THE GROWING YEARS

1
 GENERAL OBJECTIVES

Relate the nutritional

requirements of infants
to their growth and
physiological
development.
 Specific Objectives
 Define these terms:
• Neonate, infant
• Gestational age, small for gestational
age (SGA), pre-term, term, post-term
• Developmental milestones, velocity of
growth
 Describe physical growth and changes in
body composition experienced during
infancy.
 Relate the importance of nutrition in
infancy to meeting physiological needs.
 Specific Objectives
Describe how the composition of
nutrients and protective factors in
breast milk meet the nutritional and
physiological needs of infants.
Compare breastfeeding and formula
feeding.
Explain the weaning process
Describe major food/nutrition-related
concerns in infancy
4
 The Growing Years
(Infant, Toddler, Preschooler, School-aged Child, Adolescent)

Age ranges:
Infant = birth - 1 year
Toddler = 1 - 2 years
Preschooler = 2 - 6 years
School-aged Child = 7 - 12 years
Teenager = 13 - 19 years
Adolescent = 10 - 19 years
 Childhood = a period between infancy &
adolescence
 Adolescence = a period between childhood
& adulthood
 The Growing Years
(Infant, Toddler, Preschooler, School-aged Child, Adolescent)

 Growth = physical increase in size, weight,

quantitative progress
 Development = qualitative progress in motor
skills, cognition, language &
communications, social & emotional areas
 Great diversity in size, growth rates &
developmental skills.
 Chronological age is just a rough indicator to
base the development of physical, cognitive
& socio-emotional skills.
Infancy
 Definitions
Gestational Age = age of the infant at birth, as
determined by length of pregnancy (weeks
since last menstrual period).

Pre-term Term infant Post-term

infant infant
weeks <37 38 39 40 41 >42

early full late

term term term

American College of Obstetricians & Gynecologists, 2013

 Newborn Classification System
Birth weight Gestational Age
Pre-term Term Post-term
(<37 wks) (37-42 wks) (>42 wks)
Small Small for pre- Small for Small for post-
(<10th term term term
percentile)
Appropriate Appropriate Appropriate Appropriate for
(10-90th for pre-term for term post-term
percentile)
Large Large for pre- Large for Large for post-
(>90th term term term
percentile)
 Newborn Classification System
Category grams
Extremely Low Birth Weight, ELBW < 1000
Very Low Birth Weight, VLBW < 1500
Moderately Low Birth Weight, MLBW 1500-2500
Low Birth Weight, LBW < 2500
Normal Birth Weight, NBW 2500-4000
High Birth Weight, HBW > 4000

LBW may be due to:

1) shortened period of gestation = prematurity
OR
2) retarded intra-uterine growth = small-for-
gestational-age (SGA)
10
 TOPIC FOCUS
In this topic, we will be focusing on
term infants (37-42 weeks gestational weeks).
 Physical Growth
 An infant’s birth weight is determined by:
• mother’s medical history
• events during pregnancy
• nutritional status before & during pregnancy: pre-
pregnancy weight, weight gain during pregnancy,
adequacy of dietary intakes
• fetal characteristics

 Growth after birth is determined by:

• genes
• hormones
• environment
• nutrition
 Physical Growth
 Period of most rapid extra-uterine growth &
development!
• Birth weight doubles by 5 months, triples by 1 year, quadruples by
2 years.
• Birth length increases by 30% by 5th month, by 50% by 1 year,
doubles by 3-4 years.
 Growth proceeds at rapid but decelerating rate
• Weight gain ~ 1 kg/month initially, then ~ 0.5 kg/month from the
3rd month.
• Length increase ~ 1”/month initially, then ~ 0.5”/month over the
second 6 months .
• Head circumference increases ~ 2 cm/month initially, then ~ 1
cm/month from the 4th month & ~ ½ cm/month from the 6th month.
During the first few days 6 – 10% weight loss occurs due to
high energy demands & fluid losses → regained by 10th
day with adequate intake.
 Weight Gain - First 5 Years

15

10

0 1 2 3 4 5
Decrease in gradient = growth is at a decelerating rate
 Changes In Body Proportions
Newborn infants have
 relatively larger head, faces rounder
 more rounded rather than flattened chests,
more prominent abdomens
 extremities proportionally shorter

As they grow,
 limb length increase > trunk length
 head proportion ↓
 torso fastest growing segment in 1st year of life
 legs fastest growth at later infancy & childhood
Changes In Body Proportions

