Infancy: Birth to 12 Months

Childhood Obesity: Contributing Factors

- Genetic and Other Biological Factors -Impact of the Child's Environment

The following signs indicate that an infant is ready for complementary foods.

-Can sit with some back support -Has lost the extrusion reflex; -Can hold his or her head up steady and straight -Shows interest in consuming foods that adult caregivers and older children eat -Opens his or her mouth when he or she sees food.

Chronic Health Problems Associated with Childhood Obesity

-Impaired glucose tolerance, insulin resistance, and type 2 diabetes -Breathing problems, including sleep apnea and asthma -Musculoskeletal problems, including joint discomfort -Fatty liver disease, gallstones, and gastroesophageal reflux (heartburn) -Social and psychological problems, such as discrimination and poor self-esteem

Adults can use the following tips to reduce children's intake of sweet treats:

-Serve small portions of sweets and do not serve them regularly. -Avoid buying or serving sugary soft drinks. -At restaurants, order water, juice, or low-fat or fat-free milk, if appropriate. -Do not offer sweets as rewards. Serve fruit, especially fresh fruit, for dessert.

Micronutrients

A baby who consumes a commercially prepared, iron-fortified infant formula obtains adequate amounts of most vitamins and minerals. Healthy full-term infants are born with a supply of iron (as ferritin) that lasts until they double their birth weight, which is normally around 4 to 6 months of age. At this age, the addition of iron-containing foods is recommended. Formula-fed infants usually receive much more than the AI for iron (0.27 mg iron/day) because most infants are given iron-fortified infant formula that provides 12 mg/L of iron. Because cow's milk is a poor source of iron, infants who drink cow's milk have a high risk of iron deficiency anemia. To reduce the risk of iron deficiency, most infants who are not consuming an iron-fortified infant formula should receive a supplemental dose of 8 to 10 mg of iron per day. Breastfed babies do not need to be given as much iron because the iron in breast milk is well absorbed. Preterm or low-birth-weight infants as well as babies born to mothers who were iron deficient during pregnancy have lower iron stores at birth than infants born to women with adequate iron status during pregnancy. Thus, preterm and low-birth-weight infants deplete their iron stores earlier than other infants. Experts with the AAP recommend that such infants be given an iron supplement daily, regardless of whether they are breastfed or formula-fed. Iron needs increase dramatically to 11 mg/day for infants who are 6 to 12 months of age. Bottle-fed infants receive the recommended amount of the mineral from their daily consumption of iron-fortified formula. Breastfed infants, however, should be given iron-containing foods such as meats and iron-fortified cereals.

Nutrient Needs for Toddlers: Macronutrients

A toddler's RDA for protein is 13 g/day, and a preschool-age child's RDA for protein is 19 g/day. Most healthy children can easily meet their RDA for protein by consuming a varied, nutrient-dense diet. For example, a toddler who drinks 2 cups of milk (16 g protein) and eats 2 ounces of chicken (14 g protein), 2 slices of whole-wheat bread (14 g protein), and 1 tablespoon of peanut butter (7 g protein) during a day obtains 51 g of protein just from those foods. According to results of the National Health and Nutrition Examination Survey, 2005-2008, preschool children ate a considerable amount of their total carbohydrate in the form of added sugars. Preschool-age girls and boys consumed 13.1 and 13.5%, respectively, of their total calories from added sugars. Caregivers can help children obtain adequate amounts of fiber by serving unprocessed vegetables, whole fruits, and whole grains. Preschool-age children typically do not eat recommended amounts of fruits and vegetables. According to one report, American children between 2 and 5 years of age consume only about 11 to 12 g of fiber daily. For children who are 1 to 3 years of age, the AI for fiber is 19 g/day. For children who are 4 to 8 years of age, the AI for fiber is 25 g/day. Some fat, especially sources of essential fatty acids, is needed for normal growth and brain development. Toddlers should consume between 30 to 40% of total kcal from fat, whereas older children should limit their fat intake to 25 to 35% of total kcal. Many toddlers and preschoolers eat more than the recommended amount of unhealthy saturated fats. Because arterial plaque formation (precursor of atherosclerosis) begins early in life, it is advisable for caregivers to encourage young children to eat foods that supply "healthy fats," such as seeds, nuts, and avocadoes. Milk and some other dairy products are rich sources of protein, calcium, magnesium, and vitamin D (if fortified). Whole milk, however, is major source of saturated fat in young children's diets. According to the American Academy of Pediatrics, reduced-fat forms of milk can be given to children who are between 1 and 2 years of age, but only as part of a diet that supplies 30% of total calories from fat. To reduce the risk of developing cardiovascular disease later in life, children over age 2 years should consume low-fat or fat-free dairy products.

