New parents are subjected to all kinds of contradictory advice about infant nutrition. But with a few simple guidelines – and some advice from Precision Nutrition parents – you can be sure that you are getting your infant off to the healthiest start.
In life, as in other things, where you start can determine where you finish.
Infancy — the first year of life — is a prime time for growth and changes throughout the body.
What we eat as infants strongly affects our long-term body weight, health, metabolic programming, immune system, and overall aging.
The first 6 months
Breast is best for both mom and baby.
Babies can be exclusively breast-fed for their first six months of life.
Breast milk is the optimal nutrient mix for infants. It’s full of good stuff like antibodies, antimicrobial factors, enzymes, and anti-inflammatory factors along with fatty acids (which promote optimal brain development).
Breastfeeding keeps the baby developing and growing properly, helps infants fight off disease (such as gastrointestinal and respiratory infections) both now and in the future, and may even ensure that the baby grows up to prefer healthy food.
Because breastfeeding stimulates the release of beneficial hormones such as oxytocin and prolactin, it can help the mother lose weight and bond with her baby.
Breast milk is delivered in a biodegradable “organic package”, so mom doesn’t need to use as much plastic packaging (since tiny humans easily absorb plastic-contained endocrine disruptors).
Do your best. And get help if you need it.
Not every mother takes to breastfeeding naturally or quickly. If breastfeeding is difficult, PN parents Erin Weiss-Trainor and Krista Schaus suggest you seek support from a doula or a midwife.
In addition, lactation consultants are very helpful. The techniques they teach have helped many women successfully breastfeed, even after a difficult start.
[Erin also recommends the work of Jack Newman and Dr. Sears (The Breastfeeding Book and The Baby Book About Everything).]
And while breastfeeding is best, don’t feel guilty if you can’t breastfeed exclusively. There are many circumstances that might make breastfeeding difficult.
For example, you might not be able to breastfeed if you have a health problem, or are taking particular medications. You are not to blame. Just do your best.
“Don’t feel you’ve failed if you have to resort to some formula, or exclusively use formula,” says PN parent Brian St. Pierre.
In fact, most formula-fed children do just fine. Just be sure to talk to your pediatrician about the best formula option. And avoid soy-based infant formulas.
What mom eats/drinks can pass into breast milk.
What you as a pregnant or nursing mother eat, your baby eats.
Of course, breast milk will be especially healthy if mom eats nutritiously while she’s pregnant and breastfeeding.
For example, PN parent Amanda Graydon had a daily shake with greens+, creatine, glutamine, beta-alanine, and BCAAs. She also supplemented with carnitine and a few additional nutrients, all of which can be passed along, in small amounts, through breast milk.
But it doesn’t have to be that sophisticated. Just follow simple and fundamental Precision Nutrition habits and take advantage of our quick-prep tips (such as zipping up some fruits and veggies in the blender for easy and nourishing Supershakes).
Supplementation while breastfeeding
Breast milk will provide all of the nutrients the infant needs for the first six months of life. However, some babies may need a bit of supplementation at times.
Because modern life — especially in northern latitudes — leaves so many of us with low vitamin D levels, many mothers are deficient in vitamin D while pregnant and breastfeeding. Additionally, preemies are often low in vitamin D.
This means that infants may need a vitamin D supplement. The American Academy of Pediatrics (AAP) recommends a daily vitamin D supplement of 400IU for all breast-fed infants, starting immediately after birth.
Note: once formula fed infants are up to about 30 oz of formula per day (which is usually around 2 months), you can discontinue vitamin D supplementation. However, it is recommended that breast fed infants continue vitamin D supplementation for at least one year.
In the end, some babies can get enough vitamin D from breast milk. But the mom needs to have solid vitamin D levels for this to happen, which most don’t. If you’re pregnant or a new mom, check with your doctor and pharmacist about testing your vitamin D levels, and the best and safest options for your infant.
Breastfeeding mothers who eat an exclusively plant-based (vegan) diet should supplement with vitamin B12.
A fetus will store iron from the mother’s blood while in the womb. Premature babies need extra iron because they do not build up enough stores.
Breast milk doesn’t have much iron, but it is well absorbed. Iron stores will last until about six months of age, thus no iron supplement should be required during this time. Formula-fed infants will likely get enough iron.
Babies are born with a sterile environment inside. As they pass through the birth canal, the mothers’ bacteria colonize infants’ mucous membranes and gastrointestinal tract. This is normal and desirable — just how Nature intended.
However, in an environment of modern cleanliness, or perhaps after a C-section, this bacterial colonization doesn’t happen as easily or well. This can lead to later gastrointestinal, respiratory, and/or ear-nose-throat type infections in babies, as well as a lower immune system.
In this case, parents can supplement with an infant probiotic formulation — talk to your pharmacist to find out what’s best.