16
Changes In Body Composition
 % body fat ↑ from ~13% at birth to ~30%
between 6 - 9 months, then ↓ to ~23% by 1
year.
 Muscle mass, ~25% body weight at
birth, ↑ slowly as mobility increases.
 % fat-free mass ↓ throughout infancy
due to the ↓ in water from ~75% at birth
to ~ 60% at 4 months & from ↑ in body fat
content.
 Development
 Neurodevelopment: from the moment of birth, infants
can fixate on object visually & follow their movements.
Gives preferential attention to figures that resemble the
human face.
 Cognitive: the infant perceives a problem, uses memory
to determine if it resembles a past experience & generates
ideas to bring about a possible solution. Early – repetitive
activity eventually becomes planned, indicating thinking
before acting. Later – efforts to manipulate environment &
imitate people.
 Psychosocial: the infant initiates interaction with mother,
becomes part of a growing & complex system of signals
between them → emotional attachments are formed.
 Some Developmental Milestones
1 month 7 month 12 month
Motor – Poor control of Sits briefly, Walks with one hand
gross head, neck, trunk leaning on hands held
Motor – Hands clenched on Radial palmar Use pincer grasp to
fine contact grasp of toys hold small objects
Language Makes cooing Talks to toys Two words besides
sound ‘mama’ & ‘dada’
Personal/ Regards observer’s Reaches for & Offers toy to image in
social face & diminishes pats mirror image mirror
activity
 Nutrient Needs
Rapid growth & major changes in body
composition → high energy & nutrient demands.
Most nutrient needs of infants, in proportion to
body weight, is > double that of adults.
For example: Infant Adult
• Energy (kcal/kg/day) 90 – 120 30 – 40
• Protein (g/kg/day) 1.6 – 2.2 0.8 – 1
If
the maternal diet is adequate, breast milk
will meet the major nutrient needs of the infant.
Singapore RDAs for infants: from 3 – 12 months
https://www.healthhub.sg/live-
healthy/192/recommended_dietary_allowances
 Physiological Concerns
 A full-term newborn can digest & absorb nutrients for
normal growth from breast milk /infant formula.
 Feeding stimulates the development & maturation of the
GI tract by releasing several hormones.

A newborn requires small, frequent feeds.

 Intestinal motility not organised.
 Slow gastric emptying
• experience regurgitation / “spitting up”
 Small stomach capacity: ~7 ml at birth (increase
tenfold in first 2 weeks, can tolerate 60 - 90 ml/feed →
210 -240 ml/feed at 12 months).
 Physiological Concerns
 CHO digestion
• normal lactase/disaccharidases level at birth
• low pancreatic amylase levels, slowly rise as infancy
progresses; salivary amylase & also breast milk
amylase help
 Protein digestion
• low production of acid at birth, slowly rise as infancy
progresses
• low levels of digestive enzymes chymotrypsin &
carboxypeptidase , slowly rise as infancy progresses
 Fat digestion
• low pancreatic lipase activity, with reduced bile acid
pool at birth, slowly rise as infancy progresses
• compensated by breast milk lipases & other lipases
(lingual, gastric)
 Physiological Concerns
Renal Function
 Immature kidneys have limited ability to
concentrate urine, require low renal solute load.
Renal Solute Load = collective no. & conc. of solute particles in
solution, carried by blood to kidney nephrons for excretion in urine,
includes nitrogenous metabolites (from protein metabolism) &
electrolytes (Na+, K+, Cl-), expressed as mOsm/l.
Feeds Potential Renal Solute Load (mOsm/l)
Breast milk 93
By 4 months, functional
Cow’s milk-based formula 135 level increase, can
Soy-based formula 165 handle the increased
solute load of solid foods
Adult’s urine concentration 1300 - 1400 mOsm/l
if introduced gradually.
Newborn’s urine concentration 900 - 1100 mOsm/l
 FEEDING THE
INFANT
- - THE FIRST 6 MONTHS - -
 Exclusive Breast Feeding
Breast milk is the optimum food for infants, providing
all the nutritional requirements of healthy infants for the
first 6 months of life for their growth & development.
Exclusive breast feeding is the gold standard, defined
as giving only breast milk & no other liquids or solids
except drops or syrups of vitamin/mineral supplements
or medicines.
Breastfed infants have lower incidences of infectious
diseases, lower risk of developing allergies & lower risk
of developing obesity & other chronic diseases.
The composition of breast milk is considered the
reference pattern & serves as a guide for the
formulation of infant formulas.
 Colostrum
 More protein, fat-soluble vitamins,
carotenoids & minerals, less sugar & fat than
mature milk.
 67 kcal/100 ml (mature milk = 74 kcal/100ml)
 Abundance of immunological factors protect
against bacterial & viral infections.
 Facilitates the passage of meconium, the
infant’s first stool.
 Contains the bifidus factor – facilitates the
development of the protective L. bifidus
bacteria in the gut (→ limit growth of
enteropathogenic organisms).
 Mature Milk
After 3-6 days, colostrum evolves into
transitional milk.
By 7th -14th day the change to mature milk is
complete.
Except for fatty acids & vitamins, breast milk
appears to be relatively independent of the
nutritional status of the mother.
Maternal undernutrition → more likely to reduce
volume of milk produced rather than the quantity
of a specific component.
Breast milk has properties that protect it from bacterial contamination
e.g. freshly expressed breast milk may be kept at room temperature for
up to 10 hours (colostrum can be stored up to 12 hours at room
temperature).
 Energy Needs
For basal metabolism
(relatively constant),
maintain body
temperature (↓with time),
growth/tissue synthesis
(↓with time), physical
activity (↑with time as
motor skills develop) &
thermic effect of food. Rolfes, et. al. (1998) Life Span Nutrition: conception through life.

