Children’s Hospital
c
Haiqi Li
NUTRITION DURING
INFANCY
Children need food of appropriate
quantity and quality for optimal
growth and development
The nutritional vulnerability
Infants and children are more vulnerable
to poor nutrition than are adults
Low nutritional stores
High nutritional demands for growth
Rapid neuronal development
Illness
4 months
energy intake
30%
1 year 5%
3 years 2%
Age
Energy demands for growth
INTRODUCTION
OF NUTRITION
FEEDING OF INFANTS
Breast-feeding
Comparisons of milks
Partial breast-feeding
Weaning period
NUTRITIONAL ASSESSMENT
Nutrients requirements,
Pro,Energy,Vits
The benefits of human milk
Food change
Key points
Threpsology
INTRODUCTION
OF NUTRITION
Category of nutrients
（ 2000 Chinese Dietary Reference Intakes）
Energy：
Macronutrients:PRO,FAT,CHO
Micronutrients:minerals
vitamins
(Fat-soluble-vitamins,
water-soluble-vitamins)
Other diet elements,cellulose,water
RNIs(Recommended Nutrient Intake ),
are defined as the levels of intake of
essential nutrients,
RNIs =*EAR+ 2SD
* Estimated Average Requirement
CHO FAT PROTEIN
Macronutrients
Energy produced
Gross Energy Intake
Activity
**TEF
*BMR
Energy
Stored
“growth”
Excreta
Tissue
Synthesis
Growth
**Thermic effect of food*Basal metabolism rate
0 ?12m 95 kcal/kg.d
1y 1100 kcal/d
2y 1200 kcal/d
3y 1350 kcal/d
5y 1600 kcal/d
7y 1800 kcal/d
10y 2100 kcal/d
REQUIREMENTS OF TOTAL ENERGY
(EAR)
≈100 kcal/kg.d
(2000 Chinese Dietary Reference Intakes )
Protein in diet described as
essential(8+1) and
nonessential (13)
amino acids
EAAs
leucine isolucine lysine
methionine Phenplalane threonine
trytophan valine + histidine
Good quality of PRO
Complete protein, the protein
in a food supplies enough of
the essential amino acids
The sources of complete proteins
The amount of recommended
daily protein depends upon age,
medical conditions and the type
of diet one is following,
Reference values for protein requirements
Age Protein(g/kg/d)
0-6m 2.2
6-12m 2.0
1-3ys 1.8
4-6ys 1.5
7-10ys 1.2
11-14ys 1.0
15/18ys 0.8
A high-protein diet may put
a strain on the kidneys
Side Effects
8-15% of total energy intake
comes from protein.
The major resources
of
the energy (45-55%)
CARBOHYDRATE(CHO)
Excessive carbohydrates can cause
an increase in the total caloric
intake,causing obesity.
Side Effects
Deficient carbohydrates can cause
a lack of calories (malnutrition),or
excessive intake of fats to make up
the calories.
FAT
One of the three nutrient
supplied the calories to the
body.
The calories provided by fat
Saturated fats,animal
vegetable
Unsaturated fats,
monounsaturated from plants
polyunsaturated(fish oil,plants )
Linoleic acids is the most
important ―essential‖ fatty
acids,especially for growth
and development of infants.
Eating too much saturated fat
is one of the major risk factors
for heart disease.
Side Effects
Fat serves as the storage substance
for the body’s extra calories,
which will be the risk of obesity.
Distribution of Energy produced
P R O
8- 15%
F A T
25- 30%
C HO
45- 55%
infant(40-45%)
Micronutrients:
minerals
vitamins
Macro elements Ca,P,Mg, Na
CL,K,S
Trace elements Fe,I,Cu,Zn、
F,Cr,Se
Minerals
<6 Months infant recommended
daily intake for minerals
Calcium 360 mg
Copper 0.5-0.7 mg
Phosphorus 240 mg
Sodium 115-350 mg
Zinc 3 mg
Iron 10 mg
Iodine 40 ug
Vitamins Definition
Vitamins work together with
enzymes,co-factors (substances
that assist enzymes),and other
substances.
A group of substances essential for
normal metabolism; growth and
development; and regulation of cell
function,
FAT-SOLUBLE VITAMINS(4),
Vitamin A,D,E,K
WATER-SOLUBLE VITAMINS(9):
VitaminB1,2,3,6,12
C,H,Folate
Pantothenic acid,
There are 13 vitamins needed by
the body:Vitamins A,C,D,E,K,
and the B vitamins.
Vitamin A is found in milk,cheese,cream,
liver,kidney,and cod and halibut fish oil,
Beta carotene is a precursor to vitamin A,
The body can synthesize vitamin D
when the skin is exposed to sunshine.
Vitamin B1 is found in
fortified breads,cereals,pasta,
whole grains (especially wheat
germ),lean meats (especially
pork),fish,dried beans,peas,
and soybeans,
Most other fruits and
vegetables contain some
vitamin C.
Infant recommended daily intake for vitamins
Vitamin A 0.4 mg (400 ug,1500-2000 IU)
Vitamin D 0.01 mg (10 ug,400 IU)
Vitamin C 35 mg (35000 ug)
Vitamin E 4 mg (4000 ug)
Vitamin B1 (thiamin) 0.3 mg (300 ug)
Vitamin B2 (riboflavin) 0.5 mg (500 ug)
Folic Acid 0.04 mg (40 ug)
Vitamin B12 0.0006 mg (0.6 ug)
Vitamin K 12 ug
Vitamin A 0.4 mg (400 ug,1500-2000 IU)
Vitamin D 0.01 mg (10 ug,400 IU)
Vitamin C 35 mg (35000 ug)
Vitamin B1 (thiamin) 0.3 mg (300 ug)
Calcium 360 mg
Zinc 3 mg
Iron 10 mg
Iodine 40 ug
Protein 2.2-2.0g/kg/d
Energy intake(EAR) 100 kcal/kg.d
RNI
Other diet elements:
cellulose
water
Cellulose ( Diet - fiber )
Soluble fiber slows digestion and the
rate of nutrient absorption from
the stomach and intestine,
Insoluble fiber speeds the passage of
foods through the stomach and
intestines and adds bulk to the stool,
2 forms of fiber,soluble and insoluble
To provide a feeling of fullness
and adds bulk in the diet.
