12.4 – Infancy and Nutrition

Infancy (Birth to Age One)

^{Figure 12.4.1. Photo by Katie Smith on Unsplash}

The term infant is derived from the Latin word infans, which means “unable to speak.” Healthy infants grow steadily, but not always at an even pace. For example, during the first year of life, height increases by 50 percent, while weight triples. Physicians and other health professionals can use growth charts to track a baby’s development process. Because infants cannot stand, their length is used instead of height to determine the rate of a child’s growth. Other important developmental measurements include head circumference and weight. All of these must be tracked and compared against standard measurements for an infant’s age. Nationally-accepted growth charts are based on data collected by the National Center for Health Statistics. These charts allow for tracking trends over time and comparing with other infants among percentiles within the United States. Growth charts may provide warnings that a child has a medical problem or is malnourished. Insufficient weight or height gain during infancy may indicate a condition known as failure-to-thrive (FTT), which is characterized by poor growth. FTT can happen at any age, but in infancy, it typically occurs after six months. Some causes include poverty, lack of enough food, feeding inappropriate foods, and excessive intake of fruit juice.

Nutritional Requirements

Requirements for macronutrients and micronutrients on a per-kilogram basis are higher during infancy than at any other stage in the human life cycle. These needs are affected by the rapid cell division that occurs during growth, which requires energy and protein, along with the nutrients that are involved in DNA synthesis. During this period, children are entirely dependent on their parents or other caregivers to meet these needs. For almost all infants six months or younger, breast milk is the best source to fulfill nutritional requirements. An infant may require feedings eight to twelve times a day or more in the beginning. After six months, infants can gradually begin to consume solid foods to help meet nutrient needs.

Energy

Energy needs relative to size are much greater in an infant than an adult. A baby’s resting metabolic rate is two times that of an adult. The RDA to meet energy needs changes as an infant matures and puts on more weight. The IOM uses a set of equations to calculate the total energy expenditure and resulting energy needs. For example, the equation for the first three months of life is (89 x weight [kg] −100) + 175 kcal.

Based on these equations, the estimated energy requirement for infants:

• 0-6 months of age, 472 to 645 kilocalories per day for boys and 438 to 593 kilocalories per day for girls.
•  6-12 months,645 to 844 kilocalories per day for boys and 593 to 768 kilocalories per day for girls.
• 1-2 years, 844–1,050 kilocalories per day for boys and 768–997 kilocalories per day for girls.

Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Institute of Medicine of the National Academies (Washington, D.C.: The National Academies Press, 2005), 169–70.

How often an infant wants to eat will also change over time due to growth spurts, which typically occur at about two weeks and six weeks of age, and again at about three months and six months of age.

Macronutrients

The dietary recommendations for infants are based on the nutritional content of human breast milk. Carbohydrate makes up about 45 to 65 percent of the caloric content in breast milk, which amounts to an RDA of about 130 grams. Almost all of the carbohydrate in human milk is lactose, which infants digest and tolerate well. In fact, lactose intolerance is practically nonexistent in infants. Protein makes up about 5 to 20 percent of the caloric content of breast milk, which amounts to 13 grams per day. Infants have a high need for protein to support growth and development, though excess protein (which is only a concern with bottle-feeding) can cause dehydration, diarrhea, fever, and acidosis in premature infants. About 30 to 40 percent of the caloric content in breast milk is made up of fat. A high-fat diet is necessary to encourage the development of neural pathways in the brain and other parts of the body. However, saturated fats and trans fatty acids inhibit this growth. Infants who are over the age of six months, which means they are no longer exclusively breastfed, should not consume foods that are high in these types of fats.