 Per unit body weight, highest during infancy due to

high BMR, rapid growth & activity.
 Normal growth pattern indicates that energy needs are
met.
Nutrient Composition Of Breast Milk
Carbohydrate
 Energy source
 Lactose, the major constituent
 Easily digested
 Facilitates calcium absorption
 Also has oligosaccharides & the bifidus factor
in small concentrations → defend the infant
against harmful bacteria
Nutrient Composition Of Breast Milk
Lipids
Presence of lipase in breast milk helps with digestion.
Main source of energy ~ 55% calories. Hindmilk has 2-3
times more fat than foremilk → for satiety.
Help absorption of fat-soluble vitamins.
Source of EFAs: linoleic (18C, ω6) & α-linolenic acids(18C,
ω 3) also long chain ω3 derivatives eicosapentanoic (EPA)
& docosahexaenoic acids (DHA):
• needed for cell membrane synthesis, important for brain, eye &
nervous system development
• forms eicosanoids – regulates cell & organ functions

High cholesterol content → needed for normal

myelination in the CNS.
Inadequate fat intake → growth failure
 Protein Needs
Adequate quantity & of high biological value
to support growth:
• formation of new muscles, connective tissue &
bones
• synthesis of numerous enzymes, hormones &
plasma proteins
• replace daily losses of AAs
Absence of any 9 EAAs →
stunted/compromised growth.
Use of AAs for protein synthesis requires
adequate energy → protein-sparing.
↑ requirements: infection, illness
Nutrient Composition Of Breast Milk
Protein
Protein concentration adequate but not
high → low renal solute load (due to Protein 6%
limited capacity of kidneys & delicate
water balance during infancy).
Colostrum is whey protein dominant Fat 55%
(α-lactalbumin) → efficiently digested &
absorbed. Casein from cow’s milk tends
to form large curds when exposed to acid,
less easily digested.
Other major whey proteins : lactoferrin &
immunoglobulin IgA (IgA). CHO 39%

Contains all essential AAs in right

amounts, higher in cystine, tyrosine & Breast Milk
taurine that the young infant may not
synthesize efficiently.
 Multiple Functions Of To aid the
development,
Macronutrients In Breast Milk maturation &
Macronutrient/component Function functioning of
the
Fat Triglycerides Energy source physiologic
LC PUFA Brain & retina development systems of the
newborn.
Other fatty acids Antiviral, antibacterial
CHO Lactose Energy source
Polysaccharide/ Prevent bacterial attachment to intestine
Oligosaccharide
Protein Amino acid Protein synthesis
IgA, IgM, IgG Immune protection
Lactoferrin Iron carrier, make iron unavailable to pathogenic
bacteria; a growth factor
Lysozyme Anti-infective
Lipase Fat digestion, some antimicrobial activity
Lactalbumin Calcium carrier
Casein Carrier of Ca2+, PO42-, Fe2+, Zn2+, Cu2+
 Protective Factors
These are resistant to digestion & denaturation by acid in the
stomach.
Macrophages in colostrum & mature milk produce
complement, lysozyme & other immune factors.
Lymphocytes in breast milk produce interferon - anti viral
substance.
Immunoglobulins (IgA predominant) - protect GI & respiratory
tracts from bacteria, viruses, etc & potentially allergenic
macromolecules.
Specific prostaglandins produced in the mammary glands
protect the integrity of epithelial cells lining the GI tract.
Intestinal growth factor - stimulates growth of intestinal cells,
allows damaged cells to be replaced more rapidly  keep
digestive tract resistant to infection.
 Fluid Needs
 Need for water per unit body weight are ↑
than in adults → ↑ risk of dehydration:
• larger surface area per unit body weight, so
greater insensible losses from skin & lungs
• cannot express thirst
• higher % body water & ECF due to growing
cells & tissues
• > urine volume as kidney can’t concentrate
solute load
 Too much water intake → hyponatremia:
abnormally ↓ Na+ levels in the blood
 Fluid Needs