To prevent or treat diverticulosis,
diabetes,and heart disease
To prevent constipation
Functions
The recommendation for older
children,adolescents and adults is
20 to 35 grams per day.
Younger children will not be able
to eat enough calories to achieve
this,but introducing whole grains,
fresh fruits and other high fiber
foods is suggested,
Too much fiber may interfere with
the absorption of minerals including
iron,zinc,magnesium,and calcium.
Side Effects
FEEDING OF INFANTS
BREAST-FEEDING
Exclusive breastfeeding is fed
no foods or fluids,even water.
WHO definition
Partial breast-feeding is
defined as breast milk plus
either solid foods or other
milks,
To supply with formular
within 4~6 months For deficient
B.M intake
To replace B.M with formular
after 4~6 months preparation for
weaning
Two patterns for partial
breast-feeding
Components of human milk
"first milk"; immature milk
produced in 4-5 days post-partum
Colostrum,
Transitional Milk,2weeks
The composition is midway between
colostrum and mature milk,
Mature Milk:
colostrum middle maturity
PRO 22.5 15.6 11.5
FAT 28.5 43.7 32.6
CHO 75.9 77.4 75.0
Mineral 3.08 2.41 2.06
Ca 0.33 0.29 0.35
P 0.18 0.18 0.15
The changes of the components
during nursing (g/L)
The changes of the compositions
during the sucking period（ g/L）
I II III
Pro 11.8 9.4 7.1
Fat 17.1 27.7 55.1
The compositions of mammary secretions
changes continuously throughout the
sucking period.
foremilk hindmilk
Growth factors
Nutritional properties
Immunology
The advantages of breast-feeding
Others
IMMUNOLOGY
Breast milk contains valuable
antibodies from the mother
that can help the baby resist
infections.
Breast-feeding
reduces the incidence and lessens the
severity of bacterial infections.
are half as likely as artificially fed
infants to have ear infections in the
first year of life.
reduce the risk for subsequent
inflammatory bowel disease and
childhood lymphoma,
less likely to have diarrhea,
Nutrients Amount Function
Protein
SIgA 50-100/mg/dl Immune protection
IgM 2mg/dl Immune protection
IgG 1mg/dl Immune protection
Lactoferrin 100-150mg/dl Anti-infective
Lysozyme 5-25mg/dl Anti-infective
casein 200-300mg/d Inhibits microbial adhesion
to mucosal membranes
Carbohydrate
Oligosaccharides 1.0-1.5g/L Microbial ligands
Glycoconjugates - Microbial and viral ligands
Fat
FFA - Anti-infective
Immunology functions on the major nutrients
of human milk for the infant
SIg A comprises 90% of immunoglobulin.
The IgA secreted into milk
provides protection to infants
against pathogens in the immediate
environment of the mother-infant
dyad.
Lactoferrin
The anti-infective function of lactoferrin
was ascribed to its high affinity for iron
that may deprive microorganism of needed
iron.
Studied show that lactoferrin is bactericidal,
antiviral,and anti-inflammatory and
modulates cytokine function.
Lactoferrin Iron binding protein
inhibits growth of E.coli
0
20
40
60
80
Days Postpartum
0 2 4 6 8 d
SIgA
Lactoferrin
LYSOZYME
Lysozyme is present in the lyses mostly
gram-positive and few gram-negative
bacteria,
Contrary to the other protective proteins
in human milk(I.e.,IgA and lactoferrin),
the concentration of lysozyme decreases
during lactation,those of lysozyme
increase with prolonged lactation.
Lasozyme Bacteriolytic enzyme
Bifidus factor Growth of lactobacillus
bifidus
Low pH
Interferon Antiviral agent
Hypoallergenic May reduce subsequent atopic disease
Macrophages Phagocytic,Synthesise
lysozyme,lactoferrin,C3,C4
Cellular
Lymphocytes T-cells may trasfer delayed
hypersensitivity responses
to infant.
B-cells synthesis Ig A
Nutritional properties
The saying "breast is the best"
has its origin in biologic merit,
Breast milk contains appropriate
amounts of CHO,PRO,and FAT,
Comparison of CHO,PRO,FAT (100ml)
Human milk Cow’ s milk
CHO(g) 6.9 5.0
FAT(g) 3.7 4.0
PRO(g) 1.5 3.3
Comparison of the energy content(100ml)
Human milk Cow’ s milk Standard
E(kcal) 67 69
CHO(g) 6.9 41% 5.0 29% 40-50%
FAT(g) 3.7 50% 4.0 52% 50%
PRO(g) 1.5 9% 3.3 19% 11%
The ratio of energy from macronutrients
in breast milk is adequate
Protein quality More easily digested curd
(80:20 whey:casein ratio)
whey
casein
human milk cow’s milk
Carbohydrate and soluble
minerals are the major
contributors to osmolarity of
milk feeding,
Protein and minerals are the
major contributors to renal
solute load.
MINERAL HUMAN COW GOAT FORMULA *
Calcium 35 120 130 49 mg/100g
Chloride 43 95 130 43 mg/100g
Copper 39 20 50 61 ug/100g
Magnesium 3 13 14 41 mg/100g
Phosphorus 15 95 110 38 mg/100g
Potassium 51 152 204 71 mg/100g
Sodium 17 49 50 18 mg/100g
Comparing Milks
*ug/100g = microgram/100g milk
Human milk
Potential renal solute load (mOsm/L)
Low renal solute load
221
96
79
C o w ' s m i l k
F o r m u l a
H u m a n m i l k
Lipid quality Rich in oleic acid
Improved digestibility
and fat absorption
human milk
cow’s milk
saturated
unsaturated
oleic acid
Iron content Bioavaliable
(40- 50% absorption)
Ca,P= 2:1
Prevents hypocalcaemic tetacy
and improves calcium absorption
MINERAL HUMAN COW GOAT FORMULA
Calcium 35 120 130 49 mg/100g
Chloride 43 95 130 43 mg/100g
Copper 39 20 50 61 ug/100g *
Magnesium 3 13 14 41 mg/100g
Phosphorus 15 95 110 38 mg/100g
Potassium 51 152 204 71 mg/100g
Sodium 17 49 50 18 mg/100g
Comparing Milk
*ug/100g = microgram/100g milk
Growth
factors
Breast milk contains factors
that help infants grow and
mature,
Growth concentration Effects in
factors /milliliter the newborn
EGF 3-107ng GI growth &gut closure
NGF
Insulin 3-20μg Glycemia
IGF-I 1.3-11.0ng Stimulate systemic growth
IGF-II
TGF-α 0-8.4ng GI growth
Relaxin 0.3-0.5μg?
