NTRN 328: Infants

What are developmental milestones?

Physical or behavioral signs of development of infants
and children
• Observed through how they play, learn, speak, and act

• there are many developmental milestones to track developmental progress

What is the rate of development like during the first year of life?

Rate of growth and development very rapid during 1st
year of life
– Weight: doubles by 5-6 months; triples by 12 months

What is motor development? In what order does motor development occur?

Ability to control voluntary muscle movement
• Top down – controls head first and lower legs last
• Muscle development from central to peripheral
– E.g., shoulders and arms before hands

What kind of things does motor development influence?

• ability to self feed

• daily energy expended

What are the social and emotional developmental milestones an infant should be displaying by two months?

• begins to smile at people

• briefly calms self (brings hands to mouth and suck on hand)

What are the social and emotional developmental milestones an infant should be displaying by four months?

• smiles spontaneously, especially at people

• likes to play with people and might cry when playing stops

• copies some movements and facial expressions, like smiling or frowning

What are the social and emotional developmental milestones an infant should be displaying by six months?

• begins to recognize and respond to others’ emotions

• knows familiar faces; begins to say consonant sounds

What are the social and emotional developmental milestones an infant should be displaying by nine months?

• often clingy with familiar adults

• knows familiar faces; begins to recognize if someone is a stranger

What are the social and emotional developmental milestones an infant should be displaying by 12 months?

• often cries when mom or dad leaves

• has favorite things and people; shows fear

What are the language and communication developmental milestones an infant should be displaying by two months?

• coos

• turns head towards sound

What are the language and communication developmental milestones an infant should be displaying by 4 months?

• begins to babble

• replicated sounds/noises

What are the language and communication developmental milestones an infant should be displaying by 6 months?

• Strings vowels together when babbling; begins to
  say consonant sounds

• Responds to own name

• Responds to sounds by making similar sound

What are the language and communication developmental milestones an infant should be displaying by 9 months?

• Understands “no”
• Makes a lot of different sounds e.g., “mama” “baba”
• Uses fingers to point at things

What are the language and communication developmental milestones an infant should be displaying by 12 months?

• Responds to simple spoken requests
• Uses simple gestures e.g., shaking head, waving
bye
• Tries to say words spoken to them

What are the cognitive developmental milestones an infant should be displaying by 2 months?

• Pays attention to faces
• Begins to follow things with eyes & recognize people
at a distance

What are the cognitive developmental milestones an infant should be displaying by 4 months?

• Lets you know when he/she is happy or sad;
responds to affection
• Uses hands & eyes together in semi-coordinated
manner
• Recognizes familiar people & things at a distance

What are the cognitive developmental milestones an infant should be displaying by 6 months?

• Shows curiosity about things & tries to get things
that are out of reach
• Begins to pass things from one hand to another
• Brings things to mouth

What are the cognitive developmental milestones an infant should be displaying by 9 months?

• Plays peek-a-boo
• Watches the path of something as it falls
• Moves things smoothly from one hand to the other

What are the cognitive developmental milestones an infant should be displaying by 12 months?

• New exploration of things e.g., shaking, banging
• Starts using objects correctly e.g., cup, hair brush
• Follows simple directions e.g., “pick up the toy”

What are the movement developmental milestones an infant should be displaying by 2 months?

• Can hold head up & begins to push up when lying on
stomach
• Makes smoother movements with arms & legs

What are the movement developmental milestones an infant should be displaying by 4 months?

• When lying on stomach, pushes up to elbows
• May be able to roll over from stomach to back

What are the movement developmental milestones an infant should be displaying by 6 months?

• Rolls over in both directions
• Begins to sit without support
• Crawling begins

What are the movement developmental milestones an infant should be displaying by 9 months?

• Stands, holding on
• Mobile crawling

What are the movement developmental milestones an infant should be displaying by 12 months?

• Pulls up to stand
• Walks with help; may take a few steps unsupported
• May stand independently

What kind of things are causes of concern in a 2 month old infant?

Causes of Concern – Infant:
• Doesn’t respond to loud sounds
• Doesn’t watch things as they move
• Doesn’t smile at people
• Doesn’t bring hands to mouth
• Can’t hold head up when on their stomach and pushing
up

What kinds of nutrition related factors influence cognitive, motor, and socio-emotional development?