Micronutrients

Almost all of the nutrients that infants require can be met if they consume an adequate amount of breast milk. There are a few exceptions, though. Human milk is low in vitamin D, which is needed for calcium absorption and building bone, among other things. Therefore, breastfed children often need to take a vitamin D supplement in the form of drops. Infants at the highest risk for vitamin D deficiency are those with darker skin and low exposure to sunlight. Breast milk is also low in vitamin K, which is required for blood clotting, and deficits could lead to bleeding or hemorrhagic disease. Babies are born with limited vitamin K, so supplementation may be needed initially and some states require a vitamin K injection after birth. Also, breast milk is not high in iron, but the iron in breast milk is well absorbed by infants. After four to six months, however, an infant needs an additional source of iron other than breast milk.

The Dietary Guidelines for Americans, 2020-2025 state two additional concerns. The first is for iodine intake, “Although women of reproductive age generally have adequate iodine intake, some women, particularly those who do not regularly consume dairy products, eggs, seafood, or use iodized table salt, may not consume enough iodine to meet increased needs during pregnancy and lactation”.

In addition, choline has been added as a nutrient of concern. The Dietary Guidelines state, “Adequate intake of choline during these life stages (pregnancy and lactation) helps to both replenish maternal stores and support the growth and development of the child’s brain and spinal cord. Most women do not meet recommended intakes of choline during pregnancy and lactation. Women are encouraged to consume a variety of choline-containing foods during these life stages. Choline can be found throughout many food groups and subgroups. Meeting recommended intakes for the dairy and protein food groups—with eggs, meats, and some seafood being notable sources—as well as the beans, peas, and lentils subgroup can help meet choline needs. Meeting nutrient needs through foods and beverages is preferred, but women who are concerned about meeting recommendations should speak with their healthcare provider to determine whether choline supplementation is appropriate. Many prenatal supplements do not contain choline or only contain small amounts inadequate to meet recommendations.”

Fluids

Infants have a high need for fluids, 1.5 milliliters per kilocalorie consumed compared to 1.0 milliliters per kilocalorie consumed for adults. This is because children have a larger body surface area per unit of body weight and a reduced capacity for perspiration. Therefore, they are at greater risk of dehydration. However, parents or other caregivers can meet an infant’s fluid needs with breast milk or formula. As solids are introduced, parents must make sure that young children continue to drink fluids throughout the day.

Breastfeeding

The alveoli cells produce milk. To secrete it, they contract and push milk into the ductules and the milk sinus, which collects the milk. When a nursing infant’s gums press on the areola and nipple, the sinuses squeeze the milk into the baby’s mouth. The nipple tissue becomes firmer with stimulation, which makes it more flexible and easier for the baby to grasp in the mouth.

Lactation

^{Figure 12.4.3. During breastfeeding, the relaxation hormone oxytocin is released.“IMG_1905” by Ania I Artur Nowaccy is licensed under CC BY-NC-SA 2.0} 

Lactation is the process that makes breastfeeding possible and is the synthesis and secretion of breast milk. Early in a woman’s pregnancy, her mammary glands begin to prepare for milk production. Hormones play a major role in this, particularly during the second and third trimesters. At that point, levels of the hormone prolactin increase to stimulate the growth of the milk duct system, which initiates and maintains milk production. Levels of the hormone oxytocin also rise to promote the release of breast milk when the infant suckles, which is known as the milk ejection reflex. However, levels of the hormone progesterone need to decrease for successful milk production, because progesterone inhibits milk secretion. Shortly after birth, the expulsion of the placenta triggers progesterone levels to fall, which activates lactation.¹

New mothers need to adjust their caloric and fluid intake to make breastfeeding possible.

The RDA is 330 additional calories during the first six months of lactation and 400 additional calories during the second six months of lactation.

The energy needed to support breastfeeding comes from both increased intake and from stored fat. For example, during the first six months after her baby is born, the daily caloric cost for a lactating mother is 500 calories, with 330 calories derived from increased intake and 170 calories derived from maternal fat stores. This helps explain why breastfeeding may promote weight loss in new mothers. Lactating women should also drink 3.1 liters of liquids per day (about 13 cups) to maintain milk production, according to the IOM. As is the case during pregnancy, the RDA of nearly all vitamins and minerals increases for women who are breastfeeding their babies. The following table compares the recommended vitamins and minerals for lactating women to the levels for nonpregnant and pregnant women from Table 13.4.1.

