Lifecycle Nutrition
Developmental Nutrition
FCSN 345
Dr. Virginia Bennett
Office 134 PE
Office hours: T & Th 1:00
e-mail: bennettv@cwu.edu
Measures of a Successful
Outcome of Pregnancy
Healthy Baby
Healthy Mother
Baby Survives the First
Year of Life
Healthy Baby
Still Birth Ratio or Fetal
Death Ratio
Early in Pregnancy: difficult to have
reliable numbers of death rate
Why?
Later in Pregnancy: numbers are
more reliable after 20 wks gestation
About 6.4 stillbirths per 1000 live
births
Healthy Mother: Maternal
Mortality
Static since 1982 at 7 to 8 mothers
die per 100,000 births. About 1 death
per day in the US
Big racial difference:
White 5.0
Black 20.8
Others 18.2
Why?
Maternal Mortality
Infant Mortality
Infancy: First Year of Life
<28 days - neonatal
>28 days < 1 year - postneonatal
2006: Infant Mortality Rate in US
6.43 per 1000 live births
Ranked 42nd world-wide
1950 29.2 but we were ranked 6th worldwide
Why?
terminology
Infant: first year of life
Neonatal: under 28 days of life
Early Neonatal: under 7 days of life
Post neonatal: 28 days – 11 months
Fetal mortality: fetal deaths over 20
weeks gestation
Late Fetal mortality: deaths over 28
weeks gestation
Cause of Infant Problems
Neonatal Problems: first 28 days after
birth
What might be the reasons for problems
here?
4.7 in 2002
Post neonatal Problems: 28 days to
one year
What might be the reasons for problems
here?
2.3 in 2002
In US
Most infant deaths happen in
neonatal period
Perinatal mortality: adds fetal deaths
plus early neonatal deaths
Better Infant Mortality Rates
Japan: 3.24
Singapore: 2.29
Sweden: 2.76
Hong Kong 2.95
Cuba 6.22
CIA - The World Factbook -- Rank
Order - Infant mortality rate
Risk of Infant Mortality:
Factors
If infant mortality rate was similar to
Singapore’s we would save over
18,900 infant deaths per year
Low Birth Weight largest single factor
less than 5.5 pounds (2500 grams)
LBW risk factors:
K maternal pre-pregnancy ht & wt and
pregnancy weight gain
age
socioeconomic
poverty
number of pregnancies
race
Classification of Low Birth
Weight
Premature
< 37 weeks
Intrauterine Growth
Retardation or Small for
Gestational Age
37 weeks
wasted - thin, wt, normal
Infant Mortality Rates by
Maternal Race
14
12
10
8
6
4
2
0
White
Black
Native
Amer
Asian or All Races
Pacific
Islander
Mechanism for growth
retardation
Maternal Malnutriton
Reduced blood volume expansion
Inadequate increase in cardiac ouput
Decreased placental blood flow
Decreased placental size
Reduced nutrient transfer
Fetal Growth Retardation
How to improve Infant
Mortality Rate?
Housing
Sanitation
Diet
Health care
Nutrition Influences on Fetal
Growth
Deficiency in Calories
Too few Calories to allow adequate
reproduction of cells and decreased
development
Deficiency of Nutrients
Too little of some specific nutrient
e.g.: folic acid
spina bifida
Spina Bifida: A Neural Tube Defect
Winick: Growth Happens in
Two Ways
Increased number of cells
Increased size of cells
Critical times of increased
number of cells
1. Increased number
hyperplasia
2. Number and size
hypertrophy
+
Critical Periods
If an embryo or fetus doesn’t
receive the nutrition necessary to
help with development, the fetus
will suffer
Fertilization of the ovum(zygote)
happens
implantation of the ovum in the uterine
wall happens in the first two weeks
Critical period: cigarette smoke,
malnutrition can keep development from
Types of Fetal Growth
Failure
Intrinsic: some internal
factor
chromosome abnormalities
drug affecting cells
Extrinsic: some external
factor
poor intake of nutrients
poor blood supply
Is the fetus a perfect
parasite?
What does this mean?
Fetus takes what it needs
regardless of mother’s intake
Probably isn’t true.
It takes what it needs until it
disrupts mother’s ability to survive
From a species survival
standpoint: mother needs to
survive
Events of Pregnancy
Time
Event
0-2 weeks egg fertilized and
implanted
3-8 weeks Embryo: at end of 8
weeks
is 1 inch and
has central
nervous
system, GI tract,
limb, buds, etc.
