Feeding Babies: By Rena Mendelson, M.S., D.Sc., RD New parents can be daunted by the responsibility of caring for an infant during the first year of life. They require reliable, clear and practical information from health care providers. Access to information about feeding and care can avoid a range of problems. First Feedings Mothers who choose to breastfeed need reliable resources to prepare themselves. In addition to books, a key source is the lactation counsellor who can provide the mother with her first breastfeeding lesson in the hospital following the baby’s delivery. A follow-up visit is essential to clarify any questions she may have, ideally before she leaves the hospital. With the current practice of very short hospital stays, lactation may not be established until she has left for home. Accordingly, new mothers will need access to an "expert", to provide advice. Lactation specialists are available for home visits and can be essential players in the success of breastfeeding. Without competent, timely support, mothers run the risk of failing to establish the optimal nutritional source for their babies. Mothers in communities not supported by lactation consultants can be referred to the local public health office or the La Leche League for support. During the first four to six months, infants can grow adequately on exclusive breast milk, formula or a combination of both. This is the critical period during which mothers learn to read the cues of their babies to know when they are hungry, tired, or simply interested in being sociable. Ideally, the infant will determine these needs for him/herself. Research has routinely confirmed that infants given feeds (breastmilk or formula) of an appropriate energy density are capable of establishing their own needs and will adjust their intake as the concentration of the food is modified 1 . This is an obvious task for the breastfed infant because the amount they consume cannot be measured. However, those who bottle feed may be tempted to encourage the baby to consume more than he or she needs. Parents can use some simple guidelines to know whether the baby is getting adequate food and fluid. Fluid is adequate if there are 6-8 wet diapers per day. If the baby is ill with diarrhea or fever, more fluid will be needed in the form of water or in more extreme cases, electrolyte maintenance solutions. Extremely warm weather may also warrant the feeding of water, however excessive water feeding should be avoided. With formula-fed babies, extra care must be taken to ensure that the formula is properly prepared by following manufacturer’s instructions. Food is adequate if the baby is satisfied at the end of the feeding and shows growth at each check-up. Research has shown that breastfed babies will be somewhat lighter in weight than bottle-fed infants by six months of age. This difference usually disappears by the time they reach two years 2 . Frequency of feeding will be unique for each baby but generally, during the first few weeks, breast fed babies will eat every two to three hours, lengthening to three to four hours once breastfeeding is established. Bottle fed babies will feed every three to four hours. The energy needs are unique for each child, and no single prescription for feeding infants can be applied to all babies. New Foods During the fourth to the twelfth month of life, babies go from complete reliance on one food provided by others to partially feeding themselves a diet similar to the rest of the family. The optimal time to introduce solid foods to babies is a judgment call for the parents with the help of the physician or health professional. Four to six months has been the recommendation of the nutrition committees of both the Canadian Paediatric Society (CPS) 3 , and the American Academy of Pediatrics (AAP) 4 . Babies are ready for solid foods if they can sit up, with support, have control of their head and neck muscles, allowing them to lean toward the spoon if wanting more food and turn away when satisfied. The signs indicating that baby is ready for solids include waking in the middle of the night with hunger after having slept through the night for several weeks or months. Another sign is hunger at the end of the usual feeding that cannot be satisfied, with more milk. Generally, babies ready for solid foods will show a slowing of weight growth relative to growth in length. Adding new foods to the baby’s diet is not only a nutritional milestone, but also provides for important landmarks of oral development. Attention to the timing and process by which foods are introduced will ensure that the baby develops the capacity to accept a wide range of textures, flavors and foods, setting a pattern for healthy eating throughout life. During the period of weaning, babies should continue to be fed either breast milk or formula. They can be expected to drink approximately 26 to 40 oz. per day of formula or breast milk. Feeding the baby cow’s milk is still undesirable until one year of age. However, when it is used, it should be whole milk and not low-fat milk. This recommendation continues until 2 years of age. This will help to ensure that the baby gets enough dietary fat and not too much protein. Parents should be reminded that nutritional guidelines for adults do not apply to babies. For instance, parents may not realize the important role fat plays in baby’s growth and tissue development. Another infant feeding concern is the need for iron supplementation. A low level of iron in young children associated with anemia can cause poor learning and behavior problems. This new awareness of the importance of iron is reflected in the recent changes in feeding recommendations for babies which promote the use of iron fortified formulas for formula-fed babies from birth until one year of life. Babies who receive breastmilk get iron in a form which is quickly absorbed, so there does not appear to be any need for additional iron supplementation in this