This document provides an overview of infant nutrition, including energy and nutrient needs, development of feeding skills, common nutritional problems, and growth assessment of infants. It discusses recommendations for calories, protein, fat, and other nutrient needs. Key points include exclusive breastfeeding for the first 6 months, introducing complementary foods around 6 months, appropriate food textures for infant development stages, signs of adequate feeding, and common issues like failure to thrive, colic, and iron-deficiency anemia. Growth is monitored through weight, length, head circumference, and developmental milestones.

1. Dr.syed ziyad furqan
MBBS,BSMS,MSPH (GOLD MEDAL)

2. Infant nutrition

3. Overview
Infant nutrition:
Assessing new born health,
Energy and nutrient needs,
Development of infant feeding skills,
Common nutritional problems and concerns,
Infants at risk

4. Infant & Child Mortality Rates
PAKISTAN HEALTH & DEMOGRAPHIC SURVEY-Fact sheet (2017-2018)
Pakistan has the highest infant and child mortality rates in the
region
Neonatal mortality: 42/1000 live births
Infant mortality: 62/1000 live births
Under 5 mortality: 74/1000 live births
One in every 11 children born in Pakistan dies before reaching
the fifth birthday due to:
◦ Acute respiratory illness
◦ Malaria
◦ Dehydration caused by severe diarrhea

5. Infant Development
Is based on:
Motor development
Cognitive development
Digestive system development
It hear and move in response to familiar voice
Central nervous system of newborns is not completely mature
than older infants resulting in inconsistent signs for hunger
and satiety
Strong reflexes, especially suckle and root (breathing and
swallowing)

6. Term’s Related to Development:
• Reflex—automatic response triggered by specific stimulus
• Rooting reflex—infant turns head toward the cheek that is
touched
• Suckle—reflex causing tongue to move forward and
backward

7. Digestive System Development of
Infants
Fetus swallows amniotic fluid which stimulates intestinal
maturation and growth
At birth the healthy newborn can digest fats, protein and
simple sugars.
Common problems include gastro esophageal reflux (GER),
diarrhea, and constipation
Factors that impact rate of food passage in GI
Osmolarity of foods or liquids
Colon bacterial flora
Water and fluid balance in the body

8. Energy and Nutrient Needs
The recommendations for infants are from the Dietary
Reference Intakes (DRI), National Academy of Medicine,
American Academy of Pediatrics (AAP) and the American
Dietetic Association (ADA)
Caloric needs
Protein needs
Fats
Metabolic rate, calories, fats and protein—how do they all
work together?

9. Energy Needs
(Calories)
108 kcal/kg/day from birth to 6 months (range from 80 to 120)
98 kcal/kg/day from 6 to 12 months
The energy needs of infants are higher per kilogram of body weight
than at any other time of life
Factors that influence calorie needs
Weight and growth rate
Sleep/wake cycle
Temperature and climate
Physical activity
Metabolic response to food
Health status

10. Protein Needs
Protein Needs
1.52 grams per kilogram body weight from birth to 6 months
1.2 g/kg from 6 to 12 months
How much is that?
Newborn weighing 4 kg (8.8 lbs) needs ? g protein
6-month-old weighing 8 kg (17.6 lbs) needs ? g protein

11. Protein Needs
Excessive or inadequate protein intake can result with incorrect
mixing of formula
Infants may exceed protein recommendations:
If they consume excessive formula
if protein sources such as infant cereal are added to bottles of formula

12. Fat Needs
The AI for fat is 31 grams for infants 0–6 months of age
30 grams for infants 7–12 months of age
Breast milk contains about half of the calories from fat
◦ 40 to 50 percent of calories in infant formulas
Infants use fats more regularly for generating energy,
◦ To supply energy to the liver, brain, and muscles, including the heart
The percentage of fat in the diet will decrease as the infant accepts
complementary foods

13. Metabolism of Calories, Fats and
Protein
Metabolic rate of infants is highest of any time after birth
The higher rate is due to rapid growth and high proportion of muscle
building
Protein works as ‘energy sparer’ – when metabolism is low on
carbohydrate and/or energy intake results in protein catabolism
impacting growth
If these are not sufficient amino acids catabolism will occur

