• The caregiver-infant feeding relationship is a key factor in establishing both long term feeding behaviors and psychological development.
• The ideal food for the first months of life is breastmilk. If breastmilk is not available a commercial infant formula is recommended for the first 12 months of life.
• Gradual introduction of solid foods in the second half of the first year of life supports both nutritional and developmental needs.
• Consequences of infant feeding decisions may extend into adulthood.

This chapter stresses the importance feeding as a way to achieve an adequate energy and nutrient intake in a loving and supportive environment. Breastmilk, or a substitute commercial formula if human milk is not available, can be the baby's sole source of nutrients and energy for the first 6 months. (1) Most healthy, full-term infants have the ability to regulate their intake to consume the amount they need to grow appropriately when they are fed on demand. The addition of semisolid foods progressing to "table foods" in the latter part of the first year provides energy and nutrients as well as support for oral and fine motor development. Feeding infants in a loving and nurturing environment helps them develop a sense of security and trust.

The discussions in this chapter are directed at the feeding of healthy full term infants in developed areas of the world where malnutrition in infancy is rare. In developing countries breastfeeding and careful selection of weaning foods are the only safe and economically feasible approach to infant feeding.

TABLE –1 Nutrient Content of Human Milk and Representative Cow's Milk-Based Formulas

Differences in human and cow's milk were discussed in Chapter 6. From such comparisons it soon becomes apparent that if cow's milk is offered to infants it must be modified to be more like human milk. Commercial formula ingredients have changed through the years to reflect current knowledge about optimal infant feeding. It is likely that this process will continue as the beneficial constituents of human milk continue to be identified. Anti-allergenic factors, immunity enhancing antibodies or antigens, growth promoting factors, and biologically active factors that increase nutrient absorption have all been proposed as possible future additions to commercial infant formulas. In general, nutrients are offered in higher amounts in formula than in breastmilk because of lower bioavailability of nutrients from formula. Formulas are usually categorized by the source and form of protein. In addition to the formulas discussed in the following section, infant formulas are available for several special populations such as infants born prematurely, those with severe problems of digestion and absorption, and those with special metabolic needs.

In the United States regulations regarding the composition of infant formula have been recommended by the American Academy of Pediatrics Committee on Nutrition Task Force (3) and adopted by the by the Food and Drug Administration. (4) Laws and regulations set minimum levels for 29 nutrients and maximum levels for 9 nutrients as well as labeling and quality assurance requirements. For many years there were a very limited number of commercial infant formula choices, but formula brands have proliferated in the last few years. Some manufacturers now make brands that are marketed under different store labels.

The American Academy of Pediatrics states that, "Standard cow’s milk-based formula is the feeding of choice when breastfeeding is not used or is stopped before one year of age." (3) One difference between brands of formula is the ratio of the types of cow’s milk protein. The predominant protein of human milk is whey, and the predominant protein in cow’s milk is casein. Some formulas provide more whey proteins than others. However, the whey proteins of human and cow’s milk are of different composition. Infants appear to thrive equally well with either whey or casein predominant formulas. The proteins in whey hydrolysate formulas have been modified to have smaller peptides and be less allergenic. It is important to realize that these may still cause serious allergic responses in some infants. The butterfat of cow’s milk is replaced with vegetable fat sources to make the fatty acid profile of cow’s milk formulas more like those of human milk and to increase the proportion of essential fatty acids. Lactose is the major carbohydrate in most cows’ milk based formulas. Cow’s milk based formulas come in both a low iron (< 4.5 mg/l) and a more highly iron fortified form (10-12 mg/l). Use of formula with iron is strongly encouraged to prevent iron deficiency anemia. True intolerance of iron fortified formula is found to be low when placebo controlled and blinded trials are used to assess the effects of iron in formula.

