Despite the evidence for an impact of breastfeeding on cognitive development, there have been few published papers on mental health outcomes since the early theorists working within a developmental psychopathological framework (Hoefer and Hardy 1929) which is surprising given the popularity of attachment theory in relation to healthy psychological development (Rutter 2006). There is reluctance to suggest an association between breastfeeding and later mental health partly due to the possibility of alternative explanations such as parenting behaviours and cognitive ability (Anderson, Johnstone et al. 1999) and concern for creating guilt in women who do not breastfeed. In developed nations breastfeeding is more likely in communities with greater economic and social resources (Pollock 1994; Vohr, Poindexter et al. 2006), and the confounding socioeconomic effects complicate interpretation of this association (Li, Kendall et al. 2008). Our study addresses this issue by adjusting for many of these underlying factors, although we acknowledge that not all potential confounders (such as maternal IQ) were measured with sufficient validity

Existing research tends to focus on infant and early childhood behaviour (Golding, Rogers et al. 1997) and consistent with our findings, infants who are breastfed for at least six months have a distinct developmental advantage over non breastfed infants and infants breastfed for a short period of time (Horne, Parslow et al. 2004). One study found that low birthweight infants fed breast milk had significantly higher scores for engagement and emotional regulation on the Bayley Developmental Scale than low birthweight infants not given breast milk (Vohr, Poindexter et al. 2006). However, this study did not differentiate the effects of feeding at the breast versus feeding of breast milk through a tube or bottle (Lucas, Morley et al. 1994). Another study found that breastfed infants were more able to face adverse stimuli with greater degrees of control, show more appropriate amounts of change in arousal levels, and were more able to return to moderate states of arousal than formula fed infants (Hart, Boylan et al. 2003). However, much of this research is based on

and precision to fully control for all potential confounding effects.

breast milk (Quinn, O'Callaghan et al. 2001).

cognition and educational attainment.

et al. 1998).

A growing literature suggests that a relationship between breastfeeding and cognitive development exists (Silva, Buckfield et al. 1978; Clandinin, Chappell et al. 1980; Fergusson, Beautrais et al. 1982; Taylor and Wadsworth 1984; Doyle, Rickards et al. 1992; Wharton 1992; Makrides, Neumann et al. 1994; Michaelson, Larsen et al. 1994; Malloy and Berendes 1998; Quinn, O'Callaghan et al. 2001; Oddy, Kendall et al. 2003). In a recent critical evaluation (Drane and Logemann 2000) of the three methodological standards described by Bauchner(Bauchner, Leventhal et al. 1986), definition of outcome, correct classification of infant feeding type and control of potential confounding variables were determined in relation to cognitive development. The evaluation found that adherence to an infant feeding standard was poor with most studies classifying partial and exclusive breastfeeding together and only five considering feeding as a continuous variable (Taylor and Wadsworth 1984; Morrow-Tlucak, Haude et al. 1988; Bauer, Ewald et al. 1991; Lucas, Morley et al. 1992; Horwood and Fergusson 1998). Most studies adjusted for confounding factors including maternal education, socioeconomic status, birthweight and birth order. Few studies had well-defined and consistent outcome measures. Only five studies met all three methodological standards (Lucas, Morley et al. 1992; Lucas, Morley et al. 1994; Pollock 1994; Horwood and Fergusson 1998; Malloy and Berendes 1998); three of these found consistent advantages to breastfed infants (Lucas, Morley et al. 1992; Lucas, Morley et al. 1994; Horwood and Fergusson 1998) but two did not find significant associations (Lucas, Morley et al. 1994; Pollock 1994). The lack of association in these two studies may be explained by design issues. One study found differences for the Bayley Scale Psychomotor Index but not for Mental Development Scale Scores, when comparing infants fed donor breast milk with infants fed formula milk. In this study the low birthweight breastfed infants were fed 'drip' milk rather than own mothers' milk, which had a higher calorific value and fat content (Lucas, Morley et al. 1994). In relation to intelligence, the breastfed infant has been shown to have an advantage over the non breastfed infant (Pollock 1994), although some studies have been criticised for neglecting the possible genetic influence of maternal intelligence (Der, Batty et al. 2006).

In prospective studies after adjustment for numerous confounding variables, children breastfed for longer performed better on tests of cognition, verbal ability and school performance. Similar results have been observed in term and pre-term infants (Horwood and Fergusson 1998; Horwood, Darlow et al. 2001) and extend beyond adolescence (Lucas 2005). In a study to examine the association between duration of breastfeeding and cognitive ability at 7-8 years in a birth cohort of very low birthweight infants (Horwood, Darlow et al. 2001), increasing duration of breast milk feeding was associated with increases in both cognitive IQ (p<0.001) and performance (p<0.05). The effects on cognitive IQ are in the range of 2-5 points and may be as large as 10 points in low birthweight babies (Lucas, Morley et al. 1992; Lucas, Morley et al. 1994; Horwood, Darlow et al. 2001). The results of our study agree with this and other reports and adds to a growing body of evidence for an association between breastfeeding and cognitive development.

An early study showed small but significant increases in later intelligence and educational attainment between breast and formula-fed infants (Rodgers 1978). Fergusson et al combined males and females and tested for differences in intelligence, comprehension, expression and articulation and found significantly increased scores in infants breastfed for four months or longer for intelligence and comprehension at three, five and seven years, and expression at three and five years (Fergusson, Beautrais et al. 1982). Quinn et al speculated the observed that cognitive differences between breast- and formula-fed infants observed in

A growing literature suggests that a relationship between breastfeeding and cognitive development exists (Silva, Buckfield et al. 1978; Clandinin, Chappell et al. 1980; Fergusson, Beautrais et al. 1982; Taylor and Wadsworth 1984; Doyle, Rickards et al. 1992; Wharton 1992; Makrides, Neumann et al. 1994; Michaelson, Larsen et al. 1994; Malloy and Berendes 1998; Quinn, O'Callaghan et al. 2001; Oddy, Kendall et al. 2003). In a recent critical evaluation (Drane and Logemann 2000) of the three methodological standards described by Bauchner(Bauchner, Leventhal et al. 1986), definition of outcome, correct classification of infant feeding type and control of potential confounding variables were determined in relation to cognitive development. The evaluation found that adherence to an infant feeding standard was poor with most studies classifying partial and exclusive breastfeeding together and only five considering feeding as a continuous variable (Taylor and Wadsworth 1984; Morrow-Tlucak, Haude et al. 1988; Bauer, Ewald et al. 1991; Lucas, Morley et al. 1992; Horwood and Fergusson 1998). Most studies adjusted for confounding factors including maternal education, socioeconomic status, birthweight and birth order. Few studies had well-defined and consistent outcome measures. Only five studies met all three methodological standards (Lucas, Morley et al. 1992; Lucas, Morley et al. 1994; Pollock 1994; Horwood and Fergusson 1998; Malloy and Berendes 1998); three of these found consistent advantages to breastfed infants (Lucas, Morley et al. 1992; Lucas, Morley et al. 1994; Horwood and Fergusson 1998) but two did not find significant associations (Lucas, Morley et al. 1994; Pollock 1994). The lack of association in these two studies may be explained by design issues. One study found differences for the Bayley Scale Psychomotor Index but not for Mental Development Scale Scores, when comparing infants fed donor breast milk with infants fed formula milk. In this study the low birthweight breastfed infants were fed 'drip' milk rather than own mothers' milk, which had a higher calorific value and fat content (Lucas, Morley et al. 1994). In relation to intelligence, the breastfed infant has been shown to have an advantage over the non breastfed infant (Pollock 1994), although some studies have been criticised for neglecting the possible genetic influence of maternal intelligence (Der,

In prospective studies after adjustment for numerous confounding variables, children breastfed for longer performed better on tests of cognition, verbal ability and school performance. Similar results have been observed in term and pre-term infants (Horwood and Fergusson 1998; Horwood, Darlow et al. 2001) and extend beyond adolescence (Lucas 2005). In a study to examine the association between duration of breastfeeding and cognitive ability at 7-8 years in a birth cohort of very low birthweight infants (Horwood, Darlow et al. 2001), increasing duration of breast milk feeding was associated with increases in both cognitive IQ (p<0.001) and performance (p<0.05). The effects on cognitive IQ are in the range of 2-5 points and may be as large as 10 points in low birthweight babies (Lucas, Morley et al. 1992; Lucas, Morley et al. 1994; Horwood, Darlow et al. 2001). The results of our study agree with this and other reports and adds to a growing body of evidence for an

An early study showed small but significant increases in later intelligence and educational attainment between breast and formula-fed infants (Rodgers 1978). Fergusson et al combined males and females and tested for differences in intelligence, comprehension, expression and articulation and found significantly increased scores in infants breastfed for four months or longer for intelligence and comprehension at three, five and seven years, and expression at three and five years (Fergusson, Beautrais et al. 1982). Quinn et al speculated the observed that cognitive differences between breast- and formula-fed infants observed in

association between breastfeeding and cognitive development.

Batty et al. 2006).

their birth cohort of 3,880 infants followed to five years was due to unique constituents of breast milk (Quinn, O'Callaghan et al. 2001).

Available meta-analyses reflect a less conclusive pattern of breastfeeding effect on developmental outcomes. A meta-analysis of studies published up to 1996 found that breastfed children had higher cognitive scores, compared to bottle-fed children (Anderson, Johnstone et al. 1999) although some studies adjusted for few confounders. Another metaanalysis showed that only two studies met stringent criteria for inclusion, such as adequate adjustment for socioeconomic status of the family and stimulation of the child (Jain, Concato et al. 2002). Of these two studies, one reported a positive association between breastfeeding and intelligence (Johnson, Swank et al. 1996), while the other found no benefit (Wigg, Tong et al. 1998).

The majority of previous studies have focused on the association between breastfeeding and cognitive ability, and only a few have examined academic achievement. Where this has been studied, positive associations have been observed (Horwood and Fergusson 1998; Anderson, Johnstone et al. 1999; Jain, Concato et al. 2002). For example, Richards (Richards, Hardy et al. 2002) found a positive impact of breastfeeding on educational attainment in midlife independent of early background in 1,739 participants from the British 1946 birth cohort. Further analyses found that the association was largely mediated through adolescent cognition and educational attainment.

