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Introduction to Infant Feeding: Growth and Assessment
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Growth
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Fetal Growth from 25-40 weeks GA
Weight increases 4-fold Length and OFC increase 2-fold
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Determinants of fetal growth
Genetics Maternal/paternal genes, race, sex
estimated to account for 20% of variance in birth weight
Environmental factors
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Body Composition BMI and percentage of body weight
made up of fat increase rapidly during the first months of life Fat accounts for 0.5% of body weight
at the fifth month of fetal growth and 16% at term.
3rd trimester: increase from 1-3% of body weight to 10-16% of body weight at term
After birth, fat accumulates rapidly until approximately 9 months of age
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Minerals
Two-thirds of mineral content of full-term newborn is accummulated in the last trimester of pregnancy.
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Age-related changes in body composition. (Reprinted by permission ofMosby Year Book. Heird WC, Driscoll JM, Schullinger JN, et al.Intravenous alimentation in pediatric patients. J Pediatr 80:351, 1972.)
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Energy Reserves
Birthweight Non protein kcal Total kcal
500 50 225
800 grams 125 435
1000 grams 165 600
1500 425 1120
2000 1050 1975
3500 4175 5924
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Environmental factors Maternal health Nutrition
Glucose, fatty acids, amino acids for tissue deposition and fuel for oxidative purposes
Ability of maternal-placental system to transfer nutrients to fetus
Endocrine environment E.g. LGA infant:
glucose-insulin-growth factors
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GROWTH IN FIRST 12 MONTHS From birth to 1 year of age, normal human
infants triple their weight and increase their length by 50%.
Growth in the first 4 months of life is the fastest of the whole lifespan - birthweight usually doubles by 4 months
4-8 months is a time of transition to slower growth
By 8 months growth patterns more like those of 2 year old than those of newborn.
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Weight Gain in Grams per Day in One Month Increments - Girls
Age 10th
percentile50th
percentile90th
percentileUp to 1month
16 26 36
1-2months
20 29 39
2-3months
14 23 32
4-5months
13 16 20
5-6months
11 14 18
Guo et al., J Peds. 1991
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Weight Gain in Grams per Day in One Month Increments - Boys
Age 10th
percentile50th
percentile90th
percentileUp to 1month
18 30 42
1-2months
25 35 46
2-3months
18 26 36
3-4months
16 20 24
4-5months
14 17 21
5-6months
12 15 19
Guo et al., J Peds. 1991
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Body Composition BMI and percentage of body weight
made up of fat increase rapidly during the first months of life Fat accounts for 0.5% of body weight
at the fifth month of fetal growth and 16% at term.
After birth, fat accumulates rapidly until approximately 9 months of age
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Individual Growth Patterns
Weight and length at term appear to be primarily determined by nongenetic maternal factors
Birth weigh and birth length weakly correlate with subsequent weight and length values
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Individual Growth Patterns, cont.
African American males and females are smaller than whites at birth, but they grow more rapidly during the first 2 years
Patterns of growth in breastfed infants are different from formula fed infants
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Rates of gain for breastfed and formula fed infants during early months of life generally have been found to be similar although some reports have demonstrated greater gains by breastfed infants and others have shown greater gains by formula fed infants
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Weight gain of Breast fed vs bottle fedinfants: 8-112 days of age (g/d)
Breast fed Bottle fed
Male 29.8 + 5.8 32.2 + 5.6
Female 26.2 + 5.6 27.5 + 4.9
Nelson et al Early Human Development 19:223 1989
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Factors to Consider
Constellation of Factors Affecting theUnique Needs of the Preterm Infant
Characteristics Nutrient needs Goals Growth
expectations Outcomes that
Impact growth and nutritional needs
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Assessment
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Assessment
Screening identifies nutritional risk Nutrition Assessment
Uses information gathered in screening Adds more in depth, comprehensive
data Interprets data Develops care plan Reassess
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Assessment
Screening identifies nutritional risk Nutrition Assessment
Uses information gathered in screening Adds more in depth, comprehensive
data Interprets data Develops care plan Reassess
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Nutrition Screening: Purpose
To identify individuals who appear to have or be at risk for nutrition problems
To identify individuals who require further assessment or evaluation
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Screening: Definition
Process of identifying characteristics known to be associated with nutrition problems ASPEN, Nutri in Clin Practice 1996 (5):217-228
Simplest level of nutritional care (level 1) Baer et al, J Am Diet Assoc 1997 (10) S2:107-115
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Goals of Nutrition Assessment
To collect information necessary to document adequacy of nutritional status or identify deficits
To develop a nutritional care plan that is realistic and within family context
To establish an appropriate plan for monitoring and/or reassessment
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Information Collected
Growth Dietary Medical history Diagnosis Feeding and developmental information Psychosocial and environmental information Clinical information and appearance (hair,
skin, nails, eyes) Other (anthropometrics, laboratory)
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Interpretation Linking
information collected with:
Goals/expectations Reference
data/standards Evidence individual
Asking questions
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Challenges
Nutrient needs influenced by:genetics, activity, body composition, medical conditions and medications
Alterations in growth and measures of growthgenetics, body composition, physical limitations
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Challenges
Information Availability,
sufficiency, accuracy Interpretation
Goals, expectation, “does it make sense”
