32 Nutrition

Martha Lally and Suzanne Valentine-French

Breast milk is considered the ideal diet for newborns. Colostrum, the first breast milk produced during pregnancy and just after birth, has been described as “liquid gold” (United States Department of Health and Human Services, 2011). It is very rich in nutrients and antibodies. Breast milk changes by the third to fifth day after birth, becoming much thinner, but containing just the right amount of fat, sugar, water, and proteins to support overall physical and neurological development. For most babies, breast milk is also easier to digest than formula. Formula-fed infants experience more diarrhea and upset stomachs. The absence of antibodies in formula often results in a higher rate of ear infections and respiratory infections. Children who are breastfed have lower rates of childhood leukemia, asthma, obesity, and type 1 and 2 diabetes, and a lower risk of SIDS. The US Department of Health and Human Services recommends that mothers breastfeed their infants until at least six months of age and that breast milk be used in the diet throughout the first year or two.
A woman breastfeeding her baby.
Figure 3.11: Breastfeeding

Several recent studies have reported that it is not just babies that benefit from breastfeeding. Breastfeeding stimulates contractions in the uterus to help it return to its normal size, and women who breastfeed are more likely to space their pregnancies further apart. Mothers who breastfeed are at lower risk of developing breast cancer (Islami et al., 2015), especially among higher risk racial and ethnic groups (Islami et al., 2015; Redondo et al., 2012). Women who breastfeed have lower rates of ovarian cancer (Titus-Ernstoff, Rees, Terry, and Cramer, 2010), reduced risk for developing type 2 diabetes (Schwarz et al., 2010; Gunderson, et al., 2015), and rheumatoid arthritis (Karlson, Mandl, Hankinson, and Grodstein, 2004). In most studies, these benefits have been seen in women who breastfeed longer than six months.

However, most mothers who breastfeed in the United States stop breastfeeding around six to eight weeks, often in order to return to work outside the home (United States Department of Health and Human Services, 2011). Mothers can certainly continue to provide breast milk to their babies by expressing and freezing the milk to be bottle fed at a later time or by being available to their infants at feeding time. However, some mothers find that after the initial encouragement they receive in the hospital to breastfeed, the outside world is less supportive of such efforts. Some workplaces support breastfeeding mothers by providing flexible schedules and welcoming infants, but many do not. In addition, not all women may be able to breastfeed. Women with HIV are routinely discouraged from breastfeeding as the infection may pass to the infant. Similarly, women who are taking certain medications or undergoing radiation treatment may be told not to breastfeed (United States Department of Health and Human Services, 2011).

In addition to the nutritional benefits of breastfeeding, breast milk is free. Anyone who has priced formula can appreciate this added incentive to breastfeeding. Prices for a year’s worth of formula and feeding supplies can cost well over $1,500 (United States Department of Health and Human Services, 2011).

One early argument given to promote the practice of breastfeeding was that it encouraged bonding and healthy emotional development for infants. However, this does not seem to be the case. Breastfed and bottle-fed infants adjust equally well emotionally (Ferguson and Woodward, 1999). This is good news for mothers who may be unable to breastfeed for a variety of reasons and for fathers who might feel left out.

When to Introduce More Solid Foods

Solid foods should not be introduced until the infant is ready. According to the Clemson University Cooperative Extension (2014), infants are ready for solid food when they:

  • can sit up without needing support;
  • can hold their head up without wobbling;
  • show interest in foods others are eating;
  • are still hungry after being breastfed or formula fed;
  • are able to move foods from the front to the back of the mouth; and
  • are able to turn away when they have had enough.

For many infants who are four to six months old, breast milk or formula can be supplemented with solid foods. The first semi-solid foods that are introduced are iron-fortified infant cereals mixed with breast milk or formula. Typically, rice, oatmeal, and barley cereals are offered as a number of infants are sensitive to wheat-based cereals. Finger foods such as toast squares, cooked vegetable strips, or peeled soft fruit can be introduced by ten to twelve months. New foods should be introduced one at a time, and the new food should be fed for a few days in a row to allow the baby time to adjust to it. This also allows parents time to assess if the child has a food allergy. Foods that have multiple ingredients should be avoided until parents have assessed how the child responds to each ingredient separately. Foods that are sticky (such as peanut butter or taffy), cut into large chunks (such as cheese and harder meats), and firm and round (such as hard candies, grapes, or cherry tomatoes) should be avoided as they are a choking hazard. Honey and corn syrup should be avoided as these often contain botulism spores. In children under twelve months this can lead to death (Clemson University Cooperative Extension, 2014).

Global Considerations and Malnutrition

Children in developing countries and countries experiencing the harsh conditions of war are at risk for two major types of malnutrition, also referred to as wasting. Infantile marasmus refers to starvation due to a lack of calories and protein. Children who do not receive adequate nutrition lose fat and muscle until their bodies can no longer function. Babies who are breastfed are at much less risk of malnutrition than those who are bottle fed. After weaning, children who have diets deficient in protein may experience kwashiorkor or the “disease of the displaced child” often occurring after another child has been born and taken over breastfeeding. This results in a loss of appetite and swelling of the abdomen as the body begins to break down the vital organs as a source of protein.


Children with Kwashiorkor
Figure 3.12: Children experiencing kwashiorkor (photo courtesy of Centers for Disease Control and Prevention)

Around the world the rates of wasting have been dropping. However, according to the World Health Organization and UNICEF, in 2014 there were 50 million children under the age of five that experienced these forms of wasting, and 16 million were severely wasted (UNICEF, 2015). This means that one in every thirteen childen worldwide suffers from some form of wasting. The majority of these children live in Asia (34.3 million) and Africa (13.9 million). Wasting can occur as a result of severe food shortages, regional diets that lack certain proteins and vitamins, or infectious diseases that inhibit appetite (Latham, 1997).

The consequences of wasting depend on how late in its progression a child receives medical treatment. Unfortunately, if treatment is delayed, the child can die even after being admitted to a hospital (Latham, 1997). Several studies have reported long-term cognitive effects of early malnutrition (Galler and Ramsey, 1989; Galler, Ramsey, Salt, and Archer, 1987; Richardson, 1980), even when home environments were controlled (Galler, Ramsey, Morley, Archer, and Salt, 1990). Lower IQ scores (Galler et al., 1987), poor attention (Galler and Ramsey, 1989), and behavioural issues in the classroom (Galler et al., 1990) have been reported in children with a history of serious malnutrition in the first few years of life.

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