Nutrition during Infancy

Dr Sadia Chishty
Assistant Professor
Jamia hamdard
Infancy is the first year of life.

• It is a period of rapid growth and development.

• An infant doubles its birth weight in five months and by one year of age, the
weight is three times the birth weight.
• The normal body length of 50 cm at birth also increases to about 75 cm at the
end of the first year.
• Infancy is a crucial period. The rapid growth and development necessitate
substantial increase in nutrient needs.
The requirements for infants are divided into two stages – 0-6 months and 6-12
months.

Nutrient need during the first six month is comparatively higher.

Reference body weight for Infants: 0-6 -5.8 kg

6-12 months-8.5 kg

The requirement for energy, iron and Vitamin B are expressed in terms of Kg. Body
weight.

Table : Day’s Recommended Dietary Allowances (RDA) for Infants

 Table : Day’s Recommended Dietary Allowances (RDA) for Infants

RDA Requirements
[Link] Nutrients 0-6 months 6-12 months

1. Energy 530 Kcal/d 90 Kcal/kg/day 660 kcal/d 80 Kcal/kg/day

2. Protein 1.40g/kg/d 1.23 gm/kg/d

3. Fats Human milk 20% of energy 25 gms
4. Calcium 300(AI) 300
5. Phosphorous 200 mg/d 200 mg/d
6 magnesium 30 mg/d 75 mg/d
7. sodium 500 mg/d 650 mg/d
8. potassium 900 1100 mg/d
9. Iron ------ 6 mg/d
10. folate 25microgm/d 85microgm/d

11. Vit c 20 AI 30 AI
AI-adequate intake
 RDA Requirements
[Link] Nutrients 0-6 months 6-12 months

12. VITAMIN-A 350 AI 350 AI

13. Vitamin-D 400 IU 400 IU
Meal planning steps for infants and advise for lactating mothers:

Step 1: Identify the Infant

Find out :

Ø The age of the infant

Ø Expected body weight of the infant at that particular age
Ø Socio-economic status (the income) of the family to which the child belongs, and the
Ø region where the infant lives

Step 2: Consult RDI for Energy and Protein : For example, a five month infant weighs six Kg.

Using RDA calculate the energy and protein need for the infant.
the calculation would be as follows:
• Age : 5 Months
• Weight : 6 Kg (Expected weight at 5 months)
• RDI for energy (Kcal) : 108/ Kg
• RDI for Protein (g) : 2.05/ Kg
• Total energy requirement = 108 X 6 = 648 K Cal
• And total protein requirement = 2.05 ´X 6 = 12.3

Note: Always use the expected body weight of an infant at that particular age to calculate energy/protein needs
Step 3: Decide on the Food Item
Breast milk is the first and the best food for the infant

Breast milk is the best because:

Ø It is the most nutritious and balanced food.

Ø It gives the baby exactly the right amount and type of food. It contains antibodies which protect the baby from
infections (cough, cold, chest and stomach infections).

Ø It is free from contamination.

Ø It is economical, in fact costs nothing.

Ø It needs no preparation.

Ø It helps to develop a good bond between mother and child.

Ø Colostrum is the sticky, yellowish fluid secreted from the breast during the first few days after child birth.

If an infant receives on an average 850 ml of breast milk daily upto four months, his/her requirement
After six months, however, breast milk alone is not sufficient to make a baby grow well.
Certain other foods along with breast milk need to be given so as to meet the growing needs of the infant.
Step 4: Deciding on the Frequency of Feeding Infants
It is clear that a growing infant needs more food. But on the other hand the child’s stomach is very
small. He/She cannot eat much at one time. They need to be fed more often than the rest of the
family.
Feeding 5-6 times a day in addition to breast milk is recommended.

From birth to six months only exclusive breast feeding is done. Feeding on self/demand(whenever
they cry or seem hungry) is recommended.

