Chapter 12 Nutrition through the Life Cycle: From Pregnancy to the Toddler Years

Weight Gain during Pregnancy

During pregnancy, a mother’s body changes in many ways. One of the most notable and significant changes is weight gain. If a pregnant woman does not gain enough weight, her unborn baby will be at risk. Poor weight gain, especially in the third trimester, could result not only in low birth weight, but also infant mortality and intellectual disabilities. Therefore, it is vital for a pregnant woman to maintain a healthy weight, and her weight prior to pregnancy has a major affect. Infant birth weight is one of the best indicators of a baby’s future health. Pregnant women of normal weight should gain between 25 and 35 pounds in total through the entire pregnancy. The precise amount that a mother should gain usually depends on her beginning body mass index (BMI). See Table 12.1 "Body Mass Index and Pregnancy" for The Institute of Medicine (IOM) recommendations.

The weight an expectant mother gains during pregnancy is almost all lean tissue, including the placenta and fetus. Weight gain is not the only major change. A pregnant woman also will find that her breasts enlarge and that she has a tendency to retain water.

Source: Utah Department of Health, Baby Your Baby. “Weight Gain during Pregnancy.” © 2012 Baby Your Baby. http://www.babyyourbaby.org/pregnancy/during.

Starting weight below or above the normal range can lead to different complications. Pregnant women with a prepregnancy BMI below twenty are at a higher risk of a preterm delivery and an underweight infant. Pregnant women with a prepregnancy BMI above thirty have an increased risk of the need for a cesarean section during delivery. Therefore, it is optimal to have a BMI in the normal range prior to pregnancy.

Generally, women gain 2 to 5 pounds in the first trimester. After that, it is best not to gain more than one pound per week. Some of the new weight is due to the growth of the fetus, while some is due to changes in the mother’s body that support the pregnancy. Weight gain often breaks down in the following manner: 6 to 8 pounds of fetus, 1 to 2 pounds for the placenta (which supplies nutrients to the fetus and removes waste products), 2 to 3 pounds for the amniotic sac (which contains fluids that surround and cushion the fetus), 1 to 2 pounds in the breasts, 1 to 2 pounds in the uterus, 3 to 4 pounds of maternal blood, 3 to 4 pounds maternal fluids, and 8 to 10 pounds of extra maternal fat stores that will be needed for breastfeeding and delivery. Women who are pregnant with more than one fetus are advised to gain even more weight to ensure the health of their unborn babies.

The pace of weight gain is also important. If a woman puts on weight too slowly, her physician may recommend nutrition counseling. If she gains weight too quickly, especially in the third trimester, it may be the result of edema, or swelling due to excess fluid accumulation. Rapid weight gain may also result from increased calorie consumption or a lack of exercise.

Weight Loss after Pregnancy

During labor, new mothers lose some of the weight they gained during pregnancy with the delivery of their child. In the following weeks, they continue to shed weight as they lose accumulated fluids and their blood volume returns to normal. Some studies have hypothesized that breastfeeding also helps a new mother lose some of the extra weight, although research is ongoing.Stuebe, A. M., MD, MSc and J. W. Rich-Edwards, Sc. D. “The Reset Hypothesis: Lactation and Maternal Metabolism.” © Thieme Medical Publishers, Am J Perinatol 26, no.1 (2009): 81–88. doi: 10.1055/s-0028-1103034. New mothers who gain a healthy amount of weight and participate in regular physical activity during their pregnancies also have an easier time shedding weight postpregnancy. However, women who gain more weight than needed for a pregnancy typically retain that excess weight as body fat. If those few pounds increase a new mother’s BMI by a unit or more, that could lead to complications such as hypertension or Type 2 diabetes in future pregnancies or later in life.

Energy

During the first trimester, a pregnant woman has the same energy requirements as normal and should consume the same number of calories as usual—about 1,800 calories for a woman living a sedentary lifestyle, about 2,000 calories for a woman who is moderately active, and about 2,200 for a woman who is active. However, as the pregnancy progresses, a woman must increase her caloric intake. According to the IOM, she should consume an additional 340 calories per day during the second trimester, and an additional 450 calories per day during the third trimester. This is partly due to an increase in metabolism, which rises during pregnancy and contributes to increased energy needs. A woman can easily meet these increased needs by consuming more nutrient-dense foods. For example, an additional 340 calories could include a medium-sized banana (about 100 calories), a cup of nonfat yogurt with fruit on the bottom (about 140 calories), and a slice of whole-wheat toast (about 75 calories).

Carbohydrates

The recommended daily allowance, or RDA, of carbohydrates during pregnancy is about 175 to 265 grams per day to fuel fetal brain development. The best food sources for pregnant women include whole-grain breads and cereals, brown rice, root vegetables, legumes, and fruits. These and other unrefined carbohydrates provide nutrients, phytochemicals, antioxidants, and fiber. These foods also help to build the placenta and supply energy for the growth of the unborn baby. Refined carbohydrates, such as white bread, cookies and other baked desserts, pretzels, and chips are nutritionally deficient and should be kept to a minimum.

Protein

During pregnancy, extra protein is needed for the synthesis of new maternal and fetal tissues. Protein builds muscle and other tissues, enzymes, antibodies, and hormones in both the mother and the unborn baby. Additional protein also supports increased blood volume and the production of amniotic fluid. The RDA of protein during pregnancy is 71 grams per day, which is 25 grams above the normal recommendation. However, in most instances, there is no need for a pregnant woman to make an effort to increase protein intake as long as she has a normal appetite, because even nonpregnant women in North America typically eat that much protein. Protein should be derived from healthy sources, such as lean red meat, white-meat poultry, legumes, nuts, seeds, eggs, and fish. Low-fat milk and other dairy products also provide protein, along with calcium and other nutrients.