TGF-β? Inhibits GI growth
Growth factors in human milk
Other advantages
Convenient Proper temperature,fresh,sterile,
adapted volume,economic,
no time is required in preparation
Emotional close attachment between
mother and baby
Contraceptive effect increases the
time interval between children
Reduction in disease occurrence in later life
Insulin-dependent diabetes mellitus
inflammatory bowel disease
sudden infant death syndrome
Maternal health Possible reduction in
premenopausal breast cancer
The exclusively breast-
feeding is the best natural
food for infant,for
physiological,
immunological and possible
psychological reasons,
Breast milk is the perfect source
of nutrition for infants.
It is adequate for the initial
4-6 months,
Unknown intake Volume of milk intake not known
The disadvantages of breast-feeding
Nutrient inadequacies Prolonged breast-feeding
Transmission of infection HIV
Breast milk jaundice self-limiting,unconjugated
hyperbilirubinaemia
Transmission of drugs Antithyroid drugs
cathartics,
antimetabolites
Vitamin K deficiency insufficient vitamin K
in breast milk to prevent
haemorrhagic disease of the newborn
Emotional upset if unsuccessful Breast-feeding
can be problematic to establish.
Potential transmission environmental
contaminants nicotine,alcohol,caffeine,etc.
Less flexible Other family members cannot
help or take part,
More difficult in public places
Supplement of Vit D, Vit K
Comparison of Vit D, Vit K
——————————————
Human Cow’s DRIs
milk milk
——————————————
Vit D （ IU/100 ml） 10 40 400 IU//d
Vit K( ng/100ml) 15 60 0.1-0.5ug/kg
——————————————
—
The volume and nutrient content
of human milk change as
lactation progresses,
The volume
The volumes of colostrums are low
but water or formula supplements
are not required whilst the supply of
breast milk is becoming established.
Breast-feeding women produce an
average of 700 ml of milk daily.
0
300
600
900
1200
Months Postpartum
0 2 4 6 8 m
Milk volume secretion in lactating
women is regulated by infant
demand,
Thus,when milk has a low caloric
density,increased sucking by an
infant is thought to result in increased
emptying of the breast,causing
increased milk secretion.
The fat concentrations of
breast milk taken at feeds
would appear to be maximized
both increasing feed frequency
and milk volume removal.
In contrast,breast milk in
caloric density during the
feed as the volume available
diminishes,so that caloric
intake shows a curvilinear
relationship to volume intake.
Breastfeeding is,after all,a dynamic
process between every unique
mother-baby dyad,for which man
cannot possible do a better job than
God in designing how infant feeding
should work.
SUCCESS OF BREAST-FEEING
PRL (prolactin) secretion stimulated
① Suck as early as possible
② No bottle-feeding
③ Demand feeding,
Baby Controlled Breasteeding
Care of nipples
Nutrition During pregnancy weight gain
Milk is
synthesized into
the alveolar
lumen,where it
is stored until
milk removal
from breast is
initiated,
Tow levels of regulation must exist
regulation of milk ejection
- oxytocin
regulation of the rate of synthesis
and secretion- prolactin
Although both processes
ultimately depend on
sucking by an infant or other
stimulation of the nipple,the
mechanisms involved central
and local,are different.
Suckling stimulates the release
of prolactin which stimulates
milk production and the
release of oxytocin,
Oxytocin,in turn,stimulates
contraction (or the "let-down
reflex") of the milk glands,The
milk is squeezed out of the milk
gland,into the milk ducts,and
into the nipple.
Anterior lobe of
Pituitary gland
STEP 4:
Prolactin released
STEP5:
Milk synthesis
Milk ejected
Breastfeeding can safely
continue
Maternal HBV infection
TB infection but no disease in
the mother
CMV-positive mothers
Maternal infectious disease
Maternal HAV infection
Contraindications
Mother with severe infections
Maternal HIV infection
Comparisons of milks
No,cow’s milk is not
adequate to me!
Do you want
to drink milk?
Although cow's milk contains
most of the same components as
breast milk,these components
are not in the same amounts,
Why？？?
milk by itself is
inappropriate for
Contains too much protein and
salt.It would create too high a
solute to their immature kidneys,
especially in babies below 6months.
And infants are not generally
able to concentrate urine well.
Cow’s Milk
The infant can develop an allergy to
dairy products if given cow's milk
too early in life.
Cow’s milk can irritate the baby’s
intestine,causing the baby to lose
small amounts of blood,
Regular cow’s milk is not good
for babies,It is not similar
enough to breast milk,
It doesn’t contain the right kind
of fat or enough iron,which
baby needs for proper growth
and development.
Modified cow’s milk to
mimic the desirable
qualities of breast milk
such as a lower protein
and sodium content,a
higher lactalbumin to
casein ratio and emulsified
fat are well tolerated by
most infants.
Formula
Infant formula contains a balance
of protein,fat,and carbohydrate
that is similar to breast milk,It
has been enriched with vitamins
and minerals,like breast milk,
Modification of cow’s milk
Formula Human millk
52
40.6
7.4
46
45
9
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?°°×??
??????????
??·?
Contributions of energy (%)
The presence of enzymes and other
bioactive components in breast
milk that have beneficial effects in
digestion and metabolism have not,
as yet,been replicated in formula.
In addition,breast milk contains
enzymes that facilitate digestion.
In another words,formula
cannot copy breast milk
exactly,
For example,the
antibodies found in
breastmilk,however,can
never be added to
formulas.
Breast or formula feeding is
recommended until the age of
12 months,and there are
advantages in continuing to
18 months of age.
Calories 75 69 67
Protein (gm) 1.1 3.5 1.5
Lactalbumin (%) 80 18 60
Casein (%) 20 82 40
Water (mL) 87.1 87.3 90
Fat (gm) 4.5 3.5 3.8
Carbohydrate (g) 7.1 4.9 6.9
Ash (gm) 0.21 0.72 0.34
pH Alkaline Acid Acid
Bacterial Content Sterile Nonsterile Sterile
Composition /100 mL B.M C.M Formula
WEANING PERIOD
Introduction to solid foods
Weaning is the period of adaptation
to solid or the period of changing
from a predominant milk feeding to
predominant adult diet.