Despite the evidence for an impact of breastfeeding on cognitive development, there have been few published papers on mental health outcomes since the early theorists working within a developmental psychopathological framework (Hoefer and Hardy 1929) which is surprising given the popularity of attachment theory in relation to healthy psychological development (Rutter 2006). There is reluctance to suggest an association between breastfeeding and later mental health partly due to the possibility of alternative explanations such as parenting behaviours and cognitive ability (Anderson, Johnstone et al. 1999) and concern for creating guilt in women who do not breastfeed. In developed nations breastfeeding is more likely in communities with greater economic and social resources (Pollock 1994; Vohr, Poindexter et al. 2006), and the confounding socioeconomic effects complicate interpretation of this association (Li, Kendall et al. 2008). Our study addresses this issue by adjusting for many of these underlying factors, although we acknowledge that not all potential confounders (such as maternal IQ) were measured with sufficient validity and precision to fully control for all potential confounding effects.

Existing research tends to focus on infant and early childhood behaviour (Golding, Rogers et al. 1997) and consistent with our findings, infants who are breastfed for at least six months have a distinct developmental advantage over non breastfed infants and infants breastfed for a short period of time (Horne, Parslow et al. 2004). One study found that low birthweight infants fed breast milk had significantly higher scores for engagement and emotional regulation on the Bayley Developmental Scale than low birthweight infants not given breast milk (Vohr, Poindexter et al. 2006). However, this study did not differentiate the effects of feeding at the breast versus feeding of breast milk through a tube or bottle (Lucas, Morley et al. 1994). Another study found that breastfed infants were more able to face adverse stimuli with greater degrees of control, show more appropriate amounts of change in arousal levels, and were more able to return to moderate states of arousal than formula fed infants (Hart, Boylan et al. 2003). However, much of this research is based on

The Long-Term Effects of Breastfeeding on Development 73

breastfeeding may have a positive effect on the development of neuroendocrine aspects of the stress response, which may affect development (Huizink, Robles de Medina et al. 2003). There is some evidence to date in human studies (Strathearn, Mamun et al. 2009), but this hypothesis is largely informed by rat models (Uvnäs-Moberg 1998). Rat pups who experienced a greater frequency of maternal contact during nursing in the first ten days after birth (licking and grooming) exhibited a more controlled response to acute stress as adults (e.g. a lower magnitude of hypothalamic-pituitary-adrenal (HPA) response) (Liu, Diorio et al. 2000). In humans the pattern of mother-infant interaction differs between breastfeeding and bottle-feeding. The amount of mutual touch, tactile stimulation and mother's gaze to infant were significantly elevated during breastfeeding compared with bottle-feeding (Lavelli and Poli 1998). Breastfeeding helps promote attachment between the mother and the infant which is known to have a positive influence on the child's psychological development

More rigourous research is required to investigate the plausible biological mechanisms discussed above and any other factors we have not considered, eg, since we have not adjusted for maternal IQ in any of the studies, there is a possibility that this factor

Breastfeeding for a longer duration appears to have significant benefits for the development, cognitive IQ, educational attainment and mental health of the child into adolescence. Our study has demonstrated that following adjustment for socioeconomic, psychological and maternal exposures in early life, a longer duration of breastfeeding was positively associated with the developmental, cognitive, educational and psychological health and wellbeing of children and adolescents. Therefore, public health programs aimed at increasing

Breastfeeding for six months or longer is preferable to shorter breastfeeding or formula feeding because it is independently and longitudinally associated with better development, cognition, educational attainment and mental health throughout childhood and into

Mothers should be encouraged, enabled and supported to continue breastfeeding for six months and longer in order to promote the optimum developmental health and well-being

Professor WH Oddy developed the hypotheses, statistical analyses, wrote the main drafts of the manuscript, and is responsible for correspondence and requests for reprints. Associate Professor Li played a lead role in the conceptualisation of the chapter, undertook statistical analyses and with Associate Professor Whitehouse and Dr Robinson contributed to the

breastfeeding duration could be of long-term benefit for child and adolescent health.

confounds or mediates some of the breastfeeding effects we have shown.

into adulthood (Crowell and Waters 2005).

of their infants into childhood and adolescence

interpretation and discussion of the results and other sections.

**6. Information on contributors**

**4.1 Directions for future research**

**4.2 Conclusion**

**5. Key findings**

adolescence.

small and non-random samples with a few exceptions to this (Sacker, Quigley et al. 2006). One exception includes the results from a large, cluster-randomized trial, whereby the authors did not find significant differences in behavioural outcomes at age six for those infants whose mothers were encouraged to breastfeed exclusively and for longer durations; however, the age at follow-up was considerably less than in our study, the children were only assessed at one point in time and a short form behavioural measure was used (Kramer, Aboud et al. 2008). Later childhood outcomes in breastfed children include greater resilience against stress and anxiety associated with parental separation and divorce at ten years in a study of 8958 children (Montgomery, Ehlin et al. 2006).

Breastfeeding may influence children's academic achievement by promoting brain development and general health. Nutrients in breast milk that are essential for optimum brain growth, such as long-chain polyunsaturated fatty acids (LCPUFA), may not be contained in formula milk (Larque, Demmelmair et al. 2006). LCPUFAs are structural elements of cell membranes and are essential in the formation of new tissue, including neurons. Makrides et al. noted an increased docosahexanoic acid (DHA; 22:6n-3) content of brain cortex with breastfeeding (Makrides, Neumann et al. 1994). Breastfed infants had a greater proportion of DHA in their erythrocytes and brain cortex and scored better on visual and developmental tests than did formula-fed infants. Crawford highlighted arachidonic acid (AA; 20:4n6) and DHA as vital components of breast milk that support development of the newborn brain (Crawford 1993) and research supports this (Crawford, Bloom et al. 1999; Crawford, Bloom et al. 2001).

Animal studies have found that LCPUFA may also play a neuroprotective role in early development, eliminating the build-up of neurotoxic levels of certain molecules (e.g., Ca2+) and inhibiting glutamatergic synaptic transmission (Lauritzen, Blondeau et al. 2000). Further studies (Das 2002; Farkas, de Wilde et al. 2002; Das 2003) have identified that certain LCPUFAs, including eicosapentaenoic acid, docosahexaenoic and arachidonic acid, act as secondary messengers, inducing the release of acetylcholine and noradrenaline, which are neurotransmitters known to be involved in cognitive development (Sarter and Bruno 1997; Dalley, McGaughy et al. 2001). The specific fatty acid content of breast milk is essential for central nervous system development, including the brain in the neonate. Breastfeeding may have long-term consequences for child mental health outcomes because of the maternal fatty acids and other bioactive components essential for neurodevelopment (Keating and Hertzman 1999; McCain and Mustard 1999; Yehuda, Rabinovitz et al. 1999). Further, breast milk may contain elements relevant to the stress response. For example, the hormone leptin in breast milk may reduce stress in infants through its action on the hippocampus, hypothalamus, pituitary gland, and adrenal gland (Montgomery, Ehlin et al. 2006), whereas formula milk may have a depressant effect on newborn behavior (DiPietro, Larson et al. 1987).

Breastfeeding may also promote growth and development by facilitating the mother-child bonding, interaction and, indirectly, cognitive growth (Quinn, O'Callaghan et al. 2001). Positive maternal contact may induce a biological response in offspring. In rats, variations in maternal licking and grooming have been shown to promote the development of neural systems that mediate hypothalamic–pituitary–adrenal axis and behavioral responses to stress in offspring as well as certain forms of learning and memory (Caldji, Tannenbaum et al. 1998; Liu, Diorio et al. 2000). Stimulation associated with maternal contact during breastfeeding may have a positive effect on the development of neuroendocrine aspects of the stress response, which may affect development (Huizink, Robles de Medina et al. 2003). There is some evidence to date in human studies (Strathearn, Mamun et al. 2009), but this hypothesis is largely informed by rat models (Uvnäs-Moberg 1998). Rat pups who experienced a greater frequency of maternal contact during nursing in the first ten days after birth (licking and grooming) exhibited a more controlled response to acute stress as adults (e.g. a lower magnitude of hypothalamic-pituitary-adrenal (HPA) response) (Liu, Diorio et al. 2000). In humans the pattern of mother-infant interaction differs between breastfeeding and bottle-feeding. The amount of mutual touch, tactile stimulation and mother's gaze to infant were significantly elevated during breastfeeding compared with bottle-feeding (Lavelli and Poli 1998). Breastfeeding helps promote attachment between the mother and the infant which is known to have a positive influence on the child's psychological development into adulthood (Crowell and Waters 2005).

#### **4.1 Directions for future research**

More rigourous research is required to investigate the plausible biological mechanisms discussed above and any other factors we have not considered, eg, since we have not adjusted for maternal IQ in any of the studies, there is a possibility that this factor confounds or mediates some of the breastfeeding effects we have shown.

#### **4.2 Conclusion**

72 Contemporary Pediatrics

small and non-random samples with a few exceptions to this (Sacker, Quigley et al. 2006). One exception includes the results from a large, cluster-randomized trial, whereby the authors did not find significant differences in behavioural outcomes at age six for those infants whose mothers were encouraged to breastfeed exclusively and for longer durations; however, the age at follow-up was considerably less than in our study, the children were only assessed at one point in time and a short form behavioural measure was used (Kramer, Aboud et al. 2008). Later childhood outcomes in breastfed children include greater resilience against stress and anxiety associated with parental separation and divorce at ten years in a

Breastfeeding may influence children's academic achievement by promoting brain development and general health. Nutrients in breast milk that are essential for optimum brain growth, such as long-chain polyunsaturated fatty acids (LCPUFA), may not be contained in formula milk (Larque, Demmelmair et al. 2006). LCPUFAs are structural elements of cell membranes and are essential in the formation of new tissue, including neurons. Makrides et al. noted an increased docosahexanoic acid (DHA; 22:6n-3) content of brain cortex with breastfeeding (Makrides, Neumann et al. 1994). Breastfed infants had a greater proportion of DHA in their erythrocytes and brain cortex and scored better on visual and developmental tests than did formula-fed infants. Crawford highlighted arachidonic acid (AA; 20:4n6) and DHA as vital components of breast milk that support development of the newborn brain (Crawford 1993) and research supports this (Crawford, Bloom et al. 1999;

