CHAPTER 1:  NUTRITIONAL NEEDS OF INFANTS
             Introduction                                         Nutrition Assessment
             Good nutrition is essential for the growth and       To determine an infant’s nutritional needs 
             development that occurs during an infant’s first     and develop a nutrition care plan, an accurate 
             year of life. When developing infants are fed the    assessment of the infant’s nutritional status 
             appropriate types and amounts of foods, their        must be performed. The nutrition assessment 
             health is promoted. Positive and supportive          provides the nutritionist or health counselor 
             feeding attitudes and techniques demonstrated        with important feeding practices and other 
             by the caregiver help infants develop healthy        information pertinent to an infant’s health. 
             attitudes toward foods, themselves, and others.      Nutrition education sessions can then be 
                                                                  designed to encourage positive, appropriate 
             Throughout the first year, many physiological        feeding practices and, if necessary, recommend 
             changes occur that allow infants to consume          strategies to correct inappropriate practices. By 
             foods of varying composition and texture. As         communicating periodically with a caregiver 
             an infant’s mouth, tongue, and digestive tract       about an infant’s nutritional needs in the first year 
             mature, the infant shifts from being able to         of life, better care for the infant is assured.
             only suckle, swallow, and take in liquid foods,      The assessment should include an examination of:
             such as breast milk or infant formula, to being 
             able to chew and receive a wide variety of           ▘  Health and medical information – 
             complementary foods. See Chapter 5, page 101,            Information gathered through chart 
             for more information regarding complementary             review, caregiver interview, health care 
             foods. At the same time, infants progress from           provider referral form(s), or other sources 
             needing to be fed to feeding themselves. As              that may include history of chronic or 
             infants mature, their food and feeding patterns          acute illnesses or medical conditions, birth 
             must continually change.                                 history, developmental disabilities, a clinical 
                                                                      assessment identifying signs of nutritional 
             For proper growth and development, an infant             deficiencies, and other pertinent information 
             must obtain an adequate amount of essential              (e.g. immunization record);1, 2
             nutrients by consuming appropriate quantities                                     
                                                                                            1, 3 
             and types of foods. During infancy, a period of      ▘  Dietary intake data:
             rapid growth, nutrient requirements per pound of         •   Feeding history – Eating behaviors, feeding 
             body weight are proportionally higher than at any            techniques, feeding problems, and 
             other time in the life cycle. Although there are             environment; 
             many nutrients known to be needed by humans,             •   Appetite and intake – Usual appetite, 
             requirements have been estimated for only a                  factors affecting intake such as preferences, 
             limited number of these.                                     allergies, intolerances, chewing/swallowing 
                                                                          problems, feeding skills;
             This chapter includes sections on nutrition              •   Diet history – Breastfed and/or infant 
             assessment, the Dietary Reference Intakes (DRIs),            formula-fed; frequency and duration of 
             and background information on important                      breastfeeding; frequency and amount of 
             nutrients needed during infancy. Counseling                  infant formula or complementary foods 
             points that relate to the information presented              fed; age at introduction of complementary 
             in this chapter are found in Chapter 8, pages                foods; variety of complementary foods 
             157–158.                                                     provided; vitamin/mineral or other 
                                                                                                  I N F A N T   N U T R I T I O N  A N D   F E E D I N G               11
                          supplements given; and problems such as         based on the nutrient content of foods consumed 
                          vomiting, diarrhea, constipation, or colic;     by healthy infants with normal growth patterns, 
                          and                                             the nutrient content of breast milk, investigative 
                      •   Socioeconomic background – Primary and          research, and metabolic studies. It is difficult to 
                          other caregivers, food preparation and          define precise nutrient requirements applicable to 
                          storage facilities, use of supplemental         all infants because each infant is unique. Infants 
                          feeding and financial assistance programs,      differ in the amount of nutrients ingested and 
                          access to health care, and ethnic and/or        stored, body composition, growth rates, and 
                                                          1
                          cultural influences on the diet.                physical activity levels. Also infants with medical 
                                                                          problems or special nutritional needs (such as 
                   ▘  Anthropometric Data – Anthropometric                metabolic disorders, chronic diseases, injuries, 
                      measurements, i.e., weight for age, length          premature birth, birth defects, other medical 
                      for age, weight for length, and head                conditions, or being on drug therapies) may have 
                                              1 and
                      circumference for age;                              different nutritional needs than healthy infants. 
                                                                          The DRIs for vitamins, minerals, and protein 
                   ▘  Biochemical Data – Data used to diagnose or         are set at levels thought to be high enough to 
                      confirm nutritional deficiencies or excesses;1,4    meet the nutrient needs of most healthy infants, 
                      in the WIC Program, hemoglobin, hematocrit,         while energy allowances, referred to as Estimated 
                      or other hematological tests are performed to       Energy Requirement (EER), are based on average 
                      screen for iron deficiency anemia.                  requirements for infants. See page 15 for more 
                                                                          information regarding EER. 