It can be defined as the period
which commences when solid are
introduced and continues until
after sucking has been discontinued
Except human milk or
formula (cow’s milk),the rich
semisolid and solid foods are
introduced to infants.
Introduction of other foods
( supplement foods)
Definition
Principles of initial feeding
The age at which it begins
also varies in different
societies and very much
depends on their culture and
tradition.
WHEN
After 6 months of age,breast
milk becomes increasingly
nutritionally inadequate as a
sole feed,leading to deficiencies
in energy,vitamins and iron.
Physiologic Rationale for the
introduction of solid foods at 4-
6months
The digestive system has developed
sufficiently to permit good
absorption of a variety of foods.
The secretion of saliva has increased
and facilitates the swallowing of solid
foods.
The ―extrusion reflex‖ useful for
sucking and fixing the nipple in the
month has gradually disappeared.
The mucosal barrier has matured
and the risks of food allergies have
diminished.
The head control has improved; the
baby sit up; lean forward,turn away
and send cues of satiety to the
caregiver.
The neuromuscular coordination has
improved; the tongue is now able to
pass solids from the front to the back
of the month.
Many babies will exhibit
behavioural changes from 3-4
months of age,such as
increased crying and poor
sleeping,which may
represent hunger and a need
for solid food,
At a scientific level,the most
universal recommendation that
the diet of breast milk or
formula be supplemented no
sooner than four months nor
delayed beyond six months is
based on physiological maturity.
Breast-feeding
Solid food 100
100
Age of infant(m)
1 2 3 4 5 6 7 8 9
80
60
40
20
0 0
20
40
60
80
Early weaning foods such as
pureed non-wheat cereals,
fruit and vegetables tend to be
high in energy,vitamins and
minerals.
WHAT
Fruits and vegetables are readily
available and are given quite
frequently after cereals was
introduced,
Cereals gradually replaced by fish or
meat congee (after 7 months).
Congee should be replaced by soft
rice to meet the need of energy.
Iron-fortified cereals and meats can
provide adequate iron,
Avoid giving too much juice
Calcium can obtained from cheese,
yogurt,and other dairy products.
Breast milk is not a rich source of
iron,but healthy infants have
adequate iron stores to last until 8
months of age,Iron-rich foods can
be started at this age (see diet for
age).
Milk 750ml AbsorbedIron(mg)
4th-5th months
0.1-0.4
± 0.5
0.015
+ Iron
Stores
For daily iron
absorption
requirement
(0.55mg/d)
Adequate
Adequate
Inadequate
+ Iron
Stores
+ Iron
Stores
Milk 750ml AbsorbedIron(mg)
5th-6th months
0.1-0.3?
± 0.5
0.012
Fortified
cereal
For daily iron
absorption
requirement
(1mg/d)
Adequate
Adequate
Inadequate
There is no evidence that the choice
of initial feeding regimen among
breast,bottle or mixed feeding
influences the timing of the
subsequent introduction of a feeding
pattern more varied in texture,flavor
and /or feeding method,
Formula
Formula gradually replace B.M.
The pattern of breast-feeding
| | | | | | | | | | | | |
0 1 2 3 4 5 6 7 8 9 10 11 12(m)
B.M
The first introduced food is iron fortified cereals.
The pattern of partial breast-feeding
Formula
Formula completely replace B.M.
| | | | | | | | | | | | |
0 1 2 3 4 5 6 7 8 9 10 11 12(m)
B.M
The first introduced food is iron fortified cereals.
Formula
The first introduced food is iron fortified cereals.
| | | | | | | | | | | | |
0 1 2 3 4 5 6 7 8 9 10 11 12(m)
The pattern of bottle-feeding
Formula
HOW
The introduction of
solids has also got an
educational value,
— period of adaptation
Little by little -- adaptation
To sample under favorable condition
,neophobia,,smelling
Semisolid to solid – swallowing,chewing
Feeding skills training
Introduce single-ingredient foods,one at
a time,so that the offending food can be
identified if an adverse reaction occurs.
After 3-4 months,six smaller
meals would be more beneficial
for digestive systems,growth and
development,
Schedules
6AM 9AM 12AM 3PM 6PM 9PM
Once babies can chew( at 6 months),
more lumpy foods and a variety of
tastes and textures should be
introduced,
Added sugar and salt are best
avoided in weaning foods because
early exposure may produce
unhealthy dietary preferences in
later childhood and adult life,
The critical period of learning to
chew is between 6-8 months,
Delaying introduction of solids may
predispose baby to refusal of solids
and thus suffer from malnutrition.
Some nutritionists have
suggested that dietary fat
intake should be reduced to
supply less than 35% of energy
requirements and fiber intake
increased,
Breast or formula-fed infants
obtain about half their energy
from fat,
After 1 year of age,whole cow’s
milk still provides a major
contribution to the diet of most
children.