Nutrition-Related Concerns of Adolescents

According to the results of the survey, most high school students did not eat enough fruits and vegetables; they drank too many sugar-sweetened soft drinks; and they did not obtain enough physical activity. Adolescent girls who have poor eating habits and nutritionally inadequate diets are a concern of public health experts. Teenage girls may become pregnant, and their bodies' lack of adequate nutrient stores could lead to serious complications during pregnancy and poor pregnancy outcomes. Furthermore, girls who have poor eating habits as adolescents may continue to make unhealthy food choices after they reach adulthood.

Adolescence

Adolescence is the life stage that begins at puberty, the period in which a child undergoes numerous physiological changes that eventually enable the young person to be capable of reproduction. The timing of puberty varies but usually occurs between ages 9 and 15 years. By the end of adolescence, the individual has reached adulthood—physical and reproductive maturity, which generally occurs around 18 to 21 years of age. In this chapter, we refer to children who are 12 to 19 years of age as adolescents.

Growth and Development for Adolescence

Adolescence is the second most rapid period of physiological growth that occurs after birth. (An infant grows at a faster rate than an adolescent.) During adolescence, nearly every organ in the body increases in size as healthy children gain weight and become taller. The final period of rapid growth, which may be referred to as "the adolescent growth spurt," is associated with puberty. During the adolescent growth spurt, a female's ovaries secrete high levels of estrogen, and a male's testes secrete high levels of testosterone. Estrogen and testosterone (the "sex hormones") have many effects on the maturing person's body, including increasing the rate of bone growth. The long bones in the arms and legs increase in length by cellular activity that occurs in the "growth plates" (epiphyseal plates) near the ends of the bones. A person reaches his or her adult height when the epiphyseal plates close. In girls, the adolescent growth spurt typically begins around the ages of 10 to 13 years. Girls usually experience an increase in weight about 6 months before their stature growth spurt occurs. Skeletal growth is almost complete about 2 years after a girl's first menstrual period. Thus healthy girls generally reach their adult height during the middle of adolescence. Boys enter the growth spurt a year or two later than girls. For most boys, the growth spurt begins between 12 and 15 years of age, but adolescent males usually attain their adult height later than girls. The timing of puberty and growth spurts can vary widely among adolescents, primarily as a result of interactions among genetic, environmental, and nutritional factors. Obese girls, for example, typically enter puberty earlier than their nonobese peers. If a girl experiences puberty earlier than the norm, she is likely to be shorter as an adult than a girl who enters puberty later. The shorter stature results from the earlier-than-normal closure of her epiphyseal plates.

Physiological Readiness for Weaning

After a healthy infant is 6 months of age, he or she is physiologically ready for weaning, the gradual process of shifting from breastfeeding or bottle feeding to eating solid foods and drinking from a cup. Infants must reach certain physiological milestones before weaning. A significant and noticeable nutrition-related milestone is the emergence of the first primary tooth, which generally occurs at about 6 to 8 months of age. Usually, the first teeth to erupt are the two bottom front teeth. Most children have all 20 primary teeth by age 2½ to 3 years. Gross motors skills are abilities to control large muscles of the arms, legs, and back. A healthy 6-month-old baby has acquired enough control over his or her gross muscles to sit up alone without assistance, such as sitting in a high chair. Fine motor skills involve abilities to control the movement of smaller muscles, such as those found in the fingers. Mastery of fine motor skills enables babies to move their fingers in a coordinated, purposeful manner. By the eighth or ninth month of life, the infant has developed the pincer grasp, which enables the baby to pick up objects with its thumbs and forefingers. The baby uses its pincer grasp to feed itself finger foods, small pieces of food such as ripe bananas, cooked string beans, or cooked chicken. Finger feeding is usually a messy process, and the baby can appear to be "playing with food" to some adults. Babies, however, need to practice the skills needed to feed themselves. As the infant's fine motor skills mature, he or she is able to use a spoon and hold a cup. As infants' muscular coordination improves, beverages such as water or infant formula can be offered from a cup at meal times. Sugar-sweetened, caffeinated, carbonated, or artificially sweetened beverages are not appropriate for babies. Added sugars promote dental caries; caffeine interferes with sleep; and long-term consequences for infants who consume carbonated beverages and artificial sweeteners are unknown. According to recommendations of the American Academy of Pediatrics, babies should not be given fruit juice before they are 12 months of age. Fruit juice lacks the fiber content of whole, mashed, or pureed fruit, and children may consume the beverages in place of more nutritious foods. Pear, apple, or prune juices contain high amounts of the sugars sorbitol and fructose that may cause infants to experience diarrhea, gas, or abdominal pain. Nursing bottle caries is a form of dental decay that occurs in young children who suck on a bottle that contains any sugar-containing substance (including formula or juice) for several hours at a time. As a result of this practice, the child's teeth are bathed in a sugary solution that oral bacteria can metabolize for energy. The bacteria produce lactic acid, which damages tooth enamel. To prevent caries, nighttime bottles should contain only water, and bottles of formula should be offered only during regular feedings.