_{1King, J. “Contraception and Lactation: Physiology of Lactation.” Journal of Midwifery and Women’s Health 52, no. 6 (2007): 614–20.}

Components of Breast Milk

Human breast milk not only provides adequate nutrition for infants but also helps to protect newborns from disease. In addition, breast milk is rich in cholesterol, which is needed for brain development. It is helpful to know the different types and components of breast milk, along with the nutrients they provide to enable an infant to survive and thrive.

Colostrum

Colostrum is produced immediately after birth, prior to the start of milk production, and lasts for several days after the arrival of the baby. Colostrum is thicker than breast milk and is yellowish or creamy in color. This protein-rich liquid fulfills an infant’s nutrient needs during those early days. Although low in volume, colostrum is packed with concentrated nutrition for newborns. This special milk is high in fat-soluble vitamins, minerals, and immunoglobulins (antibodies) that pass from the mother to the baby. Immunoglobulins provide passive immunity for the newborn and protect the baby from bacterial and viral diseases.²

^{2 American Pregnancy Association. “Breastfeeding: Overview.” Accessed June 6, 2019.}

Transitional Milk

Two to four days after birth, colostrum is replaced by transitional milk. Transitional milk is a creamy liquid that lasts for approximately two weeks and includes high levels of fat, lactose, and water-soluble vitamins. It also contains more calories than colostrum. After a new mother begins to produce transitional milk, she typically notices a change in the volume and type of liquid secreted and an increase in the weight and size of her breasts.³

^{3 American Pregnancy Association. “Breastfeeding: Overview.” Accessed June 6, 2019.}

Mature Milk

Mature milk is the final fluid that a new mother produces. In most women, it begins to secrete at the end of the second-week post-childbirth. There are two types of mature milk that appear during feeding. Foremilk occurs at the beginning and includes water, vitamins, and protein. Hind-milk occurs after the initial release of milk and contains higher levels of fat, which is necessary for weight gain. Combined, these two types of milk ensure that a baby receives adequate nutrients to grow and develop properly.

About 90 percent of mature milk is water, which helps an infant remain hydrated. The other 10 percent contains carbohydrates, proteins, and fats, which support energy and growth. Similar to cow’s milk, the main carbohydrate of mature breast milk is lactose. Breast milk contains vital fatty acids, such as docosahexaenoic acid (DHA) and arachidonic acid (ARA). In terms of protein, breast milk contains more whey than casein (which is the reverse of cow’s milk). Whey is much easier for infants to digest than casein. A complete protein, which means all of the essential amino acids, is also present in breast milk. Complete protein includes lactoferrin, an iron-gathering compound that helps to absorb iron into an infant’s bloodstream.

In addition, breast milk provides adequate vitamins and minerals. Although absolute amounts of some micronutrients are low, they are more efficiently absorbed by infants. Other essential components include digestive enzymes that help a baby digest breast milk. Human milk also provides the hormones and growth factors that help a newborn to develop.⁴

^{4 American Pregnancy Association. “Breastfeeding: Overview.”Accessed June 6, 2019.}

Diet and Milk Quality

A mother’s diet can have a major impact on milk production and quality. As during pregnancy, lactating mothers should avoid illegal substances and cigarettes. Some legal drugs and herbal products can be harmful as well, so it is helpful to discuss them with a health-care provider. Some mothers may need to avoid certain things, such as spicy foods, that can produce gas in sensitive infants. Lactating women can drink alcohol in moderation ( 1 standard drink per day) according to the CDC, though they must avoid breastfeeding until the alcohol has completely cleared from their milk. Typically, this takes about two hours for 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor, depending on a woman’s body weight. Precautions are necessary because exposure to alcohol could be harmful to an infant’s development, growth, and sleep patterns.