14. Other Nutrients and Non-nutrients
Fluoride—0.1 – less than 6 months of age
0.5 mg/d for 7-12 months of age
Fluoride helps to reduce tooth decay by decreasing the solubility of
tooth enamel, decreasing the production of acid by oral bacteria, and
by supporting further remineralization
Vitamin D—400 IU/day
The AAP recommends that all breastfed and partially breastfed
infants receive 400 IU of vitamin D daily
It has an essential role in bone mineralization and calcium and
phosphorus homeostasis, and regulates genes associated with
immune response and cellular growth

15. Sodium—120 mg/day for 0-6 months of age
370 mg for 7- to 12-month-old infants
• Typical infants do not have difficulty in maintaining electrolytes and
body fluids
• Infants do not sweat as much as older children so losses from
sweating are minimal
• Do not need added salt in diet to maintain adequate sodium intake
• Illnesses such as diarrhea or vomiting cause the loss of fluid

16. Iron— infants 0–6 months of age need 0.27 mg of iron/day
11 mg/day for 7-12 months of age
Infants are at risk for iron deficiency because of rapid
growth in the first year
◦From 4 to 12 months of age, an infant’s blood volume will double
◦Newborns at risk for iron deficiency include infants of diabetic mothers,
growth-restricted (IUGR) newborns, and preterm infants
Infants born at term generally have adequate iron stores that will last
through 4–6 months of age
AAP recommends initiation of supplemental iron for exclusively
breastfed infants starting at 4 months of age
Vitamin B12 supplementation may be needed for breastfed vegan
infants if the maternal diet is inadequate

17. Growth Assessment
Physical growth is defined as the increase in the mass of body tissues
that occurs in genetically determined rates, patterns, and ages
Interpretation of growth
•Weight for age
•Length for age
•Weight for length
•Head circumference for age

18. To avoid measurement errors
● Use measuring equipment that was recently calibrated.
● Confirm that the scale is on zero before starting.
● Weigh the infant nude or wearing a dry diaper.
● Confirm the position of the infant for length measurements:
◦ ● Head position—the infant’s eyes are looking straight up and the head is in
midline, touching the head board.
◦ ● Neither hips nor knees are bent.
◦ ● Heel is measured with foot flat against the foot board.
● Head circumference measure is at the widest part of the head.

20. Warning signs of growth difficulties include:
•No increase in weight or length;
•Continued decline or rapid increase in weight, length, or head
circumference percentile
•Head circumference increases are reflective of brain growth
•Atypical rates of head circumference growth (notable slowing or rapid
increase) will warrant close follow-up by the infant’s primary care
physician

21. Feeding in Early Infancy
AAP & ADA recommend exclusive breast feeding for 1- 6 months &
continuation to 1 yr
Initiate breast feeding right after birth
Growth rate and health status indicate adequacy of milk volume
Standard infant formula provides 20 cal/oz
Preterm formula provides 22-24 cal/oz

22. Rates of breast feeding vs. bottle feeding in Pakistan
Exclusive breast feeding: is
37-38% and declines to 21%
by age of 5 months.
Bottle feed:
More than 1 in 5 babies
under 2 months of age is
being fed using a bottle
This proportion rises to 46%
at age 9-11months
The percentage of bottle feed
has increased in recent years
Pakistan Health & Demographic Survey 2012-2013

23. Exclusive Breastfeeding (EBF) – need of
the times effective counseling
According to WHO “Exclusive breastfeeding” is defined as no
other food or drink, not even water, except breast milk (
including milk expressed or from a wet nurse) for 6 months of
life, but allows the infant to receive ORS, drops and syrups
(vitamins, minerals & medicines) if needed.
Pakistan Health & Demographic Survey 2012-2013

24. Development of Infant
Development of Infant Feeding
Skills
Infants are born with reflexes that will prepare them to feed
successfully
◦ rooting, sucking, gagging, swallowing, and grasping
Infants are also born with food-intake regulation mechanisms that
develop over time
◦ pleasure of the sensation of fullness
◦ Inherent preferences for sweet taste
◦ After 4-6 weeks purposely signal wants and needs
Depression in a caregiver leads to lower level of interaction which in
turn reduce the number or volume of feedings and increasing the risk
of slower weight gain