For more on beneficial bacteria, see All About Probiotics.
Fluids & hydration
The amount of fluid in breast milk or formula will usually be enough, so normally you shouldn’t need to supplement with water.
However, infants easily and quickly become dehydrated under certain conditions, such as if the infant has a fever or is vomiting a lot; or if the climate is very hot.
Rehydration is also crucial if infants have diarrhea. (In this case, add a little sugar and salt to the water to make a simple electrolyte solution.)
Use urine colour as a guide: Dark yellow urine will signify dehydration. Clear urine signifies potential over-hydration. You want to see something somewhere in the middle. (Baby will undoubtedly oblige with a urine sample, probably at the most socially inconvenient time.)
Introducing solid food
Until about 4-6 months old, infants can’t digest most foods.
Infants are ready for solid foods once they have doubled their birth weight, providing they can hold their heads up, sit in a high chair, open their mouths when food is presented, and swallow. This usually occurs around six months old.
At first, offer solid foods in addition to breast milk, not as a replacement for it. The first “solid” foods should also be liquid-like. (Don’t give your baby beef jerky right off the bat.)
Take your time when introducing new foods.
Don’t rush. Lean Eating Coach, mother, and Registered Nurse Eileen MacRae suggests offering one new food every 3-4 days. This gives you time to see how your baby responds.
If you notice any type of negative reaction (such as respiratory, skin, or GI issues), wait 1-3 months before trying that food again.
Solid food timeline
Step 1: Rice cereal (maybe)
Rice cereal with breast milk or formula is a common first food. It’s generally well-tolerated with low potential for allergy.
However, rice cereal is rooted in tradition rather than science. There’s no strong evidence that this is a better option than other single-grain cereals (or grains in general). Try it and see how it goes.
Step 2: Vegetables
Vegetables are full of nutrients and not as sweet as fruits. Puréed vegetables such as sweet potatoes, beets, squashes, or carrots are easy to cook and mash.
Step 3: Fruit
Introduce fruit after vegetables. If fruit is the first food, baby might expect every food to taste sweet; an important factor considering that food tastes formed early in life can persist.
Also, babies don’t yet have the ability to digest fructose effectively. So, unless you want explosive diarrhea, keep fruit intake moderate and avoid high-fiber fruits like prunes for a while.
You can try things like:
- mashed banana with breast milk
- cooked and puréed fruit (such as pears, peaches, or apples)
Step 4: Higher-protein foods
This includes well-cooked and mashed beans/lentils/green peas, and finely chopped meats. You could even add a little undenatured, unflavored whey protein to pureed foods, formula, etc.
It can take a while for the infant’s GI tract to adjust. Some undigested food might be found in the stool; this is okay and all part of the process.
12 months and older
By around one year old, you can add a pretty good roster of foods, such as:
- tree nuts
- string beans
- puréed fresh fruit
- egg yolk (note: iron from egg yolks isn’t well absorbed)
- mashed lentils/beans (make sure these are adequately cooked)
- meat, chicken, or mild-tasting fish
Finely chop, mash, and/or purée most of these, especially meat or any little bits that can’t be easily gummed — or that can cause choking.
Introduce with caution
While fish is usually tolerated easily, experts vary on when to introduce shellfish/crustaceans. The general consensus is to wait until the child is a little older. Shellfish is a common childhood allergen, along with:
- whole eggs/egg white
- cow’s milk
Also look for any reactions when introducing nightshades — potatoes, tomatoes, and peppers.
If or when you add these to your child’s diet later on, observe carefully and look for any reactions before adding something else. Most kids will do just fine with many of these foods.
What does baby like?
Every mom and dad has a feeding-time horror story of their baby deciding to redecorate the wall, floor, ceiling, or hapless parent’s shirt.
Bbbbbbtttt goes baby. Splat go the mashed peas everywhere. OK, let’s try that one later.
Sometimes it’s hard to know what babies will like from one bite to the next. Be patient and persistent.
Here are some tricks and tips for helping your baby eat a wide variety of foods despite an often-picky infant palate.
Eat a wide variety of foods while pregnant.
What you eat can affect what baby will tolerate and like.
Adoptive mom and PN parent Susan Olding can attest to this: Her daughter, adopted at ten months from China, showed a strong preference for the dominant flavour notes of her native cuisine right from the start, happily gobbling up bitter and cool green veggies like bok choy, gai lan, and watercress.
Use timing to your advantage.
Introduce new foods when babies are hungriest. For Amanda Graydon, that was in the morning. So that’s when she’d try new foods. Smart!
Add a touch of sweetness.
Humans are born with an innate preference for sweetness, which in nature signifies valuable energy-rich foods. Blend up a little bit of sweet potato or fruit into otherwise less-sweet foods (such as more bitter vegetables).
But avoid processed sugar.