Animal studies have found that LCPUFA may also play a neuroprotective role in early development, eliminating the build-up of neurotoxic levels of certain molecules (e.g., Ca2+) and inhibiting glutamatergic synaptic transmission (Lauritzen, Blondeau et al. 2000). Further studies (Das 2002; Farkas, de Wilde et al. 2002; Das 2003) have identified that certain LCPUFAs, including eicosapentaenoic acid, docosahexaenoic and arachidonic acid, act as secondary messengers, inducing the release of acetylcholine and noradrenaline, which are neurotransmitters known to be involved in cognitive development (Sarter and Bruno 1997; Dalley, McGaughy et al. 2001). The specific fatty acid content of breast milk is essential for central nervous system development, including the brain in the neonate. Breastfeeding may have long-term consequences for child mental health outcomes because of the maternal fatty acids and other bioactive components essential for neurodevelopment (Keating and Hertzman 1999; McCain and Mustard 1999; Yehuda, Rabinovitz et al. 1999). Further, breast milk may contain elements relevant to the stress response. For example, the hormone leptin in breast milk may reduce stress in infants through its action on the hippocampus, hypothalamus, pituitary gland, and adrenal gland (Montgomery, Ehlin et al. 2006), whereas formula milk may have a

Breastfeeding may also promote growth and development by facilitating the mother-child bonding, interaction and, indirectly, cognitive growth (Quinn, O'Callaghan et al. 2001). Positive maternal contact may induce a biological response in offspring. In rats, variations in maternal licking and grooming have been shown to promote the development of neural systems that mediate hypothalamic–pituitary–adrenal axis and behavioral responses to stress in offspring as well as certain forms of learning and memory (Caldji, Tannenbaum et al. 1998; Liu, Diorio et al. 2000). Stimulation associated with maternal contact during

depressant effect on newborn behavior (DiPietro, Larson et al. 1987).

study of 8958 children (Montgomery, Ehlin et al. 2006).

Crawford, Bloom et al. 2001).

Breastfeeding for a longer duration appears to have significant benefits for the development, cognitive IQ, educational attainment and mental health of the child into adolescence. Our study has demonstrated that following adjustment for socioeconomic, psychological and maternal exposures in early life, a longer duration of breastfeeding was positively associated with the developmental, cognitive, educational and psychological health and wellbeing of children and adolescents. Therefore, public health programs aimed at increasing breastfeeding duration could be of long-term benefit for child and adolescent health.

#### **5. Key findings**

Breastfeeding for six months or longer is preferable to shorter breastfeeding or formula feeding because it is independently and longitudinally associated with better development, cognition, educational attainment and mental health throughout childhood and into adolescence.

Mothers should be encouraged, enabled and supported to continue breastfeeding for six months and longer in order to promote the optimum developmental health and well-being of their infants into childhood and adolescence

#### **6. Information on contributors**

Professor WH Oddy developed the hypotheses, statistical analyses, wrote the main drafts of the manuscript, and is responsible for correspondence and requests for reprints. Associate Professor Li played a lead role in the conceptualisation of the chapter, undertook statistical analyses and with Associate Professor Whitehouse and Dr Robinson contributed to the interpretation and discussion of the results and other sections.

The Long-Term Effects of Breastfeeding on Development 75

Broad, F. E. (1972). "The effects of infant feeding on speech quality." New Zealand Medical

Broad, F. E. (1975). "Further studies on the effects of infant feeding on speech quality." New

Caldji, C., B. Tannenbaum, et al. (1998). "Maternal care during infancy regulates the

Catalano, R., T. Bruckner, et al. (2005). "Population stress and the Swedish sex ratio."

Clandinin, M. T., J. E. Chappell, et al. (1980). "Intrauterine fatty acid accretion rates in

Crawford, M. A. (1993). "The role of essential fatty acids in neural development:

Crawford, M. A., M. Bloom, et al. (1999). "Evidence for the unique function of

Crawford, M. A., M. Bloom, et al. (2001). "Docosahexaenoic acid and cerebral evolution."

Crowell, J. and E. Waters (2005). Attachment representations, secure-base behavior, and the

Das, U. N. (2002). "The lipids that matter from infant nutrition to insulin resistance."

Das, U. N. (2003). "Long-chain polyunsaturated fatty acids in the growth and development

Der, G., G. D. Batty, et al. (2006). "Effect of breast feeding on intelligence in children:

DiPietro, J. A., S. K. Larson, et al. (1987). "Behavioral and heart rate pattern differences between breast-fed and bottle-fed neonates." Developmental Psychology 23(4): 467-474. Doyle, L. W., A. L. Rickards, et al. (1992). "Breastfeeding and intelligence.[comment]." Lancet

Drane, D. L. and J. A. Logemann (2000). "A critical evaluation of the evidence on the

Dunn, L. and L. Dunn (1981). PPVT-R. Circle Pines, Minnesota, 55014-1796, American

Grossmann, K. Grossmann and E. Waters. New York, Guilford Press. Dalley, J. W., J. McGaughy, et al. (2001). "Distinct changes in cortical acetylcholine and

Prostaglandins, Leukotrienes and Essential Fatty Acids 67(1): 1-12.

attentional task." Journal of Neuroscience 21(13): 4908-14.

of the brain and memory " Nutrition 19(1): 62-65.

and Perinatal Epidemiology 14: 349-356.

development of neural systems mediating the expression of fearfulness in the rat." Proceedings of the National Academy of Sciences of the United States of America

human brain: implications for fatty acid requirements." Early Human Development

implications for perinatal nutrition." American Journal of Clinical Nutrition 57(5

docosahexaenoic acid during the evolution of the modern hominid brain." Lipids

evolution of adult relationships : the Stony Brook Adult Relationships Project. Attachment from infancy to adulthood : the major longitudinal studies. K. E.

noradrenaline efflux during contingent and noncontingent performance of a visual

prospective study, sibling pairs analysis, and meta-analysis " British Medical

association between type of infant feeding and cognitive development." Paediatric

Journal 76(482): 28-31.

95(9): 5335-40.

4: 121-129.

Suppl): 703S-709S.

Journal 333(945).

339(8795): 744-5.

Guidance Service.

34(Supplement 1): S39-S47.

Zealand Medical Journal 82(553): 373-6.

Paediatric and Perinatal Epidemiology 19(6): 13-20.

World Review of Nutrition and Dietetics 88: 6-17.

We declare that none of the co-authors have competing interests.

#### **7. Abbreviations**

#### **8. Acknowledgments**

Acknowledgments are extended to the study investigators and staff responsible for the collection of the data presented here, the Raine Medical Research Foundation at the University of Western Australia and the Telethon Institute for Child Health Research. Sincere thanks are extended to all study families without whose participation this research could not have been conducted. We thank Peter Jacoby for his statistical advice.

#### **9. Funding for the research**

WH Oddy was supported by a National Health & Medical Research Council Population Health Career Development Award. J Li was supported by a Curtin University of Technology Research Fellowship Award. The Western Australian Pregnancy Cohort Study is funded by project and program grants from Raine Medical Research Foundation, the National Health & Medical Research Council of Australia, Western Australian Health Promotion Foundation and Australian Rotary Health Research Fund, National Heart Foundation of Australia and Beyond Blue.

#### **10. References**

Acknowledgments are extended to the study investigators and staff responsible for the collection of the data presented here, the Raine Medical Research Foundation at the University of Western Australia and the Telethon Institute for Child Health Research. Sincere thanks are extended to all study families without whose participation this research

WH Oddy was supported by a National Health & Medical Research Council Population Health Career Development Award. J Li was supported by a Curtin University of Technology Research Fellowship Award. The Western Australian Pregnancy Cohort Study is funded by project and program grants from Raine Medical Research Foundation, the National Health & Medical Research Council of Australia, Western Australian Health Promotion Foundation and Australian Rotary Health Research Fund, National Heart

Achenbach, T. M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 Profile.

Achenbach, T. M., C. Edelbrock, et al. (1987). "Empirically based assessment of the

Anderson, J. W., B. M. Johnstone, et al. (1999). "Breast-feeding and cognitive development: a meta-analysis." American Journal of Clinical Nutrition 70(4): 525-535. Baron-Cohen, S., C. Knickmeyer, et al. (2005). "Sex Differences in the Brain: Implications for

Bartels, M., C. E. M. van Beijsterveldt, et al. (2009). "Breastfeeding, maternal education and

Bauchner, H., J. M. Leventhal, et al. (1986). "Studies of breast-feeding and infections. How

Bauer, G., L. S. Ewald, et al. (1991). "Breastfeeding and cognitive development of three-year-

Belfer, M. L. (2008). "Child and adolescent mental disorders: the magnitude of the problem across the globe." Journal of Child Psychology and Psychiatry 49(3): 226-236.

cognitive function: a prospective study in twins." Behavior Genetics 39(6): 616-622.

good is the evidence?" Journal of the American Medical Association 256(7): 887-892.

behavioural/emotional problems of 2- and 3-year-old children." Journal of

Burlington, University of Vermont, Department of Psychiatry.

Abnormal Child Psychology 15(4): 629-650.

Explaining Autism." Science 310(5749): 819-823.

old children." Psychological Reports 68((3 Pt 2)): 1218.

We declare that none of the co-authors have competing interests.

LCPUFA Long-Chain Polyunsaturated Fatty Acids

WALNA Western Australian Literacy and Numeracy Assessment

could not have been conducted. We thank Peter Jacoby for his statistical advice.

PPVT Peabody Picture Vocabulary Test

**7. Abbreviations**

**8. Acknowledgments**

**9. Funding for the research**

**10. References**

Foundation of Australia and Beyond Blue.

AA Arachidonic acid DHA DocosaHexanoic acid

The Long-Term Effects of Breastfeeding on Development 77

Lucas, A. (2005). "Long-Term Programming Effects of Early Nutrition [mdash] Implications

Lucas, A., R. Morley, et al. (1994). "A randomised multicentre study of human milk versus

Lucas, A., R. Morley, et al. (1992). "Breast milk and subsequent intelligence quotient in

Makrides, M., M. A. Neumann, et al. (1994). "Fatty acid composition of brain, retinea and

Malloy, M. H. and H. Berendes (1998). "Does breast-feeding influence intelligence quotients

McCain, M. and J. F. Mustard (1999). Early Years Study: Reversing the Brain Drain. Toronto,

Michaelson, K. F., P. S. Larsen, et al. (1994). "The Copenhagen Cohort Study on Infant

Newnham, J. P., S. F. Evans, et al. (1993). "Effects of frequent ultrasound during pregnancy:

Oddy, W., J. Li, et al. (2011). "Breastfeeding duration and academic achievement at 10 years."