Fat

There are no specific recommendations for fats in pregnancy, apart from following normal dietary guidelines. Fats should make up 25 to 35 percent of daily calories, and those calories should come from healthy fats, such as avocados. Foods with unhealthy fats, including French fries and other fast food, should be avoided. Also, it is not recommended for pregnant women to be on a very low-fat diet, since it would be hard to meet the needs of essential fatty acids and fat-soluble vitamins. Fatty acids are important during pregnancy because they support the baby’s brain and eye development. In particular, the brain depends on omega-3 and omega-6 fatty acids, such as the kind found in salmon and sunflower or safflower oil, for function, structure, and growth. Fats can also help the placenta grow and may help to prevent premature birth and low birth weight.

Fiber

Fresh fruit and whole grains, such as a bowl of muesli, are excellent sources of fiber during a pregnancy.

© Thinkstock

Ideally, a pregnant woman should eat 25 to 30 grams of dietary fiber per day. There are two types of fiber, and pregnant women should consume both. Insoluble fiberFiber that is metabolically inert, which means it does not break down as it passes through the digestive system. Insoluble fiber absorbs water and adds bulk to stool, expediting the passage of food and waste. acts as a natural laxative, which softens stools and speeds the elimination of waste material through the colon to avoid constipation. Sources of insoluble fiber include whole grains, fruits, vegetables, dried peas, and beans. Soluble fiberFiber that attracts water and turns to gel, which slows digestion. Soluble fiber is readily fermented in the colon by bacteria into gases and waste byproducts. has little effect on the intestines, however it helps to lower blood-cholesterol levels and regulate blood glucose. Sources of soluble fiber include fruits, vegetables, and beans, along with oats, barley, and other fiber-filled whole grains.

Fluids

Fluid intake must also be monitored. According to the IOM, pregnant women should drink 2.3 liters (about 10 cups) of liquids per day to provide enough fluid for blood production. It is also important to drink liquids during physical activity or when it is hot and humid outside, to replace fluids lost to perspiration. The combination of a high-fiber diet and lots of liquids also helps to eliminate waste.US Department of Health and Human Services, Office on Women’s Health. “Pregnancy: Body Changes and Discomforts.” Last updated September 27, 2010. http://www.womenshealth.gov/pregnancy/you-are-pregnant/body-changes -discomforts.cfm.

Vitamins and Minerals

Pregnancy requires certain conditionally essential nutrientsNutrients that are supplied only under special conditions or circumstances, such as pregnancy, stress, illness, or aging., which are nutrients that are supplied only under special conditions, such as stress, illness, or aging. The daily requirements for nonpregnant women change with the onset of a pregnancy. Taking a daily prenatal supplement or multivitamin helps to meet many nutritional needs. However, most of these requirements should be fulfilled with a healthy diet. The following table compares the normal levels of required vitamins and minerals to the levels needed during pregnancy. For pregnant women, the RDA of nearly all vitamins and minerals increases.

The micronutrients involved with building the skeleton—vitamin D, calcium, phosphorus, and magnesium—are crucial during pregnancy to support fetal bone development. Although the levels are the same as those for nonpregnant women, many women do not typically consume adequate amounts and should make an extra effort to meet those needs.

There is an increased need for all B vitamins during pregnancy. Adequate vitamin B₆ supports the metabolism of amino acids, while more vitamin B₁₂ is needed for the synthesis of red blood cells and DNA. Additional zinc is crucial for cell development and protein synthesis. The need for vitamin A also increases, and extra iron intake is important because of the increase in blood supply during pregnancy and to support the fetus and placenta. Iron is the one micronutrient that is almost impossible to obtain in adequate amounts from food sources only. Therefore, even if a pregnant woman consumes a healthy diet, there still is a need to take an iron supplement, in the form of ferrous salts. Also remember that folate needs increase during pregnancy to 600 micrograms per day to prevent neural tube defects. This micronutrient is crucial for fetal development because it helps produce the extra blood a woman’s body requires during pregnancy.

For most other minerals, recommended intakes are similar to those for nonpregnant women, although it is crucial for pregnant women to make sure to meet the RDAs to reduce the risk of birth defects. In addition, pregnant mothers should avoid exceeding any recommendations. Taking megadose supplements can lead to excessive amounts of certain micronutrients, such as vitamin A and zinc, which may produce toxic effects that can also result in birth defects.

Foods to Avoid

A number of substances can harm a growing fetus. Therefore, it is vital for women to avoid them throughout a pregnancy. Some are so detrimental that a woman should avoid them even if she suspects that she might be pregnant. For example, consumption of alcoholic beverages results in a range of abnormalities that fall under the umbrella of fetal alcohol spectrum disorders. They include learning and attention deficits, heart defects, and abnormal facial features. Alcohol enters the unborn baby via the umbilical cord and can slow fetal growth, damage the brain, or even result in miscarriage. The effects of alcohol are most severe in the first trimester, when the organs are developing. As a result, there is no safe amount of alcohol that a pregnant woman can consume. Although pregnant women in the past may have participated in behavior that was not known to be risky at the time, such as drinking alcohol or smoking cigarettes, today we know that it is best to avoid those substances completely to protect the health of the unborn baby.

Pregnant women should also limit caffeine intake, which is found not only in coffee, but also tea, colas, cocoa, chocolate, and some over-the-counter painkillers. Some studies suggest that very high amounts of caffeine have been linked to babies born with low birth weights. The American Journal of Obstetrics and Gynecology released a report, which found that women who consume 200 milligrams or more of caffeine a day (which is the amount in 10 ounces of coffee or 25 ounces of tea) increase the risk of miscarriage.Weng X, Odouli R, and Li D-K. “Maternal caffeine consumption during pregnancy and the risk of miscarriage: a prospective cohort study.” Am J Obstet Gynecol 2008;198:279.e1-279.e8. Consuming large quantities of caffeine affects the pregnant mother as well, leading to irritability, anxiety, and insomnia. Most experts agree that small amounts of caffeine each day are safe (about one 8-ounce cup of coffee a day or less).American Medical Association, Complete Guide to Prevention and Wellness (Hoboken, NJ: John Wiley & Sons, Inc., 2008), 495. However, that amount should not be exceeded.