26. The cues infants give for feeding may include:
•Watching the food being prepared and anticipation of eating
•Tight fists or reaching for the spoon as a sign of hunger
•Showing displeasure if the feeding pace is too slow or if the feeder
temporarily stops
•Starting to play with the food or spoon as satiety sets in
•Slowing the pace of eating, or turning away from food when wanting
the feeding to end
•Refusing or spitting out food when they have had enough to eat

27. Adequate feeding
An exclusively breast- fed infant who is getting adequate feeds will:
Pass urine 6-7 times in 24hrs.
Show a weight gain of about ½ to 1 kg/month
An approximate indicator is that infant’s birth weight should double by 5-6
months
At the age of one year, they should be triple of their birth weight
Other criteria of satisfactory quality of nutrition are :
◦ Hemoglobin (Hb) for age
◦ Skin
◦ Normal elimination
◦ Energy
◦ Sleep Cycle

28. Weaning
The Introduction to Solid Foods
Begin with food on spoon in small portion approximately size of 1-2
tbsp with one or two meals per day
Food offered from spoon stimulates muscle development
At 4-6 months, offer small portions of semisoft food on a spoon once
or twice each day

29. Do’s and Don'ts for Weaning
Infant should not be overly tired or hungry
Use small spoon with shallow bowl
Allow infant to open mouth & extend tongue
Place spoon on front of tongue with gentle pressure
Avoid scraping spoon on infant’s gums
Pace feeding to allow infant to swallow
First meals may be 5-6 spoons over 10 minutes

30. Improper positioning may cause choking, discomfort, and
ear infections
Position young bottle-fed infants in a semi-upright
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

31. When to Begin to Drink from a Cup
Developmental readiness for a cup begins at 6 to 8 months
Wean to a cup at 12 to 24 months
First portion from cup is 1-2 oz
Early weaning may result in plateau in weight (due to reduced calories)
and/or constipation (from low fluid intake)
Changing from a bottle to a covered “sippy” cup with a small spout is not
the same developmental step as weaning to an open cup
Open cup drinking skills also encourage speech development

32. Food Texture and Development
Weaning is not complete till the calories from mother’s milk is provided by
foods and beverages
Baby can swallow pureed foods at 4-6 months
Early introduction of lumpy foods may cause choking
Can swallow very soft, lumpy foods at 6-8 months
By 8-10 months, can eat soft mashed foods
Its IMPORTANT to give infants the foods that don’t require much
chewing as they don’t develop mature chewing skills until they
are toddlers

33. Best choices as First foods
Should be iron fortified- 6 months onwards
These foods should low risk of allergies- hypoallergenic
There should be various pureed forms of fruits and vegetables
Only one new food over 2-3 days
Commercial baby foods are not necessary but do provide sanitary and
convenient choices
Home made baby food can also suffice the needed if prepared with
care
From 9-12 months onward baby can eat soft table foods

34. Inappropriate and Unsafe Food Choices
Foods that choke infants
Popcorn
Peanuts
Raisins, whole grapes
Stringy meats
Gum & gummy-textured candy, hard candy or jelly beans
Hard fruits or vegetables

35. Water
Breast milk or formula provide adequate water for healthy infants up
to 6 months.
All forms of fluids contribute to water intake
Additional plain water needed in hot, humid climates
Dehydration is common in infants
Pedialyte or sports drinks provide electrolytes but lower in calories
than formula or breast milk
Limit juice
AAP recommends juice is not needed to meet the fluid needs before
the age of 6 months
Avoid colas and tea

36. How Much Food is Enough for Infants??
Breastfed
From 6–8 months old, feed baby half a cup of soft food two to three
times a day
◦ soft, lumpy texture
From 9–11 months old, baby can take half a cup of food three to
four times a day, plus a healthy snack
◦ chop up soft food into small pieces instead of mashing it
Non-breastfed
From 6–8 months old, baby will need half a cup of soft food four
times a day, plus a healthy snack.
From 9–11 months old, baby will need half a cup of food four to five
times a day, plus two healthy snacks

37. How infants learn food
preferences
• Infants learn food preferences
• Flavor of breast milk influenced by mother’s diet
• Genetic predisposition* to sweet taste
• Food preference from infancy sets stage for lifelong food
habits

