Feeding During the First Year of Life

Tuberculosis infection Breast-feeding is contraindicated until completion of approximately 2 wk of appropriate maternal therapy Varicella-zoster infection Herpes simplex infection Breast-feeding is contraindicated with active herpetic lesions of the breast CMV infection Hepatitis B infection Hepatitis C infection Breast-feeding is not contraindicated Alcohol intake Limit maternal alcohol intake to <0.5 g/kg/day (for a woman of average weight, this is the equivalent of 2 cans of beer, 2 glasses of wine, or 2 oz of liquor) Cigarette smoking Discourage cigarette smoking, but smoking is not a contraindication to breast-feeding Chemotherapy, radiopharmaceuticals Breast-feeding is generally contraindicated

CMV, cytomegalovirus; HbsAg, hepatitis B surface antigen; HIV, human immunodeficiency virus; HTLV, human T-lymphotropic virus.

Mothers should be encouraged to nurse at each breast at each feeding starting with the breast offered 2nd at the last feeding. It is not unusual for an infant to fall asleep after the 1st breast and refuse the 2nd. It is preferable to empty the 1st breast before offering the 2nd in order to allow complete emptying and therefore better milk production. Table 42-5 summarizes patterns of milk supply in the 1st week.

Table 42-5 PATTERNS OF MILK SUPPLY

DAY OF LIFE	MILK SUPPLY
Day 1	Some milk (~5 mL) may be expressed
Days 2-4	Lactogenesis, milk production increases
Day 5	Milk present, fullness, leaking felt
Day 6 onward	Breasts should feel “empty” after feeding

Adapted from Neifert MR: Clinical aspects of lactation: promoting breastfeeding success, Clin Perinatol 26:281–306, 1999.

New mothers should be instructed about infant hunger cues, correct nipple latch, positioning of the infant on the breast, and feeding frequency. It is also suggested that a physician or a lactation expert observe a feeding to evaluate positioning, latch, milk transfer and maternal responses, and infant satiety. Attention to these issues during the birth hospitalization allows dialogue with the mother and family and can prevent problems that could occur with improper technique or knowledge of breast-feeding. As part of the discharge teaching process, issues surrounding infant feeding, elimination patterns, breast engorgement, basic breast care, and maternal nutrition should be discussed. A follow-up appointment is recommended within 24-48 hr after hospital discharge.

Nipple Pain

Nipple pain is one of the most common complaints of breast-feeding mothers in the immediate postpartum period. Poor infant positioning and improper latch are the most common reasons for nipple pain beyond the mild discomfort felt early in breast-feeding. If the problem persists and the infant refuses to feed, consideration needs to be given to nipple candidiasis, and both mother and baby should be treated if candidiasis is found. In some cases, especially if accompanied by engorgement, it may be necessary to express milk manually until healing has occurred.

Engorgement

In the 2nd stage of lactogenesis, physiologic fullness of the breast occurs. If the breasts are firm, overfilled, and painful, the cause may be incomplete removal of milk due to poor breast-feeding technique or other reasons such as infant illness. Frequent breast-feeding or, in some cases, manual milk expression before breast-feeding may be required.

Mastitis

Mastitis occurs in 2-3% of lactating women and is usually unilateral, manifesting with localized warmth, tenderness, edema, and erythema after the 2nd postdelivery week. Sudden onset of breast pain, myalgia, and fever with fatigue, nausea, vomiting, and headache can also occur. Organisms implicated in mastitis include Staphylococcus aureus, Escherichia coli, group A streptococcus, Haemophilus influenzae, Klebsiella pneumoniae, and Bacteroides spp. Diagnosis is confirmed by physical examination. Oral antibiotics and analgesics, while promoting breast-feeding or emptying of the affected breast, usually resolve the infection. A breast abscess is a less-common complication of mastitis, but it is a more serious infection that requires intravenous antibiotics as well as incision and drainage, along with temporary cessation of feeding from that breast.

Milk Leakage

Milk leakage is a common event in which milk is involuntarily lost from the breast either in response to breast-feeding on the opposite side or as a reflex in response to other stimuli, such as an infant’s cry. Milk leakage usually resolves spontaneously as lactation proceeds.