6-8m 9-11m 12-23m
RNI of Energy 682 830 1092
(kcal/d)
E.from Milk 486 375 313
(kcal/d)
E.from O.F 196 455 779
(kcal/d)
E%from O.F 29 55 71
ENERGY PROVIDED BY MILK AND O.F
NUTRITIONAL ASSESSMENT
Anthropometry
Laboratory
Food intake
Clinical manifestations
Malnutrition
Anthropometric evaluation
of malnutrition in children
purposes,determine ―yes or no‖
& the degree of the severity
Reference NCHS by WHO
Indicators W/age,L/age,W/L
Normal Wasted Stunted
Weight/age% 100 70 70
Height/age% 100 100 84
Weight/height% 100 70 100
Statistics middle value,SD
Cut -off-point middle value
-2SD
Underweight
W/age<middle- 2SD
moderate,W/age< middle-
(2SD～ 3 SD)
severe:W/age<middle - 3 SD
L/age<middle- 2SD
moderate:L/age<middle –
(2SD～ 3 SD)
severe,L/age <middle - 3 SD
Stunted
W/L <middle -2SD
moderate,W/L <middle –
(2SD～ 3 SD)
severe,W/L <middle - 3 SD
Wasting
Anthropometry
Weight
Height
Mid-arm-circumference
Skinfold thickness
Food intake
Dietary recall
Dietary diary
Laboratory
Low plasma albumin
Low concentration of specific
mineral and vitamins
Immunodeficiency
Clinical manifestations
Marasmus,kuashiorkor
c
Haiqi Li
NUTRITION DURING
INFANCY
Children need food of appropriate
quantity and quality for optimal
growth and development
The nutritional vulnerability
Infants and children are more vulnerable
to poor nutrition than are adults
Low nutritional stores
High nutritional demands for growth
Rapid neuronal development
Illness
4 months
energy intake
30%
1 year 5%
3 years 2%
Age
Energy demands for growth
INTRODUCTION
OF NUTRITION
FEEDING OF INFANTS
Breast-feeding
Comparisons of milks
Partial breast-feeding
Weaning period
NUTRITIONAL ASSESSMENT
Nutrients requirements,
Pro,Energy,Vits
The benefits of human milk
Food change
Key points
Threpsology
INTRODUCTION
OF NUTRITION
Category of nutrients
（ 2000 Chinese Dietary Reference Intakes）
Energy：
Macronutrients:PRO,FAT,CHO
Micronutrients:minerals
vitamins
(Fat-soluble-vitamins,
water-soluble-vitamins)
Other diet elements,cellulose,water
RNIs(Recommended Nutrient Intake ),
are defined as the levels of intake of
essential nutrients,
RNIs =*EAR+ 2SD
* Estimated Average Requirement
CHO FAT PROTEIN
Macronutrients
Energy produced
Gross Energy Intake
Activity
**TEF
*BMR
Energy
Stored
“growth”
Excreta
Tissue
Synthesis
Growth
**Thermic effect of food*Basal metabolism rate
0 ?12m 95 kcal/kg.d
1y 1100 kcal/d
2y 1200 kcal/d
3y 1350 kcal/d
5y 1600 kcal/d
7y 1800 kcal/d
10y 2100 kcal/d
REQUIREMENTS OF TOTAL ENERGY
(EAR)
≈100 kcal/kg.d
(2000 Chinese Dietary Reference Intakes )
Protein in diet described as
essential(8+1) and
nonessential (13)
amino acids
EAAs
leucine isolucine lysine
methionine Phenplalane threonine
trytophan valine + histidine
Good quality of PRO
Complete protein, the protein
in a food supplies enough of
the essential amino acids
The sources of complete proteins
The amount of recommended
daily protein depends upon age,
medical conditions and the type
of diet one is following,
Reference values for protein requirements
Age Protein(g/kg/d)
0-6m 2.2
6-12m 2.0
1-3ys 1.8
4-6ys 1.5
7-10ys 1.2
11-14ys 1.0
15/18ys 0.8
A high-protein diet may put
a strain on the kidneys
Side Effects
8-15% of total energy intake
comes from protein.
The major resources
of
the energy (45-55%)
CARBOHYDRATE(CHO)
Excessive carbohydrates can cause
an increase in the total caloric
intake,causing obesity.
Side Effects
Deficient carbohydrates can cause
a lack of calories (malnutrition),or
excessive intake of fats to make up
the calories.
FAT
One of the three nutrient
supplied the calories to the
body.
The calories provided by fat
Saturated fats,animal
vegetable
Unsaturated fats,
monounsaturated from plants
polyunsaturated(fish oil,plants )
Linoleic acids is the most
important ―essential‖ fatty
acids,especially for growth
and development of infants.
Eating too much saturated fat
is one of the major risk factors
for heart disease.
Side Effects
Fat serves as the storage substance
for the body’s extra calories,
which will be the risk of obesity.
Distribution of Energy produced
P R O
8- 15%
F A T
25- 30%
C HO
45- 55%
infant(40-45%)
Micronutrients:
minerals
vitamins
Macro elements Ca,P,Mg, Na
CL,K,S
Trace elements Fe,I,Cu,Zn、
F,Cr,Se
Minerals
<6 Months infant recommended
daily intake for minerals
Calcium 360 mg
Copper 0.5-0.7 mg
Phosphorus 240 mg
Sodium 115-350 mg
Zinc 3 mg
Iron 10 mg
Iodine 40 ug
Vitamins Definition
Vitamins work together with
enzymes,co-factors (substances
that assist enzymes),and other
substances.
A group of substances essential for
normal metabolism; growth and
development; and regulation of cell
function,
FAT-SOLUBLE VITAMINS(4),
Vitamin A,D,E,K
WATER-SOLUBLE VITAMINS(9):
VitaminB1,2,3,6,12
C,H,Folate
Pantothenic acid,
There are 13 vitamins needed by
the body:Vitamins A,C,D,E,K,
and the B vitamins.
Vitamin A is found in milk,cheese,cream,
liver,kidney,and cod and halibut fish oil,
Beta carotene is a precursor to vitamin A,
The body can synthesize vitamin D
when the skin is exposed to sunshine.
Vitamin B1 is found in
fortified breads,cereals,pasta,
whole grains (especially wheat
germ),lean meats (especially
pork),fish,dried beans,peas,
and soybeans,
Most other fruits and
vegetables contain some
vitamin C.
Infant recommended daily intake for vitamins
Vitamin A 0.4 mg (400 ug,1500-2000 IU)
Vitamin D 0.01 mg (10 ug,400 IU)
Vitamin C 35 mg (35000 ug)
Vitamin E 4 mg (4000 ug)
Vitamin B1 (thiamin) 0.3 mg (300 ug)
Vitamin B2 (riboflavin) 0.5 mg (500 ug)
Folic Acid 0.04 mg (40 ug)
Vitamin B12 0.0006 mg (0.6 ug)
Vitamin K 12 ug
Vitamin A 0.4 mg (400 ug,1500-2000 IU)
Vitamin D 0.01 mg (10 ug,400 IU)
Vitamin C 35 mg (35000 ug)
Vitamin B1 (thiamin) 0.3 mg (300 ug)
Calcium 360 mg
Zinc 3 mg
Iron 10 mg
Iodine 40 ug
Protein 2.2-2.0g/kg/d
Energy intake(EAR) 100 kcal/kg.d
RNI
Other diet elements:
cellulose
water
Cellulose ( Diet - fiber )
Soluble fiber slows digestion and the
rate of nutrient absorption from
the stomach and intestine,
Insoluble fiber speeds the passage of
foods through the stomach and
intestines and adds bulk to the stool,
2 forms of fiber,soluble and insoluble
To provide a feeling of fullness
and adds bulk in the diet.
To prevent or treat diverticulosis,
diabetes,and heart disease
To prevent constipation
Functions
The recommendation for older
children,adolescents and adults is
20 to 35 grams per day.
