Nutrition the first year

Nutrition: A Guide for Your Baby’s First Year
Compiled by Gwinnett Pediatrics and Adolescent Medicine
Edited by Susan Smiley, M.D.
 
Congratulations on your new baby! Good nutrition is essential to your child’s overall health, happiness, and well being. We have written this guide to assist you in starting your child on a path of good life long nutrition.   Please remember that all babies are individuals and what is best for one may not be best for all. At each visit, your provider will consider your child's individual needs when making nutrition recommendations.  
 
Breast versus bottle
Deciding whether to breast or bottle feed is a personal decision for every mother. 
The American Academy of Pediatrics encourages breastfeeding for the first year.  However, breastfeeding may not be best for all mothers and babies. Fortunately, the nutritional needs of your baby can also be met with iron fortified infant formula.  
 
Whether you choose to breast or bottle feed, most providers recommend “ad lib” feeing. This means feeding your baby when he or she shows signs of hunger. For most newborns, this will be about every 2-3 hours.   Newborns can show signs of hunger and fullness. Signs of hunger include: moving head side to side, opening mouth, placing hands in mouth, rooting reflex (opens mouth when cheek is lightly stroked). Signs of fullness include: slow sucking, turning away from breast or bottle.
 
All newborns lose weight after birth. We will monitor your baby’s weight closely at office visits and make recommendations accordingly. 
 
Breastfeeding
Breastfeeding provides nutrition and other health benefits to your baby. Many assume that breastfeeding will just come “naturally” and not require much effort or practice. In fact, it is just the opposite.   Most women and their babies need help in learning how to become a successful breastfeeding duo. This feeding guide is only meant to offer basic information and should not be used as the only breastfeeding resource.   At the end of this guide, you will find a list of suggested reading. 
 
In the first several days after birth, your breasts produce colostrum. Colostrum is similar to true breast milk but is easier to digest and richer in antibodies. Also, the flow of colostrum tends to be slower and allows baby to learn how to nurse. After several days, your breasts will begin to produce transitional breast milk and eventually mature breast milk. Most new mom’s will recognize the change from colostrum to transitional milk as their breasts become larger and firmer during this stage. 
 
Most providers recommend “ad lib” feeing. This means feeding your baby when he or she shows signs of hunger. For most breastfeeding newborns, this will be about every 2-3 hours or 8-12 feedings in 24 hours. Signs of hunger include: moving head side to side, opening mouth, place hands in mouth, rooting reflex (opens mouth when cheek is lightly stroked). Most breastfed babies will nurse for about 10-15 minutes on each breast. Watch your baby for signs of active nursing: can hear swallowing, sucking rhythmically and deeply in short bursts, can see jaw movement and cheeks appear to “suck in”. Signs of fullness include: slow sucking and turning away from the breast.
 
Breast milk provides nutrition, antibodies, and vitamins. However, it does not contain enough Vitamin D. Vitamin D promotes the absorption of calcium and is needed for healthy bone growth.   Thus, breastfed babies require vitamin D supplementation. Vitamin D can be bought over the counter in a variety of forms. Common preparations include:Poly- Vi- Sol, ( a source of 9 vitamins including vitamin D; some forms also contain iron), Tri-Vi-Sol (contains vitamin A, C, and D; some forms also contain iron), and D-Vi- Sol (contains only vitamin D).  
 
Breastfed and partially breastfed infants should be supplemented with 400 IU/day of vitamin D.
 
Your baby is feeding well if: he or she seems satisfied, is having 6-8 wet diapers a day, several bowel movements a day, and is gaining weight.   If you are concerned your baby is not feeding well, schedule a visit with our office. 
 
Bottle-feeding
Iron fortified infant formulas are a nutritious alternative to breast milk.   There are many formula brands available but Enfamil and Similac are preferred by most GPAM providers.   For most babies, cow’s milk formula is recommended. Your provider will advise you if your baby needs another formula type (ex soy, lactose free, hypoallergenic). Infant formulas are supplemented with vitamins (including vitamin D) and minerals.   Thus, most formula fed babies do not require supplemental vitamins. Infant formula is sold in 3 forms: ready to feed, concentrate, or powder. Ready to feed formula requires no preparation. Simply pour the ready to feed formula into the bottle.   However, this ease and convenience comes at a higher cost. Concentrated liquid formula and powdered formula are prepared by mixing with water. When preparing bottles, follow formula label instructions precisely. Using too much water or too much formula can cause problems for your baby.  
 
