Feeding Requirements for the Infant and Younger Child

Growth, particularly weight gain, is the best overall measure of adequacy of infant nutrition. Early infancy is the period in life associated with the most rapid weight gain. It is, however, usually preceded by a brief period of weight loss, seen first after birth, although few children remain more than 10% below birth weight after 5 days.¹ Growth patterns differ between breastfed and artificially fed infants. Average weights of breastfed babies are similar to or higher than formula-fed babies until 4-6 months, after which breastfed babies slow significantly in their weight gain. Length and head circumference remain similar.²

Neonatal Daily Requirements:

• Fluid:
  • 0-6 months: 150 mL / kg per day (min)
  • 6 months: 120 mL / kg per day

Aside: These values for fluid requirements reflect oral milk volume of feeds. This is clearly different to volume requirements in a nil per oral (NPO) newborn. In other words, babies’ water (parenteral) and milk (oral) requirements are different: For normal nutrition, babies need 150-200 ml/kg per day of milk. This volume is substantially more than their water or intravenous fluid requirements. Newborns who are fasted should not be given the volume of fluid required for nutrition intravenously as this invariably leads to water overload. Parenteral fluid management requires regular clinical monitoring: signs of dehydration should be corrected, but equally, signs of over-hydration, such as rapid weight gain and eyelid oedema, avoided.²

Breast-milk feeding should be the primary aim for very sick babies. When babies are too ill or too premature to suckle at the breast, most mothers can establish lactation by expression. EBM can be fed via a tube until the baby is well enough to be placed on the breast.²

• Energy:  
  • Preterm: 110 – 135 kcal per kg
  • 1 month: 500 kJ (120 kcal) per kg
  • 12 months: 440 kJ (105 kcal) per kg

Normal stool frequency can range widely between infants, from five times in one day to only once every five days. In other words, be circumspect rather than quick to label a newborn constipated. Do not treat for constipation unless the baby is passing hard pellets. Not just stool frequency, but their baby’s stool colour, is a constant source of parental anxiety; and not without reason. But again, the range of normal for stool colour of newborns is also wide. Stool colour can normally be anything except: red (fresh blood); black (altered blood); or chalky-grey/white (= conjugated hyperbilirubinaemia).

Normal stools in a thriving baby is pretty reassuring: that’s a good start to life.

The Post-discharge Pre-term Infant:

Target weight gain in the pre-discharge preterm baby, when on full enteral feeds, is 10-25 grams/kg per day, with a neat average of 15g/kg per day. (Weight gains in excess of 25g/kg/day raise concerns about fluid retention.) Subsequently, the Royal Prince Alfred Hospital, for instance, provides routine post-discharge iron and vitamin supplementation for preterms born before 35 weeks with birth weight less than 2.5 kg. Supplementation is considered on an individual basis for babies born after 34 weeks and who are growth restricted.³

The Term Infant:

Breastfeeding alone is adequate, if not the preferred, nutrition for the first six to 12 months of life. Newborns will normally demand feed every 2-5 hours, including overnight, with length of feeds varying between as little as 5-6 minutes, and up to 20-30 minutes, long. Mum’s usually know when bub’s taken their full or the flow from that breast has started to slow. When the pauses between bursts of suckling are longer than the suckling itself, it’s time to try the other breast.

Neonatal appetite spurts occur naturally at: 2 weeks; 6 weeks; and 3 months of age. At all these times, but at 6 weeks especially (when the largest spurt in appetite is seen), the baby may become fussy as it awaits an increase in milk supply; which will come in response to the baby’s extra efforts at feeding, including increased frequency of demand feeding and more vigorous suckling. If not already, at these times, allow the infant to demand feed, even second-hourly if need be, and things should settle in about 48 hours or so, as the baby’s extra effort stimulate maternal neurohumoral reflexes (involving prolactin) and, after a brief lag-time, further milk production will come on line. In other words, this is not the time to tell mum to consider stopping breastfeeding because she is not producing enough milk. Instead, advise her to be patient for a couple of days and the infant’s extra efforts will be rewarded, and the infant settle.