8-40 weeks Fetal period: growth and
development
Role of the Placenta
Nutrient and waste product
exchange
Hormone production
Estrogen: helps develop the
infrastructure of pregnancy
Progesterone:
Relaxes smooth muscle
Relaxes the uterus
Relaxes the digestive system: slower
Placenta Roles
Transport Mechanisms:
Passive Diffusion:
Oxygen -Carbon dioxide
Fatty acids-Steroids
Nucleosides
-Electrolytes
Fat-soluble vitamins
Role of the Placenta
Placenta is Selectively
Permeable
Not all molecules can cross
the placenta
Vitamin D can
Parathyroid Hormone (PTH)
can’t
Allows for bone remodeling
Placental Transport
Facilitated Diffusion:
Most monosaccharides
Active Transport:
Amino acids
--some cations (Ca,
Iron)
Iodine
--Phosphate
Water-soluble vitamins (at high
concentrations Vitamin C can pass via
diffusion)
Solvent Drag: electrolytes
Pregnancy
Nutrient Needs to Support
Pregnancy
Energy:
No increase in Cal for first
trimester
Why?: 1. Very small embryo; 2.
Increased absorption of most
nutrients and Cal due to
decreased motility of GI tract due
to hormones of pregnancy
300 Cal increase during 2nd and
Nutrient Needs During
Pregnancy
Protein:
Determine pre-pregnancy
needs based on RDA: 0.8
grams protein/kg. This is
generally around 45 to 50
grams Protein per day.
Add 15 grams to this for pregnancy
Generally around 60 to 65 grams/day
is sufficient
Methylated
Molecule
SAH
Molecule
SAM
Homocysteine
Methyl-H4 Folate
Methylene-H4 Folate
Methionine
B12
H4 Folate
serine
glycine
purine
Purine precursor
Nutrients of Special Interest
Folate: related to neural tube
defects and spina bifida
Reduced absorption during
pregnancy because of interaction
with estrogen
Produces folate deficient women
Interferes with proper formation of
spinal column: affects 400,000
births per year
Nutrients of Special Interest
Iron: Blood volume increases by 50%
during pregnancy
Body conserves Iron during pregnancy
No menstruation
3 time increase in absorption
But still doesn’t keep up with production of
red blood cells
Hemoglobin concentration falls: normal
above 13 g/dl. In pregnancy may fall below
12 g/dl
RDA up from 15 to 30 mg/day
Special Supplemental Food
Program for Women, Infants, and
Children
To battle against problems during
pregnancy and infancy, WIC was
developed to provide supplemental food to
low socioeconomic and at risk women and
infants.
Nutrition education also provided
Recent study: for each $1 spent, $4 save down
the road;
Avg costs: Normal Birth Weight= $1,700;
Premie or low birth weight = $77,000
Information on WIC
http://www.fns.usda.gov/wic/
In 2005 we had about 8 million
receiving WIC assistance in the US;
This cost about $1.4 Billion
In 2005 we had about 160,000
receiving WIC assistance in
Washington; This cost about $28
Million dollars
Body Mass Index
Kg/ meters 2
175#/2.2 #/kg = 79.5 kg
72 “ X .0254 meters/inch = 1.83
meters
1.83 meters 2 = 3.35
79.5 / 3.35 = 23.7
Weight Gain During Pregnancy
Based on Pre-pregnancy BMI
Underweight (BMI<19.8) : 28-40 #
Normal weight(BMI 19.8-26) : 25 to
35 #
Overweight(BMI 26-29): 15 to 25 #
Obese(BMI over 29): 13 # minimum
Other Modifiers: Small stature(<62 in)
: low end of range; black: high end of
range
Wt Gain for multifetal pregnancies
Twins: 35-45 lbs. Underwt at the
upper end of range; overwt at the
lower end
4-6 lb first trimester; 1.5 lb/wk after
450 Cal per day above prepregnancy
amount
Triplets: 50 lbs with 1.5 lb/wk
throughout pregnancy
Cal intake should reflect enough intake
to meet wt gain goals
Average weight of multifetal
pregnancies
Singletons: 7.7 lbs(3440 grams)
Mean gestational age: 39-40 wks
6% lbw
Twins: 5.4 lbs(2400 grams)
37 weeks; 54 % lbw
Triplets: 4.0 lbs(1800 grams)
33-34 wks; 90% lbw
Rate of Weight Gain
First Trimester: 2 to 4 pounds
Second and Third Trimester: 1 pound
per week
3 pounds + (26 weeks x 1 # per