Benefits of Breastfeeding

Breastfeeding has a number of benefits, both for the mother and for the child. Human milk contains immunoglobulins, enzymes, immune factors, and white blood cells. As a result, breastfeeding boosts the baby’s immune system and lowers the incidence of diarrhea, along with respiratory diseases, gastrointestinal problems, and ear infections. Breastfed babies also are less likely to develop asthma and allergies, and breastfeeding lowers the risk of sudden infant death syndrome. In addition, human milk encourages the growth of healthy bacteria in an infant’s intestinal tract. All of these benefits remain in place after an infant has been weaned from human milk. Some studies suggest other possible long-term effects. For example, human milk may improve an infant’s intelligence and protect against diabetes and obesity, although research is ongoing in these areas.

Breastfeeding has a number of other important benefits. It is easier for babies to digest human milk than bottle formula, which contains proteins made from cow’s milk that require an adjustment period for infant digestive systems. Breastfed infants are sick less often than bottle-fed infants. Breastfeeding is more sustainable and results in less plastic waste and other trash. Breastfeeding can also save families money because it does not incur the same cost as purchasing formula. Other benefits include that human milk is always ready. It does not have to be mixed, heated, or prepared. Also, human milk is sterile and is always at the right temperature.

In addition, the skin-to-skin contact of breastfeeding promotes a close bond between mother and baby, which is an important emotional and psychological benefit. The practice also provides health benefits for the mother. Breastfeeding helps a woman’s bones stay strong, which protects against fractures later in life. Studies have also shown that breastfeeding reduces the risk of breast and ovarian cancers, as well as reducing the risk of type 2 diabetes.^5,6

Breastfeeding has been associated with the following physiological and psychological benefits for the mother:

• Increased social interaction
• Decreased anxiety
• Decreased cortisol levels (decreased stress levels)
• Decreased blood pressure

These changes appear to be related to the increased circulating levels of the hormone oxytocin.⁶

^{5 National Cancer Institute. “Reproductive History and Cancer Risk.” Accessed June 6, 2019}

^{6 Moberg, KU and Prime, DK.Oxytocin effects in mothers and infants during breastfeeding. Infant. 2013; 9(6)201-206.}

The Baby-Friendly Hospital Initiative

In 1991, the WHO and UNICEF launched the Baby-Friendly Hospital Initiative (BFHI), which works to ensure that all maternities, including hospitals and free-standing facilities, become centers of breastfeeding support. A hospital can be denoted as “baby-friendly” when it does not accept substitutes to human breast milk and has implemented ten steps to support breastfeeding. These steps include having a written policy on breastfeeding communicated to health-care staff on a routine basis, informing all new mothers about the benefits and management of breastfeeding, showing new mothers how to breastfeed their infants, and how to maintain lactation, and giving newborns no food or drink other than breast milk, unless medically indicated. Since the BFHI began, more than fifteen thousand facilities in 134 countries, from Benin to Bangladesh, have been deemed “baby-friendly.” As a result, more mothers are breastfeeding their newborns and infant health has improved, in both the developed world and in developing nations.⁷

^{7 United Nations Children’s Fund. “The Baby-Friendly Hospital Initiative.” Accessed June 6, 2019.}

Barriers to Breastfeeding

Although human milk is ideal for almost all infants, there are some challenges that nursing mothers may face when starting and continuing to breastfeed their infants. These obstacles include painful engorgement or fullness in the breasts, sore and tender nipples, lack of comfort or confidence in public, and lack of accommodation to breastfeed or express milk in the workplace.

One of the first challenges nursing mothers face is learning the correct technique. It may take a little time for a new mother to help her baby properly latch on to her nipples. Improper latching can result in inadequate intake, which could slow growth and development. However, International Board Certified Lactation Consultants (IBCLCs), OB nurses, and registered dietitians are all trained to help new mothers learn the proper technique. Education, the length of maternity leave, and laws to protect public breastfeeding, among other measures, can all help to facilitate breastfeeding for many lactating women and their newborns.