Foodborne Illness

For both mother and child, foodborne illness can cause major health problems. For example, the foodborne illness caused by the bacteria Listeria monocytogenes can cause spontaneous abortion and fetal or newborn meningitis. According to the CDC, pregnant women are twenty times more likely to become infected with this disease, which is known as listeriosis, than nonpregnant, healthy adults. Symptoms include headaches, muscle aches, nausea, vomiting, and fever. If the infection spreads to the nervous system, it can result in a stiff neck, convulsions, or a feeling of disorientation.American Pregnancy Association. “Listeria and Pregnancy.” © 2000–2012 American Pregnancy Association. http://www.americanpregnancy.org/pregnancycomplications/listeria.html.

Foods more likely to contain the bacteria are unpasteurized dairy products, especially soft cheeses, and also smoked seafood, hot dogs, paté, cold cuts, and uncooked meats. To avoid consuming contaminated foods, women who are pregnant or breastfeeding should take the following measures:

• Thoroughly rinse fruits and vegetables before eating them
• Keep cooked and ready-to-eat food separate from raw meat, poultry, and seafood
• Store food at 40° F (4° C) or below in the refrigerator and at 0° F (−18° C) in the freezer
• Refrigerate perishables, prepared food, or leftovers within two hours of preparation or eating
• Clean the refrigerator regularly and wipe up any spills right away
• Check the expiration dates of stored food once per week

You will learn more about foodborne illness and its consequences in Chapter 14 "Nutrition and Society: Food Politics and Perspectives" and Chapter 15 "Achieving Optimal Health: Wellness and Nutrition".

Food Contaminants

It is always important to avoid consuming contaminated food to prevent food poisoning. This is especially true during pregnancy. Heavy metal contaminants, particularly mercury, lead, and cadmium, pose risks to pregnant mothers. As a result, vegetables should be washed thoroughly or have their skins removed to avoid heavy metals.

Pregnant women can eat fish, ideally 8 to 12 ounces of different types each week. Expectant mothers are able to eat cooked shellfish such as shrimp, farm-raised fish such as salmon, and a maximum of 6 ounces of albacore, or white, tuna. However, they should avoid fish with high methyl mercury levels, such as shark, swordfish, tilefish, and king mackerel. Pregnant women should also avoid consuming raw shellfish to avoid foodborne illness. The Environmental Defense Fund eco-rates fish to provide guidelines to consumers about the safest and most environmentally friendly choices. You can find ratings for fish and seafood at http://www.edf.org.

Nausea and Vomiting

Nausea and vomiting are gastrointestinal issues that strike many pregnant women, typically in the first trimester. Nausea tends to occur more frequently than vomiting. These conditions are often referred to as “morning sickness,” although that’s something of a misnomer because nausea and vomiting can occur all day long, although it is often the worst in the first part of the day.

Increased levels of the pregnancy hormone human chorionic gonadotropin may cause nausea and vomiting, although that is speculative. Another major suspect is estrogen because levels of this hormone also rise and remain high during pregnancy. Given that a common side effect of estrogen-containing oral contraceptives is nausea this hormone likely has a role. Nausea usually subsides after sixteen weeks, possibly because the body becomes adjusted to higher estrogen levels.

It can be useful for pregnant women to keep a food diary to discover which foods trigger nausea, so they can avoid them in the future. Other tips to help avoid or treat nausea and vomiting include the following:

• Avoid spicy foods
• Avoid strong or unusual odors
• Eat dry cereal, toast, or crackers
• Eat frequent, small meals
• Consume more unrefined carbohydrates
• Get moderate aerobic exercise
• Drink ginger tea, which aids in stomach upset
• Seek fresh air when a bout of nausea comes on

A severe form of nausea and vomiting is a condition known as hyperemesis gravidarum. It is marked by prolonged vomiting, which can result in dehydration and require hospitalization. This disorder is relatively rare and impacts only 0.3 to 2 percent of all pregnant women.Eliakim, R., O. Abulafia, and D. M. Sherer. “Hyperemesis Gravidarum: A Current Review.” Am J Perinatol 17, no. 4 (2000): 207–18.

Food Cravings and Aversions

Food aversions and cravings do not have a major impact unless food choices are extremely limited. The most common food aversions are milk, meats, pork, and liver. For most women, it is not harmful to indulge in the occasional craving, such as the desire for pickles and ice cream. However, a medical disorder known as pica is willingly consuming foods with little or no nutritive value, such as dirt, clay, and laundry starch. In some places this is a culturally accepted practice. However, it can be harmful if these substances take the place of nutritious foods or contain toxins.

Gestational Hypertension

Gestational hypertensionA possible complication of pregnancy characterized by raised blood pressure levels. is a condition of high blood pressure during the second half of pregnancy. Also referred to as pregnancy-induced hypertension, this condition affects about 6 to 8 percent of all pregnant women. First-time mothers are at a greater risk, along with women who have mothers or sisters who had gestational hypertension, women carrying multiple fetuses, women with a prior history of high blood pressure or kidney disease, and women who are overweight or obese when they become pregnant.

Hypertension can prevent the placenta from getting enough blood, which would result in the baby getting less oxygen and nutrients. This can result in low birth weight, although most women with gestational hypertension can still deliver a healthy baby if the condition is detected and treated early. Some risk factors can be controlled, such as diet, while others cannot, such as family history. If left untreated, gestational hypertension can lead to a serious complication called preeclampsiaA possible complication of pregnancy marked by elevated blood pressure and high levels of protein in the urine., which is sometimes referred to as toxemia. This disorder is marked by elevated blood pressure and protein in the urine and is associated with swelling. To prevent preeclampsia, the WHO recommends increasing calcium intake for women consuming diets low in that micronutrient, administering a low dosage of aspirin (75 milligrams), and increasing prenatal checkups.World Health Organization. “WHO Recommendations for Prevention and Treatment of Pre-eclampsia and Eclampsia.” 2011. Accessed June 8, 2012. http://whqlibdoc.who.int/publications/2011/9789241548335_eng.pdf.