Formula-fed (term) babies:

• 120-180 mL/kg per day
• 3-4 hours between feeds
• wet nappy with every feed

Formula is used at 3/4 strength for the first 24-48 hours, starting at 30-40 ml/ kg per 24 hours and aiming for 150 mL / kg per day, which is usually reached over 5-7 days by increments of 30 ml/kg per 24h, as tolerated.

• Day 5 to 3 months: 150 mL/kg per day, which is half-way of the 120-180 range recommended above (some, especially preterm, infants may require up to 180-200 mL/kg/day)
• 3 – 6 months: 120 mL/kg per day
• 6 – 12 months: 100 mL/kg per day (some infants may reduce to 90 mL/kg/day, as they often are also taking solids at this stage)⁴

(In terms of calorie requirements, this equates to: from Day 5 on, through to 5-6 months, 100-110 kcal / kg per day, and then 70-80 kcal / kg per day for the next six months (i.e. age 6-12 months ) after that.)

Feed frequency should be 3-4 hourly although, with reflux or abdominal distension, smaller volumes and more frequent feeds may help.

AGE (Months)	0-1 months	1-2 months	2-3 months	3-6 months
average weight (kg)	4.2	4.8	5.2	5.5 +
fluid per day (mL)	720	750	900	960
feeds per day	6-8	5-6	4-5	4-5

Dietary Allergens:

From 6 months onwards, the infant well established on solids needs at least 600-750 ml milk per day. Because of a presumed allergy risk, and because of inadequate nutritional content, sheep’s milk, goat’s milk, evaporated milk, rice, oat or almond drinks, or cow’s milk used as a drink, should not be given to the infant—i.e. under 1 year of age. Based on preliminary evidence of tolerance induction, complementary feeding during a window period at 4-6 month age may reduce the risk of food allergy,⁵ coeliac disease, and Type I DM.⁶ Peanut allergy is the most common food allergy and also the allergy most likely to persist for life. Breastfeeding is felt to protect against food allergy induction (except perhaps for egg allergy) in the infant with a family history of allergy, especially where mum takes probiotics during the third trimester of pregnancy and during lactation. Meanwhile, synbiotics (pro- and pre-biotics in combination) may help reduce the risk of allergy in the allergy-prone non-breastfed infant. Extensively hydrolysed rice protein-based formula, while recommended for children with cow’s milk allergy, is not recommended for prophylaxis alone.

The Australasian Society of Clinical Immunology and Allergy (ASCIA) guidelines state that:

When your infant is ready, at around 6 months, but not before 4 months, start to introduce a variety of solid foods, starting with iron rich foods, while continuing breastfeeding. All infants should be given allergenic solid foods including peanut butter, cooked egg, dairy, and wheat products in the first year of life. This includes infants at high risk of allergy.

ASCIA (2016)

Fortification:

Babies who may benefit from fortifiers are those with greatly increased nutritional requirements e.g. very-low birth weight (VLBW) or those requiring fluid restriction (heart failure or chronic liver disease). For babies with greater nutritional requirements, it is not appropriate to add calories only; such babies need a range of additional nutrients.

Disease that increase micronutrient requirements

All of these indications will be managed under paediatrician supervision:

• burns: vitamin C, B complex, folate, zinc
• HIV/AIDS: zinc, selenium, iron
• renal failure/dialysis: vitamin C, B complex, folate; (Cu, Cr, Mb)
• hemofiltration: vitamin C, B complex, trace elements
• protein-energy malnutrition: zinc, selenium, iron
• refeeding syndrome: phosphate, magnesium, potassium
• short bowel syndrome: vitamins A, B12, D, E, K, folate, zinc
• chronic malabsorption states: magnesium, selenium
• liver disease: vitamins A, B12, D, E, K, zinc, iron; (Mn, Cu)
• high fistula output, chronic diarrhoea: zinc, magnesium, selenium, folate, B complex, B12
• pancreatic insufficiency: vitamins A, D, E, K
• inflammatory bowel disease: folate, B12, zinc, iron²