Contraindications to Breastfeeding

Although there are numerous benefits to breastfeeding, in some cases there are also risks that must be considered. In the United States, the CDC and the American Academy of Pediatrics recommend that a new mother with HIV should not breastfeed, because the infection can be transmitted through human milk. These women typically have access to bottle formula that is safe and can be used as a replacement for breast milk. However, in developing nations where HIV infection rates are high and acceptable infant formula can be difficult to come by, many newborns would be deprived of the nutrients they need to develop and grow. Also, inappropriate or contaminated bottle formulas cause 1.5 million infant deaths each year. As a result, the WHO recommends that women infected with HIV in the developing world should nurse their infants while taking antiretroviral therapy (ART) to lower the risk of transmission.⁸

Breastfeeding also is not recommended for women undergoing radiation or chemotherapy treatment for cancer. Women who have had breast surgery also may not be able to breastfeed.  When breastfeeding is contraindicated for any reason, feeding a baby formula enables parents and caregivers to meet their newborn’s nutritional needs.

^{8 World Health Organization. “Questions and Answers on HIV and infant feeding.” Accessed June 6, 2019.}

Bottle-Feeding

^{Figure 12.4.4.“A Quiet Feeding” by evilpeacock is licensed under CC BY-NC-SA 2.0} 

Most women can and should breastfeed when given sufficient education and support. However, as discussed, a small percentage of women are unable to breastfeed their infants, while others choose not to. For parents who choose to bottle-feed, infant formula provides a balance of nutrients. However, not all formulas are the same and there are important considerations that parents and caregivers must weigh. Standard formulas use cow’s milk as a base. They have 20 calories per fluid ounce, similar to human milk, with vitamins and minerals added. Soy-based formulas are usually given to infants who develop diarrhea, constipation, vomiting, colic, or abdominal pain, or to infants with a cow’s milk protein allergy. Hypoallergenic protein hydrolysate formulas are usually given to infants who are allergic to cow’s milk and soy protein. This type of formula uses hydrolyzed protein, meaning that the protein is broken down into amino acids and small peptides, which makes it easier to digest. Preterm infant formulas are given to low birth weight infants if human milk is unavailable. Preterm infant formulas have 24 calories per fluid ounce and are given until the infant reaches the desired weight.

Infant formula comes in three basic types:

• Powder that requires mixing with water. This is the least expensive type of formula.
• Concentrates, which are liquids that must be diluted with water. This type is slightly more expensive.
• Ready-to-use liquids that can be poured directly into bottles. This is the most expensive type of formula. However, it requires the least amount of preparation. Ready-to-use formulas are also convenient for traveling.

The average infant should consume about 24 fluid ounces of human milk or formula per day. When preparing formula, parents and caregivers should carefully follow the safety guidelines, since an infant has an immature immune system. All equipment used in formula preparation should be sterilized. The prepared, unused formula should be refrigerated to prevent bacterial growth. Parents should make sure not to use contaminated water to mix formula in order to prevent foodborne illnesses. Follow the instructions for powdered and concentrated formula carefully—a formula that is overdiluted would not provide adequate calories and protein, while the over-concentrated formula provides too much protein and too little water which can impair kidney function.

It is important to note again that both the American Academy of Pediatrics and the WHO state that human milk is far superior to infant formula. This table compares the advantages of giving a child human milk to the disadvantages of using bottle formula.

Introducing Solid Foods

Infants should be breastfed or bottle-fed exclusively for the first six months of life according to the WHO. (The American Academy of Pediatrics recommends human milk or bottle formula exclusively for at least the first four months, but ideally for six months.) “All infants who are fed human milk exclusively or who receive both human milk and infant formula (mixed fed) will need a vitamin D supplement of 400 IU per day beginning soon after birth.”¹

Infants should not consume solid foods prior to four to six months because solids do not contain the right nutrient mix that infants need. Also, eating solids may mean drinking less human milk or bottle formula. If that occurs, an infant may not consume the right quantities of various nutrients. If parents try to feed an infant who is too young or is not ready, their tongue will push the food out, which is called an extrusion reflex. After approximately four to six months, the suck-swallow reflexes are not as strong, and infants can hold up their heads and move them around, both of which make eating solid foods more feasible.