Influenced by several nutrition-related factors
• Severe, acute malnutrition
• Chronic under nutrition
• Iron deficiency anemia
• Iodine deficiency

Describe the digestive system development of an infant. What are some common digestive problems associated with this population?

• Fetus swallows amniotic fluid

  • Stimulates intestinal maturation and growth

• At birth, a healthy term infant can digest fats, protein and simple sugars

• Common problems:

  • Gastroesophageal reflux (GERD), diarrhea, constipation

New parents must learn:

New parents must learn

• Infant’s cues of hunger and satiety

• Temperament of infant
  – Emotionality, attention span, reaction to food, ability to soothe

  
  

  
  

• How to respond to infant cues
  – Early and appropriately
  – Balance assistance and development
  – Allow infant to guide feeding

What does the growth of an infant reflect?

• nutritional adequacy

• health status

• economic and environmental adequacy

Describe the metabolic rate of infants

• Metabolic rate of infants is highest of any time after birth
– Related to rapid growth and increased proportion of muscle
• Low energy and/or carbohydrate intake results in protein
catabolism impacting growth

what are the energy needs of infants (birth - 6months)?

Average 108 kcals/kg/day

can range from 80-120 kcal/kg/day

what are the energy needs of infants (7 months - 12 months)?

98 kcals/kg/day

what are some factors influencing energy needs of infants?

Factors influencing energy needs:
• Weight and growth rate
• Sleep/wake cycle
• Physical activity
• Health status/recovery from illness

What are the protein needs of an infant (Birth - 6mo)?

1.5 g/kg/day

What are the protein needs of an infant (7mo - 12 mo)?

1.2 g/kg/day

What are some factors that influence protein needs in infants?

• Protein needs influenced by factors similar to energy, but
also influenced by body composition

What are the fat needs of an infant (Birth - 6mo)?

31 grams/day

What are the protein needs of an infant (7mo - 12 mo)?

30 grams/day

What percentage of calories does fat make up in breastmilk?

50%

What kind of fat is in breast milk?

• Breast milk contains short- and medium-chain fatty
acids (in addition to the long-chain)
– Easier to digest and utilize than long-chain fatty acids

How do we assess infant growth? Why is it important and what are some warning signs to look for?

• Measures over time identify change in growth rate and
need for intervention

• Warning signs:
– Lack of weight or length gain
– Plateau in weight, length or head circumference for >1
month
– Drop in weight without regain in a few weeks

what are the best indicators of dietary adequacy?

• Growth and health status are better indicators of
dietary adequacy than volume of breast milk or formula
alone

What is the recommendation for feeding in early infancy?

• Recommendation: exclusive breast feeding for first
six months and continuation to one year
– Infant formulas designed to replicate human milk; however,
numerous components cannot be replicated

Compare the protein content of infant formulas with breast milk.

Breast milk: 7% of calories

Formula: 9-12% of calories

Compare the carbohydrate content of infant formulas with breast milk.

Breast Milk: 38% calories

Formula: 41-43% calories

Compare the fat content of infant formulas with breast milk.

Breast Milk: 55% calories

Formula: 48-50 calories

Should cow’s milk be used during infancy?

• Whole, reduced-fat or skim cow’s milk should not be
used in infancy
– Can be introduced at 12 months old

• Potential consequences of early introduction:
  – Iron-deficiency anemia
  • Low iron-content
  • Occult intestinal blood loss
  • Calcium & casein – iron absorption
  – increased protein and mineral
  – Does not contain the correct balance of fats

Discuss soy protein based formulas.

• Soy protein in place of milk protein should be limited in its use
  – Developmental stages sensitive to estrogen  vulnerable to estrogen-like effects of phytoestrogens

• Lactose free and hydrolyzed formulas are better for infants unable to breastfeed or be fed cow’s milk formulas

Discuss the development of infant feeding skills from birth to 4-6 weeks.

Infants born with reflexes and food intake regulatory
mechanisms
• Need to coordinate sucking, swallowing, and
breathing
• 4 – 6 weeks reflexes fade
– Infant begins to purposely signal wants and needs

Discuss development of infant feeding skills from birth - 5mo.