Gestational Diabetes

About 4 percent of pregnant women suffer from a condition known as gestational diabetesA possible complication of pregnancy characterized by elevated blood glucose levels., which is abnormal glucose tolerance during pregnancy. The body becomes resistant to the hormone insulin, which enables cells to transport glucose from the blood. Gestational diabetes is usually diagnosed around twenty-four to twenty-six weeks, although it is possible for the condition to develop later into a pregnancy. Signs and symptoms of this disease include extreme hunger, thirst, or fatigue. If blood sugar levels are not properly monitored and treated, the baby might gain too much weight and require a cesarean delivery. Diet and regular physical activity can help to manage this condition. Most patients who suffer from gestational diabetes also require daily insulin injections to boost the absorption of glucose from the bloodsteam and promote the storage of glucose in the form of glycogen in liver and muscle cells. Gestational diabetes usually resolves after childbirth, although some women who suffer from this condition develop Type 2 diabetes later in life, particularly if they are overweight.

Energy

Energy needs relative to size are much greater in an infant than an adult. A baby’s resting metabolic rate is two times that of an adult. The RDA to meet energy needs changes as an infant matures and puts on more weight. The IOM uses a set of equations to calculate the total energy expenditure and resulting energy needs. For example, the equation for the first three months of life is (89 x weight [kg] −100) + 175 kcal.

Based on these equations, the estimated energy requirement for infants from zero to six months of age is 472 to 645 kilocalories per day for boys and 438 to 593 kilocalories per day for girls. For infants ages six to twelve months, the estimated requirement is 645 to 844 kilocalories per day for boys and 593 to 768 kilocalories per day for girls. From the age one to age two, the estimated requirement rises to 844–1,050 kilocalories per day for boys and 768–997 kilocalories per day for girls.Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids, Institute of Medicine of the National Academies (Washington, D.C.: The National Academies Press, 2005), 169–70. How often an infant wants to eat will also change over time due to growth spurts, which typically occur at about two weeks and six weeks of age, and again at about three months and six months of age.

Macronutrients

The dietary recommendations for infants are based on the nutritional content of human breast milk. Carbohydrates make up about 45 to 65 percent of the caloric content in breast milk, which amounts to a RDA of about 130 grams. Almost all of the carbohydrate in human milk is lactose, which infants digest and tolerate well. In fact, lactose intolerance is practically nonexistent in infants. Protein makes up about 5 to 20 percent of the caloric content of breast milk, which amounts to 13 grams per day. Infants have a high need for protein to support growth and development, though excess protein (which is only a concern with bottle-feeding) can cause dehydration, diarrhea, fever, and acidosis in premature infants. About 30 to 40 percent of the caloric content in breast milk is made up of fat. A high-fat diet is necessary to encourage the development of neural pathways in the brain and other parts of the body. However, saturated fats and trans fatty acids inhibit this growth. Infants who are over the age of six months, which means they are no longer exclusively breastfed, should not consume foods that are high in these types of fats.

Micronutrients

Almost all of the nutrients that infants require can be met if they consume an adequate amount of breast milk. There are a few exceptions, though. Human milk is low in vitamin D, which is needed for calcium absorption and building bone, among other things. Therefore, breastfed children often need to take a vitamin D supplement in the form of drops. Infants at the highest risk for vitamin D deficiency are those with darker skin and no exposure to sunlight. Breast milk is also low in vitamin K, which is required for blood clotting, and deficits could lead to bleeding or hemorrhagic disease. Babies are born with limited vitamin K, so supplementation may be needed initially and some states require a vitamin K injection after birth. Also, breast milk is not high in iron, but the iron in breast milk is well absorbed by infants. After four to six months, however, an infant needs an additional source of iron other than breast milk.

Fluids

Infants have a high need for fluids, 1.5 milliliters per kilocalorie consumed compared to 1.0 milliliters per kilocalorie consumed for adults. This is because children have larger body surface area per unit of body weight and a reduced capacity for perspiration. Therefore, they are at greater risk of dehydration. However, parents or other caregivers can meet an infant’s fluid needs with breast milk or formula. As solids are introduced, parents must make sure that young children continue to drink fluids throughout the day.

Lactation

LactationThe medical term for the process of producing and secreting breast milk. is the process that makes breastfeeding possible, and is the synthesis and secretion of breast milk. Early in a woman’s pregnancy, her mammary glands begin to prepare for milk production. Hormones play a major role in this, particularly during the second and third trimesters. At that point, levels of the hormone prolactin increase to stimulate the growth of the milk duct system, which initiates and maintains milk production. Levels of the hormone oxytocin also rise to promote the release of breast milk when the infant suckles, which is known as the milk ejection reflex. However, levels of the hormone progesterone need to decrease for successful milk production, because progesterone inhibits milk secretion. Shortly after birth, the expulsion of the placenta triggers progesterone levels to fall, which activates lactation.King, J. “Contraception and Lactation: Physiology of Lactation.” Journal of Midwifery and Women’s Health 52, no. 6 (2007): 614–20. © 2007 Elsevier Science, Inc.

New mothers need to adjust their caloric and fluid intake to make breastfeeding possible. The RDA is 330 additional calories during the first six months of lactation and 400 additional calories during the second six months of lactation. The energy needed to support breastfeeding comes from both increased intake and from stored fat. For example, during the first six months after her baby is born, the daily caloric cost for a lactating mother is 500 calories, with 330 calories derived from increased intake and 170 calories derived from maternal fat stores. This helps explain why breastfeeding may promote weight loss in new mothers. Lactating women should also drink 3.1 liters of liquids per day (about 13 cups) to maintain milk production, according to the IOM. As is the case during pregnancy, the RDA of nearly all vitamins and minerals increases for women who are breastfeeding their babies. The following table compares the recommended vitamins and minerals for lactating women to the levels for nonpregnant and pregnant women from Table 12.2 "Recommended Nutrient Intakes during Pregnancy".

Calcium requirements do not change during breastfeeding because of more efficient absorption, which is the case during pregnancy, too. However, the reasons for this differ. During pregnancy, there is enhanced absorption within the gastrointestinal tract. During lactation, there is enhanced retention by the kidneys. The RDA for phosphorus, fluoride, and molybdenum also remains the same.