But unless under paediatrician supervision, additional fortification of formula with folate, iron, sodium, vitamins C, D, and E, should await until feeds are fully established—i.e. 150-200 mL/kg per 24 h has been achieved. Again, unless under paediatrician supervision, iron should not be started until 12 weeks of age.^{7, 8} Because much of a child’s iron stores built up during pregnancy are utilised in the first few months of life, the American Academy of Pediatrics (AAP) recommends that, beginning at 4 months of age, breastfed infants be given daily iron supplementation until they begin eating iron-rich foods.⁹ All Basic Infant Formulae made up to full-strength will provide approximately 280 kJ/100ml (20 kcal/30ml). By using Low-Birth Weight (LBW) formulas, or concentrated standard formulas, adequate nutrition may be achieved with 120-150 mL/kg per 24 h. LBW formulas should be given diluted (15-20 kcal/30ml or 210-280 kJ/100ml) until full daily volumes are achieved. Standard strength (24k cal/30mL) should then be introduced.

Reflux

Small amounts of effortless posseting or physiological reflux are common in babies. Normal, healthy babies reflux about 30 times a day. The best cure for this reflux, for most babies, is time. But in some cases of recurrent vomiting and, where other causes have been excluded, thickening feeds can be appropriate. Because thickened feeds reduce suckling efficiency they may, however, decrease volume taken. Breast-fed babies can be given an alginate thickener before feeds, and bottle feeds can be thickened with a preparation based on rice starch, corn starch, locust bean gum, or carob bean gum. The use of alginate in one trial reduced the median number of vomiting episodes per day from 8.5 to 3 (vs. from 7 to 5 in the placebo group).^{10, 11} Carobel, from locust or carob bean, composed principally of mannan and galactan, i.e. non-available hemicelluloses, provides no energy contribution but may increase bulk and frequency of stools, due to undigested carbohydrate. Corn flour, on the other hand, contributes approximately 30 Calories / 250ml, or an 18% increase in calories. Corn flour is not, however, recommended in infants under 3 months old due to inadequate amylase levels. (Note that corn flour (corn starch) is absolutely no substitute for formula, it is only additive, and that thickened feeds can contribute to constipation.)

The range of formula options has increased in recent years, with options now including specifically modified
proteins, long-chain polyunsaturated fatty acids (LCPUFA), and probiotics. Changes between types of formula are made for a variety of reasons, including irritability, poor sleep and posseting. In the normal thriving infant there is little indication to change the type of formula. Care should be taken when changing between formulas to use the correct scoop and dilution (as these vary significantly between brands). There are a number of special types of formulas available over the counter including soy, AR (anti-reflux), low-lactose and hypoallergenic or partially hydrolysed formulas. They have specific indications and should not be encouraged unless there is evidence that they are required. That is low-lactose formula for proven lactose intolerance.²

The Older Infant

A cup can be introduced at around 6 months, to teach infants the skill of sipping drinks. The use of cow’s milk-based formulas is not recommended until after 12 months of age (Infant formulas in Australia are all iron-fortified).¹² Start to offer solids before regular milk feeds, as they a more major source of nutrition. Human milk or formula should be the major source of milk until one year of age when cow’s milk can be used instead (human milk can be continued over one year of age). However, from 8-9 months cow’s milk can be used in the preparation of foods such as custard and on cereal. Other milk products such as custard, yoghurt and cheeses can also be used from this time.

Around 6 months a child’s nutrient stores and requirements are no longer met by breast milk or formula alone, in particular for iron and zinc. Human milk or formula is still the most important part of the baby’s diet. Baby rice cereal is an excellent first solid food because of its smooth texture and high iron content. Other pureed foods to introduce are: vegetables such as pumpkin, potato, carrot and zucchini; fruit such as cooked apple and pear.