Younger children will not be able
to eat enough calories to achieve
this,but introducing whole grains,
fresh fruits and other high fiber
foods is suggested,
Too much fiber may interfere with
the absorption of minerals including
iron,zinc,magnesium,and calcium.
Side Effects
FEEDING OF INFANTS
BREAST-FEEDING
Exclusive breastfeeding is fed
no foods or fluids,even water.
WHO definition
Partial breast-feeding is
defined as breast milk plus
either solid foods or other
milks,
To supply with formular
within 4~6 months For deficient
B.M intake
To replace B.M with formular
after 4~6 months preparation for
weaning
Two patterns for partial
breast-feeding
Components of human milk
"first milk"; immature milk
produced in 4-5 days post-partum
Colostrum,
Transitional Milk,2weeks
The composition is midway between
colostrum and mature milk,
Mature Milk:
colostrum middle maturity
PRO 22.5 15.6 11.5
FAT 28.5 43.7 32.6
CHO 75.9 77.4 75.0
Mineral 3.08 2.41 2.06
Ca 0.33 0.29 0.35
P 0.18 0.18 0.15
The changes of the components
during nursing (g/L)
The changes of the compositions
during the sucking period（ g/L）
I II III
Pro 11.8 9.4 7.1
Fat 17.1 27.7 55.1
The compositions of mammary secretions
changes continuously throughout the
sucking period.
foremilk hindmilk
Growth factors
Nutritional properties
Immunology
The advantages of breast-feeding
Others
IMMUNOLOGY
Breast milk contains valuable
antibodies from the mother
that can help the baby resist
infections.
Breast-feeding
reduces the incidence and lessens the
severity of bacterial infections.
are half as likely as artificially fed
infants to have ear infections in the
first year of life.
reduce the risk for subsequent
inflammatory bowel disease and
childhood lymphoma,
less likely to have diarrhea,
Nutrients Amount Function
Protein
SIgA 50-100/mg/dl Immune protection
IgM 2mg/dl Immune protection
IgG 1mg/dl Immune protection
Lactoferrin 100-150mg/dl Anti-infective
Lysozyme 5-25mg/dl Anti-infective
casein 200-300mg/d Inhibits microbial adhesion
to mucosal membranes
Carbohydrate
Oligosaccharides 1.0-1.5g/L Microbial ligands
Glycoconjugates - Microbial and viral ligands
Fat
FFA - Anti-infective
Immunology functions on the major nutrients
of human milk for the infant
SIg A comprises 90% of immunoglobulin.
The IgA secreted into milk
provides protection to infants
against pathogens in the immediate
environment of the mother-infant
dyad.
Lactoferrin
The anti-infective function of lactoferrin
was ascribed to its high affinity for iron
that may deprive microorganism of needed
iron.
Studied show that lactoferrin is bactericidal,
antiviral,and anti-inflammatory and
modulates cytokine function.
Lactoferrin Iron binding protein
inhibits growth of E.coli
0
20
40
60
80
Days Postpartum
0 2 4 6 8 d
SIgA
Lactoferrin
LYSOZYME
Lysozyme is present in the lyses mostly
gram-positive and few gram-negative
bacteria,
Contrary to the other protective proteins
in human milk(I.e.,IgA and lactoferrin),
the concentration of lysozyme decreases
during lactation,those of lysozyme
increase with prolonged lactation.
Lasozyme Bacteriolytic enzyme
Bifidus factor Growth of lactobacillus
bifidus
Low pH
Interferon Antiviral agent
Hypoallergenic May reduce subsequent atopic disease
Macrophages Phagocytic,Synthesise
lysozyme,lactoferrin,C3,C4
Cellular
Lymphocytes T-cells may trasfer delayed
hypersensitivity responses
to infant.
B-cells synthesis Ig A
Nutritional properties
The saying "breast is the best"
has its origin in biologic merit,
Breast milk contains appropriate
amounts of CHO,PRO,and FAT,
Comparison of CHO,PRO,FAT (100ml)
Human milk Cow’ s milk
CHO(g) 6.9 5.0
FAT(g) 3.7 4.0
PRO(g) 1.5 3.3
Comparison of the energy content(100ml)
Human milk Cow’ s milk Standard
E(kcal) 67 69
CHO(g) 6.9 41% 5.0 29% 40-50%
FAT(g) 3.7 50% 4.0 52% 50%
PRO(g) 1.5 9% 3.3 19% 11%
The ratio of energy from macronutrients
in breast milk is adequate
Protein quality More easily digested curd
(80:20 whey:casein ratio)
whey
casein
human milk cow’s milk
Carbohydrate and soluble
minerals are the major
contributors to osmolarity of
milk feeding,
Protein and minerals are the
major contributors to renal
solute load.
MINERAL HUMAN COW GOAT FORMULA *
Calcium 35 120 130 49 mg/100g
Chloride 43 95 130 43 mg/100g
Copper 39 20 50 61 ug/100g
Magnesium 3 13 14 41 mg/100g
Phosphorus 15 95 110 38 mg/100g
Potassium 51 152 204 71 mg/100g
Sodium 17 49 50 18 mg/100g
Comparing Milks
*ug/100g = microgram/100g milk
Human milk
Potential renal solute load (mOsm/L)
Low renal solute load
221
96
79
C o w ' s m i l k
F o r m u l a
H u m a n m i l k
Lipid quality Rich in oleic acid
Improved digestibility
and fat absorption
human milk
cow’s milk
saturated
unsaturated
oleic acid
Iron content Bioavaliable
(40- 50% absorption)
Ca,P= 2:1
Prevents hypocalcaemic tetacy
and improves calcium absorption
MINERAL HUMAN COW GOAT FORMULA
Calcium 35 120 130 49 mg/100g
Chloride 43 95 130 43 mg/100g
Copper 39 20 50 61 ug/100g *
Magnesium 3 13 14 41 mg/100g
Phosphorus 15 95 110 38 mg/100g
Potassium 51 152 204 71 mg/100g
Sodium 17 49 50 18 mg/100g
Comparing Milk
*ug/100g = microgram/100g milk
Growth
factors
Breast milk contains factors
that help infants grow and
mature,
Growth concentration Effects in
factors /milliliter the newborn
EGF 3-107ng GI growth &gut closure
NGF
Insulin 3-20μg Glycemia
IGF-I 1.3-11.0ng Stimulate systemic growth
IGF-II
TGF-α 0-8.4ng GI growth
Relaxin 0.3-0.5μg?
