This chapter will address the following American College of Graduate Medical Education competencies: patient care, medical knowledge, interpersonal and communication skills, and professionalism.

Patient Care: Early feeding routines may be influenced by preexisting family eating patterns and food choices, economic status, cultural norms, and the family’s nutritional knowledge and skills. The multiple influences on infant and toddler feeding require that the health care provider have a family-centered and nonjudgmental approach to nutritional guidance. This chapter will help the pediatric health care provider assess feeding in an infant or toddler and partner with the family to achieve evidence-based healthy feeding goals.

Medical Knowledge: This chapter will help the pediatric health care provider understand nutrition, child development, and the psychosocial and behavioral aspects of feeding essential to helping the family lay the groundwork for a healthy lifestyle for their child.

Interpersonal and Communication Skills: This chapter will help pediatric health care providers create an atmosphere which supports dialogue with families about their feeding practices in a nonjudgmental way that fosters trust and promotes effective communication.

Professionalism: This chapter will help the pediatric health care provider “meet families where they are” with respect and compassion while working with them toward achieving healthy nutrition for their child.

Infancy is a period of rapid growth during which the achievement of normal growth creates a healthy framework for the rest of childhood. It is vital that families understand healthy feeding, because this can set the stage for positive food-related behaviors, healthy food preferences, and family relationships centered on a healthy food environment.

Maternal body mass index (BMI) is a strong predictor of childhood obesity.¹ Infants born to mothers who are overweight or have obesity have greater body fat than those born to normal-weight women and are twice as likely to have obesity by age 2.² Exclusively breast-fed infants of overweight women have been found to have larger head circumferences and increased fat mass at 2 weeks of age. At 3 months, fat mass of infants with mothers who were overweight was increased compared to infants whose mothers had normal weight even though there was no difference in weight for length or head circumference between groups.²

Gestational diabetes affects 20% to 25% of women with obesity and 3% to 15% of women overall. Maternal obesity seems to be an independent risk factor for gestational diabetes, and is also correlated with having a large for gestational age (LGA) infant and with overweight in childhood and adolescence.³ When a mother with gestational diabetes becomes hyperglycemic, the fetus responds with hyperinsulinemia, thought to result in fetal insulin resistance and altered metabolic programming. Hyperinsulinemia may also affect appetite through its effects on hypothalamic development of the fetus.⁴

Birth weight can also influence metabolic programming. Both small for gestational age (SGA) and LGA infants are at risk for developing metabolic syndrome, which includes insulin resistance, hypertension, central obesity, dyslipidemia with increasing risk of diabetes, and cardiovascular disease.⁵ Fetal growth restriction (FGR) is thought to change insulin-glucose metabolism to enhance survival of the fetus. The timing of FGR can affect later disease risk. If there is symmetrical growth restriction of weight, length, and head circumference throughout pregnancy, infants may be at increased risk for arterial hypertension as they age. A fetus not receiving adequate nutrition later in the pregnancy is at increased risk for glucose intolerance and type 2 diabetes mellitus.⁵

Birth weight, gestational diabetes, and elevated maternal BMI increase the risk for childhood obesity. Identifying these risk factors early on will enable the clinician to assess for patterns of growth and feeding practices that contribute to obesity.

The healthy breast-fed infant is considered the norm of optimal human growth,⁶ and the World Health Organization (WHO) growth chart standards based on measurements from predominantly breast-fed infants in developed countries are recommended for plotting of weight, length, and head circumference for the first 24 months of life (http://www.cdc.gov/growthcharts/who_charts.htm). The necessary equipment (calibrated scales, a recumbent length board with a stationary headpiece and a moveable foot piece, and nonstretch tape which is used to measure the head) and training are needed to ensure accurate measurement and weight for length classification (http://www.orphannutrition.org/nutrition-best-practices/growth-charts/using-the-who-growth-charts/#how_to_take_measurements).

Premature infants are plotted on premature growth charts up to 50 weeks of age (Fenton: http://ucalgary.ca/fenton/2013chart). After that, corrected age is used to plot on the WHO chart until 24 months (http://www.adhb.govt.nz/newborn/guidelines/admission/CorrectedAge.htm).