Again, remember that what your baby starts with will affect their adult food preferences. So avoid processed sugar — especially hidden in commercial baby foods along with fruit purées and juices — as much as possible.
And avoid honey for the first year or so, as it can contain bacteria that infants can’t yet deal with.
Keep at it.
If your baby refuses to eat a particular food, that’s okay. (This might happen more often with vegetables.)
Leave the food out of the routine for a while and come back to it later. Often babies and children need to try novel foods over and over before they adjust to them. Keep the experience as positive and relaxed as possible, and do your best.
Don’t worry; if baby’s eating various other foods, nutrient intake should be adequate.
“Let baby lead the way when it comes to solid foods,” Erin Weiss-Trainor suggests.
“With our first, we followed the “books” and started to introduce solids around 4-6 months. We started with cereal-based foods, then fruits and veggies, then meats and dairy. We avoided eggs, honey, and nuts/seeds until older.
“With baby #2 and 3, we let them explore more. Once they showed signs of interest (reaching for food on our plates), I’d share right from our plate – making sure food size and texture was age-appropriate.”
Stick with whole foods.
Infants are intuitive eaters. They know how much they need.
But there is a catch – the conditions have to be right. Force-feeding and/or introducing processed foods (such as juice or jam) before whole foods can destroy this delicate self-regulation.
Follow your baby’s hunger levels and food preferences, while seeking to gently expand their repertoire with high-quality, nutrient-rich choices.
A lunchtime snapshot before Amalynn (2-yr old daughter of JB and Amanda) digs in.
Learning hunger cues is important for both parents and babies. (And parents, why not re-learn your own natural hunger cues along with discovering your infant’s?)
Remember that infants will be highly self-regulated. They’ll want to eat when they’re hungry, and stop when they’re full.
I trusted my kids’ hunger
“When they told me they were hungry”, says Erin Weiss-Trainor, “I fed them. And when they weren’t hungry, I stopped.” It was a natural cycle of supply and demand.
“When the baby needed to eat more, I made more milk. As they ate less, I produced less. It’s a beautiful thing to experience – baby being so in tune with hunger. And mom and baby being so in tune with each other.”
Try not to pressure your baby into a set schedule in the early days, or wake them to feed during the night.
Relax and see if you can find their rhythms. (Trust us, babies will wake up just fine on their own and let you know when it’s midnight snack time!)
If baby is spitting up a lot or making large watery stools, especially if they’re supplementing with formula, they may be over-feeding. Back off slightly and see if you notice a difference in their hunger signals and bowel habits.
Help your baby communicate
Because language develops relatively late, and both babies and adults get frustrated and cranky when they can’t communicate effectively, Krista Schaus recommends teaching your baby sign language.
When baby can sign for “more”, “hungry”, “full”, “gimme that thing”, and even “diaper change”, life becomes easier.
“My son was signing before six months,” Krista says. “He even made up his own signs by the time he was one year old.”
Weight gain & growth
Each baby is unique. Just like in Scrawny to Brawny, some are fast gainers. Some are slow gainers. Some will gain fast right out of the gate then stabilize, others will lag and then blast off.
As babies slow down their growth, they’ll be less hungry on average (although 60% of their intake is feeding their brains rather than the rest of their developing bodies).
But again, appetite will vary day to day. Some days, babies will be ravenous all-consuming beasts. Other days, there’s not a mashed banana in the world that’ll interest them.
So don’t panic if your baby doesn’t seem to be sticking to a steady weight gain or eating schedule. These are just average guidelines:
- During the first three months, you can expect your baby to gain around 2 lb/month.
- 6 months – 1 lb/month
- 9 months – less than 1 lb/month
Consider the time of day when the infant is weighed (e.g., when they last eliminated and ate). Babies usually only get weighed when they go to the doctor. This is often enough (and might be often enough for some adults).
Making food at home
It’s easy and cost-effective to make baby food at home. All you need is a food processor or small blender such as a Magic Bullet. (Or a bit of elbow grease and a fork for mashing.)
Early on, your baby’s food choices will be limited, but over time you can mash, chop, and/or purée most of the foods you happen to be eating. Makes food prep simple, and more importantly — you know exactly what your baby’s getting.
Make sure you blend/mash the food well, and avoid any foods that might cause choking. Chunks/clumps of any food, hot dogs, candy, nuts, grapes, nut butter, and popcorn all tend to cause problems.
Of course, follow the basic rules of food safety. Wash your hands, refrigerate or heat food appropriately, discard uneaten food promptly, etc.
If you use commercial baby food, check the ingredients. Only feed out of the jar if you are going to use the entire jar.
If you’re feeding your older baby a relatively wide range of high-quality, nutrient-dense foods when they’re hungry, that’s probably all you need to worry about. But here are some general guidelines for nutrient intake in older babies and young children (6 months – 2 years).