week) = 29#
Components of Weight Gain
Infant 7.5 #
amniotic fluid 2 #
Placenta
1.5 #
mother’s
stores 7 #
Blood 4 #
Fluid 4 #
uterus 2 #
Breasts 2 #
TOTAL 30 #
Fetal Alcohol Syndrome
Physical and Mental Abnormalities
attributed to alcohol consumption
during pregnancy
low nasal bridge
small head
short nose
circumference
short eyelid opening
delayed
thin upper lip
development
underdeveloped filtrum
Source of FAS Information
http://www.nofas.or
g/
http://capwiz.com/n
ofas/issues/alert/?a
lertid=6804721&typ
e=CO
Advocacy Extra
credit assignment:
write a letter to
your members of
congress
FAS Screening
In 1996, FAS Facial Photographic
Screening/Diagnostic software (Astley &
Clarren, 1996; 2001; Astley et al., 2001;
Astley & Kinzel, 2002). The software is
used to measure the magnitude of
expression of the three facial features of
FAS (small eyes, a smooth philtrum and a
thin upper lip).
FAS Screening
FAS is characterized by growth
deficiency, a unique cluster of facial
features, cognitive/behavioral problems
and prenatal alcohol exposure. The facial
appearance is the only feature that is
unique to FAS, thus it serves as an ideal
feature to use for screening. The
screening tool performed with 99.9%
accuracy.
Alcohol Effects on Pregnancy
About 1/5 of women continue to
during pregnancy
The first few weeks are critical; many
women don’t know they are pregnant
Birth defects have occurred in women
who consume as little as two drinks
per day
No alcohol is the best if planning
pregnancy
Fetal Alcohol Effects: internal damage
Other Dietary Concerns during
Pregnancy
Caffeine:
Animal models: massive doses are
teratogenic
Smaller doses not as definitive
mixed results in epidemiological studies
generally if caffeine is consumed, it should
be moderately
Sugar Substitutes
Saccharin: A carcinogen? Limit during
pregnancy
Doses relationship: high intake = greater
risk
Aspartame (Nutrasweet):
PKU mothers should avoid
If not PKU, moderate intake probably ok
but need to increase Cal (2nd and 3rd
trimesters) and Calcium
Maternal Problems of
Pregnancy
Gestational Diabetes: Glucose
Intolerance
Hormones of pregnancy make mother’s
body resistant to insulin;Human
Placental Lactogen (HPL); Human
Growth Hormone(HGH)
Often shows up at 25 weeks of
pregnancy
Needs to be treated to control growth of
the fetus
Macrosomia: large baby and delivery
Gestational Diabetes Dx
Glucose Tolerance Test (GTT):
After Fasting:
Glucose Load given orally
Baseline Blood Glucose (BG)
BG’s every hour for three hours
two abnormally high values indicate Db
Dx
Normal BG values
Fasting
1 hr
2 hr
3 hr
105 mg/dl
190
165
145
Normal and Abnormal Glucose
Curves
250
200
150
normal
Db
100
Db
50
0
fasting
1 hours
2 hours
3 hours
Treatment of Gestational Db
Diet alone
Calculate CHO needed: Generally 50 %
of Cal
Could be less if poor control
Distribute them throughout the day
Develop and Meal Plan for Mother
Involves Food Records
Weight Checks
Ketone Testing
Blood Glucose Testing
Gestational Db Treatment
Diet and Insulin
Some individuals are never able to
control BG by diet alone and require
insulin injections
Same concerns as diet alone
With emphasis on hypoglycemia
Gestational Diabetes Resources
American Diabetes Association
http://www.diabetes.org/gestationaldiabetes.jsp
Other Problems of Pregnancy
Edema: most women suffer from
water retention: due to large blood
volume and decreased protein
concentration in blood
Pregnancy Induced Hypertension
(PIH)
massive edema, high blood pressure,
protein in urine
If untreated can result in fetal and
maternal injury or death
PIH: formerly called Toxemia
Elevated BP
Proteinuria
Massive edema
Often called preeclampsia
Eclampsia: a result of severe
preeclampsia: convulsions and coma
Can result in the death of the mother
and fetus
Treatment of PIH: Diet??