Inadequate Milk Intake

Insufficient milk intake, dehydration, and jaundice in the infant can surface after the first 48 hr of life. The infant might cry or be lethargic and have delayed stooling, decreased urine output, weight loss >7% of birth weight, hypernatremic dehydration, and increased hunger. Insufficient milk intake may be due to insufficient milk production or failure of established breast-feeding, but it can also result from health conditions in the infant that prevent proper breast stimulation. Parents should be counseled that breast-fed neonates must feed a minimum of 8 times per day. Careful attention to prenatal history can identify maternal factors that may be associated with this problem, for example, failure of breasts to enlarge during pregnancy or within the first few days after delivery. Direct observation of breast-feeding can help identify improper technique. If a large volume of milk is expressed manually after breast-feeding, then the infant might not be extracting enough milk, eventually leading to decreased milk output. Late preterm infants (34-36 wk) are at risk for insufficient milk syndrome because of poor suck and swallow patterns or medical issues.

Jaundice

Breast-feeding jaundice is a common reason for hospital readmission of healthy breast-fed infants and is largely related to insufficient fluid intake (Chapter 96.3). It may also be associated with dehydration and hypernatremia. Breast milk jaundice causes persistently high serum indirect bilirubin in a thriving healthy baby. Jaundice generally declines in the 2nd wk of life. Infants with severe or persistent jaundice should be evaluated for problems such as galactosemia, hypothyroidism, urinary tract infection, and hemolysis before ascribing the jaundice to breast milk that might contain inhibitors of glucuronyl transferase or enhanced absorption of bilirubin from the gut. Persistently high bilirubin can require changing from breast milk to infant formula for 24-48 hr and/or phototherapy without cessation of breast-feeding. Breast-feeding should resume after the decline in serum bilirubin. Parents should be reassured and encouraged to continue collecting breast milk during the period when the infant is taking formula.

Collecting Breast Milk

The pumping of breast milk is a common practice when the mother and baby are separated, such as when the mother returns to work or when there is an illness or hospitalization of the mother or infant that precludes breast-feeding. Good handwashing and hygiene should be emphasized. Electric breast pumps are more efficient and better tolerated by mothers than mechanical pumps or manual expression. Collection kits should be rinsed, cleaned with hot soapy water, and air dried after every use. Glass or plastic containers should be used to collect the milk, and milk should be refrigerated and then used within 48 hr. Expressed breast milk can be frozen and used for up to 6 mo. Milk should be thawed rapidly by holding under running tepid water and used completely within 24 hr after thawing. Milk should not be microwaved.

Growth of the Breast-fed Infant

The rate of weight gain of the breast-fed infant differs from that of the formula-fed infant, and the infant’s risk for excess weight gain during late infancy may be associated with bottle feeding. Some of the differences in weight gain are explained by the use of growth charts derived from predominantly formula-fed children, and several studies suggest that the growth pattern of the population of breast-fed infants should be considered the norm. The WHO, has published a growth reference based on the growth of healthy breast-fed infants through the 1st yr of life. The new standards (http://www.who.int/childgrowth) are the result of a study in which >8,000 children were selected from 6 countries. The infants were selected based on healthy feeding practices (breast-feeding), good health care, high socioeconomic status, and nonsmoking mothers, so that they reflect the growth of breast-fed infants in the optimal conditions and can be used as prescriptive rather than normative curves. Charts are available for growth monitoring from birth to age 6 yr. The Centers for Disease Control and Prevention now recommends use of these charts for infants 0 to 23 months of age.

Formula Feeding (Fig. 42-1)

Most women make their feeding choices for their infant early in pregnancy. In a U.S. survey, although 83% of respondents initiated breast-feeding, the percentage who continued to breast-feed declined to 50% at 6 mo. Fifty-two percent of infants received formula while in the hospital and by 4 mo 40% had consumed other foods as well. Despite efforts to promote breast-feeding and discourage complementary foods before 4 mo of age, supplementing breast-feeding with infant formula and early introduction of complementary foods remain common in the USA. Indications for the use of infant formula are as a substitute or a supplement for breast milk or as a substitute for breast milk when breast milk is medically contraindicated by maternal (see Table 42-4) or infant factors.

Infant formulas marketed in the USA are safe and nutritionally adequate as the sole source of nutrition for healthy infants for the first 4-6 mo of life. Infant formulas are available in ready-to-feed, concentrated liquid or powder forms. Ready-to-feed products generally provide 20 kcal/30 mL (1 oz) and approximately 67 kcal/dL. Concentrated liquid products when diluted according to instructions provide a preparation with the same concentration. Powder formulas come in single or multiple servings and when mixed according to instructions will result in similar caloric density.