The child may be fed 12-15 times in24 hours during the early months, which can be reduced slowly
and by four months most babies will have a routine of 6-8 feeds in 24 hours.
INFANT AND YOUNG CHILD FEEDING GUIDELINES

Infant and Young Child Feeding (IYCF) is a set of well-known and common recommendations for appropriate feeding
of new-born and children under two years of age. IYCF includes the following care practices:

• Early Initiation of Breastfeeding means breastfeeding all normal newborns (including those born by caesarean section)
as early as possible after birth, ideally within first hour. Colostrum, the milk secreted in the first 2–3 days, must not be
discarded but should be fed to newborn as it contains high concentration of protective immunoglobulin’s and cells.
• No pre-lacteal fluid should be given to the newborn.

• Colostrum contains large quantities of protective substances and growth factors and has more protein and Vitamins A
and K than mature milk.

• It enhances the development and maturation of the baby’s gastro-intestinal tract.

• The anti-infective proteins and white cells provide the first immunisation against the diseases that a baby encounters
after delivery.

• Although colostrum is secreted in small quantities (30–90 ml), it is sufficient to meet the caloric needs of a normal
newborn in the first few days of life.
• Colostrum also has a mild purgative effect, which helps to clear baby’s gut of meconium (the
first, very dark stools) and helps to prevent jaundice by clearing the bilirubin from the gut.

• It stimulates the baby’s immature intestine to develop in order to digest and absorb milk and to
prevent the absorption of undigested protein.

• Exclusive breastfeeding for the first 6 months means that an infant receives only breast milk
from his or her mother or a wet nurse, or expressed breast milk, and no other liquids or solids,
not even water.

• The only exceptions include administration of oral rehydration solution, oral vaccines, vitamins,
minerals supplements or medicines.
a) Nutritional benefits of breast feeding
The composition of human milk is best suited to the infants and provide nutrients in easily digestible and
bioavailable form.
i. Carbohydrate
Human milk is the sweetest milk due to the high amount of lactose. Lactose which is present in higher levels in
human milk facilitates the absorption of magnesium and calcium and favours amino acid absorption and nitrogen
retention.
ii. Protein
Human milk contains 1.1 g percent protein. Human milk has 20% casein and 80 % whey proteins which constitutes
lactalbumin and lactoferrin. Lactalbumin has an amino acid pattern that mainly approaches that of body protein and
provides more essential amino acids than casein. Breast milk contains amino acids specific for brain development.
Human milk offers a high tryptophan to neutral amino acids ratio which controls brain serotonin synthesis. Human
milk also contains binding proteins of thyroxine, corticosterol, vitamin D, folate and B12.
iii. Lipids
Lipids Present in human milk are unsaturated fat, essential fatty acids, prostaglandin precursors, fat soluble vitamins,
steroids, phospholipids and cholesterol. Lipids involved in the development of brain are mostly long chain
polyunsaturated fatty acids. These are abundant in the breast milk. Human milk contains cholesterol and is essential
for synthesis of myelin of the nervous system. Presence of chlorine, acetylcholine, phospholipid precursors and
carnitine ensure optimum metabolism and brain development.
iv. Minerals
Unlike vitamins, mineral content of human milk is minimally influenced by mother’s stores and immediate
intake of calcium, magnesium, phosphorus, iron, copper, zinc, sodium and potassium. Minerals in the breast
milk are largely protein bound and balance to enhance bioavailability. Calcium content in human milk is 28
mg and calcium phosphorus ratio of 2:1 in human milk is favourable. Breast milk ensures better oxygen
saturation and increases the bioavailability of trace elements like copper, cobalt, selenium, iron and zinc.