Growing babies and children need plenty of fat, particularly saturated, monounsaturated, and omega-3 fats. Look for naturally occurring whole-food fats such as:
- butter and other high-fat dairy;
- eggs; and
- fatty fish from healthy animals. (But be aware of heavy metals in fish – See All About Eating Seafood.)
Nuts, seeds, and nut butters (including flax, hemp, and chia seeds) can come later once you’re sure that your child tolerates them and can eat them properly.
Omega-3 fats (DHA/EPA) in particular are critical for overall health; body composition; and eye, brain and nervous system development. Consider an infant-appropriate DHA/EPA supplement.
Babies need iron for cognitive, neurological, motor, and behavioral development, and they start to require additional dietary iron around 6 months.
Start adding iron-rich foods around this time. This can begin with iron-fortified rice cereal and over time include other iron-rich foods such as:
- leafy greens
- orange-fleshed squash
- nuts & seeds
- peas & lima beans
- chicken or beef liver (try sneaking a little bit in to blended meat)
- red meat (beef, venison, ostrich, etc.)
- chicken (dark meat) and duck
While some iron is important, don’t go overboard. Check to be sure you aren’t overdoing the iron if you rely on a lot of fortified baby foods. (Here’s a link to some more reading on iron for babies and children.)
Note: Cow’s milk contains very little iron, can cause iron to be lost in the feces, and can damage an infant’s GI tract. Don’t give babies younger than 1 year old soy/almond/hemp/rice/cow’s milk.
Cells need zinc. Infants older than six months of age who eat a 100% plant-based (vegan) diet might need a zinc supplement.
Foods rich in zinc:
- peas & beans
- nuts & seeds
- napa cabbage
- hearts of palm
- sun-dried tomatoes
- cocoa powder
- meat, poultry (especially darker cuts), fish
Infants older than six months of age eating a 100% plant-based (vegan) diet will need a vitamin B12 supplement.
If water isn’t fluoridated, a supplement might be necessary. Too much will also cause problems.
Iodine keeps the thyroid healthy. Infants older than six months of age who eat non-iodized salt and a limited variety of foods might need a supplement.
Foods rich in iodine include:
- dried prunes
- sea vegetables
- iodized salt
You can often sneak sea vegetables in particular into baby food to hide the taste — sprinkle a little crumbled dried seaweed into mashed veggies and blend it up.
Stick with mostly water or herbal tea. Save vegetable and fruit juices for special occasions, unless you make them yourself from blending up fresh/cooked fruits and vegetables.
The first couple of years of a child’s life can establish life-long taste preferences and their metabolic environment. Sugar now means cavities, body fat, and over-sweet taste preferences later.
Juice is high in sugar and is often the leading source of sugar for infants. And despite package claims, juice is also a poor source of fruit and/or vitamins.
Artificially sweetened beverages can make naturally sweet foods taste less appealing. Also, artificial sweeteners might have negative health outcomes.
Summary and recommendations
Infants don’t shop and prepare their own food. That means they depend on parents and caregivers to shop and prepare foods that promote optimal health. And that means you and me.
To give your baby the best start:
- If you can, breastfeed for at least the first six months of the infant’s life.
- If required, add a vitamin D and/or B12 supplement after 2-3 months.
- At around six months of age, start with some basic solid foods.
- Start with something like rice cereal, then vegetables, then fruits and protein-dense foods. Introduce only one new food at a time, and see how it goes.
- Choose whole foods. These are nutritious and satiating, and develop appropriate taste preferences.
- Follow your baby’s hunger signals, and food preferences, while also gently and patiently adding food variety and mealtime structure. Don’t rush new foods, but be persistent and stick with it.
- Talk with your doctor and pharmacist about supplements (calcium, greens, iron, zinc, iodine, omega-3 fats, probiotics, etc.) if appropriate.
- Go for organic and/or food items with lower levels of pesticides. Use the following list if you are unable to buy exclusively organic.
- Minimize added sugars. This includes fruit juice and other processed foods. Read labels.
- For the first six months of life breast milk usually provides enough fluid. After six months of age, water and herbal tea are fine. Avoid cow, soy, and other processed milks for the first year.
- Do your best. Parenting is hard enough, and each child is unique. Don’t try to get it “perfect”. Use the basic PN habits and quick food prep tips to make things easier.
Predict your child’s risk of obesity: http://healthland.time.com/2012/11/29/predicting-obesity-at-birth//
Dr Sears’ Website: http://www.askdrsears.com/
Baby Lead Weaning: http://en.wikipedia.org/wiki/Baby-led_weaning
The AAP and WHO: http://www.aap.org/en-us/Pages/Default.aspx ; http://www.who.int/en/
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Adequate nutrition during infancy and early childhood is essential to ensure the growth, health and development of children to their full potential1. It has been recognised worldwide that breastfeeding is beneficial for both the mother and child, as breast milk is considered the best source of nutrition for an infant 2. Economic and social benefits are also provided to the family, the health care system and the employer.