In the United States formulas that provide protein in the form of soy protein isolate with added methionine account for about 25% of the formulas fed to infants. While they are safe and nutritionally equivalent alternative to cow’s milk formulas, soy formulas are not really

needed by 25% of formula fed infants. Soy based formulas are indicated primarily in the case of vegetarian families and for the very small number of infants with galactosemia and hereditary lactase deficiency. (2) They are often used inappropriately as a solution to feeding associated problems that are due to physiological immaturities of infancy such as spitting, colic and soft stools. Many infants with true protein milk allergy will also develop allergy to soy proteins. These formulas are contraindicated in preterm infants because they may provide inadequate bone mineralization. They are also inappropriate for infants with cow milk protein-induced enteropathy or enterocolitis, for most previously well infants with acute gastroenteritis, and for prevention of colic or allergy. (2)

These formulas have been developed primarily for infants who can not digest and absorb nutrients from other formulas or those who have severe milk protein allergies. Proteins for these formulas are hydrolyzed to form free amino acids and small peptides. Most casein hydrolysate formulas are lactose free. Formulas may also contain varying amounts of medium chain triglycerides (MCT) to enhance digestion and absorption of fatty acids. These formulas are expensive, and have a strong taste. They should be used only for infants who truly need them.

Follow-up formulas have been developed for older infants and toddlers. These products have higher protein and mineral content than standard formulas. They have been developed to complement the high carbohydrate diet that results when weaning foods such as cereals and fruits and vegetables are added to the diet. Follow-up formulas have the advantage of being higher in iron than cow’s milk, but offer no clear advantage when weaning foods are chosen carefully. (3) The use of whole, 2%, 1%, or nonfat cow's milk, goat’s milk or evaporated milk in the first year is strongly discouraged. Use of these products may lead to iron deficiency anemia. These milks have high solute loads and limited levels of essential fatty acids, vitamin E, zinc, and other nutrients. Goat’s milk has inadequate folate.

Feeding infants formulas made from recipes, substitute, or imitation milks that have not been proven to support adequate nutrition should be strongly discouraged. Malnutrition was observed in infants fed a barley water, corn syrup, and whole milk formula suggested in a magazine for mothers. (5) Kwashiorkor, an advanced protein-deficiency state of malnutrition, has been reported in infants fed a nondairy creamer as a substitute for milk. (6) Substitute or imitation milks should not be offered to infants. Substitute milk is defined by the U.S. Food and Drug Administration as nutritionally equivalent to whole or nonfat milk based on the content of only 14 or 15 nutrients. It does not include all nutrients, and could pose significant problems for infants who have no other source of nutrients in the diet.

Standard infant formula provides 20 kcal per ounce if prepared according to manufacturers’ directions. Manufacturers market three basic types of formulas, each of which is prepared according to its form: (1) liquid concentrate prepared for feeding by mixing equal amounts of the liquid and water; (2) ready-to-feed formulas are available in an assortment of sizes (4-, 6-, and 8-oz bottles and 32-oz containers); and (3) powdered formulas that are prepared by mixing with a prescribed amount of water. All of these formulas, when properly prepared provide the nutrients important for the infant in an appropriate caloric concentration and present a solute load reasonable for the full-term infant. Errors in dilution caused by lack of understanding of the proper method of preparation, improper measurements, adding extra water to make the formula last longer, or the belief of the parents that their child should have greater amounts of nutritious food can lead to problems. Feeding dilute formula over time can lead to undernutrition and water intoxication with symptoms of hyponatremia, irritability, and in severe cases, coma. (7)

Feedings that are too highly concentrated increase kilocalories, protein, and solutes presented to the kidneys for excretion and may predispose the young infant to hypernatremia, dehydration, and tetany as well as obesity. (8;9) Problems of improper formula preparation have most frequently been reported with the use of powdered formula and occur most often when an increased need for water caused by a fever or infection is superimposed on consumption of an already high-solute formula. Infants fed concentrated formula during such illnesses may become thirsty, demand more to drink, or refuse to consume more liquid because of anorexia secondary to the illness. When presented with more milk concentrated in the protein and solutes, the osmolality of the blood increases and hypernatremic dehydration may result. Cases of cerebral damage and gangrene of the extremities have been reported to be the result of hypernatremic dehydration and metabolic acidosis.