 Recommended 1.5 ml/kcal of energy

expenditure
 When to increase fluid intake?
• when solids are introduced - to excrete
high renal solute loads of foods
• during illness, diarrhea & fever

36
 Key Vitamins & Minerals
Vitamin A:
 For growth & differentiation of epithelial tissues,
retinal function, bone growth
 Deficiency not common, occurs if the infant has
impaired fat absorption or infectious diseases, e.g.
diarrheal illness
Vitamin D:
 For bone mineralization – with calcium, phosphorus,
magnesium & protein
 If mother has poor vitamin D status, there is insufficient
amounts in breast milk to prevent rickets if the infant is
not exposed to adequate sunlight
 Infant formulas contain higher amounts than breast
milk
 Key Vitamins & Minerals
Vitamin E:
 Required to protect body cells from oxidative damage

Vitamin K:
 For normal blood coagulation
 Newborns have low levels of prothrombin (a blood
clotting protein)
 They have low stores of vitamin K at birth & low levels in
breast milk
 Newborn intestine is sterile - inadequate bacteria to
synthesize vitamin K
 At risk of hemorrhagic disease of the newborn (fatal
intra-cranial hemorrhage) → vitamin K jab given to
newborns as preventive measure
 Key Vitamins & Minerals
Vitamin C:
 For synthesis & maintenance of collagen, an
important structural protein - during rapid
growth, large amounts of new collagen needed
Thiamin, Riboflavin & Niacin:
 Essential coenzymes in energy metabolism

Vitamin B6:
 Essential coenzyme in lipid, AA & nucleic
acid metabolism, for synthesis & metabolism
of neurotransmitters, for synthesis of heme
 Key Vitamins & Minerals
Folate & Vitamin B12
 Required for DNA synthesis, protein metabolism,
healthy neurological development & function
 Depend on each other for activation
 Folate essential for cell division especially in replacing
red blood cells & cells of the GI tract
 B12 is essential for the health of myelin sheath of
nerve fibers, bone cell activity & metabolism
 Small body stores of folate at birth are rapidly
depleted to meet growth requirements
 B12 deficiency were found in a few breastfed infants
of mothers on strict vegan diets
 Key Vitamins & Minerals
Calcium:
 Because of growth, bone Breast milk  61% Ca2+
formation & mineralization, absorbed
calcium needs are high Infant formula  38% Ca2+
absorbed
 Well absorbed from breast milk
Zinc:
 A cofactor in many enzymes, diverse roles – protein
& nucleic acid metabolism, cellular immunity, heme
synthesis, bone mineralization, etc
Na+, K+, Cl-: Fluid balance
 Na+ major cation in ECF, Cl- major anion in ECF,
important regulator of fluid volume
 K+ major cation in ICF, necessary constituent of each
cell
 Key Vitamins & Minerals
Iron:
 Iron reserve at birth enough for first 4 - 6
months
 Needed as infant grows & blood volume ↑
 After 6 months, sources would be:
• Breast milk, iron-fortified formulas &
iron fortified foods e.g. cereals
 Deficiency → anemia, developmental
delays & mental development

Fluoride:
 Adequate intake essential for mineralization of
bones & teeth & reduction of dental caries
 But excess → mottling of tooth enamel
Breast Milk – Health Advantages
 Ideal nutrient composition to meet the infant’s
physiological & nutritional needs
Presence of growth factors, enzymes,
hormones & immune factors (IgA), anti-infective
factors which cannot be manufactured or added
to infant formulas
 Reduced incidence & severity of infectious GI
& respiratory diseases
 Higher bioavailability of nutrients e.g.
calcium, iron
Less likely to cause allergies
Breast Milk – Health Advantages
Fewer problems with
constipation
 Infant suckling effects aid in
the development of facial
muscles & speech
development
 Less likely to be overfed
Contraindications of Breast Feeding
Maternal:
HIV
Certain infectious disease
• Tuberculosis
• Hepatitis B
• Chicken pox
Substance abuse
• Drugs
• Smoking
• Alcohol
Certain medications
Formula Feeding

 Commercially prepared infant formulas

provide an acceptable alternative to breast
feeding.
 Formulated to be as nutritionally similar to
breast milk as possible.
 Properly prepared formulas can meet all the
energy & nutrient needs of infants for the first
4-6 months.