The World Health Organization (WHO) recommends that infants be exclusively breastfed for the first six months, followed by breastfeeding along with complementary foods for up to two years of age or beyond 3. Exclusive breastfeeding can be defined as a practice whereby the infants receive only breast milk without mixing it with water, other liquids, tea, herbal preparations or food in the first six months of life, with the exception of vitamins, mineral supplements or medicines 4. Breastfeeding an infant exclusively for the first 6 months of life carries numerous benefits such as lowered risk of gastrointestinal infection, pneumonia, otitis media and urinary tract infection in the infant while mothers return to her pre-pregnancy weight very rapidly and have a reduced risk of developing Type 2 diabetes 5, 6, 7.
Moreover, studies have shown that many mothers find it difficult to meet personal goals and to adhere to the expert recommendations for continued and exclusive breastfeeding despite increased rate of initiation 8. Some of the major factors that affect exclusivity and duration of breastfeeding include breast problems such as sore nipples or mother’s perceptions of producing inadequate milk 4, 9, 11 and societal barriers such as employment, length of maternity leave 9, inadequate breastfeeding knowledge 11, lack of familial and societal support and lack of guidance and encouragement from health care professionals 2, 9.
Another factor that leads to early cessation of breastfeeding is the advertisement of infant formulas which encourages mothers to opt for the use of pacifiers and bottle feeding 3, 9. Additionally, many mothers opt for breast milk substitutes because they need to resume work while others claim that they produce insufficient milk 10. To date, there are various types of infant formulas available on the market, and which are designed to meet the nutritional needs of infants with a variety of dietary needs 12. However, there are some problems associated with infant formulas such as the nutritional content either does not meet or exceeds the infant’s needs. For instance, it was reported that some infants who were fed on formula milk have had occasional water soluble vitamins deficiencies 13. Another problem associated with bottle feeding involves high risk of exposing the child to pathogens owing to unhygienic practices during handling and preparation of infant formula 3.
On the other hand, when breast milk or infant formula no longer supplies infants with required energy and nutrients to sustain normal growth and optimal health and development, solid foods should be introduced 14. This process is known as complementary feeding. According to the WHO recommendations, the appropriate age at which solids should be introduced is around 6 months 15 owing to the immaturity of the gastrointestinal tract and the renal system as well as on the neuro-physiological status of the infant 15. However there are concerns about the timing of complementary feeding as evidence demonstrates that this recommendation for delayed introduction of complementary foods may have detrimental consequences 17. Furthermore there are different types of weaning that mothers adopt namely child-led/natural, mother-led, gradual, partial or abrupt weaning 18. It should be noted that during the weaning process many mothers encounter infant feeding problems such as refusal-to-eat, colic, and vomiting among others 19. All these problems that mothers encounter during the feeding processes either directly or indirectly influence the feeding pattern.
The objectives of this study are to:
- Appraise the advantages of exclusive breastfeeding.
- Provide an overview of problems which hinder the practice of breastfeeding among mothers.
- Discuss the appropriateness of complementary feeding and feeding difficulties which infants encounter.
The determinants of children’s growth include genetic potentialities, family size, lifestyle, socio-economic environment, infections, nutrition and the availability of medical care20. However, nutrition is the most prominent factor which can either directly or indirectly influences children’s future development. For instance, those children who are malnourished and manage to survive do not enjoy a good health and experience impaired development in the long run 21. Along, there is a rising concern about overweight and obesity in children. Therefore, proper nutrition and nurturing during the early years of life is crucial for an infant to achieve optimal health and well-being. Hence, there is no more precious gift in infancy than breast feeding.
“Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mother”22.
Saha et al. 23 reported that the current recommendations of WHO and UNICEF on breastfeeding are as follows
- Initiation of breastfeeding within the first hour after the birth;
- Exclusive breastfeeding for the first six months;
- Continued breastfeeding for two years or more and proper introduction of solid foods starting in the sixth month which are nutritionally safe and adequate.
Exclusive breastfeeding as defined by WHO and UNICEF is the practice whereby an infant receives only breast milk from the mother or a wet nurse or expressed breast milk 24. The WHO and UNICEF, both recommend that mothers should breastfeed their child exclusively for the first 6 months and continue breastfeeding up to 2 years or longer rather than stop EBF practice as from 4-6 months 25.
Although breastfeeding an infant exclusively for the first 6 months of life carries numerous benefits, many studies are centered on the “weanling’s dilemma” in developing countries which involves choosing between the protective effects of exclusive breastfeeding against infectious diseases and the (theoretical) insufficient breast milk to meet the infants’ energy and micronutrient needs beyond four months of age 26. However, the author claimed that there is no data giving an estimate of the proportion of exclusively breastfed infants at risk of specific nutritional deficiencies.