Sterilization of bottles and formula is no longer recommended if water supplies are safe and caregivers observe clean techniques. Commercially prepared liquid formulas are sterile before they are opened, and powdered formulas are free of viable microorganisms of public health significance. To prepare formula by clean technique, the hands of the person preparing the formula should be washed carefully. All equipment to be used during preparation, including the cans that contain the milk, can openers, the bottles, and the nipples, must be thoroughly washed and rinsed. Once opened, cans of formula must be covered and refrigerated. The formula is prepared immediately before each feeding as described above. After the formula has been heated and the infant has been fed, any remaining milk should be discarded. Warm milk is an excellent medium for bacterial growth. Formula from bottles that have been partially finished should be discarded.

Microwaving of bottles of formula is generally discouraged. Serious burns have resulted from this practice. (10) Safe techniques have been proposed as parents are known to use the microwave for warming bottles despite advice to do otherwise. Recommended techniques include: heating only 4 ounces at a time in an 8 ounce, uncovered bottle, hearing for no more than 30 seconds, inverting the bottle 10 times after heating, and testing of the formula on the caregiver’s tongue or top of the hand.

Infancy is a time of rapid physical and psychosocial development. Recommendations for infant feeding reflect understandings about the best way to support optimal development. Illingworth and Lister have defined a "critical or sensitive" period of development in relation to eating. (11) For example, they point out that infants learn to chew at about 6 or 7 months of age, thus at this point they are developmentally ready to consume food. If solid foods are withheld until a later age, the child will have considerably more difficulty in accepting them.

Between 6 and 12 months of age the infant gradually progresses from pureed and strained to mashed and chopped foods. Foods should be carefully selected and modified so that they are presented in a form that can be manipulated in the mouth without the potential of choking and aspirating. Family foods like well cooked ground meats, mashed beans and peas, flaked tuna, tofu, and family casseroles can gradually be added at the end of the first year.

It is important to note that not all infants develop at the same rate and that temperamental characteristics and the temperamental "match" between caregivers and infants will influence the feeding situation. Children who are overly sensitive to their environments may not want to explore food in the same way as other children. Some children are more "neophobic" when they encounter new foods, and will take longer to warm up to these foods. Parents may need support and guidance as they seek to find the best approach to feeding their children developmentally. Disturbed feeding interactions that result from a lack of understanding and/or insistence on inappropriate parental control may result in persistent feeding problems and eating disorders.

The American Academy of Pediatrics states that newborns should be fed whenever they show signs of hunger, such as increased alertness or activity, mouthing, or rooting. By the time an infant is crying from hunger, earlier cues have usually been missed. Newborn infants will initially feed eight to twelve times a day at intervals of 2 to 4 hours. Formula fed infants usually consume 2 to 3 ounces at a feeding. Formula fed infants may go longer between feedings than breastfed infants. There is wide variation in the age at which young infants are capable of sleeping through the night without waking for feedings. Although it is easier on parents, going through the night without a feeding is not necessarily best for quiet and undemanding infants in the first weeks of life, especially if they are growing slowly.

To avoid both under or over feeding, infant caregivers should attend to the infant’s feeding cues. Infant cues for hunger and satiety may vary from subtle to obvious. A young infant who is hungry will usually suckle vigorously. Older infants will lean forward toward the food or reach out for the breast, bottle or spoon. To demonstrate satiety, a young infant may fall asleep or stop suckling at the breast. An infant who is being fed in a high chair or on a caregiver’s lap may avert his eyes, wave his arm in a "halt hand, turn away from the caregiver, start playing with the eating utensils, refuse to open his mouth, or push the dish away.