Nutritionally: offset protein loss with
additional protein in diet
Some research shows calcium
supplementation may help prevent;
mixed
Magnesium supplementation may
help
Sodium restriction DOES NOT HELP
treat or prevent
Treatment of PIH: Diet??
Antioxidants: Vit C, E, carotene
Hypertension often requires blood
pressure lowering medication
Depending on severity, may require
bedrest
Pica and Cravings
Pica: Eating Non-foods
geophagia: eating dirt
Iron deficiency?: problem if it causes a
blockage
amylophagia: eating clothing starch
Cravings:
eg: dill pickles and ice cream
reason? Overcome a deficiency?
No harm, no need for concern: If
harmful, intervention is needed
Nutritional Guidance During
Pregnancy
Positive approach to nutrition and
pregnancy
Stress positive outcomes Vs fear of
negative outcome
Stress the importance of good
nutrition
adequate protein of good quality
enough total Cal, esp CHO, to spare
protein
balance of vitamins and minerals from
Nutrition and Pregnancy
Age and Parity of Mother
Preconception Nutrition
Metabolic Interaction of Pregnancy:
synergism
Individual needs and adaptations
Nutrition Assessment
Clinical Observations
Body Measures
Lab Tests
Diet History
Lab Tests Can Indicate
Problems
Anemia of Pregnancy
Iron Deficiency: Most Common
also called microcytic, hypochromic, with
reticulocytes( immature RBCs)
treated with supplements of Iron (30 mg/day)
Other Anemias:
Folic Acid deficiencyalso called megaloblastic
anemia;
disrupts hemoglobin synthesis
B12 Deficiency: Called pernicious; also big
cells
Blood measures: Anemia
Hematocrit: Packed RBC Volume
Normal non-pregnancy: 35 %
During pregnancy 29-31%
Hemoglobin
Normal non-pregnancy: 13-14 g/100ml
Pregnancy: 10-11 g/100ml
Images of Anemia
http://health.allrefer.com/health/irondeficiency-anemia-reticulocytes.html
Folic Acid Anemia
RDA up from 180 micrograms to 400
micrograms / day
Estrogen Folic Acid Interactions
1. Disrupts absorption
disrupts an enzyme that helps with
absorption(deconjugase)
2. Increases clearance of folic acid from
blood
B12 Deficiency
Pernicious Anemia
similar to megaloblastic but caused by
deficiency of B12
If untreated, may also be associated with
neurological damage
http://health.allrefer.com/picturesimages/megaloblastic-anemia-viewof-red-blood-cells.html
Phenylketonuria and Pregnancy
PKU: genetic disease, passed
autosomal recessive trait
Inability to metabolize extra Phe to
Tyrosine
missing Phenylalanine hydroxylase
results in high phenylketones in mother
and fetal circulation
can cause mental retardation in fetus
Red Flags During Assessment
Disproportionate height to weight and
weight gain
Abuse or avoidance of foods
bizarre eating patterns
economic or psychological problems
associated with food
unhealthful lifestyle with or without
substance abuse
Lactation
3 Factors to Establish and
Maintain Breastfeeding
Anatomy
Initiation of production
Ejection of milk from alveoli
Anatomy
Functional Breasts
Large variation in structure
But almost all women who have given
birth who want to breastfeed their babies
can
Development of Breasts
Puberty: increased estrogen
associated with development of
mammary glands and alveolar cells
and ducts
Pregnancy: further proliferation of
alveoli
Birth: increase prolactin production
and secretion
Further alveolar cell proliferation
Physiology of Lactation
Full Lactation may not be attained
until 2nd or even 3rd week (in first
pregnancy)
Colostrum: first secretion: high in
protein, low in sugar and fat
First 2+ days and then transition to milk
Yellow
high in immunoglobulins
Prolactin: Control of Milk
Production
Complex neuroendocrine process
Sensory nerves of breast stimulated
nerve impulse travels to spinal cord and
hypothalamus
Induces pituitary gland to produce and
secrete hormones
– Major one is PROLACTIN
Cycle of Production
Resting Cell
Milk synthesis
Milk secretion
Resting Cell
Prolactin Control
Fat Prolactin increases two enzymes
Induces lipoprotein lipase production
which removes Triglycerides from
circulation and moves fatty acids and