Oddy, W. H., G. E. Kendall, et al. (2003). "Breastfeeding and cognitive development in

Oddy, W. H., G. E. Kendall, et al. (2010). "The long-term effects of breastfeeding on child and

Oddy, W. H., M. Robinson, et al. (2011). "Breastfeeding and early child development: a

Pollock, J. I. (1994). "Long-term associations with infant feeding in a clinically advantaged

Quinn, P., M. O'Callaghan, et al. (2001). "The effect of breastfeeding on child development at 5 years: A cohort study." Journal of Paediatrics and Child Health 37(5): 465-469. Richards, M., R. Hardy, et al. (2002). "Long-term effects of breast-feeding in a national birth

Robinson, M., W. H. Oddy, et al. (2008). "Pre- and post-natal influences on preschool mental

Rodgers, B. (1978). "Feeding in infancy and later ability and attainment: a longitudinal

study." Developmental Medicine and Child Neurology 20: 421-426.

prospective cohort study." Acta Paediatrica 100(7): 992-999.

childhood: a prospective birth cohort study." Paediatric and Perinatal

adolescent mental health: a pregnancy cohort study followed for 14 years." The

population of babies." Developmental Medicine and Child Neurology 36(5): 429-440.

cohort: educational attainment and midlife cognitive function." Public Health

health: A large-scale cohort study." Journal of Child Psychology and Psychiatry In

influencing factors." American Journal of Clinical Nutrition 59: 600-611. Montgomery, S. M., A. Ehlin, et al. (2006). "Breast feeding and resilience against psychosocial stress." Archives of Disease in Childhood 91 (12): 990-4. Morrow-Tlucak, M., R. H. Haude, et al. (1988). "Breastfeeding and cognitive development in

at 9 and 10 years of age." Early Human Development 50: 209-217.

Canada, Canadian Institute for Advanced Research. 0-7778-8953-6.

the first 2 years of life." Social Science and Medicine 26(6): 635-639.

a randomised controlled trial." Lancet 342: 887-891.

formula and later development in preterm infants." Archives of Diseases in

erythrocytes in breast- and formula- fed infants." American Journal of Clinical

Nutrition and Growth: breast-milk intake, human milk macronutritent content, and

for the Preterm Infant." J Perinatol 25(S2): S2-S6.

children born preterm." Lancet 339: 261-264.

Childhood 70: F141-F146.

Nutrition 60: 189- 194.

Pediatrics. 127: e137-45.

Epidemiology 17(1): 81-90.

Nutrition 5: 631-635.

Press.

Journal of Pediatrics 156(4): 568-74.

Farkas, E., M. C. de Wilde, et al. (2002). "Dietary long chain PUFAs differentially affect

Farquharson, J., F. Cockburn, et al. (1992). "Infant cerebral cortex phosholipid fatty-acid

Fergusson, D. M., A. L. Beautrais, et al. (1982). "Breast-feeding and cognitive development in the first seven years of life." Social Science and Medicine 16: 1705-1708. Garcia-Segura, L. M., I. Azcoitia, et al. (2001). "Neuroprotection by estradiol." Progress in

Golding, J., I. S. Rogers, et al. (1997). "Association between breast feeding, child development and behaviour." Early Human Development 49(Suppl): S175-S184. Hart, S., L. M. Boylan, et al. (2003). "Brief report: breast-fed one-week-olds demonstrate

Hoefer, C. and M. C. Hardy (1929). "Later development of breastfed and artificially fed

Horne, R. S., P. M. Parslow, et al. (2004). "Comparison of evoked arousability in breast and

Horwood, L. J., B. A. Darlow, et al. (2001). "Breast milk feeding and cognitive ability at 7-8 years." Archives of Disease in Childhood 84(Fetal Neonatal Edition): F23-F27. Horwood, L. J. and D. M. Fergusson (1998). "Breastfeeding and later cognitive and academic

Huizink, A. C., P. G. Robles de Medina, et al. (2003). "Stress during pregnancy is associated

Jain, A., J. Concato, et al. (2002). "How good is the evidence linking breastfeeding to

Johnson, D. L., P. R. Swank, et al. (1996). "Breastfeeding and children's intelligence." Psychol

Keating, D. and C. Hertzman (1999). Developmental Health and the Wealth of Nations. New

Koletzko, B., P. J. Aggett, et al. (1998). "Growth, development and differentiation: a functional food science approach." British Journal of Nutrition 80(Suppl 1): S5-S45. Kramer, M. S., F. Aboud, et al. (2008). "Breastfeeding and child cognitive development: new evidence from a large randomized trial." Arch Gen Psychiatry 65(5): 578-584. Larque, E., H. Demmelmair, et al. (2006). "Perinatal supply and metabolism of long-chain

system." Annals of the New York Academy of Sciences 967: 299 - 310. Lauritzen, I., N. Blondeau, et al. (2000). "Polyunsaturated fatty acids are potent

Lavelli, M. and M. Poli (1998). "Early mother-infant interaction during breast- and bottle-

Li, J., G. E. Kendall, et al. (2008). "Maternal psychosocial well-being in pregnancy and

Liu, D., J. Diorio, et al. (2000). "Maternal care, hippocampal synaptogenesis and cognitive

neuroprotectors." Science Signalling 19(8): 1784-1793.

feeding." Infant Behavior and Development 21(4): 667-684.

breastfeeding duration." Acta Paediatrica 97(2): 221-225.

development in rats." Nature Neuroscience 3(8): 799-806.

polyunsaturated fatty acids: importance for the early development of the nervous

with developmental outcome in infancy." Journal of Child Psychology and

infants." Journal of the American Medical Association 92: 615-619.

formula fed infants." Archives of Disease in Childhood 89(1): 22-5.

superior neurobehavioral organization." Journal of Pediatric Psychology 28(8): 529-34.

hypoperfusion." Brain Research 954(1): 32-41.

composition and diet." Lancet 340: 810-813.

Neurobiology 63(1): 29-60.

outcomes." Pediatrics 101: E91-E97.

Rep 79: 1179-1185.

York, Guildford Press.

Psychiatry and Allied Disciplines 44(6): 810-8.

intelligence?" Pediatrics 109(6): 1044-1053.

hippocampal muscarinic 1 and serotonergic 1A receptors in experimental cerebral

**1. Introduction**

body (1,2,3).

degenerative diseases (4,5).

**4**

*Brazil*

**Breastfeeding and Infant Growth**

Although it would be appropriate to consider various aspects related to the historical, social and cultural contexts, in a simplified manner it is possible to understand the child as a human being who is in a phase of life characterized by rapid growth and development. Thus, during this phase that starts with conception and continues until the beginning of adolescence, a child needs appropriate feeding, physical and emotional hygiene conditions,

Growth, more than representing an increase in body mass size and in the number of cells, should be understood as a complex, continuous and dynamic process of interaction between the child and its environment, influenced by countless factors of a biological, environmental, emotional, cultural and social nature. Thus, growth represents an adaptation of body composition that results from all vital processes involved in the construction of the human

During the nursing phase, mainly during the first year of life, growth is directly related to nutrition and to various environmental factors. Thus appropriate feeding in terms of quantity and quality is a fundamental element for growth since the child will derive from it all the energy and the approximately fifty essential nutrients that will be used for the transformation and differentiation of structures, the consolidation of reserves, the repair of tissues, as well as for the protection of the organism against infectious and chronic-

Due to their intense metabolism and rapid growth during the first two years of life, infants have high nutritional requirements. At 4 months of age, about 30% of the energy ingested is utilized for growth, with a reduction to 5% at the end of the first year of life and to 2% at 3 years. At birth, for example, the brain is responsible for about 65% of the basal metabolic

To fulfill the requirements of an organism that grows from about 3.5 kg of weight and 50 cm in length at birth to almost 13 kg and 87 cm at the end of two years of life, macro- and

rate, with this rate being reduced to 50% at the end of the first year of life (6).

safety and protection, so that its genetic expression will fully manifest.

**2. The nutritional requirements of nursing infants**

Luiz Antonio Del Ciampo *Department of Pediatrics*

*University of Sao Paulo,*

*Faculty of Medicine of Ribeirão Preto*

### **Breastfeeding and Infant Growth**

#### Luiz Antonio Del Ciampo

*Department of Pediatrics Faculty of Medicine of Ribeirão Preto University of Sao Paulo, Brazil*

#### **1. Introduction**

78 Contemporary Pediatrics

Rutter, M. (2006). "Attachment from infancy to adulthood. The major longitudinal studies."

Sacker, A., M. A. Quigley, et al. (2006). "Breastfeeding and developmental delay: findings

Sarter, M. and J. P. Bruno (1997). "Cognitive functions of cortical acetylcholine: toward a

Silva, A. A. M., Z. Mehta, et al. (2006). "Duration of breast feeding and cognitive function:

Silva, P. A., P. M. Buckfield, et al. (1978). "Poisoning, burns and other accidents experienced

Spinath, F. M., T. S. Price, et al. (2004). "The genetic and environmental origins of language

Squires, J., D. Bricker, et al. (1990). Infant/Child Monitoring Questionnaires Procedures

Strathearn, L., A. A. Mamun, et al. (2009). "Does breastfeeding protect against substantiated child abuse and neglect? a 15-year cohort study." Pediatrics 123(2): 483 -493. Stromswold, K. (2001). "The heritability of language: A review and metaanalysis of twin,

Taylor, B. and J. Wadsworth (1984). "Breast feeding and child development at five years."