TABLE -3: Hunger and Satiety Behaviors of Infants

Newborn infants demonstrate a preference for sugar solutions over water and formula and show adverse responses to sour and bitter tastes. Many other food related likes and dislikes appear to be learned. Infants may require repeated exposures before they accept a new food. Sullivan and Birch found that most infants increased intakes of vegetables when they had been exposed to them at least 5 to 10 times. (12) This study also found that breastfed infants accepted new foods more readily than those fed with bottles. One explanation for this finding may be that the passage of flavors from the mother’s diet through her milk programs the infant to be more accepting of new tastes. Young children learn their food habits from their families. Anticipatory guidance about optimizing family food habits may be helpful.

Both bottle and breast feeding parents benefit from basic feeding information in the newborn period. Lawrence (13) calls attention to the importance of positioning and interactions during feedings, and recommends the following: 1) All infants should be fed in a semi-upright position with the infant’s head held securely in the crook of the elbow of the caregiver. 2) The rooting reflex should be elicited by stimulating the central portion of the lower lip. 3) The bottle should be position so the nipple and next remain filled with milk until the end of the feeding. 4) Bottle feeding, like breastfeeding should be a social event. Semi-upright feeding has been associated with reduced incidence of entrance of milk into the middle ear during feedings. (14)

Experience with "problem eaters" in later infancy and early childhood suggests that parents can also benefit from anticipatory guidance about approaches to feeding. (15) These include: 1) The importance of introducing foods with differing tastes and textures in the second half of the first year of life. 2) Reassurance that "neophobia" is normal and that most infants benefit from repeated exposure to new foods. 3) Food should not be used as a reward or bribe. 4) Force feeding and excessive coaxing are counterproductive, and parents should pay attention to the infant’s satiety cues.

TABLE -4 Suggested Ages for the Introduction of Semisolid Foods and Table Food Age

TABLE -5 Sample Menus for Infants at Various Ages

Recommendations for the lower age limit for introduction of non-milk feedings are based primarily on achievement of indicators of physiological and developmental readiness. These include adequate head and truck motor control to indicate desire for food or satiety by learning forward or backing away as well as the disappearance of the extrusion reflux. Most infants are developmentally ready for an introduction to pureed foods between 4 and 6 months of age.

Several concerns have been raised about introduction of foods in infancy before 4 months of age. In the first weeks of life, immaturity of the kidney precludes large osmolar loads of protein and electrolytes and digestion of some fats, proteins, and carbohydrates is compromised. At age 3-5 months, infants are able to digest and absorb cereal, but at age 1-2 months carbohydrate and protein digestion and absorption are compromised by cereal ingestion. (17) In the first months of life poorly developed swallowing skills may lead to aspiration. Increased respiratory illness and persistent cough have been reported in infants given solids early (18), and coughing may increase following ingestion of formula thickened with infant cereal (19) Early introduction of a variety of solid foods may increase risk of atopic and immunological disease in susceptible children.(20;21)

If introduction of non-milk feedings is delayed past 6 or 7 months, nutritional status may be compromised. Breastmilk alone may not provide sufficient nutrients or energy for the rapidly growing infant. Growth of breastfed infants may be compromised if supplemental feedings are not initiated in the second half of the first year, but there seems to be a great deal of individual variability in response to delay in introduction of foods.

First foods for infants may be prepared from family foods or may be purchased as commercially available infant foods. Most families use a combination of food sources. Few infants require specialized infant foods beyond the first year. If feeding of semi-solid foods is delayed until the infant is developmentally ready, the period of time that modified infant foods are required is fairly short. Foods should be introduced one at a time to assure that any adverse reactions can be pinpointed. Within general categories the order of food introductions is not important.

Table -6 Advantages of Commercial and Home Preparation of Infant Foods

Cereals: Ready-to-serve dry infant cereals are fortified with electrically reduced iron. Three level tablespoons of cereal will provide about 5 mg of iron, or from one half to one third of what the infant requires. Therefore, cereal is usually the first food added to the infant's diet. Cereal and fruit mixtures in jars are fortified with ferrous sulfate to provide 7 to 9 mg of iron per 4.5 oz jar. Other sources of iron should be considered if the infant is not offered commercial infant cereals.