Although infant formulas are manufactured in adherence to good manufacturing practices and are inspected by the U.S. Food and Drug Administration (FDA), there are potential issues. Powder preparations are not sterile, and although the number of bacterial colony-forming units per gram of formula is generally lower than allowable limits, outbreaks of infections with Enterobacter sakazakii have been documented, especially in premature infants. The powder preparations can contain other coliform bacteria but have not been linked to disease in healthy term infants. Care also needs to be taken in following the mixing instructions to avoid over or under dilution, using water either boiled or sterilized, and using the specific scoops provided by the manufacturer, because scoop sizes vary. Well water needs to be tested regularly for bacteria and toxin contamination. Municipal water can contain variable concentrations of fluoride, and if the concentrations are high, bottled water that is defluoridated should be used to avoid toxicity.

Parents should be instructed to use proper handwashing techniques when preparing formula or feeding the infant. Guidance to follow written instructions for storage should also be given. Once opened, ready-to-feed and concentrated liquid containers can be covered with aluminum foil or plastic wrap and stored in the refrigerator for no longer than 48 hr. Powder formula should be stored in a cool, dry place; once opened, cans should be covered with the original plastic cap or aluminum foil, and the powdered product can be used for up to 4 wk. Prepared formula stored in the refrigerator should be warmed by placing the container in warm water for ~5 min; similar to breast milk, formula should not be heated in a microwave, because the formula can be heated unevenly and result in burns despite appearing to be at the right temperature when the surface is tested.

Formula feedings should be ad libitum, with the goal of achieving growth and development to the child’s genetic potential. The usual intake to allow a weight gain of 25-30 g/day will be 140-200 mL/kg/day in the first 3 mo of life. Between 3 and 6 mo of age and between 6 and 12 mo of age, the rate of weight gain declines. The protein and energy content of infant formulas in the USA for term infants is ~2.1 g/100 kcal and 67 kcal/dL. No recommendations have been made for follow-up or weaning formulas, although these are available and marketed.

If feedings are adequate and weight, length, and head circumference trajectories are appropriate, then infants do not need additional water, unless dictated by high environmental temperature. Vomiting and spitting up are common, and when weight gain and general well-being are noted, no change in formula is necessary. Most infants thrive on cow’s milk protein–based formulas, although some infants exhibit intolerance or allergy to cow’s milk protein.

In addition to complementary foods introduced between 4 and 6 mo of age, continued breast-feeding or the use of infant formula for the entire 1st year of life should be encouraged. Whole cow’s milk should not be introduced until 12 mo of age. In children between 12 and 24 mo of age for whom overweight or obesity is a concern or who have a family history of obesity, dyslipidemia, or cardiovascular disease, the use of reduced-fat milk would be appropriate.

Complementary Feeding

The timely introduction of complementary foods (all solid foods and liquid foods other than breast milk or formula, also called weaning foods or beikost) during infancy is necessary to enable transition from milk feedings to other foods and is important for nutritional and developmental reasons (Table 42-6). The dilemmas of the weaning period are different in different societies. The ability of exclusive breast-feeding to meet macronutrient and micronutrient requirements becomes limiting with increasing age of the infant. Current WHO recommendations on the age at which complementary food should be introduced are based on the optimal duration of exclusive breast-feeding. A WHO-commissioned systematic review of the optimal duration of exclusive breast-feeding compared outcomes with exclusive breast-feeding for 6 vs 3-4 mo. The review concluded that there were no differences in growth between the 2 durations of exclusive breast-feeding. Another systematic review concluded that there was no compelling evidence to change the recommendations for starting complementary foods at 4-6 mo. The AAP Pediatric Nutrition Handbook also states that there is no significant harm associated with introduction of complementary foods at 4 mo of age and no significant benefit from exclusive breast-feeding for 6 mo in terms of growth, zinc and iron nutriture, allergy, or infections. The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition considers that exclusive breast-feeding for ~6 mo is desirable, but that the introduction of complementary foods should not occur before 17 weeks (~4 mo) and should not be delayed beyond 26 weeks (~6 mo).

Evidence for the optimal timing for introducing specific complementary foods is lacking and is largely based on consensus and traditions. Practices vary widely among regions and cultures. Ideally, complementary foods are combined with human milk or formula to provide the nutrients required for appropriate growth. Current complementary feeding practices largely meet infants’ energy and nutrient needs. Because some complementary foods are more nutritionally appropriate than others to complement breast milk or infant formula, improved evidence-based guidelines about types, quantities, and timing of introducing complementary foods would be desirable. For example, the Feeding and Toddlers Study collected data on the food consumption patterns of U.S. infants and toddlers and showed that nearly all infants ≤12 mo consumed some form of milk every day; more infants >4 mo consumed more formula than human milk, and by 9-11 mo of age 20% consumed whole cow’s milk and 25% consumed nonfat or reduced-fat milk. These patterns are somewhat similar to patterns in Denmark, Sweden, and Canada, where whole cow’s milk can be introduced between 9 and 10 mo of age.