v. Vitamins
Breast milk contains more vitamin A, C and E than cow’s milk. Breast milk contains water soluble vitamin D
along with fat soluble fraction which protects against rickets. riboflavin, pyridoxine and B12 content of
human milk are also related to the dietary intake of mother. Heat liable vitamins like thiamine and ascorbic
acid are completely available in human milk. Breast fed infants receive about 25 -30μg of folate daily, most of
which is available for absorption.
b) Hormones and growth factor benefits
Breast milk is so rich source of hormones like thyroid stimulating hormone (TSH), thyroxin, parathyroid hormone,
corticosteroids, calcitonin, erythropoietin, oxytocin, growth hormone releasing factor, insulin and prolactin. It contains
growth regulating factors, growth promoting factors and growth modulators.

c) Immunological benefits
These factors are present in colostrum as well as in matured milk.
i. Macrophages
Human milk contains macrophages. They contribute immunity in two ways: (a) They engulf and digest bacteria. (b) These
cells synthesize complement, a protein involved in establishing immunity to infectious organism.
ii. Lymphocytes
Lymphocytes are the white blood cells responsible for mediating most aspects of the immune system, with its ability to attack
a wide range of infectious microorganisms. Human milk contains T and B lymphocytes.
iii. Immunoglobulins
Immunoglobulin are the difference in proteins that include all types of antibodies. Immunoglobulin are resistant to the acidity
for the stomach.
[Link] and Vitamin B12 binding protein
Lactoferrin is an iron containing protein found both in colostrum and mature milk. It’s in which the growth of
staphylococcus organism and E coli by tying iron that is needed for growth. Similarly vitamin B12 binding protein
present in breast milk makes vitamin B12 unavailable to pathogens that require B12 to survive in the infant’s
gastrointestinal track.

v. Lactobacillus bifidus factor

It is a nitrogen containing carbohydrate in human milk. It encourages the growth of microorganism, lactobacillus
bifidus and produces acetic acid or lactic acid from lactose and depresses the growth of pathogenic or disease
producing organism like Escherichia coli.

vi. Enzymes
Breast milk supplies enzymes like amylase, lipoprotein, lipase, bile salt, stimulated lipases, oxidases, lacto peroxidase,
and leucocyte myeloperioxidase. These enzymes increase digestibility and also act as defence against microbes.
Enzymes like lysozyme, peroxidase and xanthine oxidase promote cell maturation.

d) Psychological benefits
An infant derives a sense of security and belonging in the mother and child relationship from the comfort of being
held than from feeding process.
Breast feeding during illness

•Breast Feeding is to be done during illness because -

•Breast milk is the most easily digestible food for the sick baby
•Breast feeding is the best pacifier to the sick baby
•Breast milk satisfies the nutritional and fluid demands
•Breast milk offers anti-infective and immunological factors.
Artificial feeding
Though no milk can be real substitute for mother’s milk, sometimes it is necessary to give
artificial feeding. Circumstances under which artificial feeding is essential are ALLIANCE .

The mother is suffering from serious illness, fever or infection,

Another pregnancy intervenes during lactation

The child is too weak to nurse or cannot because of harelip for cleft palate

Breast milk has completely stopped or insufficient for the child

Mother is not available to feed the child

The mother is on anticoagulants, steroids and radioactive drugs,

Death of the mother.
The process of introducing food other than breast milk in the diet of the infant is called supplementary
complimentary feeding.

Complimentary feeding
Complimentary feeding should begin around 6 months of age. Complimentary feeding is a gradual process which
begins from the moment other foods (like liquid, semi solid or solid food preparation) are started and continues till
the time the child is completely taken off the breast (1-1½ Years.)

The Complimentary Foods for Infants

Depending on the age of the infant liquid, semi-solid or solid supplement can be served to the infant.