No formula can imitate the immunological benefits

or the unique digestibility & nutritional
bioavailability of breast milk.
 Composition Of Infant Formulas

Higher nutrient Protein 9% 6%

concentration in formulas
compared with breast
Fat 55%
milk 49%

• to compensate for lower

bioavailability of
nutrients
CHO 42% 39%
Form: powder, ready-to-
use, liquid concentrate
Infant Formula Breast Milk
20 kcal/oz
 Categories Of Infant Formulas
Healthy, full YES Standard
term infant? infant formulas
Modified cow’s milk-based formulas
NO Whey-predominant formulas
Casein: whey = 40:60 (similar to breast milk)
Formulas for Casein-predominant formulas
Special Needs Casein: whey = 80:20 (similar to cow’s milk)

Congenital Milk Lactose Preterm

Disorders/ Hypersensitivity intolerance
Inborn Errors
of Metabolism Allergic Lactose-free Breastfed?
to soy? Formulas

Medical NO YES
Formulas NO YES Formulas Breast milk,
Soy Protein Hydrolysate for Preterm may be
Based Formulas Infants fortified with
Pre-digested special
Formulas
proteins supplements
 Consequences Of Diluted &
Concentrated Formulas
 In impoverished  Mixing error/a
areas of developing conscious effort by
countries & low caregiver to provide
income families  more dense &
nutritious feeds 
dilute feeds to make concentrated feeds
formulas last longer
 Large amounts of
 Feeds provide protein & electrolytes
insufficient energy & • ↑ renal solute load
essential nutrients  • Dehydration
under-nutrition & • Metabolic acidosis
growth failure
• Fever & illness
Issues Breastfeeding Formula Feeding
Nutrition/ Health benefits, refer previous Infant formulas are much better
Health slide matched to the ingredients/
Advantages Content varies according to milk profile of breast milk though
production stage, which meets the many factors cannot be
infant’s changing nutritional manufactured/duplicated
requirements Tendency to encourage the infant
The infant determines amount fed to finish the bottle

Preparation Is readily available, does not need Can be subject to contamination,

to sterilize equipment, in safe, mixing errors
clean form at the right temperature Need to carry formula, bottles, etc

Cost Free Expensive

Convenience Mother must be available to feed Anyone can feed the infant at any
or provide expressed milk time
Mother must express milk if
feeding is missed

Other issues Early breastfeeding may be Infants may not tolerate formula
uncomfortable, certain well
medications can interrupt
breastfeeding
 FEEDING THE
INFANT
- THE SECOND 6 MONTHS -
 General Objectives
Explain the weaning process

Specific Objectives
Discuss the types of food to introduce for
weaning
Differentiate the various stages and texture of
food for weaning
Understand the process of food preparation for
weaning
Discuss the pros and cons of commercial infant
food
Understand the feeding behaviours of infants 52
 Infant Feeding Patterns
3 overlapping stages:
Nursing period (first 6 months)
oBreast milk/ formula provides complete nutrition for
the infant (first 6 months )
As physical & developmental capabilities mature,
 Transitional period (at 7 months)
• Specially prepared semi-solid foods are introduced,
composition & consistency progressively modified
(weaning)
• Breast milk/ formula continues
 Modified adult period (by 1 year)
• Eating a variety of foods from a mixed diet
(contributing ⅓ – ½ of dietary intake)
• Breast milk/formula still main source of energy &
nutrients
 Weaning
the process of expanding the diet to include foods &
drinks other than breast milk/infant formula
WHY?
Intake of breast milk/infant formula alone may not
be sufficient to provide total nutrient needs of the
infant after 6 months due to continued growth &
increasing activity.
To provide nutrients that can’t be supplied
adequately by breast milk/infant formula e.g. iron.
Supplementary foods are introduced based on the
infant’s nutritional needs, physiologic maturation &
development of feeding skills.
The infant is ready when able to sit up with support &
open his mouth when he sees food coming.
 Delayed Weaning
A gradual process BUT should not be delayed
beyond 7 months!!
Because…
 Infants may be at risk of iron deficiency due to depleted
iron stores in the liver.
 Deficiencies in energy, macronutrients & essential
nutrients might occur.
 Infants may not readily adopt to new foods or methods
of feeding if weaning is not started during this window
period.
• will lead to a reduction in dietary diversity
• infants may grow to be fussy eaters

Weaning: a critical nutritional & physiological

stage in an infant’s life.
 Weaning - Tips
Introduce one single-ingredient food at a time at
weekly intervals → spacing new foods to identify food
intolerance or allergies & give the infant time to accept
them.
Introduce a little food before a milk feed when the infant
is alert & hungry.
Give the infant a chance to taste individual foods.
Do not omit foods because you don’t like it.
Do not force if the infant refuses a new food.