Uvnäs-Moberg, K. (1998). "Oxytocin may mediate the benefits of positive social interaction and emotionsBottom of Form 1" Psychoneuroendocrinology 23(8): 819-835 Vestergaard, M., C. Obel, et al. (1999). "Duration of breastfeeding and developmental milestones during the latter half of infancy." Acta Paediatrica 88(12): 1327 - 1332. Vohr, B. R., B. B. Poindexter, et al. (2006). "Beneficial effects of breast milk in the neonatal

Wharton, B. A. (1992). "Food for the brain." Proceedings of the Royal College of Physicians

Whitehouse, A. J. O., M. Robinson, et al. (2011). "The effects of breast-feeding duration on

Wigg, N. R., S. Tong, et al. (1998). "Does breastfeeding at six months predict cognitive development?" Australian and New Zealand Journal of Public Health 22(2): 232-236. World Health Organisation (2003). Global strategy for infant and young child feeding. Geneva,

Yehuda, S., S. Rabinovitz, et al. (1999). "Essential fatty acids are mediators of brain

Zhou, S. J., P. Baghurst, et al. (2007). "Home environment, not duration of breast-feeding, predicts intelligence quotient of children at four years." Nutrition 23(3): 236-241. Zubrick, S. R., S. R. Silburn, et al. (2000). "Mental health disorders in children and young

intensive care unit on the developmental outcome of extremely low birth weight

language ability to middle childhood." Paediatric and Perinatal Epidemiology

biochemistry and cognitive functions." Journal of Neuroscience Research 56(6): 565-

people: scope, cause and prevention." Australian and New Zealand Journal of

by a thousand Dunedin three year olds: a report from the Dunedin Multidisciplinary Child Development Study." New Zealand Medical Journal 87:

Journal of Child Psychology and Psychiatry 47(9): 974-977.

from the millennium cohort study." Pediatrics 118(3): e682-9.

unifying hypothesis." Brain Research Reviews 23(1-2): 28-46.

population based cohort study." Eur J Epidemiol 21: 435-441.

disability and ability." Child Development 75(2): 445-54.

adoption, and linkage studies. ." Language 77(4): 647-723.

infants at 18 months of age." Pediatrics 118(1): e115-123.

of Edinburgh 22: 336-346.

Psychiatry 34(4): 570-578.

25(1): 44-52.

Author.

570.

Developmental Medicine and Child Neurology 26(1): 73-80.

Manual, University of Oregon, Center on Human Development.

242-244.

Although it would be appropriate to consider various aspects related to the historical, social and cultural contexts, in a simplified manner it is possible to understand the child as a human being who is in a phase of life characterized by rapid growth and development. Thus, during this phase that starts with conception and continues until the beginning of adolescence, a child needs appropriate feeding, physical and emotional hygiene conditions, safety and protection, so that its genetic expression will fully manifest.

Growth, more than representing an increase in body mass size and in the number of cells, should be understood as a complex, continuous and dynamic process of interaction between the child and its environment, influenced by countless factors of a biological, environmental, emotional, cultural and social nature. Thus, growth represents an adaptation of body composition that results from all vital processes involved in the construction of the human body (1,2,3).

During the nursing phase, mainly during the first year of life, growth is directly related to nutrition and to various environmental factors. Thus appropriate feeding in terms of quantity and quality is a fundamental element for growth since the child will derive from it all the energy and the approximately fifty essential nutrients that will be used for the transformation and differentiation of structures, the consolidation of reserves, the repair of tissues, as well as for the protection of the organism against infectious and chronicdegenerative diseases (4,5).

#### **2. The nutritional requirements of nursing infants**

Due to their intense metabolism and rapid growth during the first two years of life, infants have high nutritional requirements. At 4 months of age, about 30% of the energy ingested is utilized for growth, with a reduction to 5% at the end of the first year of life and to 2% at 3 years. At birth, for example, the brain is responsible for about 65% of the basal metabolic rate, with this rate being reduced to 50% at the end of the first year of life (6).

To fulfill the requirements of an organism that grows from about 3.5 kg of weight and 50 cm in length at birth to almost 13 kg and 87 cm at the end of two years of life, macro- and

Breastfeeding and Infant Growth 81

recommendations/day

0 - 6 m 7 - 12 m

Table 2. Nutritional recommendations for infants younger than one year and biochemical

Breast-Feeding and Nutrology of the Brazilian Society of Pediatrics. Thus, it is understood that breast milk, because of its quality, completeness, biological complexity and appropriate nutrient balance, guarantees the nutritional status, the growth and the development of nursing infants during the first months of life (14,15,16,17,18). This is the case even in the presence of unfavorable conditions (19), with no benefits having been found that compensate

Energy (kcal/kg/day) 110 100 - 110 71 kcal Protein (g) 2.1 2.1 1.2 g Fat\* 35 % 35 % 3.8 g Carbohydrates \*\* 50 % 50 % 7 g Water (ml/kg/day) 150 150 87.6 g Calcium (mg) 400 600 33 mg Iron (mg) 6 10 0.07 - 0.15 μg Iodine (μg) 40 50 7 μg Copper (mg) 0.4 - 0.6 0.6 - 0.7 40 μg Chromium (mg) 10 - 40 20 - 60 50 ng Manganese (mg) 0.3 - 0.6 0.6 - 1.0 0.6 μg Selenium(mg) 10 15 1 μg Fluorine (mg) 0.1- 0.5 0.2 - 1.0 16 μg Zinc (mg) 5 5 300 μg Magnesium (mg) 40 60 3 mg Potassium (mg) 500 700 58 mg Sodium (mg) 120 200 15 mg Chlorine (mg) 180 300 42 mg Phosphorus mg/dl 300 500 15 mg Vitamin A (μg) 375 375 53 μg Vitamin D (μg) 7.5 10 0.04 μg Vitamin E (mg) 3 4 0.34 mg Vitamin K (μg) 5 10 0.2 μg Vitamin C (mg) 30 35 4.0 mg Vitamin B1 (mg) 0.3 0.4 0.02 mg Vitamin B2 (mg) 0.4 0.5 0.03 mg Vitamin B6 (mg) 0.3 0.6 0.01 mg Vitamin B12 (mg) 0.3 0.5 0.3 μg Pantothenic acid (mg) 2 3 0.25 mg Folic acid (μg) 25 35 5 μg Niacin (mg) 5 6 0.2 mg

Breast milk (quantity/100 ml)

Nutrient Nutritional

\* 35% of total daily calories \*\* 50% of total daily calories

composition of breast milk

micronutrients of appropriate quantity and quality are necessary. In general, a child in good health and well fed should gain 25 to 30 grams per day in the first trimester of life, with its birth weight doubling between 4 and 5 months, tripling by 11 months to 1 year, and quadrupling by 2 years to 2 years and 3 months. Regarding length, a child should gain 15 centimeters in the first year of life and 10 centimeters in the second year (7,8).

For an appropriate occurrence of these somatic changes some recommendations should be followed in order to meet the nutritional requirements of the child during each growth phase in association with its life characteristics, since the period from six months to three years of life is the one during which a child is more subjected to nutritional risks.

The necessary quantity of daily calories may vary from 125 kcal/kg/day for newborns to 110 kcal/kg/day at six months of age and from 95 to 100 kcal/kg/day from six months to two years of age (9,10). The distribution of this energy consumption is presented in Table 1.

Table 1. Daily energy consumption of nursing infants

The protein requirements range from 1.8 g/kg/day for the first six months to 1.5 g/kg/day in the second semester and 1.2 g/kg/day in the second year of life, considering proteins of high biological value that should account for about 15% of the total daily calorie intake.

Lipids should account for about 30% to 35% of the total daily calorie intake, supplying appropriate amount of the essential fatty acids, linoleic and linolenic acids, and carbohydrate should account for about 50% to 55% of the daily calorie intake. In addition to these nutrients, the feeding of an infant should also satisfy the requirements of water (150 ml/kg/day), vitamins and minerals (48), as specified in Table 2 (7,9,10)

#### **3. Breastfeeding and growth**

There is an intimate relationship between physical growth and nutritional status which can be understood as the quantitative reflex of the food consumed daily by the child. According to the World Health Organization (WHO)(11), appropriate infant feeding should provide a sufficient quantity of food to cover the nutritional needs and to protect the airways against the aspiration of foreign substances and should not exceed the metabolic and functional capacity of the digestive tract and the renal system of the child.

There is a current consensus that breast milk as the exclusive food and offered freely satisfies all the needs of an infant during the first six months of age, being the only ideal food for the child's growth and development (8,12,13). Universally supported and disseminated by the World Health Organization, the practice of breast-feeding finds important allies in Brazil in the National Program of Encouragement of Breast-feeding (PNIAM in the Portuguese acronym) of the Health Ministry and in the Departments of

micronutrients of appropriate quantity and quality are necessary. In general, a child in good health and well fed should gain 25 to 30 grams per day in the first trimester of life, with its birth weight doubling between 4 and 5 months, tripling by 11 months to 1 year, and quadrupling by 2 years to 2 years and 3 months. Regarding length, a child should gain 15

For an appropriate occurrence of these somatic changes some recommendations should be followed in order to meet the nutritional requirements of the child during each growth phase in association with its life characteristics, since the period from six months to three

The necessary quantity of daily calories may vary from 125 kcal/kg/day for newborns to 110 kcal/kg/day at six months of age and from 95 to 100 kcal/kg/day from six months to two years of age (9,10). The distribution of this energy consumption is presented in Table 1.

> **Energy consumption kcal/kg/day**  basal metabolism 50 - 55 growth in the 1st year of life 15 - 20 growth in the 2nd year of life 8 - 10 physical activity 20 - 30

> > excretions 8 - 10

The protein requirements range from 1.8 g/kg/day for the first six months to 1.5 g/kg/day in the second semester and 1.2 g/kg/day in the second year of life, considering proteins of high biological value that should account for about 15% of the total daily calorie intake.

Lipids should account for about 30% to 35% of the total daily calorie intake, supplying appropriate amount of the essential fatty acids, linoleic and linolenic acids, and carbohydrate should account for about 50% to 55% of the daily calorie intake. In addition to these nutrients, the feeding of an infant should also satisfy the requirements of water (150

There is an intimate relationship between physical growth and nutritional status which can be understood as the quantitative reflex of the food consumed daily by the child. According to the World Health Organization (WHO)(11), appropriate infant feeding should provide a sufficient quantity of food to cover the nutritional needs and to protect the airways against the aspiration of foreign substances and should not exceed the metabolic and functional

There is a current consensus that breast milk as the exclusive food and offered freely satisfies all the needs of an infant during the first six months of age, being the only ideal food for the child's growth and development (8,12,13). Universally supported and disseminated by the World Health Organization, the practice of breast-feeding finds important allies in Brazil in the National Program of Encouragement of Breast-feeding (PNIAM in the Portuguese acronym) of the Health Ministry and in the Departments of

specific dynamic action of food 5 - 8

Table 1. Daily energy consumption of nursing infants

**3. Breastfeeding and growth**

ml/kg/day), vitamins and minerals (48), as specified in Table 2 (7,9,10)

capacity of the digestive tract and the renal system of the child.

centimeters in the first year of life and 10 centimeters in the second year (7,8).

years of life is the one during which a child is more subjected to nutritional risks.