group. Regardless of the type of milk used, the continued use of iron fortified cereals is an important means of delivering iron to young children. The pediatric nutrition committees of the CPS and the AAP have also indicated that nutrient supplementation is not required from 6-12 months of life if the baby is eating a variety of foods which contain iron and vitamin C. Vitamin D supplementation is recommended for the exclusively breast fed infant. In the case of breast fed babies whose mothers are strict vegetarians (vegan), vitamin B12 is also recommended 4,5 . In spite of these recommendations, surveys show that 50% of babies get supplements even though they are not recommended 6 . Supplements should be recommended, however, for infants who are at risk. This would include infants with clinical issues (gastrointestinal malabsorption syndromes), those who have poor food intake, infants who receive cow’s milk instead of formula during the first year of life, and infants who are receiving diets such as strict vegetarian (vegan). Fluoride supplementation may be recommended for babies over six months, depending upon the concentration of fluoride in the local drinking water 7 ,8 . Food should be gradually introduced from all four food groups until the baby is eating a variety of healthy foods at the end of 12 months. The nutrition committees of the CPS and the AAP recommend that the first solid food for infants be iron-fortified cereal 3,4. This provides babies with iron to coincide with the increased need for iron which occurs at 4-6 months of age. New foods should be introduced one at a time and repeated the next day with a minimum 3 day wait before an additional new item is provided. Each new food should be a single ingredient food to determine whether the baby has any allergic reaction to the new food. Foods which are more likely to cause allergies such as egg whites, strawberries, peanuts or seafood should be introduced after one year of age. Adding new textures and flavors to the infant’s diet provides important developmental opportunities for oral maturation. Between two and three months, babies lose the extrusion reflex which rejects solid material. By about eight months, most babies have a pair of opposing teeth. Hence the period from three to twelve months has been found to be an important period for learning to chew, transfer food to the back of the mouth, and swallow. When cereals are introduced for the first time, parents should be advised to offer small amounts of single grain cereals, such as one to two tablespoons, twice a day. Once the cereal is accepted, the feedings can be increased in volume and timed to coincide with family meals. For example, within a month of starting cereal, the baby could be fed approximately 3 - 4 tablespoons of cereal with 3 ounces of milk, either breast milk or formula, two to four times daily. Over time, each of these "meals" can be adjusted to resemble breakfast, lunch, dinner and snack. Gradually as new foods are added, the feedings will reflect the family’s usual meal choices. Between the "meals", the baby is fed breast or bottle as needed and this remains an important source of nutrition. As the meals become larger and more varied, the baby will take less and less milk between meals until about twelve months when milk is only consumed with meals and possibly as a starter for the day and as an evening snack. Attention to the timing of the meals and the amount of food is worthwhile. When new foods are introduced, the baby should have a good appetite for them. It helps when the baby is neither too hungry or too full. To facilitate this, the baby could receive milk from one breast or the first half of a bottle, then the introduction of the new food, followed by breast feeding from the other breast or from the remainder of the bottle. The mechanics of feeding can also influence the rate of success. When first introduced, weaning foods should be given with a small amount on the end of the spoon. Vestiges of the baby’s extrusion reflex may cause the infant to reject the food by spitting it out with the tongue. Parents may incorrectly interpret this reaction as the baby’s distaste for the food and eliminate it from the repertoire. While parents may assist the swallowing reflex by placing foods toward the back of the baby’s mouth, they should be cautioned not to place food so far back as to cause choking or gagging. Cereal or mashed food should not be fed to infants through the bottle because it prevents the opportunity to learn to take food from a spoon, and may cause choking. After cereal has been mastered, vegetables and fruits can be gradually added. They offer a range of vitamins and minerals which are required at this point in the baby’s life. Some fruits and vegetables can be eaten in the raw stage. Early favorites are banana, papaya and avocado because of their mushable texture. Parents may be alarmed by the brown fibers they leave behind in the diaper so some reassurance would be helpful. The last food group to be added is the meat group. This includes mashed meats and fish (around 7 to 8 months), dairy products (9 to 10 months), and egg yolk (9 to 11 months). Canned fish mashed without the bones is a good source of protein. Other protein foods might include yogurt, cheese, peas, mashed well-cooked beans and lentils which provide protein sources similar to meat products. In the meantime, pasta, rice, mashed potatoes, breads and other starchy foods can be added to form a more complete meal. The weaning diet should continue to be based on a diet of primarily breast milk or formula with a gradual addition of foods that ultimately will be typical of the family’s food. Eventually, all four food groups will provide the baby with the nutrients and energy necessary to meet the requirements for growth and development. It is convenient to use commercially prepared infant foods which are manufactured under the highest possible standards of cleanliness. These