Components of Breast Milk

Human breast milk not only provides adequate nutrition for infants, it also helps to protect newborns from disease. In addition, breast milk is rich in cholesterol, which is needed for brain development. It is helpful to know the different types and components of breast milk, along with the nutrients they provide to enable an infant survive and thrive.

Diet and Milk Quality

A mother’s diet can have a major impact on milk production and quality. As during pregnancy, lactating mothers should avoid illegal substances and cigarettes. Some legal drugs and herbal products can be harmful as well, so it is helpful to discuss them with a health-care provider. Some mothers may need to avoid certain things, such as spicy foods, that can produce gas in sensitive infants. Lactating women can drink alcohol, though they must avoid breastfeeding until the alcohol has completely cleared from their milk. Typically, this takes two to three hours for 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor, depending on a woman’s body weight.Harms, R., MD. “Breast-Feeding and Alcohol: Is It Okay to Drink?” © 1998–2012 Mayo Foundation for Medical Education and Research. Accessed February 21, 2012. http://www.mayoclinic.com/health/breast-feeding-and-alcohol/AN02131. Precautions are necessary because exposure to alcohol can disrupt an infant’s sleep schedule.

Benefits of Breastfeeding

Breastfeeding has a number of benefits, both for the mother and for the child. Breast milk contains immunoglobulins, enzymes, immune factors, and white blood cells. As a result, breastfeeding boosts the baby’s immune system and lowers the incidence of diarrhea, along with respiratory diseases, gastrointestinal problems, and ear infections. Breastfed babies also are less likely to develop asthma and allergies, and breastfeeding lowers the risk of sudden infant death syndrome. In addition, human milk encourages the growth of healthy bacteria in an infant’s intestinal tract. All of these benefits remain in place after an infant has been weaned from breast milk. Some studies suggest other possible long-term effects. For example, breast milk may improve an infant’s intelligence and protect against Type 1 diabetes and obesity, although research is ongoing in these areas.Healthy Children.org. “Breastfeeding Benefits Your Baby’s Immune System.” © 2012 American Academy of Pediatrics. Accessed February 21, 2012. http://www.healthychildren.org/English/ages-stages/baby/breastfeeding/pages/Breastfeeding-Benefits-Your-Baby%27s-Immune-System.aspx.

Breastfeeding has a number of other important benefits. It is easier for babies to digest breast milk than bottle formula, which contains proteins made from cow’s milk that require an adjustment period for infant digestive systems. Breastfed infants are sick less often than bottle-fed infants. Breastfeeding is more sustainable and results in less plastic waste and other trash. Breastfeeding can also save families money because it does not incur the same cost as purchasing formula. Other benefits include that breast milk is always ready. It does not have to be mixed, heated, or prepared. Also, breast milk is sterile and is always at the right temperature.

In addition, the skin-to-skin contact of breastfeeding promotes a close bond between mother and baby, which is an important emotional and psychological benefit. The practice also provides health benefits for the mother. Breastfeeding helps a woman’s bones stay strong, which protects against fractures later in life. Studies have also shown that breastfeeding reduces the risk of breast and ovarian cancers.National Cancer Institute. “Reproductive History and Breast Cancer Risk.” Accessed February 6, 2012. http://www.cancer.gov/cancertopics/factsheet/Risk/reproductive-history.

Barriers to Breastfeeding

Although breast milk is ideal for almost all infants, there are some challenges that nursing mothers may face when starting and continuing to breastfeed their infants. These obstacles include painful engorgement or fullness in the breasts, sore and tender nipples, lack of comfort or confidence in public, and lack of accommodation to breastfeed or express milk in the workplace.

One of the first challenges nursing mothers face is learning the correct technique. It may take a little time for a new mother to help her baby properly latch on to her nipples. Improper latching can result in inadequate intake, which could slow growth and development. However, International Board Certified Lactation Consultants (IBCLCs), OB nurses, and registered dietitians are all trained to help new mothers learn the proper technique. Education, the length of maternity leave, and laws to protect public breastfeeding, among other measures, can all help to facilitate breastfeeding for many lactating women and their newborns.

Contraindications to Breastfeeding

Although there are numerous benefits to breastfeeding, in some cases there are also risks that must be considered. In the developed world, a new mother with HIV should not breastfeed, because the infection can be transmitted through breast milk. These women typically have access to bottle formula that is safe, and can be used as a replacement for breast milk. However, in developing nations where HIV infection rates are high and acceptable infant formula can be difficult to come by, many newborns would be deprived of the nutrients they need to develop and grow. Also, inappropriate or contaminated bottle formulas cause 1.5 million infant deaths each year. As a result, the WHO recommends that women infected with HIV in the developing world should nurse their infants while taking antiretroviral medications to lower the risk of transmission.World Health Organization. “Infant and Young Child Feeding.” July 2010. http://www.who.int/mediacentre/factsheets/fs342/en/index.html

Breastfeeding also is not recommended for women undergoing radiation or chemotherapy treatment for cancer. Additionally, if an infant is diagnosed with galactosemia, meaning an inability to process the simple sugar galactose, the child must be on a galactose-free diet, which excludes breast milk. This genetic disorder is a very rare condition, however, and only affects 1 in thirty- to sixty thousand newborns.Genetics Home Reference, a service of the US National Library of Medicine. “Galactosemia.” July 9, 2012. http://ghr.nlm.nih.gov/condition/galactosemia. When breastfeeding is contraindicated for any reason, feeding a baby formula enables parents and caregivers to meet their newborn’s nutritional needs.

Learning to Self-Feed

With the introduction of solid foods, young children begin to learn how to handle food and how to feed themselves. At six to seven months, infants can use their whole hand to pick up items (this is known as the palmer graspA grip that involves picking up an object with the whole hand.). They can lift larger items, but picking up smaller pieces of food is difficult. At eight months, a child might be able to use a pincer graspA grip that involves picking up an object with the fingers., which uses fingers to pick up objects. After the age of one, children slowly begin to use utensils to handle their food. Unbreakable dishes and cups are essential, since very young children may play with them or throw them when they become bored with their food.