                   Dietary Reference Intakes (DRIs)                       See Appendix A, pages 180–182, for a complete 
                   The Dietary Reference Intakes (DRIs), developed        table of DRIs for infants. 
                   by the Institute of Medicine’s Food and Nutrition      Important Nutrients
                   Board, are four nutrient-based reference values 
                   intended for planning and assessing diets. They        The following sections include information 
                   include the Estimated Average Requirement              on the food sources, functions, and concerns 
                   (EAR), the Recommended Dietary Allowance               regarding major nutrients and nutrients 
                   (RDA), the Adequate Intake (AI), and the               considered to be of public health significance  
                                                        5                 to infants in the United States. 
                   Tolerable Upper Intake Level (UL).   
                   Recommendations for feeding infants, from              For additional information on the function, 
                   infant formula to complementary foods, are based       deficiency and toxicity symptoms, and major food 
                   primarily on the DRIs. The DRIs for infants are        sources of the nutrients discussed below, as well as 
                    ▘  EAR is the median usual intake that is estimated to meet the requirement of half of the healthy 
                        population for age and gender. At this level of intake, half the individuals will have their nutrient 
                        needs met. The EAR is used to establish the RDA and evaluate the diet of a population.
                    ▘  RDA is the average dietary intake level sufficient to meet the nutrient requirement of nearly all 
                        (97–98 percent) healthy individuals. If there is not enough scientific evidence to establish an EAR 
                        and set the RDA, an AI is derived.
                    ▘  AI represents an approximation of intake by a group of healthy individuals maintaining a defined 
                        nutritional status. It is a value set as a goal for individual intake of nutrients that do not have a 
                        RDA.
                    ▘  UL is the highest level of ongoing daily intake of a nutrient that is estimated to pose no risk in the 
                        majority of the population. ULs are not intended to be recommended levels of intake, but they 
                        can be used as guides to limiting intakes of specific nutrients.
      12          INFANT NUTRITION AND FEEDING                                                                                                                                                                                                 I N F A N T   N U T R I T I O N  A N D   F E E D I N G               13
             other nutrients not discussed, refer to Appendix        Using this rationale, the Institute of Medicine 
             C: Nutrient Chart: Function, Deficiency and             Food and Nutrition Board has determined 
             Toxicity Symptoms, and Major Food Sources of            that the EER for infants should balance energy 
             Nutrients, pages 190–194.                               expenditure at a level of physical activity 
                                                                     consistent with normal development and allow 
             Energy                                                  for deposition of tissues at a rate consistent 
             Energy Needs                                            with health. See Table 1, page 15, for the EER, 
                                                                     reference weights, and reference lengths for 
             Infants need energy from food for activity,             infants. Modification of these requirements may 
             growth, and normal development. Energy comes            be required based on individual needs and growth 
             from foods containing carbohydrate, protein, or                   7  The kilocalories needed per unit of 
                                                                     patterns.
             fat. The number of kilocalories (often termed           body weight decrease over the first year because 
             “calories”) needed per unit of a person’s body          infants older than 6 months grow more slowly. 
             weight expresses energy needs. A kilocalorie is 
             a measure of how much energy a food supplies            Energy Intake and Growth Rate
             to the body and is technically defined as the           A general indicator of whether an infant is 
             quantity of heat required to raise the temperature      consuming an adequate number of kilocalories 
             of 1 kilogram of water 1 degree Celsius. An             per day is the infant’s growth rate in length, 
             infant’s energy or caloric requirement depends          weight, and head circumference. However, 
             on many factors, including body size and                physical growth is a complex process that can be 
             composition, metabolic rate (the energy the body        influenced by size and gestational age at birth, 
             expends at rest), physical activity, size at birth,     environmental and genetic factors, and medical 
             age, sex, genetic factors, energy intake, medical       conditions, in addition to dietary intake. An 
             conditions, ambient temperature, and growth             infant’s growth rate can be assessed by periodically 
             rate. Infants are capable of regulating their intake    plotting the infant’s weight, length, and head 
             of food to consume the amount of kilocalories           circumference for age and weight for length on 
             they need. Thus, caregivers are generally advised       Centers for Disease Control (CDC) growth charts 
             to watch their infants’ hunger and satiety cues         throughout the first year of life. See Appendix 
             in making decisions about when and how much             B:  Use and Interpretation of CDC Growth 
             to feed. See Table 2, page 46; Figure 1, page           Charts, pages 183–189. Appendix B includes 
             42; page 59; page 87; and page 123 for more             basic instructions on how to collect, record, and 
             information regarding hunger and satiety cues.          interpret weight, length, and head circumference 
             Recommended Energy Allowances                           measures and the CDC WIC growth charts for 
                                                                                                   8       9
                                                                     infants. Refer to Kleinman,  Lucas,  National 
             The World Health Organization’s (WHO) expert            Center for Chronic Disease Prevention and 
                                                               6                          10
             report on energy and protein requirements states:       Health Promotion,  and reference textbooks on 
             The energy requirement of an individual is a            pediatric nutrition or nutrition assessment for 
             level of energy intake from food that will balance      more detailed information on the anthropometric 
             energy expenditure when the individual has a            assessment of infants.