School Lunches

After the end of World War II, the U.S. Congress passed the National School Lunch Act of 1946 to help improve the nutritional status of American school-age children. The National School Lunch Act established the National School Lunch Program, a federally assisted school meal program. School breakfasts were added to the program in 1966. Today, many American children eat lunch as well as breakfast and a snack at school. In the United States, public and nonprofit private schools and residential child care institutions can participate in the National School Lunch Program. The program provides nutritionally balanced, low-cost or free lunches to children each school day. As of May 2017, the meal pattern had more fruit, vegetables, and whole grains in the participating school menu than previous menus. Additionally, schools with a high percentage of low-income children are required to serve breakfast.

Specialized Infant Formulas.

An estimated 2 to 3% of children who are less than 3 years of age are allergic to proteins in cow's milk. Eczema (a type of skin rash) is the major sign of cow's milk allergy. Other signs of cow's milk allergy may include diarrhea, refusal to eat, frequent respiratory infections, and colic (excessive crying infant syndrome), a condition in which a young infant cries excessively for no apparent reason. Most children can be expected to outgrow milk allergy by the time they are 16 years of age. Infants who cannot tolerate cow's milk-based formulas are given a specialized formula. Formulas that are based on soy protein can be used by families who are strict vegans. Babies who are allergic to the proteins in cow's milk or soy-protein formulas are often given protein hydrolysate formulas (Nutramigen® or Pregestimil). Hydrolysate formulas contain proteins that have been hydrolyzed (broken down) into polypeptides or free amino acids. Switching to a hydrolysate formula may reduce the symptoms of colic.

Major Nutrition-Related Developmental Milestones from Birth to 12 Months

Approximate Age in Months When Skills Are Often Acquired Milestones 1-2 Briefly follows objects with eyes Holds head up without support 3-4 Grasps a toy or bottle with palms of hands Begins to lose extrusion and rooting reflexes 5-6 Sits with back support 7-8 Has the strength and coordination to self-feed with a bottle Sits without support Has first teeth emerge Moves tongue from side to side and closes lips over spoon 8-10 Self-feeds finger foods Begins to drink from cup 11-12 Uses spoon to feed him- or herself; drinks liquids from a cup Has several teeth and good control over chewing ability

Toddlers and Preschool-Age Children

At 12 months of age, an infant matures into a toddler. The term toddler refers to the stiff, unsteady walking gait (toddle) that is characteristic of children who are between 1 and 3 years of age and have recently learned to walk. A preschool-age child is between 3 and 5 years of age.

Why does newborn lose weight?

At birth, a newborn's weight, length, and head circumference are measured and recorded. During the first few days after birth, the newborn typically loses about 5% of his or her birth weight; breastfed infants tend to lose more of their weight than bottle-fed ones. The early weight loss is normal and attributed to some fluid loss and to the passage of meconium. Meconium is the first feces eliminated by a newborn shortly after birth; it is black and composed mainly of intestinal epithelial cells, mucus, and bile. The weight that a healthy newborn loses is usually regained within the first 7 to 10 days of life.

Bariatric Surgery for Youth

Bariatric (weight-loss) surgery can improve the health of adolescents with extreme obesity. Serious chronic conditions that often accompany obesity, such as type 2 diabetes, hypertension, and sleep apnea, may improve after the procedures. Bariatric surgery may be an option for adolescents who have: -A BMI of 35 or more who are experiencing serious health problems that are associated with obesity (e.g., type 2 diabetes) -A BMI of 40 or more with less severe health problems (e.g., elevated blood cholesterol level) -Experienced puberty and attained his or her adult height (skeletal maturity), which is generally at 13 years of age for girls and 15 years of age for boys. Regardless of one's age, bariatric surgery is a drastic measure to lose excess body weight and involves some risks. Thus, caregivers and health care providers should carefully assess adolescents who are potential candidates for bariatric surgery to determine whether they are emotionally ready to handle the surgery and make the necessary lifestyle changes to achieve good health and well-being after the procedure.