In addition, at approximately four to six months, iron and zinc stores from birth have diminished in the infant. The introduction of solid foods allows for the addition of iron and zinc-rich foods for the infant. The first foods introduced should be rich in iron and zinc. Traditionally this was iron-fortified rice cereal, but pureed meats may also be introduced. If your baby has been primarily breastfed, puréed meat or poultry may be a good first food to introduce as they provide more easily absorbable iron and zinc than plant foods. Other foods high in zinc include beans and zinc-fortified cereals.

Solid baby foods can be bought commercially or prepared from regular food using a food processor, blender, food mill, or grinder at home. Usually, an infant cereal can be offered from a spoon between four to six months. By nine months to a year, infants are able to chew soft foods and can eat solids that are well chopped or mashed.

Infants who are fed solid foods too soon may be susceptible to developing food allergies. Therefore, as parents and caregivers introduce solids, they should feed their child only one new food at a time (starting with iron-fortified baby cereal or pureed meats, followed by fruits or vegetables), to help identify allergic responses or food intolerances.

^{1 Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 56} 

Learning to Self-Feed

With the introduction of solid foods, young children begin to learn how to handle food and how to feed themselves. At six to seven months, infants can use their whole hand to pick up items (this is known as the palmar grasp). They can lift larger items, but picking up smaller pieces of food is difficult. At eight months, a child might be able to use a pincer grasp, which uses fingers to pick up objects. After the age of one, children slowly begin to use utensils to handle their food. Unbreakable dishes and cups are essential, since very young children may play with them or throw them when they become bored with their food.

Feeding Problems during Infancy

Parents and caregivers should be mindful of certain diet-related problems that may arise during infancy. Certain foods are choking hazards, including foods with skins or foods that are very small, such as grapes. Other examples of potential choking hazards include raw carrots and apples, raisins, and hard candy. Parents should also avoid adding salt or seasonings to an infant’s food.

Heating an infant’s food presents a risk of accidental injury or burns, which may occur if the food is heated unevenly or excessively. Keep in mind that an infant cannot communicate that the food is too hot. Also, parents and caregivers should never leave a baby alone at mealtime, because an infant can accidentally choke on pieces of food that are too big or have not been adequately chewed. Raw honey and corn syrup both contain spores of Clostridium botulinum. They produce a poisonous toxin in a baby’s intestines, which can cause the foodborne illness botulism. After the age of one, it is safe to give infants honey or corn syrup. However, honey as an ingredient in the food, such as in cereal, is safe for all ages because it has been adequately heat-treated.

Overnutrition

Overnutrition during infancy is a growing problem. Overfed infants may develop dietary habits and metabolic characteristics that last a lifetime. According to Singhal, A,  the consequences of overnutrition and growth acceleration in infancy include long-term obesity, along with Type 2 diabetes and cardiovascular disease later in life. Therefore, parents and other caregivers should restrain from overfeeding, and ideally give their infants breast milk to promote health and well-being.⁹

^{9 Singhal, A. The Impact of Human Milk Feeding on Long-Term Risk of Obesity and Cardiovascular Disease. Breastfeed Med. 2019; 14(Suppl 1): S-9–S-10. Accessed June 6, 2019.}