Most babies do well with cool or room temperature bottles. If your baby prefers a warm bottle, do not place the bottle in the microwave as the bottle can heat unevenly and burn your baby’s mouth.    Instead, run the bottle under warm water for a few minutes. Test the temperature of the formula by squirting a few drops on the inside of your wrist before serving it to your baby. The bottle should be lukewarm, not hot. 
 
Always hold your baby during a feeding. Never prop the bottle and allow your baby to feed alone. Never put your baby to bed with a bottle. Propping a bottle can lead to ear infections, tooth decay, and is a choking hazard. 
 
Refrigerate any bottles you prepare for later feedings to prevent bacterial growth.  Prepared bottles of formula should be stored in the refrigerator for no longer than 24 hours. Discard any bottles left out of the refrigerator longer than 1 hour. Discard unfinished bottles. Germs and enzymes from your baby’s mouth can enter the bottle and spoil the formula. 
 
Gassiness and spit up are common to newborn babies. Many parents become concerned that the formula is contributing to these symptoms and want to switch to a different formula. Typically, a formula change may not necessary. If you have concerns about these symptoms or wish to discuss a formula change, please call our office to speak with a nurse or schedule a visit. 
 
As mentioned earlier, all babies are unique individuals and will vary in their feeding schedules. As a general guideline, formula fed newborns typically take from 1/2 to 1-1/2 ounces every 3-4 hours. Signs of hunger include: moving head side to side, opening mouth, place hands in mouth, rooting reflex (opens mouth when cheek is lightly stroked). Signs of fullness include: slow sucking and turning away from the bottle.
 
Your baby is feeding well if: he or she seems satisfied, is having 6-8 wet diapers a day, several bowel movements a day, and is gaining weight.   If you are concerned your baby is not feeding well, schedule a visit with our office. 
 
 
Spit up and burping
Burping allows babies to get rid of air swallowed during feeding. Most infants spit up a small amount of breast milk or formula after feeding or during burping.   The spit up is effortless, not projectile, and resembles the formula or breast milk. Spit up usually comes out of the babies mouth but can also come out the nose. It may appear a bit curdled. If spit up is projectile, contains any blood or bile (bright green in color), contact our office immediately. Spit up is typically not bothersome to babies and does not affect their feeding. If you feel otherwise, please contact our office. To reduce spit up: feed your baby when hungry, keep your baby in a semi upright position during feeding and for 30 minutes afterward, and avoid over feeding.  
 
2 months
Breast milk or formula is all that is still needed to meet baby’s nutritional needs. Juice and water are not recommended at this age. Breastfeeding or bottle feeding should still be on demand (when your baby is hungry).   Breastfed and formula-fed infants have different needs for the frequency of feeding. Breastfed babies continue to require about 8-12 feedings in 24 hours.   Formula fed babies will typically feed every 3-4 hours. At times, your baby may be going a bit longer between feedings or during growth spurts may feed more frequently.   So, remember to monitor your baby’s signs of hunger and fullness (slow sucking, turning away from breast or bottle). If you are concerned your baby is not feeding well, schedule a visit with our office. 
 
4 months
By about 4 months of age, babies loose the “tongue thrust reflex” so that they no longer push food out of their mouths. As a result, they may be ready to begin solid foods. Breast milk or formula will continue to be your baby’s primary source of nutrition at this age. 
 
To eat solid foods, your baby needs good head and neck control and should be able to sit with support. Your baby should sit upright in an infant seat when eating solids. 
 