Energy Needs for toddlers

Between the ages of 2 and 10 years, a healthy child grows at a steady pace. As the child's bones, muscles, and blood volume enlarge, his or her energy and nutrient intakes must be adequate enough to support this growth. Energy: The number of calories a child needs varies by body size, gender, and physical activity level. The Institute of Medicine created the following formula to calculate the Estimated Energy Requirement (EER) for toddlers: EER=([89 kcal/kg/day]×[weight in kg])−80EER=([89 kcal/kg/day]×[weight in kg])−80 Therefore, a child who weighs 28 pounds (12.7 kg) needs about 1050 kcal/day based on the calculations below: (89 kcal/kg/day×12.7 kg=approximately 1130)−80=1050 kcal/day

Genetic and Other Biological Factors

Biological factors that contribute to obesity include: -Having overfat parents. If both parents are obese, the child has 10 times the risk of obesity as a child who has only one obese parent. -Having a mother who was overfat during pregnancy. When compared to children whose mothers have healthy body weight during pregnancy, babies born to overweight mothers are nearly three times as likely to be overweight. Furthermore, obese women are more likely than healthy women to have large babies, and such infants have a high risk of childhood obesity. Gaining too much weight and/or having diabetes during pregnancy. Women who gain too much weight during pregnancy or have diabetes are more likely to give birth to high-birth-weight babies. Such children are at risk of developing excess body fat in childhood. -Smoking during pregnancy. Although the reasons are unclear, women who smoke during pregnancy set the stage for the future development of overweight and obesity in their babies. -Being undernourished during prenatal development. Undernutrition during pregnancy contributes to delivery of a low-birth-weight (LBW) infant. LBW infants are more likely to develop hypertension, CVD, and type 2 diabetes later in life, which are chronic diseases associated with obesity. At this point, scientists have been unable to explain why prenatal undernutrition contributes to hypertension, CVD, and type 2 diabetes in adulthood. Biological factors, however, are not entirely responsible for the current obesity epidemic. In many cases, it is difficult to determine whether genes play a more important role than environmental factors in the development of childhood obesity. Is a child obese because the youngster inherited genes from his or her parents that "program" for obesity? Or is a child obese because his or her caregivers provide the child with an excess of foods that are high in empty calories and do not encourage the child to be physically active?

What Not to Feed Infants

By the end of the first year, babies should be eating a variety of foods. However, the following foods and beverages are not recommended for infants: -Honey may contain spores of Clostridium botulinum that can produce a potentially fatal toxin in children under 1 year old. -Regular, low-fat, or skim cow's or goat's milks contain more protein and minerals than the infant's immature kidneys can excrete and are low in iron, folate, and vitamin C. -Unpasteurized (raw) milk may be contaminated with bacteria or viruses. -Cookies, candy, chips, pastries, or anything with added sugar, solid fat, or salt provide too many calories and sodium in relation to an infant's energy and sodium needs. Furthermore, such foods are likely to displace more nutrient-dense items from the child's diet. -Small pieces of hard or coarse foods, such as whole nuts, grapes, chunks of cooked meat, raw carrots, popcorn, and hot dogs, can cause choking. Caregivers should supervise meals to keep infants or young children from stuffing too much food into their mouths at one time. -Rare poultry, beef, or pork might be contaminated with bacteria that are common causes of food-borne illness.

Weight Status Classifications: Children and Adolescents (Ages 2 to 19)

Classification BMI-for-Age Percentile Desirable weight > 5th to < 85th Overweight ≥ 85th to < 95th Obese ≥ 95th Extreme obesity ≥120% of the 95th

Health Problems Associated with Childhood Obesity

Compared to children who have healthy body weights, obese children and adolescents are more likely to have elevated blood pressure, cholesterol, and glucose levels. These chronic conditions are risk factors for cardiovascular disease (CVD). Obese children are more likely to experience weight-based bullying and teasing than children who are not obese. Many obese children and adolescents do not "grow out" of their excess body fat. Compared to children who have healthy body weights, obese children are more likely to be obese as adults. Furthermore, obese children are more likely to be extremely obese when they are adults.

Complementary Foods

Complementary baby foods are solid, pureed (ground up, moistened, and blended), or mashed foods as well as beverages other than breast milk or formula. Caregivers should introduce complementary foods when the infant is 4 to 6 months of age. Experts with the American Academy of Allergy, Asthma & Immunology recommend the gradual introduction of new foods to babies. Adding a new food to feedings for a period of time (3 to 5 days) can help caregivers determine if the baby has adverse responses that may indicate allergies, such as wheezing, vomiting, or itchy skin, to the particular food. Babies are usually given baby cereal mixed with formula or breast milk, single vegetables, or fruits before meats are introduced. Fruits and vegetables, however, are not sources of heme iron. Therefore, infants can benefit from consuming meat before being offered fruits and vegetables because meat contains heme, the easily absorbed form of iron.