\* 35% of total daily calories

\*\* 50% of total daily calories

Table 2. Nutritional recommendations for infants younger than one year and biochemical composition of breast milk

Breast-Feeding and Nutrology of the Brazilian Society of Pediatrics. Thus, it is understood that breast milk, because of its quality, completeness, biological complexity and appropriate nutrient balance, guarantees the nutritional status, the growth and the development of nursing infants during the first months of life (14,15,16,17,18). This is the case even in the presence of unfavorable conditions (19), with no benefits having been found that compensate

Breastfeeding and Infant Growth 83

Still in terms of nutritional disorders and being invested with great importance in the prevention of health problems in infancy and in future life, breast milk plays an important role regarding the problem of excessive weight gain. Studies by different investigators have demonstrated the protective role of breast milk against obesity in infancy and adolescence (39,40,41) and have detected an association of a reduced prevalence of overweight and obesity with different feeding practices, demonstrating the protective effect of mother's milk (42,43,44,45,46,47). An adequate duration of breastfeeding is associated with low prevalence of obesity during school age. Also, the excess of protein contained in infant formulas and consumed by early children may influence weight gain, indicating that as excessive increase

of weight would be associated with high amount of protein of infant formulas (48,49).

Although breast milk has low levels of iron, its high bioavailability makes it much more absorbed than other infant formulas. The finding of iron deficiency is not common in fullterm children and breastfed, according to the Nutrition Committee of the American Academy of Pediatrics, although this fact is much more common in breastfed infants with cow's milk. Should be considered the possibility of iron supplementation after the sixth month of life for full-term children and when introducing complementary feeding. For those born prematurely or underweight, will be given iron supplements, even two years old (50). Calcium and phosphorus have lower levels in human milk, but the Ca / P in (around 2.2) is very favorable to the absorption of calcium. Breastfeeding and child's sun exposure in areas with good sunlight conditions are essential in the prevention of vitamin D deficiency.

Human growth, understood as a seasonal and pulsatile phenomenon characterized by different rates along time, can be assessed with the use of growth curves that provide references both for body growth as a whole and for the growth of different parts of the

The instruments used to assess growth have been modified over time in order to better fit the conditions of infant populations since there is still discordance among authors about what should be used as reference or standard of infant growth. The various growth curves classically used, constructed for widely varying pediatric groups, when taken as reference do not always reflect the reality of each particular child since questions such as type of feeding, birth and health conditions during the first years of life, for example, can modify

Starting in 2006, with the publication of the new growth curves of the WHO for children younger than 5 years, constructed with better defined criteria (singletons born at term to a non-smoking mother, with no diseases, exclusively breast-fed during the first six months of life and living under appropriate environmental and economic conditions) and therefore permitting to consider that all of these children will develop in a similar manner, we are able use an instrument that better represents the description of the physiological growth of these children from the beginning of life. More than a reference, these curves represent a growth

[1] Wolansky N. Genetic and ecological factors in human growth. Hum Biol 1970;42:349-56. [2] Spyrides MHC, Struchiner CJ, Barbosa MTS, Kac G. Effetct of a predominant breastfeeding duration on infant growth: a prospective study using nolinear mixed

organism such as the head, the length of the limbs, the length of the trunk etc.

the parameters analyzed.

**4. References**

pattern for children in this age range.

effect models. J Pediatr (Rio J) 2008;84(3):237-43.

for the risks and the disadvantages of introducing complementary foods before six months of life, which, in addition to being of poorer nutritional quality compared to breast milk, may be associated with contamination and the triggering of allergic diseases, interfering with the absorption of essential nutrients such as iron and zinc and therefore increasing infant morbidity and mortality (20)

The protective effects of breastfeeding are also evident in relation to other situations or diseases such as celiac disease, sudden infant death, neonatal hypocalcemia, acrodermatitis enteropathica, Crohn's disease, diabetes and cardiovascular disease, among many others, that every day is more described.

Although it is recognized that allergic diseases are related to various genetic and environmental components, in recent years breastfeeding has also been studied with respect to protective effects against atopic eczema, asthma and hay fever (21,22,23,24,25).

 This contact is very important to the child's psychological development in the first months of life. Mother, well aware of the reasons to breastfeed the child with pleasure, will release the endogenous betaendorphin more reason, in this case pharmacologically demonstrated, to enhance this pleasure. Thus, it can be argued that breastfeeding promotes a strong bond between mother and child, with benefits for both stimuli, full of affection and bonuses and leading to a mother-child interaction at its most elevated and perfectly natural. Also, the infant has his sucking needs met, without the use of pacifiers, which can deform the teeth and palate, as well as facilitating contamination of the oral cavity. In addition, the breast feeding acts as a positive factor in the development of speech through early and continuous exercise of facial muscles. Studies suggest that learning ability and IQ of children exclusively breastfed, and adequate time, are higher than those not breastfed. Although these studies still need to proof, is visible to those who work and live with infants the distinct impression that those who are exclusively breastfed are more calm and smiling, and have more restful sleep than those who do not breastfeeding 26,27,28 .

Several studies published in the specialized literature have shown a positive association between the duration of the breast-feeding period and infant growth (29,30,31,32,33,34). Motil et al (35) did not observe significant differences between infants exclusively breast-fed or receiving milk formulas, and concluded that the quantity of protein found in breast milk did not limit growth. Kramer et al (33) demonstrated that infants who are exclusively breast-fed for a longer period of time can experience accelerated weight and length gain during the first months of life, showing no growth deficit at one year of age, or even growing more than infants fed artificial milk during adolescence (16,36).

By being a species-specific food, balanced and equilibrated in order to satisfy the needs of the infant and containing all the essential nutrients for growth and development, breast milk is one of the priorities in the fight against infant malnutrition(37,38), with the practice of breast-feeding being established and widely disseminated as one of the Basic Actions for Infant Health since the Alma-Ata Conference in 1978.

for the risks and the disadvantages of introducing complementary foods before six months of life, which, in addition to being of poorer nutritional quality compared to breast milk, may be associated with contamination and the triggering of allergic diseases, interfering with the absorption of essential nutrients such as iron and zinc and therefore increasing

The protective effects of breastfeeding are also evident in relation to other situations or diseases such as celiac disease, sudden infant death, neonatal hypocalcemia, acrodermatitis enteropathica, Crohn's disease, diabetes and cardiovascular disease, among many others,

Although it is recognized that allergic diseases are related to various genetic and environmental components, in recent years breastfeeding has also been studied with respect

Bringing the infant to the breast has not only for mother and child the sense of satisfying hunger, there is much more, because the contact of the mouth with the breast and the child's body with the body of his mother bring warmth and comfort. This contact is very important to the child's psychological development in the first months of life. Mother, well aware of the reasons to breastfeed the child with pleasure, will release the endogenous betaendorphin more reason, in this case pharmacologically demonstrated, to enhance this pleasure. Thus, it can be argued that breastfeeding promotes a strong bond between mother and child, with benefits for both stimuli, full of affection and bonuses and leading to a mother-child interaction at its most elevated and perfectly natural. Also, the infant has his sucking needs met, without the use of pacifiers, which can deform the teeth and palate, as well as facilitating contamination of the oral cavity. In addition, the breast feeding acts as a positive factor in the development of speech through early and continuous exercise of facial muscles. Studies suggest that learning ability and IQ of children exclusively breastfed, and adequate time, are higher than those not breastfed. Although these studies still need to proof, is visible to those who work and live with infants the distinct impression that those who are exclusively breastfed are more calm and smiling, and have more restful sleep than

Several studies published in the specialized literature have shown a positive association between the duration of the breast-feeding period and infant growth (29,30,31,32,33,34). Motil et al (35) did not observe significant differences between infants exclusively breast-fed or receiving milk formulas, and concluded that the quantity of protein found in breast milk did not limit growth. Kramer et al (33) demonstrated that infants who are exclusively breast-fed for a longer period of time can experience accelerated weight and length gain during the first months of life, showing no growth deficit at one year of age, or even growing more than

By being a species-specific food, balanced and equilibrated in order to satisfy the needs of the infant and containing all the essential nutrients for growth and development, breast milk is one of the priorities in the fight against infant malnutrition(37,38), with the practice of breast-feeding being established and widely disseminated as one of the Basic Actions for

to protective effects against atopic eczema, asthma and hay fever (21,22,23,24,25).

infant morbidity and mortality (20)

that every day is more described.

those who do not breastfeeding 26,27,28 .

infants fed artificial milk during adolescence (16,36).

Infant Health since the Alma-Ata Conference in 1978.

Still in terms of nutritional disorders and being invested with great importance in the prevention of health problems in infancy and in future life, breast milk plays an important role regarding the problem of excessive weight gain. Studies by different investigators have demonstrated the protective role of breast milk against obesity in infancy and adolescence (39,40,41) and have detected an association of a reduced prevalence of overweight and obesity with different feeding practices, demonstrating the protective effect of mother's milk (42,43,44,45,46,47). An adequate duration of breastfeeding is associated with low prevalence of obesity during school age. Also, the excess of protein contained in infant formulas and consumed by early children may influence weight gain, indicating that as excessive increase of weight would be associated with high amount of protein of infant formulas (48,49).

Although breast milk has low levels of iron, its high bioavailability makes it much more absorbed than other infant formulas. The finding of iron deficiency is not common in fullterm children and breastfed, according to the Nutrition Committee of the American Academy of Pediatrics, although this fact is much more common in breastfed infants with cow's milk. Should be considered the possibility of iron supplementation after the sixth month of life for full-term children and when introducing complementary feeding. For those born prematurely or underweight, will be given iron supplements, even two years old (50). Calcium and phosphorus have lower levels in human milk, but the Ca / P in (around 2.2) is very favorable to the absorption of calcium. Breastfeeding and child's sun exposure in areas with good sunlight conditions are essential in the prevention of vitamin D deficiency.

Human growth, understood as a seasonal and pulsatile phenomenon characterized by different rates along time, can be assessed with the use of growth curves that provide references both for body growth as a whole and for the growth of different parts of the organism such as the head, the length of the limbs, the length of the trunk etc.