Rice cereal is most often recommended as the first solid food. Rice cereal is gluten free and less often associated with an allergic response.    The cereal can be mixed with breast milk, formula, or water. The cereal can be made thick or thin. Typically, use 1 teaspoon of cereal mixed with 4-5 teaspoons of breast milk, formula, or water. Use an infant spoon to feed your baby.   Do not share your baby’s spoon. Spoon sharing can increase the growth of bacteria in your baby’s mouth and increase his or her risk to develop dental decay. Unless otherwise instructed by your provider, do not add cereal to your baby’s bottle. 
 
Offer your baby rice cereal when he or she is hungry but not “starving”.   Place the spoon near your baby’s lips and allow him or her to smell and taste. The first spoonful may be rejected. In fact, more may end up on you and your baby than in his or her mouth! Do not worry, things will improve with practice. Babies know and will let you know when they are hungry and when they are full. Signs of hunger include: leaning forward in infant seat, moving head side to side, opening mouth, placing hands in mouth, and puckering lips. Signs of fullness include: leaning back, turning away from the spoon, not opening the mouth, and spitting out the cereal. Offer cereal 1-2 times a day and let your baby decided how much to eat. 
 
Rice cereal may change the consistency and/or frequency of your baby’s stools. If your baby’s stools become hard or infrequent, please see our website (www.gwinnettpeds.com) or speak with one of our phone advice nurses for information on how to recognize and treat newborn constipation. Of course, you may always schedule a visit with a GPAM provider. 
 
It may take some time for your baby to learn how to eat cereal from a spoon. Thus, continue to provide feedings of either formula or breast milk as it will still provide most of your baby’s nutritional needs. 
 
6 months
By 6 months, most babies have mastered eating cereal with a spoon and are ready for some new tastes. There are many commercially prepared baby foods available. Avoid brands with added fillers and sugars. Gerber and other baby food manufacturers will typically sell their baby food in “stages” from 1 to 3. Stage 1 foods are usually a finely pureed single ingredient fruit or vegetable. Stage 1 foods are thus designed for beginners.   Stage 2 and 3 foods progress to thicker, mixed varieties. So, begin with stage 1 foods and slowly advance as your child becomes a more experienced eater. 
 
What food to introduce first, a fruit or a vegetable? There is no one right answer.   The order in which foods are introduced does not matter as much as introducing foods one at a time. Introduce one single ingredient food at a time and wait about one week to watch for any allergic reactions before introducing another. If your baby does not seem to like a particular food, reintroduce it later. It can take several tries before babies accept certain foods.  
 
Spoon baby food from the jar into a bowl. Do not feed directly from the jar, as bacteria from your baby’s mouth can contaminate the remaining food. Discard opened jars of baby food within 1-2 days. Store unopened jars in your kitchen pantry at room temperature. 
 
Offer your baby solids 2-3 times a day. Your baby may lose interest in cereal as he or she discovers the tastes of fruits or veggies. It is still important to include cereal as a part of your baby’s diet. Formula or breast milk continue to serve an essential role in your baby’s nutrition. 
 
Remember, babies know and will let you know when they are hungry and when they are full.  
 
9 months      
At nine months, most babies have mastered cereal and baby foods and are ready for foods with some texture. Table foods are a big change from baby foods. Your baby will need to learn how to adjust to the new texture of table foods. Babies start by “gumming” foods and then advance to chewing. Slowly introduce your baby to varying textures such as pureed, blended, mashed, finely chopped, and soft lumps to help them in this process.   Gerber “puffs” are a “starter” table food. Puffs do not offer much nutritional value and should be discontinued once your baby has mastered more nutritional table foods. Avoid table foods with mixed textures ( ex soup with vegetables) as these are more difficult for babies to eat. Avoid foods that are high in sugar. 
 
Some suggested table foods: soft ripe fruits, soft boiled or steamed vegetables, soft rice and mashed potatoes, thinly sliced low sodium deli meats.
 
Most providers recommend that the following foods NOT be given in the first year of life: peanuts, tree nuts, shellfish, seafood, honey, and citrus.   Foods that are a choking hazard should also NOT be given in the first year. 
 