Caloric requirements of children

Infants: up to 12 months
Age	Energy (kJ / kg / day)
< 1 month	520
1 – 2 months	485
2 – 3 months	455
3 – 4 months	430
4 – 5 months	415
5 – 6 months	405
6 – 7 months	395
7 – 8 months	395
8 – 9 months	395
9 – 10 months	415
10 – 11 months	420
11 – 12 months	435
Children: 1 – 10 years
Years	MJ / day (male)	MJ / day (female)
1 – 2	5.0	4.8
2 – 3	5.9	5.5
3 – 4	6.5	6.0
4 – 5	7.1	6.4
5 – 6	7.6	6.8
6 – 7	7.9	7.1
7 – 8	8.3	7.4
8 – 9	8.7	7.7
9 – 10	9.0	7.9

The Toddler

The introduction of cow’s milk products as part of an expanding diet is appropriate, but the main milk intake
should be breast milk or formula until 12 months of age because of the risk of iron deficiency. Small amounts
of cow’s milk can be used on cereal, in custard and yoghurt from about 6 months.² Breastfeeding can continue for as long as desired, but bottle-feeding and infant formulas should stop from around 12 months, thereafter cow’s milk can be given from from a cup. However, toddlers who receive most of their calories from cow’s milk, e.g. more than 500 ml of cow’s milk in 24 hours, can become low in iron and fibre.¹³ Children should not be put to bed with a bottle of milk, for issues of dental hygiene alone. Infants and toddlers from 1 to 3 years old should have foods rich in iron, including iron-fortified cereals, red meat, and vegetables with iron, along with fruits rich in vitamin C to help absorb the iron. Although children do grow more modestly during the kindergarten years, low-fat diets are usually unnecessary because of children’s energy and nutrient needs remain relatively high. Children when hungry will eat, and should not be forced.

Young children often maintain oral intake when they are ill; however, in some cases additional supplements should be
added to oral feeds to maintain nutritional status. Such supplements may be energy substrates or complete supplements:

• Energy supplements: e.g. glucose polymers (Polyjoule) or fat emulsions (Calogen (long-chain fats), Liquigen (medium chain fats)) added to normal foods and fluids to increase energy intake.
• Complete supplements: e.g. Pediasure, Fortisip or Sustagen drinks, used in addition to usual foods to increase energy, protein and nutrient intake.²

A paediatric dietitian’s full nutritional assessment will help establish the optimum feeds. This assessment includes:

• current nutritional status
• current intake
• requirements
• medical condition / fluid restrictions

Monitoring patients on enteral feeds requires regular assessment of mechanical, metabolic, gastrointestinal, nutritional and growth parameters. Once the feeding plan has been fully implemented, regular assessment of the patient’s nutrient requirements is needed to ensure that nutritional support has been adequately maintained and to indicate when enteral feeding can be reduced or ceased.² Once the patient is able and willing to eat by mouth, enteral feeds can be reduced in proportion to the amount consumed orally. Transition from continuous feeds to overnight feeds may help establish oral intake while ensuring the patient is not nutritionally compromised.

Toddler’s diarrhoea

A clinical syndrome characterised by chronic diarrhoea often with undigested food in the stools, of a child who is otherwise well, gaining weight, and growing satisfactorily, the so-called “toddler’s” diarrhoea because it usually presents between 8 and 20 months of age, often comes with a family history of functional bowel disease, such as irritable bowel syndrome. Stools from these toddlers may contain mucus and are passed 3-6 times a day; they are often looser towards the end of the day. The treatment consists of reassurance and explanation, without any specific drug or dietary therapy of proven value, although some toddlers on a high-fructose intake may have “apple-juice” diarrhoea that responds to dietary change._²

The incidence of childhood inflammatory bowel disease has increased in Australian since the 1970s. Extra-intestinal manifestations can occur in both ulcerative colitis and Crohn’s disease and include arthritis, erythema nodosum, hepatitis, and ophthalmological complications (uveitis and episcleritis). Crohn’s disease can present in several ways including recurrent abdominal pain, weight loss, chronic diarrhoea, mouth ulcers, and perianal disease or, indeed, with isolated growth failure without any gastrointestinal symptoms. Ulcerative colitis is associated with bloody diarrhoea, which extends beyond the time frame of any infective colitis. In every child who presents with chronic diarhhoea, the decision must be made as to whether to investigate further.²

In most children, chronic constipation is due to functional faecal retention (withholding of stool). Low dietary fibre and poor fluid intake rarely contribute to childhood chronic constipation, and should not be highlighted in the clinical interview. Rather, painful or fear of painful defecation are the most common triggers of constipation, leading to apprehension about defecation and a cycle of withholding and passage of hard retained stool: < 3 bowel motions per week; > 1 episode of faecal incontinence per week; large stools in the rectum or palpable on abdominal examination; passage of stools so large that they obstruct the toilet; retentive posturing and withholding behaviour; painful defecation.² Dyschezia (a healthy infant, straining and crying before passing soft stool) is normal but can be mistaken for constipation.

