Goals/expectations– Reference data/standards– Evidence– individual

Asking questions

CDC Growth Charts: Tool for Screening and Assessment

Standardized data collection methods Expanded sample Exclusions

– VLBW infants– NHANES III weight data for >6 year olds

Challenges

Challenges

Information– Availability, sufficiency,

accuracy

Interpretation– Goals, expectation,

“does it make sense”

Questions– What are goals and

expectations, “does it make sense”

Challenges

Nutrient needs influenced by:

genetics, activity, body composition, medical conditions and medications

Individuals anthropometric date influenced by:

genetics, body composition, development, history

Considerations Growth in infancy Physiology of infancy

GI Renal

Infant Development Nutrient requirements

* Recommendations Milk based feedings/Infant formulas Timing of complementary foods

– What are families actually doing? Specific issues of safety and oral health

Challenges: Recommendations for populations v.s individual

Challenges

Identification of etiology Weighing risk vs benefit Supportive of:

– Family– Individual– Development/temperament

Assessment Process

Linking information collected with:

– Goals/expectations– Reference data/standards– Evidence– individual

Asking questions

Interpretation

Linking information collected with:

– Goals/expectations– Reference data/standards– Evidence– individual

Asking questions

Interpretation: Asking Questions

Is there a problem?

Was there a problem?

Does information make sense?

What are goals and expectations?

What is etiology of the problem?

Contributing Factors

Inadequate IntakeFluid, energy

MedicalBPD, reflux, frequent illness

Feeding relationshipStress, history

Psychosocial

Joey

Adam

Adam

Adam

Intervention

Identify etiology Identify contributing

factors Support feeding

relationship Consider psychosocial

factors, family choice and input

Weigh risk v.s. benefit

Weighing Risks and Benefits

Intervention

Adequate intake vs feeding relationship

Concentrating formula vs fluid status

Impact on tolerance, compliance, errors, cost

Solution to problem vs. exacerbating problem

Examples

Common Recommendations

Breastfeed to at least 1 year Iron fortified cereal by 4-6 months Vitamin D Supplementation Introduce 1 food at a time

Screening Risks

Weight less than 5th %ile Weight greater than 90th %ile Improper or inappropriate food/formula

choices or preparation Bottle in bed

Jamie

6 months of age Family hx of allergies Mom discontinued breastfeeding when

returned to work at 5 months

Toby

11 months old FTT Receives formula in bottle. Difficulties with

bottle feeding. Likes solids. Takes few jars of stage III fruits, vegetables, dinners per day

Advised to avoid milk until baby over 12 months of age (excluded milk, cheese, yogurt, butter)

Mattie

10 month old “colicky, irritable” Young mother, lives in small apartment, “thin

walls” neighbors complain about noise Baby has 10-12 bottles per day of formula, or

juice. Has bottle in bed at nap and night Weight at 75th %ile, length and 75th %ile

Zoe

8 months old Exclusive breastfeeding Weight and length at 50th %ile. Hct within normal limits Mom believes breast milk provides all

nutrients and offering anything else will result in infant discontinuing or “weaning” from breast