No discussion of table foods is complete without warning about choking. Never leave your baby unattended during feeding. Your baby should always eat seated in a high chair.   Offer table foods in small amounts so that your baby does not put too much food in his or her mouth at a time.   Foods that are small, round, and firm, those that are stringy or sticky, and those that swell when moist are the most dangerous.   Examples of choking hazards: whole grapes, cherries with pits, hard candy, caramel, raisins, popcorn, nuts, seeds (sunflower, watermelon, etc), hot dogs, chunks of meat, sausages, hard cheese, raw veggies (celery, carrots) hard fruits (apples), peanut butter.
 
Your baby will enjoy joining the family for meal times on a breakfast, lunch and dinner schedule but will also need a morning, afternoon, and bedtime “snack”. Consider these “snacks” more like a “mini-meal” and offer nutritious foods. The amount of food your baby eats at a time will vary. Frequent meal and snack offerings will provide adequate nutrition and variety. 
 
Babies can be slow to accept new tastes and textures. If your baby does not seem to like a certain food, do not give up on it but offer it again at another feeding.   It can take 10-15 tries before your baby is willing to accept a new food. 
 
It is also time to introduce your baby to a sippy cup. There are many types of sippy cups available.   You may need to try a few different sippy cups to discover your baby’s favorite. Fill the sippy cup with a few ounces of water and teach your baby how to hold the cup and drink from it. Avoid drinks like juice that are high in sugar.    If you do give your baby juice, serve only 100% fruit juice instead of juice drinks, offer no more than 4 ounces a day, and not in a bottle. 
 
12 months
Your baby is a year old! Such an exciting milestone! A big change at this age is         the introduction of whole milk. Most one year old babies can leave behind formula or breast milk and begin whole milk.   Why not skim milk or 2% milk? Babies require the fat in whole milk for optimal growth and brain development. You can either “wean” formula or just make the switch.   To wean, you simply gradually add whole milk to formula. If your baby has been on lactose free, soy, or hypoallergenic formula, talk to your provider before making the change to whole milk. 
 
By 12 months, most babies have mastered using a sippy cup. Thus, it is time to discontinue use of the bottle. Your baby may disagree! If so, instead of eliminating the bottle all at once, try cutting them out gradually beginning at mealtimes. 
 
At one year, most babies are eating 3 meals and 2-3 planned nutritious snacks a day. Your child’s appetite will vary from meal to meal and day to day. Trust your child’s ability to know when he or she is hungry or full. If you have not already done so, pull the high chair to the table so your 1 year old can participate in family meals.   One year olds are already asserting their independence and like to feed themselves. So, cover the floor and try not to worry about the mess! Remember, avoid foods that can cause choking.   Cut any firm, round food (hot dog, carrot, grape) into thin slices. Always supervise your child. Avoid drinks or foods that are high in sugar. 
 
If your baby rejects a certain food, try offering it again later. Babies can love green beans one day, reject them the next, and then love them again two days later. So, keep offering a variety of healthy foods. Remember, it can take 10-15 tries before your baby is willing to accept a new food. 
Food Allergies
It is prudent to include a brief mention of food allergy. Food allergies are a complex topic that cannot be fully discussed in this nutrition guide. Rather, we will take this opportunity to mention some of the most common allergies and signs of allergy. Some of the most common foods triggering allergy include: milk, eggs, peanuts, soy, wheat, tree nuts (walnuts, cashews), fish, shellfish.   Signs of food allergy can be quite varied but include: itchy red bumps, redness and swelling of face or extremities, itching and swelling of lips, tongue, or mouth, nausea, vomiting, diarrhea, runny or stuffy nose, sneezing, coughing, and wheezing.   If you feel your child is having a severe, life threatening reaction: call 911.   Please discuss any concerns about possible food allergy in your child with a GPAM provider. 
 
Recommended Reading:
1)   The Complete Book of Breastfeeding by Marvin Eiger, MD and Sally Wendkos Olds
2)New Mother’s Guide to Breastfeeding by Joan Younger Meek, MD
3)Guide to Your Child’s Nutrition by William H. Dietz, MD PhD and Loraine Stern, MD
4)Food Fights by Laura A. Jana, MD and Jennifer Shu, MD
5)Heading Home with Your Newborn by Laura A. Jana, MD and Jennifer Shu, MD
Revised 11/2010


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