Conversely, the organic causes of chronic constipation are rare:

• Cow’s milk protein allergy (non-IgE) may manifest as constipation in the first 3 years of life
• Hirschsprung’s disease – usually presents in first 48 hours of life, with failure to pass meconium
• Coeliac disease
• hypothyroidism
• hypercalcaemia
• drugs – e.g. codeine, antacids
• spinal cord lesions
• anorectal malformations

Don’t over fuss about child feeding and in, most instances, simply allowing the child’s natural processes and instincts, with the occasional intervention for reassurance and guidance, to lead the way is the simplest and best approach. A non-thriving or malnourished child or a pale-looking child warrants investigation and some dietary modification.

References

1. Wright C. M., Parkinson K. N. “Postnatal weight loss in term infants: what is “normal” and do growth charts allow for it?” Archives of Disease in Childhood – Fetal and Neonatal Edition 2004;89:F254-F257.
2. Alex, George; Gibbs, Susie; Hardkar, Winita and Nightingale, Michael. “Gastrointestinal conditions.” In (Eds.) Gwee, Amanda; Rimer, Romi and Marks, Michael. The Royal Children’s Hospital Melbourne: Paediatric Handbook. 9th Edn. (West Sussex: John Wiley & Sons Ltd, 2015)
3. Enteral Nutrition for the Preterm Infant_ed 22nd Dec.doc (nsw.gov.au)
4. “Infant Feeding.” Paediatric Emergency Care Handbook. Royal Australian college of General Practitioners. : 2.1-2.7
5. Poole JA, Barriga K, Leung DY, Hoffman M, Eisenbarth GS, Rewers M, Norris JM. “Timing of initial exposure to cereal grains and the risk of wheat allergy.” Pediatrics. 2006 Jun;117(6):2175-82. doi: 10.1542/peds.2005-1803. PMID: 16740862.
6. Norris JM, Barriga K, Klingensmith G, et al. “Timing of Initial Cereal Exposure in Infancy and Risk of Islet Autoimmunity.” JAMA. 2003;290(13):1713–1720. doi:10.1001/jama.290.13.1713.
7. Rao, Raghavendra, and Michael K Georgieff. “Iron therapy for preterm infants.” Clinics in perinatology vol. 36,1 (2009): 27-42. doi:10.1016/j.clp.2008.09.013
8. Berglund S, Westrup B, Domellof M. Iron supplements reduce the risk of iron deficiency anemia in marginally low birth weight infants. Pediatrics. 2010;126(4):e874-83.
9. Iron-Deficiency Anemia in Children (stanfordchildrens.org)
10. Miller S. Comparison of the efficacy and safety of a new aluminium-free paediatric alginate preparation and placebo in infants with recurrent gastroesophageal reflux. Current Medical Research and Opinion 1999;15(3):160­–68.
11. Kwok, T’ng Chang et al. “Feed thickener for infants up to six months of age with gastro-oesophageal reflux.” The Cochrane database of systematic reviews vol. 12,12 CD003211. 5 Dec. 2017, doi:10.1002/14651858.CD003211.pub2.
12. National Health and Medical Research Council (NHMRC). Eat For Health: Infant Feeding Guidelines – Summary. Canberra: NHMRC. 2012.
13. Kids Health Information : Nutrition – babies and toddlers (rch.org.au)
14. ASCIA. “Infant feeding and allergy prevention.” Australasian Society of Clinical Immunology and Allergy (ASCIA) Guidelines. 2016. http://www.allergy.org.au/.

Further:

• Nutrient Reference Values | for Australia and New Zealand (nrv.gov.au)
• Stallings VA. Feeding Infants and Toddlers Study (FITS) 2016: “Findings and Thoughts on the Third Data Cycle.” The Journal of Nutrition. 2018 Sep;148(suppl_3):1513S-1515S. DOI: 10.1093/jn/nxy158.