EXPRESSED BREAST MILK
Breastfeeding is beneficial both to the infant and the mother27. However, owing to certain circumstances, mothers are unable to breastfeed, so they wish to express their milk because it is the only opportunity for the infant to have the human milk 28. Expressing is simply a way of taking milk from the breast without the baby suckling and this can be achieved either by the hand or manual pump or electric pump 29. The reasons why some mothers express breast milk are shown in Figure 2.1.
While breast milk in a bottle is far superior to any infant formula, expressing or pumping breast milk do have some disadvantages unlike direct breastfeeding as shown in Figure 2.2.
COMPOSITION OF BREAST MILK
Human milk is species-specific and is superior to any other breast milk substitute 32 and it is also assumed to the ideal food for infant during the first 4-6 months, ensuring proper growth and development 33. Human milk which is the most natural food available for infant is unique whereby its nutritional composition varies from mother to mother, from day to day, during the day and during a feed 34, 35. Human milk contains several factors such as immunoglobulin, T lymphocytes, enzymes such as lysozymes, phagocytes among others which are not present in breast milk substitute 36. A comparison of composition of human colostrum, human mature milk, cow’s milk and standard formula is depicted in Table 2.1.
|Table 2.1: Comparison of composition of human colostrum, human mature milk, cow’s milk and standard formula37Click here to View table|
CHARACTERISTICS OF BREAST MILK
“Breast milk is unique in its physical structure and types and concentrations of protein, fat, carbohydrate, vitamins and minerals, enzymes, hormones, growth factors, host resistance factors, inducers and modulators of the immune system, and anti-inflammatory agents” 12. There are three phases of milk namely, colostrum, transitional milk and mature milk each with distinct characteristics.
Infant’s first milk
The first milk that is synthesized by the breast for the baby right after birth is thick, yellow-coloured fluid called colostrum. The yellow color is owing to the high concentration of beta-carotene, a precursor of vitamin A which is required for the protection against infection and for early retinal development 38. It has also been stated that the amount of colostrum obtained is limited but it rich in nutrients and substances that the infant needs in the first days of life 12. The “liquid gold” is rich in proteins, fat-soluble vitamins, minerals, and immunoglobulins A- sIgA33. It should be noted that IgA protects the infant’s immune system by identifying and destroying foreign objects such as bacteria and viruses12. Another advantage of colostrum is that the mother will have less blood loss because the uterine contracts as the baby suckle. Furthermore, colostrum also contains white cells which help to prevent infection in the infant and it also consists of lactose which prevents hypoglycemia and at the same time helps the newborn to pass meconium 38. This in turn, promotes the excretion of bilirubin.
Transitional milk is used to describe the postcolostral period (7 to 21 days post partum) when the composition of the milk changes more slowly than in the first few days following parturition39. The content of transitional milk includes high levels of fat, lactose, water-soluble vitamins, and contains more calories than colostrum but lower levels of immunoglobulins 33.
Mature milk (21 days post partum) also varies but to a lesser extent than in early lactation 39. Mature milk looks thinner, paler and is more watery than colostrum 33. Additionally, it consists of 90% water which is required to maintain hydration of the infant and the remaining 10% consists of carbohydrates, proteins and fats which are important for both growth and to meet energy needs of the baby. There are two types of mature milk: Foremilk and hind- milk.
Foremilk is the first milk available in large amount at the beginning of a feeding which is watery thus, providing all the water the baby needs from it. Therefore, no other drinks such as water or juice are required before 4-6 months, even in hot climate 40. Foremilk is rich in proteins, lactose and other essential nutrients but contains less fat 33.
Hind- milk is the richer milk, containing more fat which occurs after the initial release of milk and is more opaque and creamy white in colour40. This type of milk induces a feeling of satiety in the infant as well as making the latter feels sleepy 12.
Therefore, both foremilk and hind-milk are necessary for the baby to receive optimum nutrition in order to grow and develop well.
ADVANTAGES OF BREASTFEEDING
Breastfeeding is universally endorsed by the world’s health and scientific organizations as the best way of feeding infants 41. Many studies have been carried out and have highlighted innumerable benefits of breastfeeding for infants, for mothers and the society. Some of them include lowered risk of otitis media, gastroenteritis, respiratory illness, sudden infant death syndrome, necrotising enterocolitis, obesity, hypertension among others in infants 42 (Table 2.2). Maternal outcomes include reduced risk of breast and ovarian cancer, Type 2 diabetes, and postpartum depression (Table 2.3) while societal benefits include decrease health care related cost and fewer absences from work.