38. Common Nutritional Problems &
Concerns
Failure to thrive (FTT)
Colic
Iron-deficiency anemia
Constipation
Dental caries
Food allergies

39. Common Nutritional Problems &
Concerns
Failure to thrive (FTT)
• Inadequate weight or length gain
• Organic—diagnosed medical illness /Nonorganic—not based on medical diagnosis
or environmental
• Mixed type
Examples (poverty, maternal depression, substance abuse in home,
over dilution of formula, feeding delegated inappropriately

40. Nutritional Assessment -An Infant
In order to rule out failure to thrive in infants complete nutritional assessment
is necessary which include:
Complete anthropometric measurement
Knowledge about all growth charts and records
To understand the indicators for body composition
To know about medical, family, or any other kind of drug history
Monitor food and fluid intake through dietary assessment
Rule out all organic factors of FTT
Observe parent- infant interaction

41. Colic
Cause unknown but associated with GI upset,
Irritability, and excessive, inconsolable crying in healthy, well-fed
infants
Episodes may appear at the same time each day
Continue till 4-5 month
Change in formulas does not change pattern of colic
Recommendation:
Rocking, swaddling, bathing, or utilizing other ways of calming the
infant, positioning the baby well during feedings, or burping more
frequently

42. • Diarrhea & Constipation
Diarrhea is described as the passage of three or more loose, watery
stools per day or a stool volume greater than 10 grams per kilogram
of body weight in infants
Causes of diarrhea & constipation:
• Viral and bacterial infections
• Food intolerance
• Changes in fluid intake
• continue breastfeeding or feeds of regular strength formula or
complementary foods, ORS
• Not recommended
• Gut rest is not needed
• Foods high in simple sugar content are not recommended
• Restriction of fat

43. Constipation is defined as changes in the frequency, size, consistency,
or easy of passing stool.92 Difficulty with defecation is a common
occurrence in infancy and childhood
Recommendations:
•Normal fluid and fiber intake
•If formula fed, assess if formula is mixed correctly
•Foods with high dietary fiber content are generally not recommended
for infants
• whole-wheat crackers or apples with peels, present a choking hazard
•Routine use of prebiotics and probiotics in the treatment of childhood
constipation is not recommended

44. Iron-deficiency Anemia
• inadequate iron contributes to long-term learning delays from
its role in central nervous system development
• Less common in infants than in toddlers
• Irons stores in the infant reflect the iron stores of the mother
• Breastfed infants may be given iron supplements and iron-
fortified cereals at 4-6 months

45. Risk factors:
low birthweight, high cow milk intake, low intake of iron-rich
complementary foods, low socioeconomic status, and immigrant status
Iron supplementation is recommended for infants with severe iron
deficiency anemia at a dose of 4 to 6 mg/kg/d divided into three doses.
◦ For mild to moderate iron deficiency, the recommended dosing is 3 mg/kg/d
divided into one to two doses.
◦ When breast milk is the sole source of nutrition, supplemental iron may be
prescribed depending on the infant’s age, length of gestation, and medical
history.
◦ Older infants receive iron through iron-fortified baby cereal at 6 months of
age.
◦ For infants who are not breastfed, a usual source of iron for formula-fed
babies is iron-fortified infant formula

46. Food Allergies and Intolerances
• About 6-8% of children < 4 yrs have allergies
• irritated or inflamed intestinal lining may allow protein
fragments of larger lengths of amino acids to be absorbed
• Common symptoms are wheezing or skin rashes
• Treatment may consist of formula with hydrolyzed proteins
• Prevention of food allergies by delaying the introduction of
or avoiding specific foods thought to cause allergies for most
infants
• May decrease nutritional adequacy and reinforce
behaviors of rejecting foods and limiting variety

47. Lactose Intolerance
Gastrointestinal infections may temporarily cause lactose intolerance
because the irritated area of the intestine affects the digestion of
lactose
◦ Ability to digest lactose generally returns shortly after the illness subsides
Lactose-reduced infant formulas are available; they contain less lactose,
and additional carbohydrate is provided by other sources such as
modified cornstarch or sucrose.
Vegetarian diets
Nutrients of concern for infants on vegetarian diets include vitamin B12,
vitamin D, calcium, iron, zinc, and omega-3 fatty acids
Lacto-ovo vegetarian diets were reported to well meet the nutritional
needs of the growing infant
More restrictive vegan and macrobiotic diets may increase the risk for
nutrient deficiencies