Do not cease breastfeeding

during weaning period
 Foods To Introduce
1. Iron-fortified infant cereals
Start with single-grain e.g. plain
rice before progressing to mixed
cereals.
oNOT wheat → allergies/intolerance
Mixed with water/breast
milk/infant formula  easily
swallowed.
Source of supplemental iron.
Once infant consumes cereals,
begin to introduce vitamin C-rich
foods to promote non-heme Fe
absorption.
 Foods To Introduce
2. Vegetables & Fruits
Good sources of vitamins &
minerals, especially vitamin A, C
& folate
All fruit juices (unsweetened)
should be diluted & introduced
in a cup, not a bottle
Use fruit juices moderately:
50 – 100 ml/day as part of fruit
recommendations
 Foods To Introduce
3. Meats & Others
 Introduced between 8 & 10 months
 Sources of protein, B vitamins & iron

**Combination foods & meat-based dinners can be

introduced after single ingredient foods are well-tolerated
 Getting Started
 Dip a clean fingertip into the cereal &
offer small amounts to accustom the
infant to the taste, then introduce via
a spoon.
 Coat a little cereal on a soft spoon &
let the infant suck the food off.
Scrape it up if the infant spits & offer
it again.
 If the infant refuses, try it again the
next day. Try mixing the cereal with a
familiar taste, e.g. breast milk/infant
formula.
 Preparing Infant Foods
Blenderizing/Puréeing
1. Cook small pieces of fruit/vegetables until tender. Do
not add salt or seasoning.
2. Blenderize food with a little liquid until a smooth, even-
textured purée is produced.
3. Strain to remove any larger bits & pieces.
4. Purée can be thinned with cooled boiled water/milk if
desired.
 Preparing Infant Foods
Freezing blenderized/puréed foods
1. Allow freshly cooked purées to cool.
2. Spoon it into sterilized ice-trays.
3. Transfer trays to the freezer.
 Preparing Infant Foods
Using frozen blenderized/puréed foods
1. Set aside required number of cubes & heat in pan or
microwave until piping hot.
2. Transfer remaining cubes to a freezer bag, sealed,
labeled & dated. Return to the freezer for future use.
 Commercial Infant Foods
 In dry form or ready-prepared in jars.
 Starch added to thicken food  
amount of nutritious ingredients.
 Prepared without salt.
 Convenient if lack time to prepare
meals for infant or if traveling. Ready-
to-feed types need only to heat up &
serve straight from jar.
 Expensive → double cost of making
own food.
 Wasteful if infant doesn’t finish all of
jar.
 May help ensure a decent meal if infant
is being cared by someone else.
 Hygienic.
 Foods to Omit In The First Year
Sweets, desserts, flavored drinks
• Empty calories - can promote obesity
• Develop a sweet tooth

Canned foods - too much sodium

Egg white - potential allergen, avoid before 6 months
Unpasteurized honey - risk of botulism
Popcorn, whole grapes, hot dogs, potato chips , fishball,
hard candy, peanut butter, sticky rice cakes - choking
hazard for young children (below 5 years)
Full cream milk can be introduced after 1 year.
 Sequence of Development of Feeding Behavior
Age Reflexes Motor Feeding Behavior Food
Development
1 - 3 Rooting, Poor head Secures milk with Breast milk or
mths suck & control suckling pattern iron-fortified
swallow →→head stable →→opens mouth/ infant formula
reflexes Hands fisted
present at anticipates feeding
→→holds toys
birth
4 - 6 Rooting Palmar grasp – Suckling strength Breast milk or
mths reflex fades. to increases iron-fortified
Tongue bring objects to Chewing motion infant formula
thrust mouth begins (gumming
present if Supported
spoon food)
sitting Mouth open for
feeding
attempted spoon, bring
→→reduced hands
to bottle, holds
 Sequence of Development of Feeding Behavior
Age Reflexes Motor Feeding Food
Development Behavior
7 - 9 Gag Bears weight on Use tongue to Breast milk or iron-
mths reflex legs when held move food fortified follow up
weaker Sits briefly alone Munching/ formula
Radial palmar chewing Thin, smooth,
grasp movements when strained, pureed
Holds one object solid foods eaten, food →→thicker,
in each hand rotary chewing coarser →→
begins mashed food
Develop inferior without lumps
pincer grasp Tries to finger
feed soft food, →→mashed
sucks & bites lumpy food
Introduce food appropriate for
stage of physical/motor baby biscuits Large pieces of
development e.g. when teeth begin Holds bottle easily chewed
to erupt →give foods that develop alone, cup finger food – e.g.
the ability to chew; pincer grasp drinking baby biscuits
→finger foods
 Sequence of Development of Feeding Behavior
Age Reflexes Motor Feeding Behavior Food
Development
10 - Tooth eruption Bites nipples/teats, 3-4 feeds of
12 continues, spoons & crunchy breast milk or
mths chewing matures foods iron-fortified
Finger feeds with follow up
refined pincer formula
grasp Continue with
addition of new
food with easy-
to-chew texture
(chop, cut into
small pieces)