The instruments used to assess growth have been modified over time in order to better fit the conditions of infant populations since there is still discordance among authors about what should be used as reference or standard of infant growth. The various growth curves classically used, constructed for widely varying pediatric groups, when taken as reference do not always reflect the reality of each particular child since questions such as type of feeding, birth and health conditions during the first years of life, for example, can modify the parameters analyzed.

Starting in 2006, with the publication of the new growth curves of the WHO for children younger than 5 years, constructed with better defined criteria (singletons born at term to a non-smoking mother, with no diseases, exclusively breast-fed during the first six months of life and living under appropriate environmental and economic conditions) and therefore permitting to consider that all of these children will develop in a similar manner, we are able use an instrument that better represents the description of the physiological growth of these children from the beginning of life. More than a reference, these curves represent a growth pattern for children in this age range.

#### **4. References**

Breastfeeding and Infant Growth 85

[24] Scholtens S, Wijga AH, Brunekreef B. Breast feeding, parental allergy and asthma in

[25] Silvers KM, Frampton CM, Wickens K. Breastfeeding protects against adverse respiratory outcomes at 15 months of age. Matern Child Nutr 2009;5:243-50.

[27] Quigley MA, Hockley C, Carson C, Kelly Y, Renfrew MJ, Sacker A. Breastfeeding is Associated with Improved Child Cognitive Development: A Population-Based

[28] Chapman DJ. Breastfeeding, brain imaging, and maternal behavior. J Hum Lact.

[29] Piwoz EG, Creed de Kanashiro H, Lopes de Romana GL, Black RE, Brown KH. Feeding practices and growth among low-income Peruvian infants: a comparision of

[31] Onyango AW. Breast feeding and growth in rural Kenyan toddlers. Adv Exp Med Biol

[32] Diaz S, Herreros C, Aravena R, Casado ME, Reyes V, Schiappacasse V. Breastfeeding duration and growth of fully breast-fed infants in a poor urban Chilean population.

[33] Donma MM, Donma O. Infant feeding and growth: A study on Turkish infants from

[34] Martin RM, Smith GD, Mangtani P, Frankel S, Gunnell D. Association between breast feeding and growth: the Boyd-Orr cohort study. Arch Dis Child Fetal Neonatal

[35] Motil KJ, Sheng HP, Montandon CM, Wong WW. Human milk protein does not limit

[36] Kramer MS, Guo T, Platt RW, Shapiro S, Collet JP, Chalmers B et al. Infant breastfeeding and infant growth: biology or bias? Pediatrics 2002;110(2 Pt 1):343-7. [37] Ricco RG, Almeida CAN, Del Ciampo LA, Daneluzzi JC, Ferlin MLS, Muccillo G. Growth of exclusively breast-fed infants from a poor urban population. Arch

[38] Escuder MCL, Venâncio SI, Pereira JCR. Estimativa de impacto da amamentação sobre

[39] Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United

[40] Butte NF. Impact of infant feeding practices on childhood obesity. J Nutr 2009;139:412S

[41] Gillman MW, Rifas-Shiman SL, Camargo CAJr. Risk of overweight among adolescents

[42] Owen CG, Martin RM, Whincup PH. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics

[43] Kramer MS, Barr RG, Leduc DG, Boisjoly C, McVey-White L, Pless IB. Determinants of

weight and adiposity in the first year of life. J Pediatr 1985;106:10-14.

growth of breast-fed infants. J Pediatr Gastroenterol Nutr 1997;24:10-7.

a mortalidade infantil. Rev Saúde Pública 2003;37(3):319-25 319

who were breastfed as infants. JAMA 2001;285:2461-7.

internationally-recommended definitions. Int J Epidemiol 1996;25:103-14. [30] Galler JR, Ramsey FC, Harrison RH, Brooks R, Weiskopf-Bock S. Infant feeding

practices in Barbados predict later growth. J Nutr 1998;128:1328-35.

children followed for 8 years. Thorax 2009;64:604-9.

Cohort Study. J Pediatr. 2011 Aug, on line.

2011;27(3):304-5.

2000;478:151-62.

2002;87:F193-F201.

2005;115:1367-77.

Am J Clin Nutr 1995;62:371-6.

birth to 6 months. Pediatr Int 1999;41(5):542-8.

Latioamerican Nutr 2001;51(2):122-6.

States. Pediatrics 2004;113;e435-e439.

[26] Petherick A. Mother's milk: a rich opportunity. Nature 2010;468:S5-S8.

[6] Lissaur T & Clayden G. Illustrated Textbook of Paediatrics. London, Mosby

[7] Ricco RG, Del Ciampo LA, Almeida CAN. Puericultura. Princípios e Práticas. Atenção Integral à Saúde da Criança e do Adolescente. Editora Atheneu. São Paulo. 2ª. ed.

[11] WHO. Working Group on Infant Growth: an evaluation of infant growth: the use and interpretation of anthropometry in infants. Bull World Health Org 1995;73:165-74. [12] WHO. Expert Consultation on the Optimal Duration of Exclusive Breastfeeding. Conclusions and Recommendations. World Health Organization. Document

[13] Spyrides MHC, Struchiner CJ, Barbosa MTS, Kac G. The effect of breastfeeding practices

[14] Marques RFSV, Lopez FA, Braga JAP. Growth of exclusively breastfed infants in the

[15] Rautava S., Walker WA. Academy of Breastfeeding Medicine Founder's Lecture 2008: Breastfeeding – An extrauterine link between mother and child. Breastfeed Med

[16] Kramer MS, Guo T, Platt RW, Sevkovskaya Z, Dzikovich I, Collet JP et al. Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive

[17] Del Ciampo LA, Ricco RG, Almeida CAN. Aleitamento Materno. Passagens e

[18] Augusto RA, Souza JMP. Growth of children in exclusive breastfeeding in their first

[19] Ricco 73:165-74. Del Ciampo LA, Almeida CAN, Daneluzzi JC. Aleitamento exclusivamente ao seio, morbidade e utilização de serviços de saúde pediátrico em

[20] Monte CMG, Giugliani ERJ. Recommendations for the complementary feeding of the

[21] Gdalevich M, Mimouni D, David M, Mimouni M. Breast-feeding and the onset of atopic dermatitis in childhood: a systematic review and meta-analysis of prospective

[22] Gdalevich M, Mimouni D, Mimouni M. Breast-feeding and the risk of bronchial asthma in childhood: a systematic review with meta-analysis of prospective studies. J Pediatr

semester of life. Rev Bras Crescimento Desenvolv Hum 2007;17(2):1-11.

uma unidade básica de saúde. Pediatria (S. Paulo) 2001;23(2):193-8.

[23] Kramer MS. Breast is best: The evidence. Early Hum Dev 2010;86:729-32.

[8] WHO. Infant and Young Child Nutrition. Geneva: World Health Organization; 2002. [9] Calil VMTL, Vaz FAC. Composição bioquímica do leite materno. In: Issler H. O Aleitamento Materno no Contexto Atual. Políticas, Prática e Bases Científicas. Editora

[10] Rego JD. Aleitamento Materno. Editora Atheneu. 2ª ed. 2006. São Paulo.

on infant growth. Rev Bas Saúde Mater Infant 2005;5(2):145-53.

first 6 months of life. Rev Chil Pediatr 2006;77(5):529-30.

Transferências Mãe-Filho. São Paulo. Editora Atheneu, 2004.

breastfed child. J Pediatr (Rio J) 2004;80(5 supl):S131-S141.

breastfeeding. Am J Clin Nutr 2003;78:291-5.

studies. J Am Acad Dermatol 2001;45:520-7.

[3] Lawson M. Contemporary aspects of infants feeding. Paediatr Nurs 2007;19:39-46. [4] Longo GZ, Souza JMP, Souza SB, Szarfarc SC. Growth of children up to six months of age and breast feeding practices. Rev Bas Saúde Matern Infantil 2005;5(1):109-18. [5] Law C. Early growth and chronic disease: a public health overview. Matern Child Nutr

2005;1:169-76.

2008.

International, 3ª ed. 2007.

Sarvier, 2008. São Paulo.

A54/Inf.Doc./4. Geneva. 2001.

2009;4(1):3-10.

2001;139:261-6.

**1. Introduction**

(Inanc & Hatipoglu, 1995).

(Baysal, 1993).

**5**

*Turkey*

Şenay Çetinkaya *Pediatric Nursing, Adana School of Health, Çukurova University,*

**Nutrition in Healthy Children**

The most significant factor in the development and growth of a country is providing effective health care services to society. The purpose of each health care application is different. Among these applications, the factor that accelerates the growth and development, living healthy, protection from diseases, and healing is nutrition (Baysal, 1993; Perk, 1992). Nutrition is a basic need that affects the lives of individuals and societies, and is affected from all biological, social, cultural and economic factors. Adequate and balanced nutrition is unquestionably a precondition for the generation of healthy societies (Allen & Gillespie, 2001). Ensuring the existence of the living organism, putting his/her losses into place, getting the needed food stuffs, by means of digestion to fulfill the necessary physiological functions for survival is called *nutrition*. *Healthy nutrition* means the use of food to maintain the growth-

Nutrition has a very important role in the development of both individual's and society's health. Good nutrition is necessary for the individual to grow and develop, maintain his/her physical and mental health and resist to diseases, especially infectious diseases (Bilgel, 1997). Nutrition in the family is related to whether the sources required by the family are adequate or not to meet their nourishment, the manner of their food preparation and consumption, their socio-cultural and economic level, the environment that they live, the size of the family, their birth rate, age of the mother and personal characteristics of the individual

Nutrition has more significance in terms of the child's health (Baysal, 1993; Bilgel, 1997), because the period of life in which development and growth occur most intensively and most rapidly is the childhood period (Bilgel, 1997). The most significant factor having positive or negative effects on the development and growth of the child after birth is his/her nutritional status (Kavakl, 1992). Majority of the children comes into the world healthy. In order to sustain the healthy status and enable the organism to complete its normal development and growth, the child should be nourished adequately in terms of the food's composition and amount beginning from the first days and at every period of the childhood

development and survival and to protect health (Perk, 1992).