Fruits and Vegetables: Strained and junior vegetables and fruits provide carbohydrate and variable amounts of vitamins A and C. Vitamin C is added to a number of the fruits and all of the fruit juices. Several fruits, including apricots, have sugar added and are marketed as fruit deserts. Tapioca is added to a number of the fruits. Milk is added to creamed vegetables and wheat is incorporated into mixed vegetables. Commercial infant juices are convenient, but expensive and unnecessary. Most regular fruit juices may be used for infants. Juice should never be given in a bottle, and intakes over 4 ounces a day present a risk for oral health.

Meats and Combination Foods: Strained and junior meats are prepared with only water, except for lamb which has lemon juice added. Strained meats, which have the highest caloric density of any of the commercial baby foods are an excellent source of high-quality protein and heme iron. Water is the most abundant ingredient in meat and vegetable combinations and high-meat dinners, and these products are generally low in protein and other nutrients. The introduction of these products should be delayed until it has been determined that the infant has no allergic reactions to any of the wide variety of ingredients they contain.

Desserts: Infant puddings and fruit desserts are also available. The nutrient composition of commercial deserts varies, but all contain sugar and modified corn or tapioca starch. These products should be used in moderation.

TABLE -7 Ranges of Selected Nutrients Per Ounce in Commercially Prepared Infant Foods

*Quantity insignificant.

1995 Gerber Products Company: Nutrient Values, Fremont, MI, Rev l2/94. 1st Foods, 2nd Foods, and 3rd Foods are trademarks of Gerber Products Company.

There are two overarching considerations in preparation of foods for infants at home: (1) Food safety and (2) Preservation of nutrients. The following procedures should be followed:

• Foods should be carefully selected from high-quality fresh, frozen, or canned (without added salt or sugar) fruits, vegetables, and meats, and prepared so that nutrients are retained.
• The preparation area and all utensils should be well cleaned. Salt and sugar should be used sparingly, if at all.
• Fruits and vegetables should be cooked in minimal amounts of water or steamed until tender.
• Depending on the infant’s readiness for texture, food can be pureed or strained with a food processor, blender, grinder, or fork.
• Foods can be moistened with water, cooking water, or milk.
• If food is being prepared for future meals, it should be packaged in individual portions and refrigerated or frozen so that a single portion can be heated and fed without compromising the quality and bacterial content of the entire batch.
• Individual portions of frozen foods should not be thawed at room temperature, but should be thawed in the refrigerator or gently heated.

Food from the family menu is introduced at an early age in the diets of many infants. The age of introduction and type of food offered will reflect cultural practice. Although it has been common to offer bland foods without spices or other flavorings to infants in the US, many older infants enjoy highly flavored foods that reflect the family’s culture with no apparent adverse effects. Examples include crumbled cornbread mixed with pot liquor (the liquid from cooked vegetables)that may traditionally be fed to African American infants and mashed beans with some of the cooking liquid fed to Mexican American infants.

By the end of the first year the diets of most infants should be similar to that of the family, and dietary guidelines for older infants are similar to those for the population. Older infants need a variety of foods from all the pyramid food groups and adequate energy to support growth. Moderation is key in food choices. There is little room in the infant’s diet for large servings of foods that are low in nutrients and high in fat or sugar. On the other hand, excessive intakes of low energy/low fat foods fat have been associated with growth failure. Adequate intakes of fiber will normalize digestive and absorption processes. A target of 5 grams of fiber per day is suggested for the second 6 months of life (22) This can easily be achieved with a daily total of 1/2 cup each fruits and vegetables, and 1/2 cup of infant cereal.