Follow up formula:
Higher in protein, calcium & iron. 22 kcal/oz
 S’pore My Healthy Plate – Recommended
Daily Servings
Food 6 - 12 1-2 3-6 7 - 12 13 - 18 19 - 50 51 yrs Pregnant
Groups mths yrs yrs yrs yrs yrs & &
above Lactating
women

Brown rice 1-2 2-3 3-4 5-6 6-7 5-7 4-6 6-7
&
wholemeal
bread
Fruit ½ ½-1 1 2 2 2 2 2

Vegetables ½ ½ 1 2 2 2 2 3

Meat & 2 2 2 3 3 3 3 3½
Others
of which
dairy foods
or calcium- 1½ 1½ 1 1 1 ½ 1 1
rich foods 69
NUTRITIONAL
ASSESSMENT
Assessment of Nutritional Status
 During infancy, emphasis is placed on growth &
development.
 Growth changes are relatively large & monitoring the
progression of growth via anthropometry is the
primary tool of assessment.
 Biochemical – blood/urine tests not used extensively –
only if marginal status is suspected.
 Clinical – to evaluate developmental changes
 Dietary – the caregiver is asked to recall/record intakes.
 Breast-fed infants: ample opportunity to nurse,
adequate weight gain, seem satisfied , 6-8 wet diapers
(pale yellow, clear urine)→ receiving sufficient to meet
nutritional needs
Anthropometric Measurements in Infancy

 Recumbent Length -
measured with a
lengthboard
 Weight - measured with a
pan scale
 Skinfolds – skinfold
calipers
Anthropometric Measurements in Infancy
Head circumference – measured with a flexible
non-stretch tape just above the eyebrows
• Growth of the brain peaks at birth & during infancy,
by 1 year the brain has reached 2/3 of adult size.

73
 Growth Assessment
 Physical growth is an indicator of health &
nutritional status of infants & children.
 Gender-specific growth charts are used to plot:
weight, length, weight-for-length, head
circumference & BMI-for-age.
 They compare the size of a particular infant to the
reference population & identify those with low/high
measurements for age.
 To some extent, the growth of the skull parallels
brain growth during the first 3 years. Head
circumference may reflect normality of brain
development.
 Consistent, accurate & frequent monitoring of
growth is important Serial measurements.
 Growth Assessment
 Serial/successive measurements are used to
follow the growth of an individual infant,
detect growth abnormalities, monitor the
nutritional status & evaluate the effects of
nutrition intervention.
• Determines if an infant is maintaining,
reducing or increasing his rate of growth →
movements across percentile channels
indicates growth changes compared with the
reference population
 Growth rate is sensitive to changes in nutrition:
• ↓ during infancy indicates inadequate
nutrition
 A
S
G S
R E
O S
W S
T M
H E
N
T
76
 Growth Charts
Singapore NHG 2000 US CDC recommendations
 0 - 72 months  Use WHO growth standards to
monitor growth for 0 - 2 years
 Height-for-age
 Length-for-age, weight-for-
 Weight-for-age age, weight-for-length, head
circumference
 Weight-for-height
 9 Percentile lines: 2, 5, 10, 25,
 BMI-for-age 50, 75, 90, 95, 98
 Head circumference-  Weight-for-length < 2nd
for-age percentile = low weight-for-
length, length-for-age < 2nd
 7 Percentile lines: 3, percentile = short stature,
10, 25, 50, 75, 90, 97 weight-for-length > 98th
percentile = high weight-for-
length
Combination of > 2 indices to assess an individual’s growth
status more accurately.
 Growth Charts
 Readings below the lowest
percentile (3rd) or above the
highest percentile (97th) lines
warrant further investigation.
 Changes across two
percentile channels warrant
further investigation.