The different types of complimentary foods:

Ø Liquid Supplements (at 4-6 Months)Juices, soups or other milk substitutes (cow’s, buffalow’s, goat’s milk etc.)
are the common liquid supplement that can be given to infants

Ø Semisolid Supplements (6 Months Onwards)The first solid supplement commonly offered at 6 months is a soft,
thin, liquidy porridge made from the staple food (cereal, potato) and given with milk. Such a preparation is
called the Basicmix.
Complementary feeding means complementing solid/semi-solid food with breast milk after child attains age of six
months.
After the age of 6 months, breast milk is no longer sufficient to meet the nutritional requirements of infants.
However infants are vulnerable during the transition, from exclusive breast milk to the introduction of
complementary feeding, over and above the breast milk

The term “complementary feeding” and not “weaning” should be used. The complementary feeding must be:

•Timely - meaning that they are introduced when the need for energy and nutrients exceeds what can be provided
through exclusive breastfeeding.
•Adequate - meaning that they provide sufficient energy, protein and micro- nutrients to meet a growing child’s
nutritional needs.

• Safe - meaning the food is hygienically prepared, stored and fed with clean hands using clean utensils instead of
bottles and/or teats.

•Active feeding - styles for complementary feeding are also important. Appropriate feeding styles can provide
significant learning opportunities through responsive caregiver interaction, enhancing brain development in the most
crucial first three years.
Energy Density of Infant Foods
Energy density of foods given to infants and young children can be increased in four different ways:

i) By adding a teaspoonful of oil or ghee in every feed. Fat is a concentrated source of energy and

ii) Substantially increases energy content of food without increasing the bulk.

iii) The false belief in the community that a young child cannot digest fat has to be dispelled with by
informing that a young infant digests fat present in breast milk and all other foods like cereals and pulses and
that there is no reason to feel that a child can not digest visible fat when added to food.

ii) By adding sugar or jaggery to the child’s food. Children need more energy and hence adequate amounts of
sugar or jaggery should be added to child’s food.
iii) By giving malted foods. Malting reduces viscosity of the foods and hence child can eat more at a
time. Malting is germinating whole grain cereal or pulse, drying it after germination and grinding. Infant
Food Mixes prepared after malting the cereal or pulse will provide more energy to the child. Flours of
malted food when mixed with other foods help in reducing the viscosity of that food.
Amylase Rich Flour (ARF) is the scientific name given to flours of malted foods and must be utilised in
infant foods.
iv) By feeding thick mixtures.
Thin gruels do not provide enough energy. A young infant particularly during 6–9 months requires thick
but smooth mixtures as hard pieces in the semi-solid food may cause difficulty if swallowed. The semi-
solid foods for young infants can be passed through a sieve by pressing with a ladle to ensure that the
mixed food is smooth and uniform without any big pieces or lumps.
Frequency of Feeding

Infants and young children need to be fed 5–6 times a day in addition to breastfeeding. It must be remembered
that inadequate feeding of infants and young children during the first two years is the main cause of
malnutrition.

Continued Breastfeeding

Breastfeeding must be continued upto the age of two years or beyond.

Continuing breastfeeding while giving adequate complementary foods to the baby provides all the benefits of
breastfeeding to the baby. In other words, the child gets energy, high quality protein, vitamin A, anti-infective
properties and other nutrients besides achieving emotional satisfaction from the breastfeeding much needed for
optimum development of the child. Breastfeeding especially at night ensures sustained lactation.

In the beginning when the complementary foods are introduced after six months of age, the complementary
food should be fed when the infant is hungry. As the child starts taking complementary foods well, the child
should be given breastfeeding first and then the complementary food. This will ensure adequate lactation.
Some of the food choices for complementary feeding

