NUTRITION MANAGEMENT OF THE FULL-TERM INFANT

Growth and nutrient needs during the first year of life exceed those at any other stage of the life cycle.  However, since the organ systems are not fully developed in infancy, special considerations should be given to when and how foods are introduced.  While supplying sufficient nutrients to promote growth and maintenance, it is important for the infant’s diet to not exceed the requirements or capabilities of the infant’s digestive or excretory systems. The optimal feeding regimen is to exclusively breast-feed for six months and breast-feed with complementary foods for at least twelve months (1,2).

Breast-feeding
Breast-feeding is the optimal way to provide food for the health, growth, and development of the infant.  In addition to its unique nutrient composition, it offers immunologic and psychosocial benefits that are not provided by any other feeding substance.  Human milk is unique in that it provides docosahexaenoic acid (DHA), a long-chain fatty acid that is essential for infant brain and eye development (3,4).  Lactoferrin, an iron-binding protein found in whey of human milk, has been observed to inhibit the growth of certain iron-dependent bacteria in the gastrointestinal tract (5).  Infants who are breast-fed usually have fewer gastrointestinal and nongastrointestinal infections, including otitis media, pneumonia, bacteremia, diarrhea, and meningitis.  They have fewer food allergies and a reduced risk of certain chronic diseases throughout life (eg, type 1 diabetes, lymphoma, and Crohn’s disease) (1,2,6-9).  

    Infants nursed by a vegan mother may be at risk for vitamin B12 deficiency.  The dietary vitamin B12 intake of the mother should be assessed to determine adequacy.  Vegan mothers should be instructed to supplement their diets with foods fortified with vitamin B12 (10).

Contraindications for Breast-Feeding
Infants with certain inborn metabolism errors, such as phenyalamine, maple syrup urine disease, or galactosemia should not be breastfed (2).

Breast-feeding is contraindicated for women who:

• use addictive drugs, such as cocaine, marijuana, and phencyclidine (PCP)
• drink more than a minimal amount of alcohol
• receive certain therapeutic or diagnostic agents, such as radiation or chemotherapy (11,12)
• are infected with the human immunodeficiency virus (HIV) (2)

Women should not breast-feed when they are receiving certain therapeutic medications.  Not only is toxicity to the infant a concern, but research has indicated that some medications affect the infant’s metabolism. In addition, some agents (eg, bromocriptine) decrease milk production. Whereas most medications are considered compatible with breast-feeding, there are substances for which the risk of toxicity to the infant is considered to be greater than the benefit to the mother.  The most frequently used of these medications to be aware of include (12):

• amphetamine
• bromocriptine
• cyclophosphamide
• cyclosporine
• doxorubicin
• ergotamine
• lithium
• methotrexate
• nicotine
• phenindione

Formula Feeding
The use of commercially prepared infant formula is an acceptable alternative to breast-feeding.  These formulas are designed to approximate the composition of human milk as closely as possible.  Most commercial infant formulas are composed of milk proteins or soy protein isolate.

    Milk-based formulas are generally appropriate for use with the healthy full-term infant. Standard formulas have a 60:40 whey-to-casein ratio, which is desirable in a formula; they provide 20 kcal/oz.  Breast milk yields an 80:20 whey: casein ratio with about the same number of calories.  Soy-based formulas are often used from birth to prevent allergic disease in infants with a strong family history of allergies (13).

    As long as the commercially prepared infant formula with iron is delivered in the appropriate volumes for a term infant, it is not necessary to supplement with additional vitamins or iron. The American Academy of Pediatrics recommends that formula-fed infants be given an iron-fortified cereal or supplemented with iron by 6 months of age.  When food is introduced during the second 6 months of life, the combination of food and formula will meet the infant’s nutrient requirements (14).   Fluoride supplementation may be required if powdered or concentrated formula is used and if the community water supply contains less than 0.3 ppm of fluoride.  Fluoride should not be supplemented before 6 months of age (2).

    Therapeutic or specialized formulas are indicated for use with premature infants, as well as infants with cow’s milk allergy or intolerance, intact protein allergy, or generalized malabsorption.  Premature-infant formulas are modified in terms of their energy, macronutrient, and micronutrient content in order to meet the specialized physiologic and gastrointestinal needs of these infants.  Premature infants should be discharged home on  premature-infant formula and remain on it until 12 months of age.  Human milk fortifiers (HMFs) are specially designed to be added to expressed breast milk for the premature infant.  HMFs provide protein, energy, calcium, phosphorus, and other minerals needed for rapid growth and normal bone mineralization in the premature infant.  Hydrolysate formulas are indicated for the nutrition management of infants with allergies to intact protein from either cow’s milk or soy.  These hydrolyzed formulas, some of which also contain part of the fat as medium chain triglycerides, may also be used for infants with generalized malabsorption of both protein and fat (eg, short gut syndrome and cystic fibrosis).  Fat-modified formulas are indicated for nutrition management of infants with steatorrhea due to their limited bile salt pool, such as those with biliary atresia or other forms of malabsorption or intolerance.  Medical formulas for various disorders of inborn errors of metabolism are also available from the major formula manufacturers for disorders such as phenylketonuria and maple syrup urine disease.   