Food Allergies

Food allergies impact eight percent of young children in America. Common food allergens that can appear just before or after the first year include peanut butter, egg whites, wheat, cow’s milk, and nuts. For infants, even a small amount of dangerous food can prove to be life-threatening. If there is a family history of food allergies, exposure to a variety of foods during early life might play a role in the development of food tolerance. Accordingly, preventive interventions should be planned on an individual basis.¹⁰  The 2020-2025 Dietary Guidelines for Americans states the following guidance, “If an infant has severe eczema, egg allergy, or both (conditions that increase the risk of peanut allergy), age-appropriate, peanut-containing foods should be introduced into the diet as early as age 4 to 6 months. This will reduce the risk of developing a peanut allergy. Caregivers should check with the infant’s healthcare provider before feeding the infant peanut-containing foods. A blood test or skin prick may be recommended to determine whether peanut should be introduced to the infant, and, if so, the safest way to introduce it. More information is available in the Addendum Guidelines for the Prevention of Peanut Allergy in the United States at https://www.niaid.nih.gov/diseases-conditions/guidelines-clinicians-and-patients-food-allergy/.

Lactating women should not make any changes to their diets. Research shows that nursing mothers who attempt to ward off allergies in their infants by eliminating certain foods may do more harm than good. According to the American Academy of Allergy, Asthma, and Immunology, mothers who avoided certain dairy products showed decreased levels in their breast milk of an immunoglobulin specific to cow’s milk. This antibody is thought to protect against the development of allergies in children. Even when an infant is at higher risk for food allergies, there is no evidence that alterations in a mother’s diet make a difference.¹¹

^{10 Mazzocchi A, Venter C, Maslin K, Agostoni C. The Role of Nutritional Aspects in Food Allergy: Prevention and Management. Nutrients. 2017;9(8):850. Published 2017 Aug 9. DOI:10.3390/nu9080850 Accessed June 30, 2019.}

^{11 Gever, J. “Nursing Mom’s Diet No Guard Against Baby Allergies.” MedPage Today. © 2012 Everyday Health, Inc. March 7, 2012. Accessed June 30, 2019.} 

Baby Bottle tooth decay and Early Childhood Caries

Primary teeth are at risk for a disorder known as early childhood caries. Early childhood caries has multiple risk factors. Bacteria that cause caries (cavities) are commonly present in the mouth once the primary teeth appear. If certain diet practices occur, the risk of this disease increases.  The bacteria present in the mouth thrive on simple sugars that are present in breast milk, formula, juice, or other drinks fed through a bottle. Liquids can build up in a baby’s mouth, and the natural or added sugars lead to decay.

^{Figure 12.4.6. “Preventing Tooth Decay in Kids –Things You Need To Know” by Garfield Gagnon is licensed under CC BY-NC-ND 4.0} 

Baby bottle tooth decay is caused not only by the kinds of liquids given to an infant but also by the frequency and length of time that fluids are given. Giving a child a bottle of juice or other sweet liquids several times each day, or letting a baby suck on a bottle longer than at mealtime, either when awake or asleep, can also cause early childhood caries. In addition, this practice affects the development and position of the teeth and the jaw. The risk of early childhood caries continues into the toddler years as children begin to consume more foods with high sugar content.

Video 12.4.2: Baby Bottle Tooth Decay
Author: American Dental Association (ADA)
Published on May 5, 2015

Prevention strategies include:

• Never give an infant or toddler a bottle or “sippy cup” of milk, formula, juice, or soda at nap or bedtime or for prolonged periods of time.
• Limit juice to 4 oz or less per day and do not give any juice prior to one year of age.
• Introduce cups to children around their first birthday.
• Avoid giving children sugary snacks and beverages.
• Practice good oral hygiene starting with the eruption of the primary teeth.

^{Figure 12.4.7. Avoid prolonged exposure to beverages other than water in a bottle.  “Luciana in the New Stroller” by SheepGuardingLlama is licensed under CC BY-NC-SA 2.0} 

Visit the American Dental Association’s website for more information on baby bottle tooth decay and caring for your teeth. For more information about nutrition for children, visit the Academy of Nutrition and Dietetics.