a) Liquid supplements
i. Milk
At about the sixth month of life the frequency of breastfeeding is reduced to three or four times per day and
animal milk is substituted. Since the proportion of nutrients in animal milk differs from the human milk, the
cow’s milk is diluted with boiled and cooled water in the proportion of 2: 1 for the first feeds. The amount of
water is gradually reduced so that
in the course of a few weeks the baby receives undiluted animal milk. Two feeds, with 225 ml of milk per feed is
an ideal replacement. Sugar can be added for taste and it to increase calories.
ii. Juice of fresh fruits
Oranges, tomatoes, sweet lime, grapes, serve to supplement the protective nutrients not present in sufficient
amounts in breast milk as well as in animal milk. It is advantages to start feeding small quantities of fresh fruit
juice even in the 3rd or 4th month of life.
iii. Soup from green leafy vegetables
In case fresh fruits are not available, green leafy vegetables may be used as an alternative. Strained soup can be
given in the beginning with unstrained soup later on
b) Solid supplements
Mashed food is started around the 7th or 8th month of life. Around this time, the infant is already
receiving animal milk, fruit juice or vegetable soup and fish liver oil.

i. Cereal and starchy gruels

To meet the increasing demands of calories and protein, well-cooked mashed cereal like rice, rice
flour, rice flakes and ragi flour mixed with milk and sugar can be given. Addition of a small amount
of vegetable oil to the porridge makes it less glutinous increasing the energy density.

ii. Vegetables
Cooked, Mashed vegetables like potato, green leafy vegetables and carrots can be introduced to get
vitamins and minerals and colours in the diet

iii. Fruits
All fruits, with the exception of banana which is mashed, must be stewed and sieved for one year old
baby. Thereafter, it is given simply stewed, with the addition of little sugar and lime juice for favour.
Solid Supplements (8 Months Onwards)

By eight months the infant starts teething.

Now is the time to give :Chopped, lumpy (thick) foods :

Foods which were earlier boiled, mashed and served, now may be just boiled and cut into small pieces before being
served.
Pieces of boiled vegetables potato, carrots), cooked chapati or grains of rice can be given.

Crunchy foods like biscuits, piece of toast/rusk or any other such food which the infant can chew will help in teething.
When the staple i.e. the cereal has more foods added to it, (protein source plus vitamin/mineral source) .

A commonly used multimix in the north is ‘Kichri’ and ‘pongal’ in the south.
Multimixes can be prepared by mixing the following food items. Some ideas of multimixes for infants

a) Cereal + pulse + green leafy vegetable or

b) Cereal + pulse + milk or
c) Cereal + pulse + vegetable + curd or
d) Cereal + animal food + green leafy vegetable or
e) Cereal + milk + fruit + nuts (finely ground) or
f) Cereal + animal food + orange yellow vegetable (carrot, pumpkin etc.).
A guide to feeding a baby of 6-8 months

One Example

v On waking Breast milk

v 8 A.M. Mashed fruit/vegetable and egg yolk
v 10 A.m. Breast milk
v 12 P.M. Rice/wheat porridge
v 4 P.M. Breast Milk
v 6 P.M Rice and Fish with dark green leafy vegetable
v 8 P.M. Breast milk
v Bed-time Breast milk
Special Considerations while Feeding Infants:

While feeding infants, it is best to include foods that are:

Ø Nutritious and particularly high in energy (calories): Infants grow very fast, and therefore need extra energy. Fats,
oil, sugars are good sources of energy, hence enrich the child’s diet with these foods. Other foods such as cereals, pulses,
milk, vegetables should also be included.
Ø Easy to digest: When the infant is young, thin, liquidy, soft foods should be given which are easy to digest. As the child
grows and the digestive system develops, more solid foods can be included.
Ø Pure and clean: Infants are very prone to infections and can become ill easily. Wash your hands. Your hands,
contaminated food, utencils (bottles, spoons etc.) are the common sources of infection. While preparing baby’s food,
therefore, ensure the food is fresh, well-cooked and as clean as possible. Prepare the supplement just before the meal
time. Wash all articles used for feeding the baby thoroughly. Put the articles in alarge pan with lid and boil them for
atleast ten minutes. Leave the articles in the covered pan until needed.
Ø Easy and inexpensive to prepare: Many mothers do not have the money to buy the infant foods available in the
market. Others do not have time to prepare the supplements for the baby. Under such circumstances it is best to take out
the baby’s share of food from the meals cooked for the family. This will not only cost less but will also save on time and
energy.
Ø Served frequently: The child’s stomach is very small during the initial years. They cannot eat much at one time. The
child is also growing very fast and needs nourishing food very often. Hence feeding several times a day (minimum 5-6
times) is recommended.
Ø Liked and enjoyed by them: Introduce only one food at a time. Give enough time to the infant to get familiar with
each food, before introducing another one. If the baby does not like a particular item, change it or give it in a different
form. For example, ifmilk is disliked, give curd, it is as good as milk.
Optimal IYCF practices