Nutrient Needs for Toddlers: Vitamins and Minerals

Consuming adequate amounts of vitamin D, calcium, and iron may be a challenge for some toddlers and preschool-age children. Most ready-to-eat cereals are fortified with many vitamins and minerals. If a child drinks 2 cups of vitamin D-fortified milk or soy milk each day, his or her vitamin D and calcium intakes are likely to be adequate. As mentioned earlier, cow's milk is a poor source of iron. Young children who drink more than 2 cups of milk each day are at increased risk of iron deficiency. Iron deficiency can lead to decreased physical stamina, compromised learning ability, and lowered resistance to infection. To reduce the likelihood of iron deficiency, caregivers can limit milk consumption to 2 cups/day and include foods that are good sources of iron, such as lean meat and enriched breads and cereals, in meals and snacks.

Developmental Milestones

Developmental maturation is generally measured against milestones, skills or characteristics that a healthy infant is expected to acquire within a specific time frame. Milestones generally have age ranges that represent what is normal. Physical milestones occur in a sequential fashion, which means that a child will need to develop a particular ability involving skeletal muscles (motor skills) before he or she can progress to more advanced ones

Diet-Related Concerns

Diets of toddlers and preschoolers typically provide too much sodium and less than recommended amounts of potassium. odium and potassium are involved in fluid balance. Excessive intakes of sodium and inadequate intakes of potassium are associated with increased risk of hypertension. The incidence of caries is increasing among toddlers and preschoolers. About 28% of children 2 to 5 years of age have dental caries affecting their primary teeth. Added sugar consumption contributes to tooth decay. To reduce the risk of dental caries, caregivers can limit children's intake of added sugars and provide routine dental care for the youngsters.

Micronutrients for Adolescents

During adolescence, DRIs for all vitamins increase, especially for the vitamins that are involved in new cell synthesis (folate and vitamin B-12), collagen formation (vitamin C), protein metabolism (vitamin B-6), and bone development (vitamins A, D, and K). Adolescents' average intakes of vitamins A, D, and E are lower than the DRIs for these micronutrients. For adolescents, RDAs for most minerals, including calcium, are higher than for school-age children. On average, males between 12 and 19 years of age consume more calcium than girls, but both groups of adolescents do not meet the RDA for the mineral (1300 mg/day). Both men and women generally achieve their peak bone mass before they are 25 years of age. Low calcium intakes during adolescence places teenagers, especially girls, at increased risk of developing osteoporosis later in life

Energy and Macronutrients

Energy needs for adolescents range from fewer than 1600 kcal/day for an inactive girl who has not entered the growth spurt to more than 3200 kcal/day for an active boy who is still in his growth spurt. Many teens consume more calories than needed for their physical activity level, which results in a high prevalence of obesity in teenagers. In 2013-2014, 20.6% of American children who were 12 to 19 years of age were obese. Inadequate energy intake results in underweight, which is defined as having a body mass index (BMI) that is less than 18.5. Underweight in adolescence may be a sign of disordered eating or anorexia nervosa. As mentioned, disordered eating practices may become eating disorders, and adolescence is the life stage when eating disorders are most likely to develop. Thus, caregivers need to be concerned about the health and well-being of underweight adolescents.

Factors that influence Children's Food Choice

Factors that affect a school-age child's diet can be positive, such as having health-conscious parents who serve whole-grain products and fresh fruit with meals and snacks. Other factors, however, are negative influences, such as viewing television advertisements for sugary fruit drinks and carbonated beverages.

School-Age Children

Food-related behaviors continue to develop during the school-age years (middle childhood), which are defined as ages 6 to 11 years. During this stage, a healthy child has a steady but slow growth rate. On average, healthy children gain about 5 pounds and grow 2 to 3 inches in length annually between 6 and 11 years of age.

Benefits of Breastfeeding vs Formula

Formula: -Vitamins -Iron and Calcium -Fat and Cholesterol -Carbohydrate -Protein -Water Breastfeeding: -Water -Iron and calcium -Fat and cholesterol -Carbohydrates -Protein -Vitamins -Enzymes -Growth Factor -Immune Factors -Hormones -Antibodies

Defining Obesity in Children

Health care professionals use BMI-for-age charts that are available from the Centers of Disease Control and Prevention (CDC) to determine children's and adolescents' weight status. The BMI for children is calculated in the same way as for adults, but BMIs for children are plotted on sex-specific growth charts that define BMI-for-age percentiles for each weight classification.