Overnutrition

Overnutrition during infancy is a growing problem. Overfed infants may develop dietary habits and metabolic characteristics that last a lifetime. According to the American Journal of Clinical Nutrition, the consequences of overnutrition and growth acceleration in infancy include long-term obesity, along with Type 2 diabetes and cardiovascular disease later in life.Singhal, A. et al. “Nutrition in Infancy and Long-Term Risk of Obesity: Evidence from Two Randomized Control Trials.” Am J Clin Nutr 92 (2010): 1133–44. Therefore, parents and other caregivers should restrain from overfeeding, and ideally give their infants breast milk to promote health and well-being.

Food Allergies

Food allergies impact four to six percent of young children in America. Common food allergens that can appear just before or after the first year include peanut butter, egg whites, wheat, cow’s milk, and nuts. For infants, even a small amount of a dangerous food can prove to be life-threatening. If there is a family history of food allergies, it is a good idea to delay giving a child dairy products until one year of age, eggs until two years of age, and shellfish, fish, and nuts until three years of age.

However, lactating women should not make any changes to their diets. Research shows that nursing mothers who attempt to ward off allergies in their infants by eliminating certain foods may do more harm than good. According to the American Academy of Allergy, Asthma, and Immunology, mothers who avoided certain dairy products showed decreased levels in their breast milk of an immunoglobulin specific to cow’s milk. This antibody is thought to protect against the development of allergies in children. Even when an infant is at higher risk for food allergies, there is no evidence that alterations in a mother’s diet make a difference.Gever, J. “Nursing Mom’s Diet No Guard Against Baby Allergies.” Medpage Today. © 2012 Everyday Health, Inc. March 7, 2012. http://www.medpagetoday.com/MeetingCoverage/AAAAIMeeting/31527?utm_content=&utm_medium=email&utm _campaign=DailyHeadlines&utm_source=WC&eun=g330425d0r&userid=330425& email=mzimmerman@cox.net&mu_id=.

Early Childhood Caries

Primary teeth are at risk for a disorder known as early childhood cariesA dental disorder characterized by decay within the primary teeth. from breast milk, formula, juice, or other drinks fed through a bottle. Liquids can build up in a baby’s mouth, and the natural or added sugars lead to decay. Early childhood caries is caused not only by the kinds of liquids given to an infant, but also by the frequency and length of time that fluids are given. Giving a child a bottle of juice or other sweet liquids several times each day, or letting a baby suck on a bottle longer than a mealtime, either when awake or asleep, can also cause early childhood caries. In addition, this practice affects the development and position of the teeth and the jaw. The risk of early childhood caries continues into the toddler years as children begin to consume more foods with a high sugar content. Therefore, parents should avoid giving their children sugary snacks and beverages.

Gastroesophageal Reflux

Small amounts of spitting up during a feeding is normal. However, there is cause for concern if it is too difficult to feed an infant due to gastroesophageal refluxA disorder that occurs when stomach acid rises into the esophagus. In infancy, it is characterized by coughing, choking, or vomiting after feeding.. This condition occurs when stomach muscles open at the wrong times and allow milk or food to back up into the esophagus. Symptoms of gastroesophagel reflux in infants include severe spitting up, projectile vomiting, arching of the back as though in pain, refusal to eat or pulling away from the breast during feedings, gagging or problems with swallowing, and slow weight gain. For most infants, making adjustments in feeding practices addresses the issue. For example, a parent can feed their baby in an upright position, wait at least an hour after eating for play time, burp more often, or give a child smaller, more frequent feedings.

Diarrhea and Constipation

Diarrhea is often caused by a gastrointestinal infection and can dehydrate an infant. It is characterized by stool frequency and consistency that deviates substantially from the norm. If an infant has had several bouts of this condition, they will need to replace lost fluids and electrolytes. A common recommendation is to give a child an oral rehydration solution. Because of the immunoprotective factors in breast milk, breastfed infants are less likely to contract gastrointestinal viral illness and experience diarrhea.

Infant constipation—which is the passage of hard, dry bowel movements, but not necessarily the absence of daily bowel movements—is another common problem. This condition frequently begins when a baby transitions from breast milk to formula or begins eating solid foods. Pediatricians can provide the best guidance for handling the problem. Common recommendations include applying a small amount of water-based lubricant to an infant’s anus to ease the passage of hard stools, and feeding an infant on solid foods pureed pears or prunes, or providing barley cereal in place of rice cereal.Mayo Clinic. “Infant and Toddler Health.” March 16, 2011. © 1998–2012 Mayo Foundation for Medical Education and Research. http://www.mayoclinic.com/health/infant-and-toddler-health/MY00362. Parents can also offer their child a little more water in between feedings to help alleviate the condition.

Colic

Colic is a common problem during infancy, characterized by crankiness and crying jags. It is defined as crying that lasts longer than three hours per day for at least three days per week and for at least three weeks (which is commonly known as the “rule of 3’s”), and is not caused by a medical problem. About one-fifth of all infants develop colic, usually between the second and third weeks. Crying spells can occur around the clock, but often worsen in the early evening. Also, colicky babies may have stomachs that are enlarged or distended with gas.

There is no definitive explanation for colic. Often, colic occurs when a child is unusually sensitive to stimulation. In breastfeeding babies, colic can be a sign of sensitivity to the mother’s diet. Lactating mothers can try to eliminate caffeine, chocolate, and any other potentially irritating foods from their meals.Medline Plus, a service of the US National Library of Medicine. “Colic and Crying.” Last updated August 2, 2011. http://www.nlm.nih.gov/medlineplus/ency/article/000978.htm. However, since colic usually subsides over time, any improvement that occurs with food elimination may conincide with the natural healing process.