Water
If the infant consumes an adequate amount of breast milk, formula, or both, the infant will have an adequate intake of water.

Cow’s Milk
Cow’s milk should not be introduced until a child is 1 year of age.  The nutrient composition of cow’s milk varies substantially from that of human milk.  Feedings with cow’s milk causes a markedly high renal solute load due to its protein and sodium content, and infants are not generally able to concentrate urine well.  The ingestion of cow’s milk increases the risk for gastrointestinal blood loss and allergic reactions.  Whole milk can be introduced after the first year and continued through the second year.  After the second year, reduced-fat milk can be served (2).

Table E-1: Nutrient Comparison of Breast Milk, Formula, and Cow’s Milk

Introduction of Solid Food
There is no nutritional need to introduce solid food to infants during the first 6 months of age (1,2).  The infant’s individual growth and development pattern is the best indicator of when to introduce semisolid and solid foods.  Generally, an infant will double his birth weight and be able to sit upright without support by the time semisolid foods are introduced.  By 4 to 5 months, the infant has the ability to swallow nonliquid foods. If solids are introduced before this time, these foods may displace breast milk or formula and the infant may receive inadequate energy and nutrient needs.

    No specific schedule of introduction of food other than breast milk or formula must be followed, but certain recommendations exist:

• Iron-fortified infant cereal is commonly suggested as the first food offered.  Start with a few spoonfuls of a single-grain, iron-fortified infant cereal such as rice, once or twice a day.
• Introduce single-ingredient foods, one at a time, so that the offending food can be identified if an adverse reaction occurs.
• Vegetables might be accepted more readily if introduced before fruits, since fruits taste sweeter.
• Allow at least 3 days between the introduction of each new food.
• Begin with small amounts of foods, offering seconds as necessary.
• Avoid early introduction of the following common allergens: egg white, cow’s milk, citrus, wheat, chocolate, fish, shellfish, tree nuts, and nut butters (eg, no peanut butter until 18 to 24 months of age) because susceptible infants with a family history of allergies may experience allergic reactions.
• Take care to avoid spoilage of home-prepared foods and jars of food once they are opened.  Do not feed infants directly from the jar, as saliva added to the jar causes faster spoilage.
• Select appropriate solid foods that require minimal chewing.  Foods such as hot dogs, peanuts, grapes, berries, raw carrots and sliced apples, raisins, potato or corn chips, popcorn, seeds, round, hard candies, and gum may cause choking and aspiration in infants and children.

Table E-2: Infant Feeding Guidelines

 
References

1. Position of the American Dietetic Association: breaking the barriers to breast feeding. J Am Diet Assoc. 2001;101:1213-1220.
2. American Academy of Pediatrics Committee on Nutrition.  Breast feeding and the use of human milk (policy statement). Pediatrics. 1997;100(6):1035-1039.
3. Jorgensen MH, Hernell O, Lund P, Holmer G, Fleisher-Michaelsen K. Visual acuity and erythrocyte docosahexaenoic acid status in breast-fed and formula-fed infants during the first four months of life.  Lipids. 1996;31:99-105.
4. Makrides M, Neumann MA, Byard RW, Simmer K, Gibson RA. Fatty acid composition of brain, retina, and erythrocytes in breast- and formula-fed infants. Am J Clin Nutr. 1994;60:189-194.
5. Lawrence RA. Breastfeeding: A Guide for the Medical Profession. 4th ed. St Louis, Mo: Mosby-Year Book; 1994.
6. Forsyth JS. The relationship between breast-feeding and infant health and development. Proc Nutr Soc. 1995;54:407-418.
7. Bruno G. Prevention of atopic disease in high risk babies (long-term follow-up). Allergy Proc. 1993;14:181-186.
8. Koletzko S. Role of infant feeding practices in the development of Crohn’s disease in childhood. Br Med J. 1989;298:1617-1618.
9. American Academy of Pediatrics Work Group on Cow’s Milk Protein and Diabetes Mellitus. Infant feedings and their possible relationship to the etiology of diabetes mellitus.  Pediatrics. 1994; 94:752-754.
10. Darby ML, Loughead JL. Neonatal nutritional requirements and formula composition: a review. J Obstet Gynecol Neonatal Nurs. 1996;25:209-217.
11. Anderson PO. Drug use during breast-feeding. Clin Pharm. 1991;10:594-624. (Cited in: Nutrition Management in the Full-Term Infant. Pediatric Manual of Clinical Dietetics. Chicago, Ill: The American Dietetic Association; 1997.)
12. American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 1994;93:137-150.
13. Iyngkaran N, Yadav M, Looi LM. Effect of soy protein on the small bowel mucosa of young infants recovering from acute gastroenteritis. J Pediatr Gastroenterol Nutr. 1988;7:68-75.
14. American Academy of Pediatrics Committee on Nutrition.  Iron supplementation for infant formulas (policy statement).  Pediatrics. 1999;104(1):119-123.

Manual of Clinical Nutrition Management                                                     
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