Water

Human milk and infant formula provide all the water infants need, unless an infant sweats excessively during hot weather or loses fluid by vomiting or having diarrhea. In these cases, a supplemental bottle of 2 to 4 ounces of water may be necessary, but the volume of water depends on the volume of fluids that was lost. Dehydration can occur rapidly in infants, especially in extreme heat or severe illnesses. To treat dehydration, the infant's physician may recommend oral rehydration therapy (ORT), the administration of products that contain electrolytes (primarily sodium and chloride), water, and glucose.

Infant Formula

In 2013, however, about 19% of U.S. parents chose to feed infant formula to their newborns. Of the new mothers who initiate breastfeeding while in the hospital, the majority do not exclusively breastfeed their infants by the time the babies are 3 months old. The mothers either supplement breastfeedings with infant formula or discontinue breastfeeding entirely. Feeding fresh fluid cow's milk to infants is not recommended during the first year of life. Cow's milk does not supply enough iron, vitamins E and C, and essential fatty acids for babies, and the beverage contains more protein, sodium, potassium, and chloride than an infant's immature kidneys can process. Additionally, an infant's digestive system does not break down the protein and fat in cow's milk as easily as the protein and fat in breast milk. Popular infant formulas are based on cow's milk. Formula manufacturers modify the milk so infant formulas have a nutrient composition similar to that of human milk.

Impact of the Child's Environment

In the United States, many children are exposed to an environment that encourages overeating and consumption of foods that contain too many empty calories. Additionally, the environment often does not provide children with opportunities to participate in enough physical activity. -Easy access to foods and drinks that are high in empty calories at or near schools -Limited access to healthy and affordable foods, particularly in areas with many convenience stores and fast-food restaurants *Advertising of foods that are sources of empty calories that targets youth -Lack of established periods for daily physical activity in schools and safe places to be active in many communities -Large portion sizes of foods sold from vending machines and in restaurants and grocery stores -Excess exposure to digital media because such sedentary activities can reduce the time children spend being physically active.

Introduction of highly allergenic foods after 4 months of age

In the past, highly allergenic foods (for example, peanut butter, fish, and eggs) were not introduced into a baby's diet until the child was at least 1 year of age. However, results of current studies indicate that delaying such foods may increase the child's risk of food allergies. According to experts with the National Institute of Allergies and Infectious Diseases, infants who have a high risk of developing peanut allergy and have begun to eat solid foods should be fed a small amount of a soft, peanut-containing item (such as a mixture of peanut butter and water) when they are 4 to 6 months of age.19 Feeding a peanut-containing food to babies has been shown to reduce the infants' risk of developing peanut allergy later in childhood. Caregivers should always check with the infant's physician for advice on when to start feeding a new food to the child. Commercially prepared baby foods are available in different stages, based on an infant's age and chewing ability. However, caregivers can make their own baby foods from items that they eat. Many babies can be fed soft, finely cut up, or mashed versions of foods that are served to older family members.

Newborn

Infant during its first 4 weeks of life.

Nutritional Concerns

Many school-age children follow unhealthy dietary practices and have diets that are nutritionally inadequate. Compared to preschoolers, older children often skip breakfast. Furthermore, school-age children tend to consume more foods away from home and more fried items and sugar-sweetened beverages than younger children. Diets of school-age children tend to provide excessive amounts of saturated fat, total sugars, and sodium. Excessive intakes of saturated fat and sugar may contribute to the development of atherosclerosis and obesity, and high intake of sodium may contribute to hypertension among children. School-age children often do not eat recommended amounts of fruits and vegetables, and the youngsters typically consume less-than-recommended amounts of dietary fiber. Low fiber intake contributes to constipation; as many as 10% of American children suffer from chronic constipation.

Snacks for active toddlers

Many young children, especially physically active ones, can benefit from eating between-meal snacks. An appropriate snack for children should be nutrient dense and provide about 50 to 75 kcal. Caregivers can consider offering a snack that includes a fruit, vegetable, or whole grain, such as a short stick of celery stuffed with a teaspoon of peanut butter or ⅓ cup plain, fat-free yogurt mixed with pieces of fresh fruit and topped with some granola.