glycerol into alveolar cells
Induces a transferase enzyme that helps
make triglycerides in the cell for milk
production
Prolactin Control
Protein: casein and lactalbumin
unique to milk
Prolactin increases production of these
two proteins
Prolactin Control
CHO: lactose
Galactosyl transferase(inactive)
| lactalbumin
|
Galactosyl transferase(GT)(active)
Glu + Gal-----------> Lactose
GT
Maintenance of Milk Production
Sucking---hypothalamus--anterior
pituitary---prolactin secretion---milk
production and release
If no sucking
No milk production
Demand and Supply
less sucking, less production: more
sucking, more production
Milk Letdown: moving the milk
to nipple for baby access
Controlled by oxytocin
Sucking----hypothalamus--posterior
pituitary-----oxytocin release
myoepithilial cell contraction in ductules
forces milk to nipple
Other stimuli can induce this as well
crying, embarrassment
Human Vs Cow’s milk(per Liter)
Kcal:
Pro(g):
%
Fat(g):
%
CHO(g)
%
668
9
5.5%
40
53.9%
68
40.7%
678
35
20.6%
38
50.4%
49
28.9%
Protein Content of Milk
Species specific: The fastest newborn
growth rate = the highest level of
protein
Cows grow real fast, therefore cow’s
milk has relatively more protein than
human milk.
Why is more protein needed in cow’s
milk?
Type of protein in milk
Human milk 40 % Casein, 60 % alpha
lactalbumin
Cow’s milk 80 % Casein, 20 % alpha
lactalbumin
Human milk low in Phenylalanine
Human milk high in cystine & taurine
Babies can’t synthesize these too well.
Taurine: a conditionally essential Amino Acid,
not used in Protein Synthesis
Found free or associated with small
peptides:
Taurine Function
Taurine function:
Functions: Related to development in
infants
Also conjugation of bile acids; Taurine,
called a bile salt, is lipophilic and
hydrophilic; these are conjugated or
connected to bile acids, the combination of
which helps emulsify the fatty stuff of food
and helps with digestion and absorption;
Taurine Function
Other functions of taurine:
detoxification,
membrane stabilization,
osmoregulation, and
modulation of cellular calcium levels.
Colostrum
High protein
low sugar, fat and kcal
Immunoglobulins IgA and IgG
guard against intestinal tract infection
may pass into circulation and guard
against systemic infection
passage of meconium
helps establish bifidus flora in GI tract
Iron Supplementation and BF
Two Points of View:
Yes: milk iron directly proportional to
mother’s intake
Fetal Fe levels are generally low;
Fe needed for growth
No: Fe saturates lactoferrin, the iron
binding protein of milk
lactoferrin then unable to sequester Fe from
pathogenic bacteria; leading to more
infections
Vitamins: Cow Vs. Human
The amount of vitamins in human milk
varies more from individual to
individual than does the average
vitamin content of cow’s milk from the
average vitamin content of human
milk. Why?
Diet, genetics, other factors
Vitamin K and Infants
Infants generally low Vitamin K status
Intestinal flora make Vitamin K
Newborn gut is sterile, no bacteria to
make Vitamin K
Birth is traumatic
Vitamin K is important in blood
clotting
Vitamin K injection at birth
Breastfeeding: Best Feeding
Method
‘Sole’ food for the first 4 to 6 months
Provides benefits to baby and mother
Economic
Nutrition
Immune function
Bonding
Maternal weight loss
Convenience
Anti-infective Properties
Bifidus factor: stimulates
bifidobacteria, which fight against
pathogenic bacteria
IgA, IgM, IgG: immunoglobulins that
guard the gut against infective
bacteria
Lactoferrin: binds iron away from
bacteria
Macrophages: phagocytosis of
infective bacteria
When not to breastfeed?
HIV infected mother
Although WHO says go ahead in
developing countries
The risk of infection is less than the harm by
not having good nutrition available during
early months
Galactosemia: one in 50,000 births
Inability to convert galactose to glucose
and developmental problems result
Breastfeeding Promotion
Incidence: how many select
breastfeeding as a feeding choice:
Breastfeeding at 1 week
Duration: how long does mother
breastfeed? sole food for 5 to 6
months.