foods are beneficial and well tolerated by infants. However, parents may believe that they are more expensive. The choice is a personal one taking into account time, cost, and waste and considering the baby’s total diet. Self feeding As soon as the baby is able to transfer an object from the hand to the mouth, hard rolls or biscuits can be provided to support this skill required for self-feeding. This often appears around the same time as teething and a hard bagel or teething biscuit can provide some comfort to the gums. Foods which easily break up in the mouth such as cookies, pretzels and crisp bacon pose a threat of choking. From 8-12 months of age, babies also develop the pincer reflex which allows them to pick up small food pieces between the thumb and the forefinger. Small pieces of cereal, meat, cheese, fruit and vegetable can be prepared and the baby can enjoy the independence of self feeding. During this time an increasing variety of food can be added to the diet. Pieces of toast, grilled cheese sandwich, French toast, and pasta are only a few examples. By 12 - 18 months of age, the baby can consume most of the food that is available to the other members of the family. They can replace formula with whole milk but should not be fed 2% or skim milk until at least 2 years of age. The main goal for parents at this time is to encourage the child to enjoy a variety of foods and to develop some independence in feeding. Some cautionary notes Food safety is critical to avoid serious problems. Parents need to be vigilant about proper sanitation and food temperature. Sanitary practices include proper cleaning of hands, utensils and foods. Overlooking these basics can cause food poisoning. Foods which are safely prepared for the baby can be frozen in small meal size batches and reheated as needed. If reheated in the microwave, they must be stirred carefully to distribute the heat. Microwaves can create hot spots in food that can cause burns in the baby’s mouth. In their enthusiasm for giving babies good food, most parents don’t realize that the use of orange or dark green vegetables such as cooked carrots, winter squash and other foods high in beta carotene should be limited to one item per day. This is because of the risk of hypercarotenemia, a high blood level of carotene which is harmless but may cause the baby to acquire an orange skin color. Parents should also be cautioned about the use of home prepared spinach, turnips, carrot soup or carrot juice. These foods contain nitrite, and extensive consumption can cause methemoglobinemia. The nitrite content in these vegetables can be minimized by discarding water used in parboiling the vegetables, and using fresh water for further cooking. Nitrites can be further reduced by minimizing the time of storage in the refrigerator. Nitrite levels tend to rise when these foods are stored in the refrigerator for one or more days. During the first year, honey must be avoided because it has been known to contain the spores of the botulinum organism which could cause a fatal case of botulism. Before three years of age, children should not receive foods which may cause choking or aspiration. These include round foods that might get caught in the child’s throat. Some examples are whole nuts, large peas or beans, popcorn, grapes or large berries. Other foods to be aware of are hot dogs cut up in slices that would block the throat or foods which form balls in the mouth such as peanut butter sandwiches. Some parents do not realize that ice cubes will not melt fast enough when stuck in a child’s throat and that other foods such as marshmallows can be compressed on the way into the mouth but fill up the throat when swallowed without chewing. Sweets should be monitored because of the impact they have on dental caries and because they may take up space that should be used for more nutritious foods. As soon as teeth erupt, they are vulnerable to dental decay and for this reason the baby’s teeth should be brushed or wiped clean with a cloth after meals and before bed. Baby bottle syndrome (teeth which decay upon eruption because of continuous exposure to sugar) is a preventable problem. Parents need to know of the consequences of putting a baby to bed with a bottle - especially one which may have contained fruit juice, milk or diluted sweetened drinks. Two ways of avoiding this problem are first, to encourage the use of a drinking cup as soon as the baby is able and second, to clean teeth before bedtime. Feeding babies a variety of healthy foods presents a challenge to infants, their care-takers and others. However, ultimately the goal of this adventure is to ensure that each child develops a liking for a wide range of foods and the ability to feed himself. With a choice of wholesome, safe and nutritious foods combined with the knowledge and patience of the care-giver, all children eventually reach their potential for growth and development. References: 1 . Fomon, S.J. et al. Influence of formula concentration caloric intake and growth of normal infants. Acta Pediatr Scand , 1975 64: 172. 2 . Dewey, KG, Pearson JM, Brown KH et al, Growth of breastfed infants deviates from current reference data: a pooled analysis 3 . Nutrition Committee, Canadian Paediatric Society, Meeting the Iron Needs of Infants and Young Children: An Update, 1991, 4 . American Academy of Pediatrics, Committee on Nutrition: Pediatric nutrition handbook, Elk Grove Village, IL, 1985, American Academy of Pediatrics. 5 Canadian Pediatric Society. Vitamin D Supplementation in Northern Native Communities. CMAJ 138:22230, 1988. 6 Curtis, D.M. Infant nutrient Supplementation. The Journal of Pediatrics1990, 117: 5111-5118. 7 American Academy of Pediatrics, Committee on Nutrition, Fluoride Supplementation for Children: Interim Policy Recommendations,Pediatrics 1995, 95(5):777. 8 Nutrition Committee, Canadian Paediatric Society, The Use of Fluoride in Infants and Children, 1995, CPS statement 95-02.
|