             body size and composition and level of physical         In general, most healthy infants double their 
             activity, consistent with long-term good health;        birth weight by 6 months of age and triple it by 
             and that would allow for the maintenance of                                 11  However, keep in mind that 
             economically necessary and socially desirable           12 months of age.
             physical activity. In children and pregnant or          there are normal differences in growth between 
             lactating women the energy requirement includes         healthy breastfed and formula-fed infants during 
             the energy needs associated with the deposition of      the first year of life. After 3 months of age, the 
             tissues or the secretion of milk at rates consistent    rate of weight gain in the breastfed infant may 
             with good health.                                       be lower than that of formula-fed infants, but 
12          INFANT NUTRITION AND FEEDING                                                               I N F A N T   N U T R I T I O N  A N D   F E E D I N G               13
                  differences are generally not reported between        Functions
                  these infants for length and head circumference.12    Carbohydrates are necessary in the infant’s diet 
                  Ultimately, each infant’s growth must be              because they:
                  individually assessed. 
                  In addition to health and medical information,        ▘  Supply food energy for growth, body 
                  anthropometric data, and biochemical data, the           functions, and activity;
                  nutrition assessment of an infant should include      ▘  Allow protein in the diet to be used efficiently 
                  an evaluation of breastfeeding frequency and             for building new tissue; 
                  duration, infant formula dilution and intake,         ▘  Allow for the normal use of fats in the body; 
                  appropriate amount and types of complementary            and
                  foods, and feeding skill development. For more        ▘  Provide the building blocks for some essential 
                  information regarding nutrition assessment see           body compounds.
                  pages 11–12. Assessing this dietary intake data       Carbohydrates serve as primary sources of energy 
                  will be helpful in determining which factors          to fuel bodily activities while protein and fat are 
                  are influencing the growth rate if an infant’s        needed for other essential functions in the body, 
                  growth per the CDC growth charts appears to           such as building and repairing tissues. 
                  be abnormally slow or rapid. For infants with 
                  an abnormal rate of growth, assess the feeding        Sources
                  relationship for negative interactions associated 
                  with feeding that may be contributing. For more       The major type of carbohydrate normally 
                  information on the feeding relationship refer to      consumed by young infants is lactose, the 
                  page 45. Infants with abnormally slow or rapid        carbohydrate source in breast milk and cow’s 
                  growth rates or recent weight loss should be          milk-based infant formula. Lactose-free infant 
                  referred to a health care provider for assessment.    formulas, such as soy-based infant formulas, 
                                                                        provide carbohydrates in the form of sucrose, 
                                                                        corn syrup, or corn syrup solids. These infant 
                  Carbohydrates                                         formulas are prescribed to infants who cannot 
                    AI for Infants                                      metabolize lactose or galactose, a component of 
                    0–6 months            60 g/day of carbohydrate      lactose. Some specialty infant formulas contain 
                    7–12 months           95 g/day of carbohydrate      other carbohydrates in the form of modified corn 
                                                                        starch, tapioca dextrin, or tapioca starch.
                  Carbohydrates fall into these major categories:       In later infancy, infants derive carbohydrates from 
                  simple sugars or monosaccharides (e.g., glucose,      additional sources including cereal and other 
                  galactose, fructose, and mannose), double             grain products, fruits, and vegetables. Infants 
                  sugars or disaccharides (e.g., sucrose, lactose,      who consume sufficient breast milk or infant 
                  and maltose), and complex carbohydrates or            formula and appropriate complementary foods 
                  polysaccharides (e.g., starch, dextrins, glycogen,    later in infancy will meet their dietary needs for 
                  and indigestible complex carbohydrates such           carbohydrates.
                  as pectin, lignin, gums, and cellulose). Dietary 
                  fiber is another name for indigestible complex        Carbohydrates in Fruit Juices
                  carbohydrates of plant origin (these are not 
                  broken down by intestinal digestive enzymes).         Some fruit juices, such as prune, apple, and 
                  Sugar alcohols, including sorbitol and mannitol,      pear, contain a significant amount of sorbitol 
                  are also important to consider for infants.           and proportionally more fructose than glucose. 
                                                                        Infants can absorb only a portion of the sorbitol 
                                                                        (as little as 10 percent) and fructose in these 
                                                                              13 Unabsorbed carbohydrate is in these
                                                                        juices.
      14          INFANT NUTRITION AND FEEDING                                                                                                                                                                                          I N F A N T   N U T R I T I O N  A N D   F E E D I N G               15