The most commonly fed complementary foods between 4 and 11 mo are infant cereals. Nearly 45% of infants between 9 and 11 mo consume noninfant cereals. Infant eating patterns also varied, with up to 61% of infants 4-11 mo of age consuming no vegetables. Among those who consumed vegetables, French fries were one of the common foods fed as vegetables.

The AAP provides the following recommendations for initiating complementary foods (Pediatric Nutrition Handbook, 6th edition):

The period of introducing increasingly diverse complementary foods gives the opportunity to provide adequate nutrition or to increase the risk of over- or underfeeding. Overconsumption of energy-dense complementary foods can support excessive weight gain in infancy, resulting in an increased risk of obesity in childhood.

Feeding Toddlers and Preschool-Age Children

The 2nd yr of life is a period when eating behavior and healthful habits can be established and is often a confusing and anxiety-generating period for parents. Growth after the 1st yr slows down, motor activity increases, and appetites decrease. Birth weight triples during the 1st yr of life and quadruples by 2 yr of age, reflecting this slowing in growth velocity. Birth length increases during the 1st yr of life and doubles by 4 yr of age. Eating behavior is erratic, and the child appears distracted as he or she explores the environment. Children consume a limited variety of foods and often only “like” a particular food for a period of time and then reject the favored food. These concerns need to be addressed in the context of growth and development and with appropriate nutritional counseling. Demonstrating adequate growth and providing guidance about behavior and eating habits will go a long way in allaying concerns of parents and other caregivers. Important goals of early childhood nutrition are to foster healthful eating habits and to offer foods that are developmentally appropriate, while not always giving in to every child’s requests, such as for sweets or French fries.

9-12 12-18 >18-24 24-26

Modified from Udall Jr JN: Infant feeding: initiation, problems, approaches, Curr Prob Pediatr Adolesc Health Care 37:369–408, 2007.

The child should progress from soft, nonsticky foods or foods with small particle size (to avoid choking and gagging) to prepared table foods with the same precautions. At this stage, the child is not capable of completely chewing and swallowing foods, and foods with a choking risk, such as hard candies and peanuts, should be avoided. Caregivers should always be vigilant and present during feeding, and the child should be placed in a high chair. The AAP and other organizations discourage eating in the presence of distractions such as television or eating in a car where an adult cannot adequately supervise or observe the child.

A newborn infant can already discriminate between sweet and sour. This same phenomenon is observed in infancy and early childhood as a preference for sweetened foods and beverages. A new food has to be offered multiple times before being considered rejected by the child. This, as well as reluctance to accept new foods, is a common developmental phase, and persistence and patience are the keys to successful feeding.

Toddlers eat or need to eat 5-7 times a day, and parents need to capitalize on these habits by offering tasty and healthful snacks. Milk continues to be an important source of nutrition, because it includes important nutrients such as vitamin D. Guidelines for vitamin D supplementation recommend a daily vitamin D intake of 400 IU/day for all infants beginning in the first few days of life, children, and adolescents who are ingesting <1000 mL/day of vitamin D-fortified milk or formula. About 2/3 of toddlers consume fruits and vegetables, and more than 75% consume a serving of vegetables on any given day, with French fries being the most commonly consumed vegetable. Preschool children also lag behind current recommendations for the number of servings of fruits, vegetables, and fiber, whereas intakes of food with fat and added sugar are high.

Feeding infants and children is a challenge, and there is no one right way to nurture a child. It takes education, encouragement, and patience to go through this period, and the medical home for the child plays a very important role in supporting the family-infant dyad.

Eating in the Daycare Setting

Many U.S. toddlers and preschool children attend daycare and receive meals and snacks in this setting. There is a wide variation in the quality of the food offered and the level of supervision during meals. Parents are encouraged to assess the quality of the food served at daycare by asking questions, visiting the center, and taking part in parents’ committees. Pediatricians should also become familiar with the quality of daycare centers in their regions. Free or reduced-price snacks and meals are provided in daycare centers of low- and medium-income communities through the U.S. Department of Agriculture (USDA) Child and Adult Care Food Program. Participating programs are required to provide meals and snacks that meet the dietary guidelines, also set by the USDA, and therefore guarantee a level of food quality. Because the reimbursement is typically low, many daycare centers still struggle in providing high-quality meals and snacks through the day.

Feeding School-Age Children and Adolescents

Nutrition Issues of Importance across Pediatric Ages