48. Infant Nutrition
Conditions & Interventions
Infants who are born preterm or who are sick early in life often
require nutritional assessment and interventions that ensure they are
meeting their nutritional needs for growth and development.
Early nutrition services and other interventions can improve long-
term health and growth among infants born with a variety of
conditions.
The number of infants requiring specialized nutrition and health care
is increasing due to the improved survival rates of small and sick
newborns.

49. Extremely low-birthweight infants (ELBW) - weighing less than 1000
grams at birth
very low-birthweight infants (VLBW) - weighing less than 1500 grams at
birth
Low birth weight infants (LBW) - weigh less than 2500 grams at birth

50. Infants born before 34 weeks of gestation. These infants have very
inadequate nutrient stores, increased nutritional demands, and
immature organ function and altered feeding patterns.
Infants affected by abnormal development in utero. These include
infants with cardiac malformations, exposure to drugs or alcohol, or
genetic conditions such as Down syndrome.
Infants at risk for chronic health problems. Risks home environment.
Some examples of conditions that increase nutritional risk are seizures,
cystic fibrosis, and fetal alcohol syndrome. Long-term consequences,
such as learning, attention, and behavioral problems, may not be known
for years may come from the treatment needed to save their lives, or
from the

51. Infants at Risk
Advancement in health care can reduce infant mortality
Advancement in neonatal health care can increase survival of infants
who were preterm, low birth weight or with chronic conditions
Key questions regarding infants:
Regardless of what condition is involved, these nutrition questions are helpful:
• How often does your baby feed? How long does a feeding generally take?
• How does your baby behave during a feeding? Pulls away, arches back, looks
irritable or calm?
• How does your baby behave after feedings? Satisfied, still hungry, anxious?
• Has your baby had any other fluids from a bottle?
• How many wet diapers and stools does your baby have every day?

52. Nutrient Needs
Energy Needs- RDA may not be appropriate, DRI are used instead
May be the same, more or less depending on the special needs
Increased calories required for :
• Difficulty breathing
• Infections
• Temperature regulation
• Fever
• Recovery from surgery
Decreased calories recommended for spina bifida or Down syndrome

53. Calorie and Protein Needs
Calorie Requirements:
AAP suggests 120 cal/kg for preterm infants
The European Society for Gastoenterology and Nutrition gives a
caloric range of 95-165 cal/kg
Recovering infants may need as much as 180 cal/kg
Protein Requirements:
2.2 g/kg adequate if growth or digestion are not affected
3.0-3.5 g/kg required for preterm or recovery from illness
4 g/kg may be needed for ELBW
Form of protein
Hydrolyzed protein or single amino acid formulas
Specific amino acid formulas such as for PKU

54. Fat Needs
Fat Requirements
Provide up to 55% calories from fat
Low-fat diet rarely required
Medium-chain triglycerides (MCT) beneficial to VLBW and ELBW
infants because of low pancreatic and liver enzymes
Essential fatty acids and DHA and AA important
Vitamin & Mineral Requirement:
May need additional vitamins and minerals to support “catch-up”
growth or during recovering from illness
Human-milk fortifiers provide additional calories and nutrients
Preterm infant formulas may have higher amounts of vitamins and
minerals

55. Growth
Tracking growth reflects nutritional status for most infants
Additional methods to use if underlining conditions exist include:
• Growth charts for specific conditions
• Biochemical indicators
• Body composition
• Head circumference
• Medications
• Does Intrauterine Growth Predict Outside Growth?
Depends on:
• Intrauterine environment
• Fetal origins theory
• Other factors like air pollution
• Interpretation of growth based on a pattern of weight gain

56. Activity…..
There are three cases of mothers;
Samina is a worker in a local bank
Mehr is a factory worker
Sara is a housewife
Both the mothers have to rejoin after maternity leave. Please
give suggestions to facilitate EBF to these women
Also what role does family and friends can play in it?

57. QUESTIONS ?
THANKS!