Premature infants are typically discharged on fortified human milk or specialty premature formulas higher in calories, protein, vitamins, and minerals than standard formula.^7,8 The American Academy of Pediatrics (AAP) suggests that there is not enough information at this time to make a general recommendation and that feeding should be individualized to optimize the growth trajectory of the infant over the first year of life.⁹ A meta-analysis of preterm infants did not support the use of these formulas. The meta-analysis excluded infants growth restricted at birth, and when the exclusions were reviewed, these infants did show that preterm formula provided for 2 to 6 months after discharge resulted in weight gain of 500 g more, 5 to 10 mm more linear growth, and 5 cm larger head circumference at 12 to 18 months corrected gestational age.¹⁰ Preterm infants are at risk for metabolic syndrome.^11,12 Rapid weight gain during the first 3 to 4 months of life may result in changes in body composition (increased fat), increased waist circumference, and an acute insulin response that tracks into young adulthood.¹³ Normal growth for a premature infant is 16 g/kg/day, 0.9 cm/week for length, and 0.9 cm/week for head circumference.¹⁴

During the first week of life, all infants lose weight. Breast-fed infants should not lose more than 7% of their birth weight.¹⁵ Formula-fed babies have been shown to lose a median of 3.5% of their birth weight.¹⁶ If breast-fed infants are given water or formula, they generally lose more weight and are less likely to gain weight by day 4 to 5. Babies typically reattain their birth weight by 8 to 14 days of life, with a median for breast-fed infants of 8.3 days and 6.5 days for formula-fed infants.¹⁶ Breast-fed infants gain weight more rapidly during the first 2 months and more slowly from 3 to 12 months.⁸

For infants up to 24 months, weight-for-length ratio is utilized to assess how proportionate the weight is to the height. Once the length is measured, it can be plotted against the weight. Where the 2 measurements intersect on the weight for stature grid, the value can be plotted as a percentile. Percentiles greater than 95 suggest that weight gain is exceeding normal gain for length.¹⁷ Percentiles can also be tracked over time to show trends in rapid weight gain (Table 4-1).

Although infant BMI is available using the WHO growth standards (www.who.int/childgrowth/standards/en), it currently is used only in research studies. These research studies show that growth in infants with BMI greater than or equal to the 95th percentile to less than the 99th percentile, and infants with BMI greater than or equal to the 99th percentile, is different than in infants with BMI greater than or equal to the 25th percentile and 85th percentile or less.⁹ A retrospective study of children who had obesity at age 5 years showed that infants with BMI greater than 95th percentile had different growth patterns than infants with BMI less than 95th percentile.¹³ BMI decreased for all infants in the first week. Infants with BMI greater than 95th percentile continued to increase BMI from 1 week to 24 months with BMI greater than 17 by 4 months. BMI in normal-weight infants leveled off to less than 17 and remained stable until 24 months. When percentiles were used to assess growth in the first year, the upward trend was more significant between ages 12 and 24 months than it was from birth to 12 months.¹³ The earlier the BMI increased by 3 or more units from birth, the more likely the child was to develop obesity. BMI at birth did not correlate with obesity at 5 years.¹³

Breast-feeding

Infants who were ever breast-fed have a 15% to 30% reduction in adolescent and adult obesity. Each additional month of breast-feeding reduces obesity risk by 4%.¹⁸ A 2013 WHO meta-analysis of long-term effects of breast-feeding on weight suggests a decrease in risk of later obesity of 10%.¹⁸ Breast-feeding seems to enhance self-regulation. When breast milk is fed from a bottle, this self-regulation declines and excessive weight gain is noted in the second 6 months.¹⁵ Therefore, it is important to determine how the infant is receiving breast milk. The AAP and the WHO agree that exclusive breast-feeding is recommended for 6 months with appropriate introduction of complementary food at this time. Breast-feeding should continue for 12 months or longer.¹⁵

Support needed during breast-feeding

It is important that the pediatric and obstetric health care providers support the mother in her feeding decision making during pregnancy. Parents can be encouraged to deliver at a baby-friendly hospital which follows the 10 steps to successful breast-feeding (see http://pediatrics.aappublications.org.easyaccess2.lib.cuhk.edu.hk/content/129/3/e827.full#content-block).