Parents and caregivers who are feeding bottle formula to colicky babies should talk with pediatricians about replacing it with a protein hydrolysate formula.American Academy of Pediatrics. “Colic.” HealthyChildren.org. © American Academy of Pediatrics. Last updated May 12, 2011. http://www.healthychildren.org/English/ages-stages/baby/crying-colic/pages/Colic.aspx. Whether breastfeeding or bottle-feeding, it is also important not to overfeed infants, which could make them uncomfortable and more likely to have crying fits. In general, it is best to wait between two and three hours from the start of one feeding to the start of the next. If food sensitivity is the cause, colic should cease within a few days of making changes. Eventually, the problem goes away. Symptoms usually begin to dissipate after six weeks and are gone by twelve weeks.Medline Plus, a service of the US National Library of Medicine. “Colic and Crying.” Last updated August 2, 2011. http://www.nlm.nih.gov/medlineplus/ency/article/000978.htm.

Newborn Jaundice

Yellowing skin is one sign of newborn jaundice.

© Thinkstock

Newborn jaundiceA condition that can occur within a few days of birth and is characterized by yellowed skin or yellowing in the whites of the eyes. is another potential problem during infancy. This condition can occur within a few days of birth and is characterized by yellowed skin or yellowing in the whites of the eyes, which can be harder to detect in dark-skinned babies. Jaundice typically appears on the face first, followed by the chest, abdomen, arms, and legs. This disorder is caused by elevated levels of bilirubin in a baby’s bloodstream. Bilirubin is a substance created by the breakdown of red blood cells and is removed by the liver. Jaundice develops when a newborn’s liver does not efficiently remove bilirubin from the blood. There are several types of jaundice associated with newborns:

• Physiologic jaundice. The most common type of newborn jaundice and can affect up to 60 percent of full-term babies in the first week of life.
• Breast-milk jaundice. The name for a condition that persists after physiologic jaundice subsides in otherwise healthy babies and can last for three to twelve weeks after birth. Breast-milk jaundice tends to be genetic and there is no known cause, although it may be linked to a substance in the breast milk that blocks the breakdown of bilirubin. However, that does not mean breastfeeding should be stopped. As long as bilirubin levels are monitored, the disorder rarely leads to serious complications.
• Breastfeeding jaundice. Occurs when an infant does not get enough milk. This may happen because a newborn does not get a good start breastfeeding, does not latch on to the mother’s breast properly, or is given other substances that interfere with breastfeeding (such as juice). Treatment includes increased feedings, with help from a lactation consultant to ensure that the baby takes in adequate amounts.

Newborn jaundice is more common in a breastfed baby and tends to last a bit longer. If jaundice is suspected, a pediatrician will run blood tests to measure the amount of bilirubin in an infant’s blood. Treatment often involves increasing the number of feedings to increase bowel movements, which helps to excrete bilirubin. Within a few weeks, as the baby begins to mature and red blood cell levels diminish, jaundice typically subsides with no lingering effects.American Pregnancy Association. “Breastfeeding and Jaundice.” © 2000–2012 American Pregnancy Association. Accessed February 21, 2012. http://www.americanpregnancy.org/firstyearoflife/breastfeedingandjaundice.htm.

Energy

The energy requirements for ages two to three are about 1,000 to 1,400 calories a day. In general, a toddler needs to consume about 40 calories for every inch of height. For example, a young child who measures 32 inches should take in an average of 1,300 calories a day. However, the recommended caloric intake varies with each child’s level of activity. Toddlers require small, frequent, nutritious snacks and meals to satisfy energy requirements. The amount of food a toddler needs from each food group depends on daily calorie needs. See Table 12.5 "Serving Sizes for Toddlers" for some examples.

Macronutrients

For carbohydrate intake, the Acceptable Macronutrient Distribution Range (AMDR) is 45 to 65 percent of daily calories (113 to 163 grams for 1,000 daily calories). Toddlers’ needs increase to support their body and brain development. Brightly-colored unrefined carbohydrates, such as peas, orange slices, tomatoes, and bananas are not only nutrient-dense, they also make a plate look more appetizing and appealing to a young child. The RDA of protein is 5 to 20 percent of daily calories (13 to 50 grams for 1,000 daily calories). The AMDR for fat for toddlers is 30 to 40 percent of daily calories (33 to 44 grams for 1,000 daily calories). Essential fatty acids are vital for the development of the eyes, along with nerve and other types of tissue. However, toddlers should not consume foods with high amounts of trans fats and saturated fats. Instead, young children require the equivalent of 3 teaspoons of healthy oils, such as canola oil, each day.

Micronutrients

As a child grows bigger, the demands for micronutrients increase. These needs for vitamins and minerals can be met with a balanced diet, with a few exceptions. According to the American Academy of Pediatrics, toddlers and children of all ages need 600 international units of vitamin D per day. Vitamin D-fortified milk and cereals can help to meet this need. However, toddlers who do not get enough of this micronutrient should receive a supplement. Pediatricians may also prescribe a fluoride supplement for toddlers who live in areas with fluoride-poor water. Iron deficiency is also a major concern for children between the ages of two and three. You will learn about iron-deficiency anemia later in this section.

High-Risk Choking Foods

Certain foods are difficult for toddlers to manage and pose a high risk of choking. Big chunks of food should not be given to children under the age of four. Also, globs of peanut butter can stick to a younger child’s palate and choke them. Popcorn and nuts should be avoided as well, because toddlers are not able to grind food and reduce it to a consistency that is safe for swallowing. Certain raw vegetables, such as baby carrots, whole cherry tomatoes, whole green beans, and celery are also serious choking hazards. However, there is no reason that a toddler cannot enjoy well-cooked vegetables cut into bite-size pieces.

Picky Eaters

The parents of toddlers are likely to notice a sharp drop in their child’s appetite. Children at this stage are often picky about what they want to eat. They may turn their heads away after eating just a few bites. Or, they may resist coming to the table at mealtimes. They also can be unpredictable about what they want to consume for specific meals or at particular times of the day. Although it may seem as if toddlers should increase their food intake to match their level of activity, there is a good reason for picky eating. A child’s growth rate slows after infancy, and toddlers ages two and three do not require as much food.