• Form and texture. Solid foods offered to infants should be in a form easily masticated and not given in small pieces. Choking and aspiration can occur if small pieces of hot dogs, grapes, hard candy, nuts, and other food in small, hard pieces are consumed.
• Honey. Sometimes honey is used as a sweetener for home-prepared infant foods and formulas. In the past, honey has also been recommended for use on pacifiers to promote sucking in hypotonic infants. However, honey has been implicated as a source of spores of Clostridium botulinum during infancy. These spores are extremely resistant to heat and are not destroyed by present methods of processing honey. Botulism in infancy is caused by ingestion of the spores, which germinate into the toxin in the lumen of the bowel. Honey should not be fed to infants less than 1 year of age. (3)
• Microwaving: Microwaving of infant foods, like infant formulas, is potentially dangerous. Microwave ovens heat in an uneven pattern, and some infants have been seriously burned. If microwaves are used, the food should be removed from the jar, heated only to a warm temperature and thoroughly stirred before giving to the infant.

Spitting up: During the early months of life, some otherwise healthy infants spit up a small amount of any milk or food digested at each feeding. If an infant is growing well and appears to suffer no distress associated with feeding, this can be interpreted as a normal event. When growth is inadequate or the spitting up appears to be associated with pain and/or feeding aversions, further evaluation is warranted.

Colic: Colic is described as persistent, unexplained crying in infants. (23) Colic affects 10 to 30% of infants throughout the world, and affects breastfed infants at the same rate as those fed formula. For the most part, most infants with colic will outgrow the problem with no adverse consequences, and treatment consists of comforting measures for both the infant and parent. Most infants with colic do not respond to nutritional therapies. Cow’s milk proteins in mother’s milk may be associated with higher rates of colic for some infants. If nursing mother’s chose to decrease dairy products in the diet, an adequate source of calcium should be assured. (24) Some infants have been found to respond favorably to a protein hydrolysate formula in some studies, but other studies have not reached this conclusion. (25)

Screening for Infants With Special Health Care Needs: During observations of feeding and assessment of physical growth infants with problems may be identified. A poor suck and poor weight gain may be indicative of abnormalities of muscle tone, which may later be diagnosed as cerebral palsy. Stiffening and arching during a feed may precede the diagnosis of spasticity. Delays in achieving the developmental landmarks may be indicative of generalized developmental delays. Short stature and poor weight gain may result from physical or neurological difficulties. Assessment and intervention for babies who have these symptoms will require an interdisciplinary team that will include physicians, therapists skilled in oral motor intervention, nurses, and dietitians.

Early Childhood Caries: (Also known as Nursing Bottle Syndrome and Baby Bottle Tooth decay) This is a condition of rampant infant caries that develop between one and three years of age. The cause of this condition is not entirely clear, but there are at least two components: 1) Presence of carbohydrate in the mouth with bacterial fermentation of carbohydrates that leads to production of acids and demineralization of tooth structure. 2) Presence of bacteria in the mouth. This process often proceeds rapidly once it has started. It usually begins with the development of spots on the primary maxillary incisors. These decalcified lesions may progress to frank caries within 6 to 12 months in infants and young children because the enamel layer on new teeth is thin. Risk of developing early childhood caries is associated with lack of water fluoridation, ethnicity (American and Alaska native children and Mexican American children are at especially high risk), maternal dental health, later weaning from the bottle, and going to bed with bottles. Children who develop early childhood caries often require extensive dental work, and their secondary teeth are at risk of caries as well. Anticipatory guidance to prevent early childhood caries is important. Parents can benefit from information about the importance of primary teeth, early use of cups for liquids, problems associated with putting a child to bed with a bottle, and use of fluoride.

Etiology of chronic disease is usually multifactorial, and the ability to establish a relationship between disease prevalence and early nutritional experiences is limited. Nevertheless, some provocative reports have been published. Bergstrom (26) found that early introduction of formula feeding and short duration of breastfeeding were associated with higher total cholesterol and other adverse lipid levels in adolescents. Low anthropological measurements both at birth and at one year have been associated with increased risk of later cardiovascular disease. Animal models provide support for a role of nutritional programming in utero and early in life in the establishment of metabolic pathways that eventually influence health outcomes in later adulthood. (26)

Obesity: . In the past, there has been speculation that formula feeding and the early introduction of semisolid foods might be factors in excessive intakes of energy and the development of infant obesity, and that obese infants very often become obese adults. Breastfeeding and delayed introduction of solids may be protective against childhood obesity. (27) The association between weight for length and development of obesity later in life is very limited.