TGF-β? Inhibits GI growth
Growth factors in human milk
Other advantages
Convenient Proper temperature,fresh,sterile,
adapted volume,economic,
no time is required in preparation
Emotional close attachment between
mother and baby
Contraceptive effect increases the
time interval between children
Reduction in disease occurrence in later life
Insulin-dependent diabetes mellitus
inflammatory bowel disease
sudden infant death syndrome
Maternal health Possible reduction in
premenopausal breast cancer
The exclusively breast-
feeding is the best natural
food for infant,for
physiological,
immunological and possible
psychological reasons,
Breast milk is the perfect source
of nutrition for infants.
It is adequate for the initial
4-6 months,
Unknown intake Volume of milk intake not known
The disadvantages of breast-feeding
Nutrient inadequacies Prolonged breast-feeding
Transmission of infection HIV
Breast milk jaundice self-limiting,unconjugated
hyperbilirubinaemia
Transmission of drugs Antithyroid drugs
cathartics,
antimetabolites
Vitamin K deficiency insufficient vitamin K
in breast milk to prevent
haemorrhagic disease of the newborn
Emotional upset if unsuccessful Breast-feeding
can be problematic to establish.
Potential transmission environmental
contaminants nicotine,alcohol,caffeine,etc.
Less flexible Other family members cannot
help or take part,
More difficult in public places
Supplement of Vit D, Vit K
Comparison of Vit D, Vit K
——————————————
Human Cow’s DRIs
milk milk
——————————————
Vit D （ IU/100 ml） 10 40 400 IU//d
Vit K( ng/100ml) 15 60 0.1-0.5ug/kg
——————————————
—
The volume and nutrient content
of human milk change as
lactation progresses,
The volume
The volumes of colostrums are low
but water or formula supplements
are not required whilst the supply of
breast milk is becoming established.
Breast-feeding women produce an
average of 700 ml of milk daily.
0
300
600
900
1200
Months Postpartum
0 2 4 6 8 m
Milk volume secretion in lactating
women is regulated by infant
demand,
Thus,when milk has a low caloric
density,increased sucking by an
infant is thought to result in increased
emptying of the breast,causing
increased milk secretion.
The fat concentrations of
breast milk taken at feeds
would appear to be maximized
both increasing feed frequency
and milk volume removal.
In contrast,breast milk in
caloric density during the
feed as the volume available
diminishes,so that caloric
intake shows a curvilinear
relationship to volume intake.
Breastfeeding is,after all,a dynamic
process between every unique
mother-baby dyad,for which man
cannot possible do a better job than
God in designing how infant feeding
should work.
SUCCESS OF BREAST-FEEING
PRL (prolactin) secretion stimulated
① Suck as early as possible
② No bottle-feeding
③ Demand feeding,
Baby Controlled Breasteeding
Care of nipples
Nutrition During pregnancy weight gain
Milk is
synthesized into
the alveolar
lumen,where it
is stored until
milk removal
from breast is
initiated,
Tow levels of regulation must exist
regulation of milk ejection
- oxytocin
regulation of the rate of synthesis
and secretion- prolactin
Although both processes
ultimately depend on
sucking by an infant or other
stimulation of the nipple,the
mechanisms involved central
and local,are different.
Suckling stimulates the release
of prolactin which stimulates
milk production and the
release of oxytocin,
Oxytocin,in turn,stimulates
contraction (or the "let-down
reflex") of the milk glands,The
milk is squeezed out of the milk
gland,into the milk ducts,and
into the nipple.
Anterior lobe of
Pituitary gland
STEP 4:
Prolactin released
STEP5:
Milk synthesis
Milk ejected
Breastfeeding can safely
continue
Maternal HBV infection
TB infection but no disease in
the mother
CMV-positive mothers
Maternal infectious disease
Maternal HAV infection
Contraindications
Mother with severe infections
Maternal HIV infection
Comparisons of milks
No,cow’s milk is not
adequate to me!
Do you want
to drink milk?
Although cow's milk contains
most of the same components as
breast milk,these components
are not in the same amounts,
Why？？?
milk by itself is
inappropriate for
Contains too much protein and
salt.It would create too high a
solute to their immature kidneys,
especially in babies below 6months.
And infants are not generally
able to concentrate urine well.
Cow’s Milk
The infant can develop an allergy to
dairy products if given cow's milk
too early in life.
Cow’s milk can irritate the baby’s
intestine,causing the baby to lose
small amounts of blood,
Regular cow’s milk is not good
for babies,It is not similar
enough to breast milk,
It doesn’t contain the right kind
of fat or enough iron,which
baby needs for proper growth
and development.
Modified cow’s milk to
mimic the desirable
qualities of breast milk
such as a lower protein
and sodium content,a
higher lactalbumin to
casein ratio and emulsified
fat are well tolerated by
most infants.
Formula
Infant formula contains a balance
of protein,fat,and carbohydrate
that is similar to breast milk,It
has been enriched with vitamins
and minerals,like breast milk,
Modification of cow’s milk
Formula Human millk
52
40.6
7.4
46
45
9
??·???·? ?? ?é
?°°×??
??????????
??·?
Contributions of energy (%)
The presence of enzymes and other
bioactive components in breast
milk that have beneficial effects in
digestion and metabolism have not,
as yet,been replicated in formula.
In addition,breast milk contains
enzymes that facilitate digestion.
In another words,formula
cannot copy breast milk
exactly,
For example,the
antibodies found in
breastmilk,however,can
never be added to
formulas.
Breast or formula feeding is
recommended until the age of
12 months,and there are
advantages in continuing to
18 months of age.
Calories 75 69 67
Protein (gm) 1.1 3.5 1.5
Lactalbumin (%) 80 18 60
Casein (%) 20 82 40
Water (mL) 87.1 87.3 90
Fat (gm) 4.5 3.5 3.8
Carbohydrate (g) 7.1 4.9 6.9
Ash (gm) 0.21 0.72 0.34
pH Alkaline Acid Acid
Bacterial Content Sterile Nonsterile Sterile
Composition /100 mL B.M C.M Formula
WEANING PERIOD
Introduction to solid foods
Weaning is the period of adaptation
to solid or the period of changing
from a predominant milk feeding to
predominant adult diet.