CONCERNS, CONTROVERSIES AND CONTRAINDICATIONS TO BREASTFEEDING
Although breastfeeding is optimal for infants, there are some controversies surrounding breastfeeding and very few contraindications. Breastfeeding is contraindicated due to the following
- In infants who have special health problems such as galactosemia, maple syrup urine disease and phenylketonuria 38.
- In cases where mothers have active untreated tuberculosis disease or are human T-cell lymphotropic virus type I– or II–positive 32. Breastfeeding may not be in the best interest of the baby when breastfeeding mothers have herpes simplex lesions on a breast (infant may feed from other breast if it is free from any lesions)32.
- In situations where the mother is using drugs of abuse 55
- In certain circumstances where mothers are receiving diagnostic or therapeutic radioactive isotopes,antimetabolites or chemotherapeutic agents, small number of other medications or who had been exposed to radioactive materials 32. They should not breastfeed until these substances are cleared from the breast milk 54.
- In infants born to mothers who are HIV infected, breastfeeding is discouraged owing to the risk of transmission of HIV to the infant through human milk54. Naylor &Wester38 highlighted thatWHO recommends replacement feeding if it is acceptable, feasible, affordable, sustainable and safe (AFASS).
Additionally, more and more studies are supporting the fact that if an HIV infected mother choose to or must breastfeed, it is essential to breastfeed exclusively for the first six months to reduce the risk of contaminants that may come with formula and other foods and cause gut inflammation allowing HIV organisms to reach the submucosal tissue 38. Furthermore, antiretroviral drugs can reduce the risk of HIV infection to the infant through breast milk.
PROBLEMS WITH BREASTFEEDING
Among mammals, the only species in which breastfeeding and weaning have to be learned and are not governed by instinct are the Homo sapiens56 and breastfeeding problems are very common, but last for a short time and are preventable 38. According to Giugliani56, many mothers are facing breastfeeding problems as their traditional source of learning was lost as extended families are being replaced by nuclear families. This provides few opportunities for the mothers to learn about breastfeeding. Therefore, to enable a mother to start or continue enjoying the lactation process, prevention and treatment is recommended.
Breast engorgement is mainly caused by infrequent or ineffective milk removal 38. The breasts become engorged 3-5 days postpartum 57. The breasts become full, warm and at the time when the “milk comes in” at 3-5 days after delivery, there is a rapid increase in milk volume that cause vascular congestion which is followed by oedema38. Excessive engorgement with pain and oedema can be avoided by adopting the practices as shown in Figure 2.3.
Sore nipples/ nipple trauma
One of the reasons why mothers discontinue breastfeeding and opt for early weaning is owing to sore nipples 54. This usually occurs while the baby is latching during the first week or two and it eventually makes the women feel a mild pain and discomfort. According to Giugliani56, the causes of pain during breastfeeding are shown in Figure 2.4.
Sore nipples can be prevented by teaching proper techniques on the initiation of breastfeeding 58. Additionally, the breast should be allowed to air-dry for some minutes after a feeding and nursing pads should be changed regularly to prevent milk flow 56, 57. Other precautions include expressing breast milk if the breasts are engorged and avoiding use of soap, alcohol and extra water on the breast 57.
Insufficiency of milk
Another reason causing early termination of breastfeeding is insufficient breast milk 59. Most women produce sufficient milk according to the baby’s needs, however, the complaint of “insufficient milk” is not just owing to the wrong perception of the mother but the latter lacks confidence on her ability to breastfeed 56.Other reasons that make mothers perceive that they are not producing “sufficient milk” are ineffective suckling and/or infrequent feeding routines, conditions of the baby, such as illness or ankyloglossia, condition of the mother such as fatigue, stress, and use of certain medications, psychological inhibition, pregnancy, and smoking38.
Therefore, it is important to determine the aetiology of the milk insufficiency in order to identify necessary interventions to resolve the problem 60.
There are many other problems that many mothers experience during the lactation process which include gigantomastia, plugged ducts, flat/inverted nipples, medical complications such as mastitis, breast abscess among others 54.
FORMULA FEEDING PRACTICES
According to the National Academy of Sciences 61, multiple health organisations endorse breastfeeding as the optimal form of nutrition for infants for the first year of life. However, not all mothers are able to breastfeed either temporarily or permanently, owing to a small number of health conditions of the infant or the mother 62. Hence, many infants who were unable to be breastfed were wet-nursed (given breast milk by a woman other than the child’s mother) while others, who were unfortunate were “dry-nursed”. Dry nursing refers to home prepared mixture which consisted of a liquid, either water or milk mixed with finely ground grains. Over time, cow’s milk was modified to feed infants who were unable to breastfeed. Infant formulas are food products designed to provide for the nutritional needs of infants under 1 year old63. They include powders, concentrated liquids, or ready-to-use forms. The first commercial infant formula consisted of wheat flour, cows’ milk, malt flour and potassium bicarbonate. Thereafter, new kinds of formula milk were developed whereby certain modifications were needed to make it safe and palatable for human infants61. The birth of infant formula industry became more apparent owing to the process of modifying cow milk for large-scale production in the 1920s.