By 2000, goals are 85% and 35%
Peaked in 1984 at 61% and 24%
dropping since
Breastfeeding Choice: Factors
Ethnicity: Anglo 60.5%; Black 25%;
Hispanic: 51%;
Employment: Full 53 %; Part 62 %;
None 53 %;
Acculturation: Low 53 %; Middle 38
%; High 36 %;
Trisler, T. A., Bergman, E.A.
JADA Suppl 93(9): A77.
4 groups of breastfeeding promotion
A: no peer present: Spanish taught
B: no peer present: English taught
C: peer present: Spanish taught
D. peer present: English taught
Presence of peer played no role in
incidence of breastfeeding;
Spanish taught increased rate of
incidence
Behavioral Factors Involved in
Breastfeeding Decision
Social Support: availability of family
members
Social Influence; advertising, health
professionals
Attitudes:attitudes toward formula and
BF
Self-efficacy: confidence of the
mother
Summary: Must increase BF in
minority populations
How to Influence Choice?
J Nutr Ed: Teaching Intervention
1984: 16(1): 19-22.
Three groups:
A: Pregnant woman given referral
card with telephone number with
supportive message
B: Same with a manual in Spanish
and English
C: Same with a bedside teaching
session with BF consultant
JADA 1998;98:143-148.
Counseling and Motivating videotapes
increase duration of breast-feeding in
African-American WIC participants
n=115 Af-Am women who initiated BF
Four groups:
A: no intervention B: video package
C: peer counseling
D: both
More breastfed in intervention groups
JADA 1998
Group 7-10 d
8 wk
16 wk
Control 53%
23%*
0%*
video 67%(n=33)75%(n=28)48%
vi&peer 80%
70%
40%
*p<.05
If Breastfeeding is not Chosen?
Infant formula is next best choice:
Most are cow’s milk derived and are
produced to be close to human milk in
composition
Some are soy based
Others are specialized to meet certain
needs
e.g.: PKU babies can’t have very much
phenylalanine in the diet: Lofenalac
Nutrition Education
Informative: Factual information
Attitudinal: motivates change in
attitude about nutrition and
nourishment
Behavioral: motivates change in
behavior
Therapeutic: addresses a specific
problem
When is Nut Ed needed?
High Risk Groups: poverty, lack of
education, very young(<17yo), very
old (over 35 yo), first pregnancy, high
parity, prior complications, lack of
supportive environment.
Education costs money: Cost/benefit
needs to be established
Money spent saves money
Cost/Benefit of Nutrition Ed.
WIC offers nutrition vouchers and
nutrition education to high risk
mothers.
Data collected indicates that for each $1
spent, $4.21 is saved
Individuals who don’t receive WIC are at
greater risk for low birth weight babies, and
other complications that lead to increased
health care money spent.
Nutrition Education Saves Money!
Costs of Low Birth Baby
Medicaid pays an average of $77,000
for a low birth weight baby in
additional hospital and health care
expenses.
A normal weight baby costs an average
of $1700.
Poor Fetal Nutrition is also linked to
Chronic Disease
Lancet 348:1264-1268, 1996.
N= 13,249 Death from heart disease
and stroke tended to be higher in
those men who were born with a low
birth weight and remained small at 1
year of age
Perhaps related to mother’s ability to
support pregnancy and trauma
induced in the developing fetus.
Breastfeeding and Fertility
Breastfeeding tends to suppress
menstruation and ovulation
Almost all who formula feed initiate
menstruation and ovulation sooner
Can this be used as a contraceptive
method?
Probably not. Nutritional status also
influences.
When to Add Solid Foods?
4 to 6 months: when developmental
landmarks are met; Continue
breastfeeding or formula
Iron fortified rice cereal
Add one food at a time: several days
See if there is an allergic reaction
Then add a new food
Problems of Infant Feeding
Failure to Thrive:
Baby doesn’t grow as fast as peers
Causes? Often inadequate nutrition
Monitor weight gain
Compare nutrient intake per body weight
A baby needs more than an adult
Problems of Infant Feeding
Baby Bottle Tooth Decay: Also called
Nursing Bottle Syndrome
Exposure of teeth to the carbohydrates
of formula
General Feeding Rules for
Infants and Children
Caregiver is the gatekeeper: What is
offered and when
Infant or child decides whether to eat
what is offered and also how much
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