It can be defined as the period
which commences when solid are
introduced and continues until
after sucking has been discontinued
Except human milk or
formula (cow’s milk),the rich
semisolid and solid foods are
introduced to infants.
Introduction of other foods
( supplement foods)
Definition
Principles of initial feeding
The age at which it begins
also varies in different
societies and very much
depends on their culture and
tradition.
WHEN
After 6 months of age,breast
milk becomes increasingly
nutritionally inadequate as a
sole feed,leading to deficiencies
in energy,vitamins and iron.
Physiologic Rationale for the
introduction of solid foods at 4-
6months
The digestive system has developed
sufficiently to permit good
absorption of a variety of foods.
The secretion of saliva has increased
and facilitates the swallowing of solid
foods.
The ―extrusion reflex‖ useful for
sucking and fixing the nipple in the
month has gradually disappeared.
The mucosal barrier has matured
and the risks of food allergies have
diminished.
The head control has improved; the
baby sit up; lean forward,turn away
and send cues of satiety to the
caregiver.
The neuromuscular coordination has
improved; the tongue is now able to
pass solids from the front to the back
of the month.
Many babies will exhibit
behavioural changes from 3-4
months of age,such as
increased crying and poor
sleeping,which may
represent hunger and a need
for solid food,
At a scientific level,the most
universal recommendation that
the diet of breast milk or
formula be supplemented no
sooner than four months nor
delayed beyond six months is
based on physiological maturity.
Breast-feeding
Solid food 100
100
Age of infant(m)
1 2 3 4 5 6 7 8 9
80
60
40
20
0 0
20
40
60
80
Early weaning foods such as
pureed non-wheat cereals,
fruit and vegetables tend to be
high in energy,vitamins and
minerals.
WHAT
Fruits and vegetables are readily
available and are given quite
frequently after cereals was
introduced,
Cereals gradually replaced by fish or
meat congee (after 7 months).
Congee should be replaced by soft
rice to meet the need of energy.
Iron-fortified cereals and meats can
provide adequate iron,
Avoid giving too much juice
Calcium can obtained from cheese,
yogurt,and other dairy products.
Breast milk is not a rich source of
iron,but healthy infants have
adequate iron stores to last until 8
months of age,Iron-rich foods can
be started at this age (see diet for
age).
Milk 750ml AbsorbedIron(mg)
4th-5th months
0.1-0.4
± 0.5
0.015
+ Iron
Stores
For daily iron
absorption
requirement
(0.55mg/d)
Adequate
Adequate
Inadequate
+ Iron
Stores
+ Iron
Stores
Milk 750ml AbsorbedIron(mg)
5th-6th months
0.1-0.3?
± 0.5
0.012
Fortified
cereal
For daily iron
absorption
requirement
(1mg/d)
Adequate
Adequate
Inadequate
There is no evidence that the choice
of initial feeding regimen among
breast,bottle or mixed feeding
influences the timing of the
subsequent introduction of a feeding
pattern more varied in texture,flavor
and /or feeding method,
Formula
Formula gradually replace B.M.
The pattern of breast-feeding
| | | | | | | | | | | | |
0 1 2 3 4 5 6 7 8 9 10 11 12(m)
B.M
The first introduced food is iron fortified cereals.
The pattern of partial breast-feeding
Formula
Formula completely replace B.M.
| | | | | | | | | | | | |
0 1 2 3 4 5 6 7 8 9 10 11 12(m)
B.M
The first introduced food is iron fortified cereals.
Formula
The first introduced food is iron fortified cereals.
| | | | | | | | | | | | |
0 1 2 3 4 5 6 7 8 9 10 11 12(m)
The pattern of bottle-feeding
Formula
HOW
The introduction of
solids has also got an
educational value,
— period of adaptation
Little by little -- adaptation
To sample under favorable condition
,neophobia,,smelling
Semisolid to solid – swallowing,chewing
Feeding skills training
Introduce single-ingredient foods,one at
a time,so that the offending food can be
identified if an adverse reaction occurs.
After 3-4 months,six smaller
meals would be more beneficial
for digestive systems,growth and
development,
Schedules
6AM 9AM 12AM 3PM 6PM 9PM
Once babies can chew( at 6 months),
more lumpy foods and a variety of
tastes and textures should be
introduced,
Added sugar and salt are best
avoided in weaning foods because
early exposure may produce
unhealthy dietary preferences in
later childhood and adult life,
The critical period of learning to
chew is between 6-8 months,
Delaying introduction of solids may
predispose baby to refusal of solids
and thus suffer from malnutrition.
Some nutritionists have
suggested that dietary fat
intake should be reduced to
supply less than 35% of energy
requirements and fiber intake
increased,
Breast or formula-fed infants
obtain about half their energy
from fat,
After 1 year of age,whole cow’s
milk still provides a major
contribution to the diet of most
children.
6-8m 9-11m 12-23m
RNI of Energy 682 830 1092
(kcal/d)
E.from Milk 486 375 313
(kcal/d)
E.from O.F 196 455 779
(kcal/d)
E%from O.F 29 55 71
ENERGY PROVIDED BY MILK AND O.F
NUTRITIONAL ASSESSMENT
Anthropometry
Laboratory
Food intake
Clinical manifestations
Malnutrition
Anthropometric evaluation
of malnutrition in children
purposes,determine ―yes or no‖
& the degree of the severity
Reference NCHS by WHO
Indicators W/age,L/age,W/L
Normal Wasted Stunted
Weight/age% 100 70 70
Height/age% 100 100 84
Weight/height% 100 70 100
Statistics middle value,SD
Cut -off-point middle value
-2SD
Underweight
W/age<middle- 2SD
moderate,W/age< middle-
(2SD～ 3 SD)
severe:W/age<middle - 3 SD
L/age<middle- 2SD
moderate:L/age<middle –
(2SD～ 3 SD)
severe,L/age <middle - 3 SD
Stunted
W/L <middle -2SD
moderate,W/L <middle –
(2SD～ 3 SD)
severe,W/L <middle - 3 SD
Wasting
Anthropometry
Weight
Height
Mid-arm-circumference
Skinfold thickness
Food intake
Dietary recall
Dietary diary
Laboratory
Low plasma albumin
Low concentration of specific
mineral and vitamins
Immunodeficiency
Clinical manifestations
Marasmus,kuashiorkor