Diabetes A relationship between infant diet and Insulin Dependent Diabetes Mellitus (IDDM) has received great interest in the last few years. (21). The American Academy of Pediatrics has recommended that intact cow’s milk protein should be avoided in the diets of infants who are genetically susceptible to developing IDDM. Breastfeeding is strongly recommended for infants with a family history of diabetes. Initial investigations focused on the diabetogenicity of bovine serum albumin in infancy. It now appears that several plant proteins including soy and wheat may also be diabetogenic for some individuals, and that the critical period for exposure to diabetogenic foods may extend beyond infancy. Early introduction of non-milk feedings has been associated with development of IDDM in high risk infants. Data from epidemiological and animal studies are inconclusive, but it appears prudent to recommend breastfeeding and a delay in introduction of non-milk feedings until at least 6 months of age for infants who are known to have genetic susceptibility to IDDM.

Food Allergies. Avoidance of potential allergens in infancy has been suggested as a way to prevent or delay symptoms of IgE mediated diseases such as eczema, allergic rhinitis, gastrointestinal symptoms and chronic wheezing or asthma in families with genetic susceptibility. (20). In children with high genetic risk careful attention to maternal diet in pregnancy and lactation as well as a strict hypoallergenic diet in infancy appears to reduce IgE mediated reactions in infancy and early childhood, but not to affect prevalence of atopic disease in later childhood. (20) A complete avoidance of potential allergens may be burdensome to families, but for high risk families who are willing to make significant changes, it is reasonable to suggest avoidance of highly allergenic foods during pregnancy, lactation, infancy, and early childhood with ongoing dietary guidance to assure nutrient adequacy. All infants from families with history of allergy will benefit from breastfeeding, avoidance of cow’s milk in the first year of life, and delay in non-milk feedings until 6 months.

Margin Notes and Boxes

Medium Chain Triglycerides (MCT): Form of fat composed of fatty acids with carbon chain lengths of 6 to 12 carbon atoms. Compared to fats with long chain fatty acids MCT are more easily digested and absorbed.

Whey Hydrolysate Formula: Cow’s milk based formula in which the protein is provided as whey proteins that have been hydrolyzed to smaller protein fractions, primarily peptides. This formula may provoke an allergic response in infants with cow’s milk protein allergy.

Casein Hydrolysate Formula: Infant formula based on hydrolyzed casein protein, produced by partially breaking down the casein into smaller peptide fragments and amino acids.

Osmolality: Property of a solution that depends on the concentration of the particles (solutes) in solution per unit of solvent base; measured as milliosmoles per liter (mOsm/L).

Hypernatremic dehydration: An abnormally high sodium ion concentration in the extracellular fluid, due to water loss or restriction, drawing cell water to restore osmotic balance, causing dangerous cell dehydration.

Metabolic acidosis: Abnormal rise in acid partner of the carbonic acid-base bicarbonate buffer system by excess of organic acids, which displace part of the base bicarbonate in the buffer system and cause the H+ concentration to rise.

 Neophobic: Fear of new and unfamiliar foods.

Botulism: A serious, often fatal, form of food poisoning from ingesting food contaminated with the powerful toxins of the bacteria Clostridium botulinum The toxin blocks transmission of neural impulses at the nerve terminals, causing gradual paralysis and death when affecting respiratory muscles. Most cases result from eating carelessly home-canned food, so all such food should be boiled at least 10 minutes before eating. Cases reported in infants have been related to eating spore-containing honey, so it should not be used

1. American Academy of Pediatrics, Work Group on Breastfeeding.Breastfeeding and the use of human milk. Pediatrics. 1998;101:31-36.