Gastroesophageal Reflux and spitting up

Small amounts of spitting up during feeding are considered normal. However, there is cause for concern if it is too difficult to feed an infant due to gastroesophageal reflux. This condition occurs when stomach muscles open at the wrong times and allow milk or food to back up into the esophagus. Symptoms of gastroesophageal reflux in infants include severe spitting up, projectile vomiting, arching of the back as though in pain, refusal to eat or pulling away from the breast during feedings, gagging or problems with swallowing, and slow weight gain. For most infants, making adjustments in feeding practices addresses the issue. For example, a parent can feed their baby in an upright position, wait at least an hour after eating for playtime, burp more often, or give a child smaller, more frequent feedings.

Diarrhea and Constipation

Diarrhea is often caused by a gastrointestinal infection and can dehydrate an infant. It is characterized by frequent stools and consistency that deviates substantially from the norm. If an infant has had several bouts of this condition, they will need to replace lost fluids and electrolytes. A common recommendation is to give a child an oral rehydration solution. Because of the immunoprotective factors in breast milk, breastfed infants are less likely to contract gastrointestinal viral illness and experience diarrhea.

Infant constipation—which is the passage of hard, dry bowel movements, but not necessarily the absence of daily bowel movements—is another common problem. This condition frequently begins when a baby transitions from breast milk to formula or begins eating solid foods. Pediatricians can provide the best guidance for handling the problem.

Colic

Colic is a common problem during infancy, characterized by crankiness and crying jags. It is defined as crying that lasts longer than three hours per day for at least three days per week and for at least three weeks (which is commonly known as the “rule of 3’s”) and is not caused by a medical problem. About one-fifth of all infants develop colic, usually between the second and third weeks. Crying spells can occur around the clock but often worsen in the early evening. Also, colicky babies may have stomachs that are enlarged or distended with gas.

There is no definitive explanation for colic. Often, colic occurs when a child is unusually sensitive to stimulation. Probiotics have been tried with mixed success.  In fact, a Cochrane Review in 2018 stated they are unable to recommend any treatment.¹²

^{12 Gordon, M et al. Dietary modifications for infantile colic. Cochrane Database Syst Rev. 2018 Oct 10;10: CD011029. DOI: 10.1002/14651858.CD011029.pub2. Accessed June 6, 2019}

Newborn Jaundice

Newborn jaundice is another potential problem during infancy. This condition can occur within a few days of birth and is characterized by yellowed skin or yellowing in the whites of the eyes, which can be harder to detect in dark-skinned babies. Jaundice typically appears on the face first, followed by the chest, abdomen, arms, and legs. This disorder is caused by elevated levels of bilirubin in a baby’s bloodstream. Bilirubin is a substance created by the breakdown of red blood cells and is removed by the liver. Jaundice develops when a newborn’s liver does not efficiently remove bilirubin from the blood. There are several types of jaundice associated with newborns:

• Physiologic jaundice. The most common type of newborn jaundice and can affect up to 60 percent of full-term babies in the first week of life.
• Breast-milk jaundice. The name for a condition that persists after physiologic jaundice subsides in otherwise healthy babies and can last for three to twelve weeks after birth. Breast-milk jaundice tends to be genetic and there is no known cause, although it may be linked to a substance in the breast milk that blocks the breakdown of bilirubin. However, that does not mean breastfeeding should be stopped. As long as bilirubin levels are monitored, the disorder rarely leads to serious complications.
• Breastfeeding jaundice. Occurs when an infant does not get enough milk. This may happen because a newborn does not get a good start breastfeeding, does not latch on to the mother’s breast properly, or is given other substances that interfere with breastfeeding (such as juice). Treatment includes increased feedings, with help from a lactation consultant to ensure that the baby takes in adequate amounts.

Newborn jaundice is more common in a breastfed baby and tends to last a bit longer. If jaundice is suspected, a pediatrician will run blood tests to measure the amount of bilirubin in an infant’s blood. Treatment often involves increasing the number of feedings to increase bowel movements, which helps to excrete bilirubin. Within a few weeks, as the baby begins to mature and red blood cell levels diminish, jaundice typically subsides with no lingering effects .¹³

^{13 https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/maternal-or-infant-illnesses/jaundice.html Accessed June 6, 2019.}