APPROXIMATE MOUTH PATTERNS

• Sucking/swallowing reflex

• tongue thrust reflex

• poor lip closure

DEVELOPMENTAL SKILLS HAND AND BODY CONTROL

• poor control of head, neck, and trunk

BABY CAN

• swallow liquids but pushed most solid objects from the mouth

Discuss development of infant feeding skills from 4-6mo.

APPROXIMATE MOUTH PATTERNS

• draw in lower lip as spoon is removed from mouth

• up and down movement

• immediately transfer food from front to back of tongue to swallow

DEVELOPMENTAL SKILLS HAND AND BODY CONTROL

• sit with support

• good head control

• use whole hand to grasp objects (palmar grasp)

BABY CAN

• take in a spoonful of pureed or strained food and swallows it without choking

• control the position of food in the mouth

Discuss development of infant feeding skills from 5-9mo.

APPROXIMATE MOUTH PATTERNS

• up and down munching movement

• position food between jaws for chewing

DEVELOPMENTAL SKILLS HAND AND BODY CONTROL

• begin to sit alone, unsuported

• begin to use thumb and index finger to pick up objects (pincer grasp)

BABY CAN

• begin to eat mashed foods

• eat from a spoon easily

Discuss development of infant feeding skills from 8-11mo.

APPROXIMATE MOUTH PATTERNS

• complete side to side tongue movement

• begin to curve lips around rim of cup

DEVELOPMENTAL SKILLS HAND AND BODY CONTROL

• sit alone easily

BABY CAN

• begin to eat ground or finely chopped foods

• begin to feed self with fingers

• drink from a cup (with assistance)

Discuss development of infant feeding skills from 10-11mo.

APPROXIMATE MOUTH PATTERNS

• rotary chewing (grinding)

DEVELOPMENTAL SKILLS HAND AND BODY CONTROL

• begin to put spoon in mouth

• begin to hold cup

BABY CAN

• eat chopped foods, small pieces of soft, cooked foods

What are some cues infants may give for feeding readiness?

Cues infants may give for feeding readiness
• Watching food being opened in anticipation of eating
• Tight fists or reaching for spoon
• Irritation if feeding too slow or stops temporarily

what are some cues infants give to signal satiety?

Cues infants may give to signal satiety
• Playing with food or spoon
• Slowing intake or turning away
• Stop eating or spit out food

Discuss the introduction of solid foods.

• Food offered from spoon stimulates mouth muscle
development
• Between 4-6 months, begin to
offer small portions of
pureed food on a spoon
(1-2 times/day)

What are some recommendations for introducing solid foods?

• Infant should not be overly tired or hungry
• Use small spoon with shallow bowl
• Avoid scraping spoon on infant’s gums
• Pace feeding to allow infant to swallow
• First meals may be 5-6 spoons over 10 minutes

What is the importance of feeding position?

• Improper positioning may cause choking, discomfort,
and ear infections
• Spoon-feeding should be with infant seated with back
and feet supported
• Adults feeding infants should be directly in front of
infant making eye contact

What food textures should be introduced at what ages?

Early introduction of lumpy foods may cause choking
• 6 months: can swallow pureed foods
• 6-8 months: can swallow very soft, lumpy foods
• 8-10 months: eat soft mashed foods

What are some first foods?

4-6 months: iron-fortified baby cereal; pureed fruits,
vegetables
• Introduce only one new food over 2-3 days
• Commercial baby foods are not necessary
– Provide sanitary, convenient choices

9-12 months: soft table foods

What are some inappropriate and unsafe food choices?

Foods very likely to cause an infant to choke
• Hot dogs
• Popcorn, potato chips
• Peanuts, chunks of peanut butter
• Raisins, whole grapes
• Hard fruits or vegetables
• Stringy meats
• Gum, gummy candy, hard candy, jelly beans

How can temperament affect how much food parents give their infants?

• Infants vary in temperament
• Crying or fussiness may be interpreted as hunger
resulting in overfeeding
• First foods may appear to be rejected due to immature
tongue movement

Discuss food preferences in infants?