Energy and Nutrient Needs

Most of an infant's energy intake is used for growth. During its first 3 months, a healthy infant generally needs about 49 kcal/lb/day (108 kcal/kg), which is higher than the number of calories required during any other time in life. If a 150-pound adult consumed 49 kcal/lb/day, he or she would be obtaining 7350 kcal/day! Protein is a critical nutrient for the infant's growth and development. During the first 6 months, an infant's Adequate Intake (AI) for protein is 1.52 g/kg body weight. Breast milk and infant formula provide enough high-quality protein to meet the young infant's needs. After 6 months of age, an infant's growth rate slows, and the baby's Recommended Dietary Allowance (RDA) for protein decreases to 1.2 g/kg body weight. Even though there are no recommendations for total lipid intake for infants, both breast milk and infant formula provide about 55% of calories from fat. The high amount of fat ensures a concentrated source of energy for the infant and provides the essential fatty acids, linoleic acid and alpha-linolenic acid. Breast milk naturally provides arachidonic acid and docosahexaenoic acid, whereas these two fatty acids are added to most commercially prepared infant formulas. The main carbohydrate in a young infant's diet is lactose, either from breast milk or from cow's milk-based infant formulas. Cereals or other starchy foods are not appropriate for infants who are under 4 months of age because the babies do not have adequate amounts of the enzyme amylase that is required for efficient starch digestion

Does adding complementary food before infants are 4 months of age helps them sleep through the night?

No. Many caregivers think adding complementary foods to infants' diets before they are 4 months of age helps babies sleep through the night, but there is no scientific evidence to support the practice. As an infant's nervous system matures, the baby stays awake more often during the day and sleeps for longer periods at night. Thus, staying asleep between midnight and 5 A.M. is a developmental milestone that the majority of healthy babies reach when they are 3 months of age, regardless of what they are eating.

Infantile gastroesophageal reflux (GER)

Occurs when stomach contents flow back into the esophagus after a feeding, and the baby often vomits a small amount of food ("spits up") as a result. About 50% of babies experience GER several times a day during their first 3 months of life. To reduce the likelihood of "spitting up," both bottle-fed and breastfed infants should be kept upright for 30 minutes after eating. It is also helpful to interrupt each feeding session a few times to "burp" the baby by sitting the child upright and gently rubbing or patting its back. Most babies do not require treatment for GER, because the condition often resolves by itself. If a baby forcibly vomits ("projectile vomiting") or fails to gain weight, caregivers should contact the child's physician. Treatment depends on the cause of the vomiting, but in severe cases, medication or surgery may be necessary.

What is a healthy weight for an infant?

On average, a healthy infant doubles his or her birth weight by about 4 to 6 months of age and triples his or her birth weight by his or her first birthday. Additionally, an infant's length increases by 50% during the first year of life. In general, exclusively breastfed infants gain weight more rapidly during the first 2 to 3 months of life than formula-fed infants. From 6 to 12 months of age, weight gain is slower for breastfed infants than for formula-fed babies.

Overweight and Obesity in Children

Over the past few decades, U.S. public health officials became concerned about the increasing prevalence of obesity among children and adolescents ("childhood obesity"). Approximately 17% of American children who are between the ages of 2 and 19 years are obese.

Preventing Childhood Obesity

The Institute of Medicine and the American Academy of Pediatrics developed a set of policy recommendations that may reduce the likelihood of obesity among preschool-age children. Some of the major recommendations focused on specific physical activity and dietary behaviors: -New mothers should breastfeed their babies exclusively for the first 6 months of life and continue breastfeeding along with introducing appropriate foods after 6 months. -Communities and child care providers should provide opportunities for children to be physically active throughout the day. -Caregivers should limit children's exposure to computers, smartphones, video games, tablets, and TV ("screen time") to less than 2 hours per day.

Nutrient Recommendations and Status

The amount of energy and nutrients required during adolescence reflects the individual's stage of growth and level of physical activity. Early in adolescence, when a girl is at the peak of her growth spurt, she consumes more calories than a boy of the same age, especially if she is involved in sports. By age 13 or 14 years, girls' growth rate slows and boys' growth spurts begin. As a result, adolescent boys' food intake typically surpasses that of adolescent girls.

Reflexes of newborns

The muscular movements of a newborn occur primarily as uncoordinated reflexes. A reflex is an involuntary muscular reaction that occurs in response to a stimulus, such as a loud sound or caregiver's touch. Healthy newborns typically exhibit three nutrition-related reflexes: -The suck reflex enables an infant to draw milk and swallow when a nipple is put into its mouth. -The rooting reflex causes an infant to turn its head and open its mouth as the baby's cheek is stroked. Rooting is a survival mechanism that helps a newborn find the nipple of a breast or bottle to begin sucking. -The extrusion reflex causes a baby's tongue to thrust forward when a solid or semisolid object is placed in his or her mouth. This reflex helps prevent young infants from eating foods before they are able to digest them. The extrusion reflex also enables young infants to reject solid foods that may cause choking. The suck, rooting, and extrusion reflexes help infants obtain and consume liquid food (breast milk). These reflexes disappear by the age of 4 to 6 months, which is around the age when an infant is physiologically ready to consume solid foods.