Questions What are goals and
expectations, “does it make sense”
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Considerations Growth in infancy Physiology of infancy
GI Renal
Infant Development Nutrient requirements
* Recommendations Milk based feedings/Infant formulas Timing of complementary foods
What are families actually doing? Specific issues of safety and oral health
Challenges: Recommendations for populations v.s individual
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Challenges
Identification of etiology Weighing risk vs benefit Supportive of:
Family Individual Development/temperament
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Growth Assessment
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Growth Concerns
Underweight
Short stature
Overweight
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A variety of growth references were developed and and used
in the U.S. since the early 1900’s
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Growth references: timeline Stuart/Meredith
Growth Charts (1946-76)
Caucasian, Boston/Iowa city, small sample size
NCHS growth charts (1976-1978)
NCHS AAP/MCHB study
group Used cross sectional
data from NHES, NHANES, and FELs (infant)
CDC produced normalized version
1978 WHO recommended international use
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Growth reference timeline: continued
2000 CDC growth charts: revision of NCHS growth charts
2006 WHO released new international growth standards
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Assessment of Growth
Growth Charts CDC/NCHS
http://www.cdc.gov/growthcharts/ World Health Organization
http://www.who.int/childgrowth/en
Specialized growth charts Patterns, rates, velocity
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NCHS growth charts: Concerns Infant data: Fels study
Primarily formula fed Underrepresented groups: largely
caucasian, middle class Intervals of measurements (q3
months from 3-36 months) may not define dynamic patterns during rapid growth phases
Statistical smoothing proceedures
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CDC Growth charts: 2000
Based on 5 cross sectional nationally representative surveys between 1963 and 1995
Included more breastfed infants
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CDC/NCHS Growth Charts
Data from previous NCHS charts came from private study of primarily white, formula-fed, middle-class infants from southwestern Ohio before 1975
Newer charts have more representative data (some breastfeed and ethnic diversity) from NHANES and use more sophisticated smoothing techniques
16 new charts provided by gender and age
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CDC Growth Charts (compared to older NCHS
Standardized data collection methods
Expanded sample Exclusions
VLBW infants NHANES III weight data for >6 year
olds
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CDC Growth Charts (compared to older NCHS
Standardized data collection methods
Expanded sample Exclusions
VLBW infants NHANES III weight data for >6 year
olds
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CDC/NCHS Growth Charts
Clinical charts for infancy for girls and boys: weight length weight for length OFC
Choice between outer limits at 3rd and 97th or 5th and 95th percentiles
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Adam
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Adam
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Carl
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WHO Child Growth Standards
Released new growth standards April 2006 Assumed that infants and children
between birth and 5 years grow similarly when needs are met.
Concerns for CDC charts included: Frequency of growth measures during
dynamic periods of infant growth Statistical methods
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WHO growth charts
Data from Brazil, Ghana, India, Norway, Oman and USA
Multiethnic, affluent Exclusive breastfeeding to 4 months Solids according to recommendations
6 months Continued breastfeeding to 12 months
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WHO growth charts
Full term low birthweight infants not excluded
Birth to 2 years N 1743 ----- 882
2-5 years N 6669
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WHO v.s. CDC
Infancy WHO mean > CDC mean birth-6
months “healthy breastfed infants track
weight/age along WHO but falter on CDC”
Cross at 6 months and WHO mean < 6months
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WHO v.s. CDC CDC
Heavier, shorter WHO
taller WHO
Higher estimates of overweight Lower estimates of underweight,
undernutrition
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Dietary Information
Family Food Usage 24 hour recall Diet history 3-7 day food record or diary Food frequency Other Information
Food preparation, history, feeding observation, feeding problems, likes/dislikes, feeding environment
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Dietary Information
Evaluate fluid, macro and micronutrients (energy, protein, vitamin D, Calcium/phosphorus, iron, other)
Compare intake to: DRI ? Condition or syndrome specific Equations
Link intake to: Additional information collected in
individual assessment process
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Comparison of individual intake data to a reference or estimate of nutrient needs
DRI: Dietary Reference Intakes
periodically revised recommendations (or guidelines) of the National Academy of Sciences
quantitative estimates of nutrient intakes for planning and assessing diets for healthy people
AI: Adequate Intake
UL: Tolerable Upper Intake Level
EER: Estimated Energy Requirement
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Approaches to Estimating Nutrient Requirements
Direct experimental evidence (ie protein and amino acids)
Extrapolation from experimental evidence relating to human subjects of other age groups or animal models
ie thiamin--related to energy intake .3-.5 mg/1000 kcal Breast milk as gold standard (average [] X usual intake) Metabolic balance studies (ie protein, minerals) Clinical Observation (eg: manufacturing errors B6, Cl) Factorial approach Population studies
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Interpretation: Asking Questions
Is there a problem?Was there a
problem?Does information
make sense?What are goals and
expectations?What is etiology of
the problem?
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Contributing Factors
Inadequate IntakeFluid, energy
MedicalBPD, reflux, frequent illness
Feeding relationshipStress, history
Psychosocial
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Intervention Identify etiology Identify contributing
factors Support feeding
relationship Consider
psychosocial factors, family choice and input
Weigh risk v.s. benefit
Weighing Risks and Benefits