a) Early initiation of breastfeeding; immediately after birth, preferably within one hour.

b) Exclusive breastfeeding for the first six months of life i.e. 180 days (no other foods or fluids, not even
water; but allows infant to receive ORS, drops, syrups of vitamins, minerals and medicines when
required).

c) Timely introduction of complementary foods (solid, semisolid or soft foods) after the age of six months
i.e. 180 days.

d) Continued breastfeeding for 2 years or beyond.

e) Age appropriate complementary feeding for children 6–23 months, while continuing breastfeeding.
Children should receive food from 4 or more food groups mentioned below and fed for a minimum
number of times (2 times for breasted infants 6–8 months; 3 times for breastfed children 9–23 months; 4
times for non-breastfed children 6–23 months).
 Feeding during illness

•Never starve the child.

•Feed energy-rich cereals-pulse diet with milk and mashed vegetables.
•Feed small quantities at frequent intervals.
•Continue breastfeeding as long as possible.
•Give plenty of fluids during illness.
•Use oral rehydration solution to prevent and correct dehydration during diarrhea episodes.
 Growth Assessment in Infants

• Growth chart is a valuable tool to assess the growth measurement by plotting the weight and height on
the growth chart.
• Within the first 3-4 days, a newborn loses 5-10% of birth weight.
• This weight is usually regained in 2 weeks by term babies and longer by premature babies
• An average baby doubles the weight in 4-6 months , triples it by one year and quadruples it by two
years of age.

• Tooth eruption as an element of growth but it is not reliable as it varies child to child.
• Teething starts in infants usually at 6 months of age. A new tooth appear approximately in every month.
• By 2-2.6 years of age baby will have 20 primary teeth.
 INTERPRETATION OF GROWTH CURVE

• The actual weight measurement is marked on the growth chart, the

plotting produces a line Or graph.

• The point of age when weight is assessed., I.e., how old is the child
is also marked on growth chart.

• A growth curve is formed by joining the plotted points on growth

chart.
• On each growth chart there are three colored printed areas.

• Green band : it is the median which is average.. Weight of all

normal and healthy children falls in this area.

• Yellow band: weight of moderately under weight children fall in this

Uses of Growth chart: area or below the second curve.
• Orange band: weight of severely underweight children fall below
• Useful tool for growth monitoring, the 3rd curve.
• Diagnosis of risk risk child, • As long as the baby is gaining weight mother should not concern.
• Educational tool for parents counseling, But if the weight and age is plotted on x-y’ axis and gets a straight flat
• Help in evaluating effectiveness of any curve the it is dangerous situation and child should receive immediate
intervention programme care. Downward growth curve also needs attention.
Points to be considered while introducing complementary foods :

•Introduce only one food at a time

•Allow the infant to become familiar with the foods before trying to give another
•Give a very small amounts of any new food at the beginning, for example, one teaspoon full or less.
• At first strained fruits, vegetables and cereals are given.
• Variety in choice of food is important
• If, after several trials, the baby has an acute dislike for a particular food, omit that item for a week or two and
then try again.
• Food should be given between breast feeds.
• Give freshly prepared food
• By one year, the infant can be given family diet, modified, in small quantities but at frequent intervals in
addition to milk. The best indication of adequacy of the diet is the growth pattern of the child.