Training in breast-feeding assessment can be attained by completing the AAP Breastfeeding Residency Curriculum (http://www2.aap.org/breastfeeding/curriculum/). The AAP and the American College of Obstetricians and Gynecologists also publish the Breastfeeding Handbook for Physicians. Pediatricians may choose to work alongside an International Board Certified Lactation Consultant (IBCLC) to attain additional competence. Some pediatricians have IBCLCs as part of their practice, while others may choose to become IBCLC-certified themselves. Because most lactation failure occurs early, a mother-infant dyad needs to be seen within 3 to 5 days of life, which is within 48 to 72 hours postdischarge.¹⁵ At that time, latch, positioning, jaundice, milk supply, engorgement, sore nipples, and, most importantly, milk transfer need to be evaluated. After 24 hours of no breast-feeding or pumping, the mammary gland alveoli begin to involute, and after 48 hours they are unable to synthesize milk.¹⁹ Therefore, early intervention is quite important to maintain early breast-feeding. Because many mothers who are new to breast-feeding will be concerned that they have an adequate milk supply, a BabyWeigh Scale (www.medelabreastfeedingus.com) can be used in the office before and after feeding to help assess the volume of milk fed to the infant (1 g gain is equal to 1 mL of volume).²⁰

Support to the mother is key to exclusive breast-feeding. The Cochrane Review on breast-feeding support found that lay support was more likely to prevent early cessation of breast-feeding at 6 months. The review also found that face-to-face support was associated with a more positive treatment effect than either phone support or mixed phone and face-to-face support.²¹ A pediatrician’s office should have a contact list of peer counselors and breast-feeding support groups to provide this support. An office may want to consider hosting a breast-feeding support group. Pediatricians should schedule a face-to-face visit in the first days after discharge to be followed with frequent peer support.

It is important to note that mothers with overweight or obesity are more likely to have delayed lactogenesis and a short duration of lactation. The early prolactin response is particularly important in milk production, and prolactin secretion in response to suckling is significantly less at 7 days postpartum in mothers with obesity than that of normal-weight mothers. This is the same time period in which mothers with overweight or obesity were likely to give up on breast-feeding.²² This is an additional reason why active support should be given to mothers during this time to prevent cessation of breast-feeding.

Transition to work

Another important period when breast-feeding mothers need support is when they transition back to work. Transitioning back to work influences the duration of breast-feeding. A study of female physicians who desired to breast-feed noted that only 34% were still breast-feeding by 12 months. Factors that sustained breast-feeding included not having to make up missed call or work, longer length maternity leave, sufficient time for milk expression, and a perceived level of breast-feeding support by colleagues, program directors, or section chiefs.²³ A Women, Infants, and Children (WIC) study found that receiving a formula discharge pack and returning to work before 3 months affected ability to sustain lactation.²⁴

Worksite lactation support policies correlate with sustaining exclusive breast-feeding for 6 months. The Affordable Care Act of 2010 amendment to the Fair Labor Standards Act regulates “reasonable” break time for nursing mothers.²⁵ Mothers need to know both the policies and the facilities available for pumping at their work site. If available, a hospital-grade pump should be used with the capacity to pump both breasts at the same time. Mothers will need storage containers and either refrigeration or a storage bag with frozen blocks to store milk. To maintain her milk supply, pumping should resemble her feeding frequency while with her infant. For further information about breast-feeding management, please see Table 5 of the AAP Policy Statement.¹⁵

Both WHO and the AAP support that complementary food be introduced at 6 months.⁹ There is conflicting research concerning the time of introduction of solid food and development of obesity. Many studies have not found differences in obesity rates with introduction at 4 months, but others have found that a delay until 20 to 24 weeks is associated with a lower risk of obesity.²⁶ Breast-fed babies tend to modulate the human milk intake to maintain a normal intake of carbohydrate, protein, and fat.²⁷ The AAP does recommend iron-fortified infant cereals or pureed meats as starter foods because of the iron and zinc provided.⁹ These foods are particularly important for the exclusively breast-fed infant because infant stores of these minerals are low by 6 months.

Infants need to be spoon-fed rather than putting food in a bottle or providing them with containers of food with a device for sucking the food. Ingesting food by sucking delays oral-motor development and may increase extra calories.

The following practices are also recommended⁹:

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  Avoid fruit juice during the first 6 months of life.

  
  
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  Limit 100% juice to 4 to 6 oz for children aged 1 to 6 years.

  
  
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  Avoid adding salt or sugar to infant foods.

  
  
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  Expose infant to a variety of pureed (to prevent choking) healthy foods, especially fruits and vegetables.

  
  
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  Encourage pureed whole fruits rather than juice or canned fruit in syrup.

  
  
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  Avoid low nutrient density, high caloric foods such as French fries, carbonated beverages, and sweets.

  
  
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  Provide 8 to 15 exposures for acceptance of a new food.

It is most important that readiness for eating is assessed because this sets the stage for developing a positive relationship with food and family. Table 4-2 indicates readiness characteristics for complementary food.