Food Jags

For weeks, toddlers may go on a food jagA behavior exhibited by a young child who insists upon eating the same foods over and over again. and eat one or two preferred foods—and nothing else. It is important to understand that preferences will be inconsistent as a toddler develops eating habits. This is one way that young children can assert their individuality and independence. However, parents and caregivers should be concerned if the same food jag persists for several months, instead of several weeks. Options for addressing this problem include rotating acceptable foods while continuing to offer diverse foods, remaining low-key to avoid exacerbating the problem, and discussing the issue with a pediatrician. Also, children should not be forced to eat foods that they do not want. It is important to remember that food jags do not have a long-term effect on a toddler’s health, and are usually temporary situations that will resolve themselves.

Toddler Obesity

Another potential problem during the early childhood years is toddler obesity. According to the US Department of Health and Human Services, in the past thirty years, obesity rates have more than doubled for all children, including infants and toddlers.Head Start, US Department of Health and Human Services. “Prevention of Overweight and Obesity in Infants and Toddlers.” 2005. Accessed February 21, 2012. http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/family Almost 10 percent of infants and toddlers weigh more than they should considering their length, and slightly more than 20 percent of children ages two to five are overweight or obese.Institute of Medicine of the National Academies. “Early Childhood Obesity Prevention Policies.” June 23, 2011. http://www.iom.edu/Reports/2011/Early-Childhood -Obesity-Prevention-Policies.aspx Obesity during early childhood tends to linger as a child matures and cause health problems later in life.

There are a number of reasons for this growing problem. One is a lack of time. Parents and other caregivers who are constantly on the go may find it difficult to fit home-cooked meals into a busy schedule and may turn to fast food and other conveniences that are quick and easy, but not nutritionally sound. Another contributing factor is a lack of access to fresh fruits and vegetables. This is a problem particularly in low-income neighborhoods where local stores and markets may not stock fresh produce or may have limited options. Physical inactivity is also a factor, as toddlers who live a sedentary lifestyle are more likely to be overweight or obese. Another contributor is a lack of breastfeeding support. Children who were breastfed as infants show lower rates of obesity than children who were bottle-fed.

To prevent or address toddler obesity parents and caregivers can do the following:

• Eat at the kitchen table instead of in front of a television to monitor what and how much a child eats.
• Offer a child healthy portions. The size of a toddler’s fist is an appropriate serving size.
• Plan time for physical activity, about sixty minutes or more per day. Toddlers should have no more than sixty minutes of sedentary activity, such as watching television, per day.

Early Childhood Caries

Early childhood caries remains a potential problem during the toddler years. The risk of early childhood caries continues as children begin to consume more foods with a high sugar content. According to the National Health and Nutrition Examinaton Survey, children between ages of two and five consume about 200 calories of added sugar per day.US Department of Health and Human Services. “Consumption of Added Sugar among US Children and Adolescents.” NCHS Data Brief, No. 87 (March 2012). Therefore, parents with toddlers should avoid processed foods, such as snacks from vending machines, and sugary beverages, such as soda. Parents also need to instruct a child on brushing their teeth at this time to help a toddler develop healthy habits and avoid tooth decay.

Iron-Deficiency Anemia

An infant who switches to solid foods, but does not eat enough iron-rich foods, can develop iron-deficiency anemiaA condition characterized by inadequate hemoglobin in the blood due to low iron levels.. This condition occurs when an iron-deprived body cannot produce enough hemoglobin, a protein in red blood cells that transports oxygen throughout the body. The inadequate supply of hemoglobin for new blood cells results in anemia. Iron-deficiency anemia causes a number of problems including weakness, pale skin, shortness of breath, and irritability. It can also result in intellectual, behavioral, or motor problems. In infants and toddlers, iron-deficiency anemia can occur as young children are weaned from iron-rich foods, such as breast milk and iron-fortified formula. They begin to eat solid foods that may not provide enough of this nutrient. As a result, their iron stores become diminished at a time when this nutrient is critical for brain growth and development.

There are steps that parents and caregivers can take to prevent iron-deficiency anemia, such as adding more iron-rich foods to a child’s diet, including lean meats, fish, poultry, eggs, legumes, and iron-enriched whole-grain breads and cereals. A toddler’s diet should provide 7 to 10 milligrams of iron daily. Although milk is critical for the bone-building calcium that it provides, intake should not exceed the RDA to avoid displacing foods rich with iron. Children may also be given a daily supplement, using infant vitamin drops with iron or ferrous sulfate drops. If iron-deficiency anemia does occur, treatment includes a dosage of 3 milligrams per kilogram once daily before breakfast, usually in the form of a ferrous sulfate syrup. Consuming vitamin C, such as orange juice, can also help to improve iron absorption.Kazal Jr., L. A., MD. “Prevention of Iron Deficiency in Infants and Toddlers.” American Academy of Family Physicians 66, no. 7 (October 1, 2002): 1217—25. http://www.aafp.org/afp/2002/1001/p1217.html.

Toddler Diarrhea

As with adults, a variety of conditions or circumstances may give a toddler diarrhea. Possible causes include bacterial or viral infections, food allergies, or lactose intolerance, among other medical conditions. Excessive fruit juice consumption (more than one 6-ounce cup per day) can also lead to diarrhea.American Academy of Pediatrics, Committee on Nutrition 1999–2000. “The Use and Misuse of Fruit Juice in Pediatrics.” Pediatrics 119, no. 2 (February 2007): 405. doi:10.1542/peds.2006-3222. Diarrhea presents a special concern in young children because their small size makes them more vulnerable to dehydration. Parents should contact a pediatrician if a toddler has had diarrhea for more than twenty-four hours, if a child is also vomiting, or if they exhibit signs of dehydration, such as a dry mouth or tongue, or sunken eyes, cheeks, or abdomen. Preventing or treating dehydration in toddlers includes the replacement of lost fluids and electrolytes (sodium and potassium). Oral rehydration therapy, or giving special fluids by mouth, is the most effective measure.