78
 Indicators - Interpretation
For Indicator CDC UNICEF
To detect Head < 5th or > 95th percentile
abnormalities circumference
in head/brain
growth
Stunting Height-for- < 5th percentile Moderate < 2 indicates chronic malnutrition,
age SD from after the age of 2 years, effects
median height- largely irreversible,
for-age, severe < may be related to lower birth
3 SD weight or short parental stature

Underweight Weight-for- < 5th percentile Moderate < 2 may be due to stunting, wasting
(thinness) age SD from or both
BMI-for-age median weight-
for-age, severe <
3 SD
Wasting Weight-for- < 5th percentile Moderate < 2 indicates acute malnutrition,
height SD from reflects recent starvation &/or
median weight- disease,
for-height, strong predictor of mortality
severe < 3 SD under 5
Overweight/ Weight-for- Obesity > 95th Overweight is defined by BMI-
Obesity height percentile for-age > 85th - > 95th percentile
BMI-for-age
 Catch-up Growth
Catch-up growth refers to growth at a rate faster
than expected.
It is seen when a child who has experienced
stunted growth due to a nutritional insult receives
adequate energy & protein.
Depending on the timing, severity & duration of
the nutritional insult, a child may "catch-up" to his
pre-insult percentile channel on the growth chart.
Nutrient intake must be sufficient to meet needs
for growth & for catch-up growth & specific
requirements depend on the stage of catch-up
growth.
Observe shifting across percentile channels on
growth charts.
NUTRITIONAL
CONCERNS
 1. Adequacy Of Oral Intake
 In the first week, it is normal for the newborn to lose a
little weight.
 In the first month, feeding patterns are quite irregular
– may breastfeed 8-12 times/day.
 Infant may fall asleep while feeding.
 To check adequacy of breastfeeding:
• feeding at least 6 times/day, 20-40 minutes/feed
• 6-8 wet nappies/day (pale yellow clear urine)
• adequate weight gain  receiving enough energy &
nutrients
 Formula-fed infants to be given as much formula they
need, do not force feed or prepare concentrated feeds.
 2. Spitting Up
 During the first few weeks, many
infants regularly spit up small
amounts of milk.
• Immature lower esophageal
sphincter (LES) & undeveloped
peristalsis
• Swallowed milk move up the
esophagus to the mouth
 Keep baby in upright position
during/after feeding & burp baby to
get rid of swallowed air.
 By the second month, becomes less
frequent → will resolve on its own.
 3. Food Hypersensitivity
 A food allergy – a hypersensitive reaction involving
the immune system, antibodies produced in response
to protein or other macromolecules.
• e.g. cow’s milk protein allergy

 A food intolerance – a hypersensitive reaction that

does not involve the immune system.
• e.g. lactose intolerance due to insufficiency of the
enzyme lactase. Rarely occurs in young children,
transient lactose intolerance may develop during
acute gastroenteritis
• e.g. adverse reactions to sulfites, a food
preservative
 3. Food Hypersensitivity
Symptoms can be mild or severe, immediate or delayed:
 GI - swelling in mouth, lips & throat; vomiting;
diarrhea; abdominal cramps/pain
 Respiratory - sneezing; tightening of the throat &
trouble breathing, wheezing; asthmatic attack; runny
nose
 Skin - hives or eczema,
 Other - watery, itchy eyes; anaphylactic shock

Prevalence of food allergy among Singapore children ~ 4-5 %

85
 4. Baby Bottle Tooth Decay
When infants are given a bottle of juice, milk/
formula at naps/bedtime,
 the fermentable CHO pools around teeth
 there is less salivary flow during sleep
 cariogenic bacteria ferments sugar to acid
 severe & rapid tooth decay

Less common in breast-fed

infants who fall asleep while
nursing. WHY?
 5. Infantile Colic
Persistent, unexplained crying of infants - often
defined by the "rule of 3": crying for > 3 hours/day,
for > 3 days/week & for >3 weeks in an infant who is
well-fed & otherwise healthy.
Occurs from 3 weeks to 3 months of age.
Distressing to parents, infant inconsolable during
crying episodes.
 6. Nutrient Supplementation
 Most healthy infants do not require
supplementation.
 Supplemental foods at 7 months ↓ risk of nutrient
deficiencies.
 Healthy full term breast-fed infants will receive
adequate micronutrients except:
• Vitamin K
• Vitamin D & B12 if mother has poor status
• Iron if exclusively breastfed > 6 months
• Flouride > 6 months, if water flouride content is low
 The Sale of Infant Foods Ethics
Committee, Singapore (SIFECS)
To guide the marketing practices of the infant food
industry as well as protect & promote the practice of
breastfeeding, MOH established SIFECS in 1979.
This Committee formulated & implemented the 'Code of
Ethics on the Sale of Infant Foods in Singapore'.
• A guide for the promotion of childhood nutrition & the marketing &
distribution of breast milk substitutes.
• The sale & distribution of infant formulas should be carried out in
such a way as to avoid competing with breast milk.
• Infant formulas must NOT be sold online.
• Informational & education materials dealing with the feeding of
infants must not idealize the use of breast milk substitutes.
Withthe establishment of the HPB in 2001, the
administration of the SIFECS was transferred to HPB