Currently, there are more than 40 formulas for healthy term infants which are being sold 64 and FDA monitors infant formula manufacturers to ensure that the product provides the appropriate nutrition for all infants. Fisher 64 pointed out that each product has a unique and desirable feature for optimal development of the infant as explained in Table 2.4.
PROBLEMS WITH INFANT FORMULA
Formula feeding have some benefits such as convenience, fewer feeding times and mothers need not worry about their food or liquid intake being passed to the baby 65. However, infant formulas do have drawbacks as shown in Figure 2.5.
Complementary feeding is the term used for giving other foods and drinks in addition to breastfeeding after the completion of the 6 months exclusive breastfeeding period69. According to WHO 7, this process covers the period from 6-24 months of age and is a critical period of growth during which infants are at high risk of nutrient deficiencies and illnesses.
The importance of introducing solid foods in addition to the infant’s milk feed is shown in Figure 2.6.
The ideal age to begin weaning is 4 to 6 months of age because besides filling the gap between the total nutritional needs of a child and the amounts provided by breast milk, it is the age when nerves and muscles in the mouth develop sufficiently to let the baby munch, bite and chew 68. Nevertheless, following the WHO recommendations in 2001 there has been considerable debate over the ideal age to begin weaning in healthy term infants 26. It has been highlighted that gastroenteritis is common in developing countries and is associated with the introduction of formula and complementary foods 14. It is to be noted that the risks of gastroenteritis is lower in developed countries, thus many are questioning whether the WHO recommendation applies for the developed countries as well 69. Furthermore, it was highlighted 14 that the debate remains over whether some infants who are not weaned until 6 months may be at risk of micronutrient deficiencies.
EARLY AND LATE INTRODUCTION OF COMPLEMENTARY FOODS
Timing of the first introduction of solid food during infancy may have potential effects on life-long health70. It can be seen that very often solid foods are either given too early or too late. According to UNICEF 71, the frequency and amounts of food that is given may be insufficient hence;hindering the normal growth of the child or their consistency or energy density may be incorrect in relation to the child’s needs. Therefore WHO 72 stated that it is advisable for mothers to adopt an appropriate complementary feeding as shown in Figure 2.7:
Some studies have shown that giving solid foods too early may lead to increased risk of chronic diseases such as islet autoimmunity (the pre-clinical condition leading to Type 1 diabetes), obesity, adult-onset celiac disease, and eczema 70.
Nevertheless, it was affirmed there is no evidence of harm even within populations that begin weaning within a few days of birth14.
A study by Kuo et al. 70 has shown that late weaning may cause deficiencies of zinc, protein, iron and vitamins B and D that leads to the suppression of growth and cause feeding problems. Iron deficiency anaemia and rickets are also found to be more prevalent among infants who are weaned after 6 months 14.
TYPES OF WEANING
There are different ways by which weaning can happen. Table 2.5 shows the different types of weaning.
The best way to help a baby’s digestive system to get used to solid foods is by introducing the foods gradually and one new food at a time so that if the infant has had any allergy, it can be spotted easily 69. Starting new foods is a critical step for the baby and it usually takes some time for infants to get used to this new way of eating. It is usually best to start weaning (around 6 months) the infant with the foods shown in Figure 2.8.
COMMON FEEDING DIFFICULTIES IN INFANTS
Many parents have concerns and questions about infant feeding and eating issues whereby the most common feeding difficulties are colic, poor appetite, food refusal or selective eating 75. It is important to treat feeding difficulties which can later leads to failure to thrive, nutritional deficiencies, impaired parent/child interactions and chronic aversion with socially stigmatizing mealtime behavior 76. According to Liu & Stein 77, feeding problems can be a result of medical disorders and inappropriate food selection. Some common feeding problems are depicted in Table 2.6.
Breastfeeding is the gold standard of infant feeding up to 6 months.It remains the most cost effective way for reducing the risk of diseases such as obesity, hypertension, eczema, type diabetes among others in later life as well as mortality. Breast engorgement, sore nipples, milk insufficiency and availability of various infant formulas are the main factors which influence breastfeeding practice in terms of initiation, exclusivity and duration. On the other hand, complementary foods in terms of nutrient-dense are normally introduced around 4 to 6 months. Difficulties encountered during the weaning process are often refusal to eat followed by vomiting, colic, allergic reactions and diarrhoea. Given related problems associated with breastfeeding, it is highly likely that in the future, nutrigenomics (or nutrigenetics) based research will provide opportunities towards personalized modification of breast milk for optimum health of neonates78.
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