Vitamin D

The placenta does not efficiently transfer vitamin D to the fetus, so newborns may have inadequate amounts of vitamin D stored in their bodies. Furthermore, vitamin D deficiency is common in women during pregnancy and lactation. To reduce the likelihood of vitamin D deficiency occurring in infants, exclusively breastfed infants should receive 10 μg (400 IU) of vitamin D each day within the first few days after birth and throughout their first year of life.15 Commercial infant formulas contain vitamin D.

Growth and Development

The rapid growth rate that characterizes the first 12 months tapers off quickly during the toddler and preschool years. From ages 1 to 2 years, a healthy child gains about 6 pounds. During the preschool years, the child gains 4 to 5 pounds/year. Increases in body length average about 2½ to 3 inches/year. A child's weight and height continue to be monitored during routine medical checkups as important indicators of the youngster's health status. The toddler period is a time of transition—physically, emotionally, cognitively, and nutritionally. Most 2-year-old children have a full set of teeth, which makes chewing easier. By the age of 3 years, most healthy children can eat with a fork or spoon, but they need assistance cutting up food. Toddlers are beginning to develop autonomy, which refers to independence from caregivers and the ability to make decisions. Adult caregivers have a major influence on young children's food choices. If toddlers observe their caregivers enjoying broccoli and carrots, the children may be willing to sample these foods. If caregivers regularly indulge in chips, candy, cookies, and soft drinks, children are likely to prefer these foods over more nutritious items.

Fluoride for infants

The recommended intake of fluoride for infants who are 6 to 12 months of age is 0.5 mg/day. fluoride reduces the risk of decayed teeth (dental caries); however, ingesting too much fluoride may result in dental fluorosis, a condition that causes discoloration of the teeth before they erupt through the gums. The level of fluoride added to municipal water supplies is twice the level of the mineral that infants need. Therefore, adding fluoridated water to powdered or concentrated infant formula may cause bottle-fed babies to have excessive intake of fluoride. To reduce the risk of dental fluorosis, caregivers can use purified, distilled, or fluoride-free bottled water to reconstitute the formula.

Treating Childhood Obesity

The treatment goal for managing overweight and obese young children and adolescents is to slow the rate of weight gain without interfering with normal growth and physical development. This goal can be accomplished by balancing the calories children consume with the calories they use for physical activity and need for normal growth. Caregivers should not place a child or youth on a weight reduction diet without consulting the child's physician. For severely obese adolescents, treatment approaches that go beyond dietary changes and increased physical activity are often necessary. Such interventions may include prescription medication and weight-loss surgery

Forms of Infant Formula

Three basic forms of commercial infant formulas are available: -Ready-to-feed formulas are poured directly from the container into a baby bottle. Such formulas are more expensive than the other types of formula, but they are convenient to use. The container must be refrigerated after opening to avoid spoiling. -Concentrated formulas are packaged in 13-ounce cans and require the addition of an equal amount of water. Although concentrated formulas are less expensive than ready-to-feed infant formulas, the concentrate requires a sterile source of water, and the product must be refrigerated after opening. Thirteen ounces of bottled water may be used to reconstitute a can of concentrated formula. If tap water is used instead of bottled water, the water should be boiled for 2 minutes, then cooled to room temperature to ensure the water is sterile. -Powdered formula is useful for breastfeeding mothers who occasionally supplement with formula. Powdered formula is less expensive than other forms of infant formulas, and the powder requires no refrigeration. Like concentrated formula, powdered formula requires a sterile source of water for reconstitution. Care must be taken to add the proper amount of water to the powder to ensure it has the necessary concentration of nutrients for infants. Some parents try to save money by adding extra water to infant formula. Adding too much water to formula results in an undernourished baby because the formula's energy and nutrient contents are inadequate to support growth. Overdilution can also result in water intoxication and hyponatremia, which can be life threatening for infants

To help children achieve and maintain a healthy weight, caregivers can:

To help children achieve and maintain a healthy weight, caregivers can: -Provide plenty of vegetables, fruits, and whole-grain products; Include low-fat or nonfat dairy products -Serve lean meats, poultry, fish, lentils, and dried beans for protein -Serve "child-size" portions -Encourage children to drink water -Limit sources of saturated fat and added sugar.

Food Jags

periods in which a young child refuses to eat a food that he or she liked in the past or wants to eat only a particular item, such as peanut butter and jelly sandwiches or cereal and milk. These behaviors usually begin in the toddler years and may continue throughout the preschool period. During a food jag, adults should continue to offer a variety of nutrient-dense foods to the child, such as whole fruits, whole-grain breads and cereals, and nut butters. After a while, the youngster is likely to become bored with eating the same food repeatedly and be more willing to add some variety to his or her diet.

Infancy

the period from birth to 12 months of age