• Infants learn food preferences based on experience
with foods
• Flavor of breast milk influenced by mother’s diet
• Genetic predisposition to sweet taste
• Food preference from infancy sets stage for lifelong
food habits

What is failure to thrive (FTT)?

• Failure to thrive (FTT): decelerated or arrested physical growth 

  • Characterized by 

    • Inadequate weight or height gain 

    • Energy deficit is suspected 

    • Can be diagnosed in infancy, but usually later 

  • Potential causes 

    • Typically not metabolic but instead environmental 

    • Environmental factors; maternal depression; mental illness (of primary caregiver); alcohol or drug abuse in home; over dilution of formula, feeding regimen 

  • Nutrition intervention 

    • May be complex and involve team approach, including registered dietician and social worker 

      • Identify causes and provide education/counseling/resources to overcome them 

      • Set plan for regular assessment 

      • solve barriers to follow-up care

      • assist with parent advocacy

What is colic?

• Colic: sudden onset of irritability, fussiness, or crying

  • Episodes may appear at the same or different time 

  • Usually disappears by 4-5 months 

  • Cause: unknown, but associated with GI upset, infant feeding practices 

    • Bad positioning → too much air getting in

  • Nutrition intervention: good feeding position and frequent burping may help 

What is iron deficiency anemia?

• Iron deficiency Anemia 

  • Less common in infants than in toddlers 

  • Infant iron stores reflect the iron stores of the mother 

  • Associated with:

    • Cows milk intake too early -> decreased SES (substituting formula for cow's milk), decreased intake of iron rich complementary foods 

  • Breastfed infants may be given iron supplements and iron fortified cereal at 4-6 months 

    • Breastmilk does not provide an adequate amount of iron when they are older 

  • Formula fed infants → iron fortified formula 

Discuss diarrhea and constipation in infants.

• Infants at increased risk because of higher metabolic rate, smaller reserves, and dependence on others for fluids 

• Infants typically have 2-6 stools per day

• Potential Causes: 

  • Viral and bacterial infections 

  • Food intolerance

  • Changes in fluid intake 

• To avoid constipation - assure adequate fluids 

• During diarrhea - continue to feed usual diet

What are some feeding techniques to reduce caries?

• Early Childhood Caries (ECC)

  • We should care abt baby teeth because they are directly associated with your adult teeth → cavities in baby teeth increases probability of complication with adult teeth

  • Feeding techniques to reduce caries 

    • Avoid high frequency consumption of sugar 

    • Limit use of bedtime bottle 

      • After 12 months we should expect them to sleep through the night without a feeding 

      • We should be cleaning teeth after nighttime bottle because milk has a lot of sugar 

    • Avoid frequent breastfeeding after first tooth 

    • Bottle wean between 12-18 months 

    • Brush or wipe emerging teeth 

    • See a dentist by 12 months 

Discuss food allergies and intolerances in infants?

• Food Allergies and Intolerance 

  • About 6-8% of children less than the age of four have food allergies 

  • Takes several years for immune system to fully develop 

    • Different antibodies in infants fed breastmilk vs formula 

  • Common symptoms: skin rashes, diarrhea, vomiting 

  • Not currently recommended that food introduction be delayed 

    • Decreased variety in the diet and reinforces food rejection 

  • Treatment may consist of formula with hydrolyzed proteins

What is lactose intolerance?

• Lactose Intolerance: inability to digest disaccharides lactose due to the absence or limited quantity of the enzyme lactase 

  • Characterized by

    • cramps , nausea, pain, alternating diarrhea and constipation

  • Uncommon during infancy 

    • Tend to be overestimated 

    • Common due to baby stomach size and underdeveloped sphincter 

  • Do not want to completely remove lactose from body because it will enable the body to stop producing any lactase at all 

    • Feed to the point of tolerance -> some lactose in the diet without GI comps or symptoms associated with the intolerance 

Discuss vegetarian diets in infants.

• Vegetarian Diets

  • Can support normal growth and development in infants when well planned to meet their nutritional needs

  • Of concern: vitamin B12, vitamin D, calcium, iron, zinc, omega 3 fatty acids 

  • more restrictive vegan diets may increase risk for nutrient deficiencies

  • DHA content in breast milk is decreased in vegetarian mothers than non-vegetarian mothers