#### Şenay Çetinkaya

*Pediatric Nursing, Adana School of Health, Çukurova University, Turkey*

#### **1. Introduction**

86 Contemporary Pediatrics

[44] von Kries R, Koletzko B, Sauerwald T, von Mutius E, Bamert D, Grunert V et al. Breast

[45] Tulldahl J, Pettersson K, Andersson SW, Hulten L. Mode of infant and achieved growth in adolescence: early feeding patterns in relation to growth and body composition in

[46] Toschke AM, Vignerova J, Lhotska L, Osanvoca K, Kolezko B, von Kries R. Overweight and obesity in 6 to 14 year-old Czech children lin 1991: protective effect of breast-

[47] Balaban G, Silva GAP. Efeito protetor do aleitamento materno contra a obesidade

[48] Koletzo B, Von Kries R, Closa R. Lower protein in infant formula is associated with lower weight up to age 2 y: a randomized clinical trial. Am JmClin Nutr

[49] Koletzo B, von Kries R, Closa R. Can infant feeding choices modulate later obsity risk?

[50] Gartner LM, Morton J, Lawrence RA. Breastfeeding and the use of human milk.

feeding and obesity: cross sectional study. Br Med J 1999;319:147-50.

adolescence. Obes Res 1999;7:431-7.

feeding. J Pediatr 2002;141:764-9.

2009;89(6):1836-45.

infantil. J Pediatr (Rio J) 2004;80(1):7-16.

Am L Clin Nutr 2009;89(5):1502S-1508S.

Pediatrics 2005;115(2):496-502.

The most significant factor in the development and growth of a country is providing effective health care services to society. The purpose of each health care application is different. Among these applications, the factor that accelerates the growth and development, living healthy, protection from diseases, and healing is nutrition (Baysal, 1993; Perk, 1992).

Nutrition is a basic need that affects the lives of individuals and societies, and is affected from all biological, social, cultural and economic factors. Adequate and balanced nutrition is unquestionably a precondition for the generation of healthy societies (Allen & Gillespie, 2001).

Ensuring the existence of the living organism, putting his/her losses into place, getting the needed food stuffs, by means of digestion to fulfill the necessary physiological functions for survival is called *nutrition*. *Healthy nutrition* means the use of food to maintain the growthdevelopment and survival and to protect health (Perk, 1992).

Nutrition has a very important role in the development of both individual's and society's health. Good nutrition is necessary for the individual to grow and develop, maintain his/her physical and mental health and resist to diseases, especially infectious diseases (Bilgel, 1997).

Nutrition in the family is related to whether the sources required by the family are adequate or not to meet their nourishment, the manner of their food preparation and consumption, their socio-cultural and economic level, the environment that they live, the size of the family, their birth rate, age of the mother and personal characteristics of the individual (Inanc & Hatipoglu, 1995).

Nutrition has more significance in terms of the child's health (Baysal, 1993; Bilgel, 1997), because the period of life in which development and growth occur most intensively and most rapidly is the childhood period (Bilgel, 1997). The most significant factor having positive or negative effects on the development and growth of the child after birth is his/her nutritional status (Kavakl, 1992). Majority of the children comes into the world healthy. In order to sustain the healthy status and enable the organism to complete its normal development and growth, the child should be nourished adequately in terms of the food's composition and amount beginning from the first days and at every period of the childhood (Baysal, 1993).

The requirements stated below should be met in order to determine the adequateness of

1. Providing the energy that is spent by basal metabolism, and that is used to maintain life

4. Letting an infant who has a growing and developing organism take the nourishment in

As the concept of adequateness in nutrition is searched, the problem of what kind of nutrition the human organism needs in various age periods under the environmental and living conditions has come up. The most practical standard to determine the adequateness in nutrition is that the child keeps his/her birth weight and height within the percentile

In order to overcome the nutrition problems, the importance of eliminating social inequalities which are the basic source of the problem should be emphasized by highlighting that health services constitute an equal, costless, qualified and reachable right.

The foods include 3 essential nutrients which are protein, carbohydrate and fat, in different ratios. All the energy (calorie requirement), building blocks (amino acids, fatty acids), vitamins and minerals are taken to the organism by means of the nutrients. Requirement of each one changes depending on the environment where the individual lives and his/her daily activity. The suggested values in numerical expression of the requirement are given according to the age, body surface (m2), weight (kg) and height (cm) of the individual. Although it is advocated that the ideal evaluation is the rating of body surface to weight or to height and the second rank belongs to m2, the most commonly used one is the criteria of age-weight in practice. Example: The calorie requirement of 0-3 month-old infant is 120

In the first 4-6 months of life, breast milk and various infant formulas can provide with the complete nutrition to a growing infant. Still, breast milk is recommended nearly for all infants as the source of nutrient. However, very few numbers of infants are fed through only breastfeeding for more than 2-3 months. In this regard, all kind of efforts should be made to encourage breastfeeding. Another option is iron-fortified formulas which support sufficient growth of infants. These formulas are not the only ways to give nutritional supplements. Following the months 4-6, solid foods and fruit juice are being introduced in a manner such that they will gradually substitute the nutrients and calories that came from breast milk or formula. Because infants' activities increase in this period (despite a decrease in growth rate) their energy requirements also increase. A diet (milk) which has relatively high fat content and high calories is required to provide them with adequate energy. Nutritional supplements start forming a source for some important nutrients (iron) within the second 6 months. Genetic coordination of neoplasm is remarkable. However, a variety of nutritional

2. Providing the energy that is spent in daily activity as a result of muscle movements, 3. Providing with the building blocks that is needed by organism and required for

ideal quality and quantity for sustaining this feature (Arcasoy et al, 1994).

Also preventive health services should be prioritized among the health services.

nutrition, and to discuss clinical adequacy of the nutrition:

channel where he/she begins to live (Arcasoy et al, 1994).

regeneration and synthesis process,

**2. Nutrition requirements**

Kcal/kg (Arcasoy et al, 1994).

functions,

Accomplished nutrition plays a major part in healthy growth and development of a newborn infant. Infants in various countries of the world are exposed to malnutrition because of social, economic and cultural reasons. Inadequate and unbalanced nutrition leads growth and development failures and deaths among children (Yapicioglu et al, 2002).

Whereas neonatal mortality rate per a thousand live births is 26 in the world, 40 in Africa, 7 in Europe, 35 in East Mediterranean countries according to the report of 2010 World Health Organization (WHO), this rate is 14 in Turkey (WHO, 2010). With regard to 2010 WHO report it is stated that infectious diseases such as diarrhea, pneumonia and bronchitis are the leading diseases that cause infant deaths in developing countries, and one of the easiest ways to prevent these infections is breastfeeding (WHO, 2010). Death rates of infants who are not breastfed are 4-6 times more than the breastfed ones. According to WHO, the high ratio of nursing mothers contributes to survival of infants at an annual average of 1.5 million (Baysan et al, 2009). In a research conducted by Wilson and his colleagues it is determined that the probability of catching respiratory diseases among infants who are at least 15 weeks old and regularly breastfed is low. The probability of catching respiratory diseases is 17% for the infants at least 15 week old and particularly breastfed, it is 26.8-35.2% for those partially breastfed, and it is 30.7-33.7% for those only bottle-fed (Wilson et al, 1998).

According to Turkey Demographic and Health Survey (TDHS 2008), the 68.9% of the infants between 0-1 months are exclusively breastfed. When they are 2-3 months-old this ratio decreases to 42%. Moreover, the ratio in which the newborn infants are breastfed within the first 1 hour is 39%, that within the first day is 73.4%, and the ratio of those who are fed with other nutrients before mother's milk is 23.2% (www.scribd.com/doc/ 21717405/ TNSA-2008-ana -Rapor-tr, 172).

Malnutrition problems in Turkey are particularly observed during the infancy. The 12.2% of the infants under the age of five suffer acute and chronic malnutrition (TDHS 2003). Anemia can also be considered among malnutrition problems. In our country an average of 50% in preschool age, the 30% of school children, and 50% of the pregnant or breastfeeding women are anemic. Primary causes of anemia are the iron deficiency, vitamin B6, vitamin B12 and folic acid intake or their low bioavailability (TUIK, 2006). Furthermore, unbalanced nutrition is an important health concern in the World as it is in Turkey. The widespread availability of fast-food style, nutrition with monotype food, and sedentary lifestyles led the increase in adiposity caused by unbalanced nutrition (Aslan, 2007; TDHS, 2003). Adiposity in childhood period draws attention as a growing concern both in the world and in our country.

To raise healthy and productive generations, the childhood period that lasts from impregnation to the end of adolescence along with the growth-development within this period are crucial for the future of societies. While Maslow places nutrition to forefront among required physical needs (in Hierarchy of Basic Human Needs) Henderson underlines the importance of the subject by claiming that adequate and balanced nutrition comes in the first place among 14 basic needs (Birol, 1997).

Whatever the long-term benefits of nutrition are, ensuring people they would have good nutrition falls to the international laws. This law issue has been expressed in various ways at international declarations and documents about human rights since the Declaration on Rights of the Child was adopted in 1924 (Bellamy, 1998).

Accomplished nutrition plays a major part in healthy growth and development of a newborn infant. Infants in various countries of the world are exposed to malnutrition because of social, economic and cultural reasons. Inadequate and unbalanced nutrition leads growth and development failures and deaths among children (Yapicioglu et al, 2002).

Whereas neonatal mortality rate per a thousand live births is 26 in the world, 40 in Africa, 7 in Europe, 35 in East Mediterranean countries according to the report of 2010 World Health Organization (WHO), this rate is 14 in Turkey (WHO, 2010). With regard to 2010 WHO report it is stated that infectious diseases such as diarrhea, pneumonia and bronchitis are the leading diseases that cause infant deaths in developing countries, and one of the easiest ways to prevent these infections is breastfeeding (WHO, 2010). Death rates of infants who are not breastfed are 4-6 times more than the breastfed ones. According to WHO, the high ratio of nursing mothers contributes to survival of infants at an annual average of 1.5 million (Baysan et al, 2009). In a research conducted by Wilson and his colleagues it is determined that the probability of catching respiratory diseases among infants who are at least 15 weeks old and regularly breastfed is low. The probability of catching respiratory diseases is 17% for the infants at least 15 week old and particularly breastfed, it is 26.8-35.2% for those

partially breastfed, and it is 30.7-33.7% for those only bottle-fed (Wilson et al, 1998).

2008-ana -Rapor-tr, 172).

first place among 14 basic needs (Birol, 1997).

Rights of the Child was adopted in 1924 (Bellamy, 1998).

According to Turkey Demographic and Health Survey (TDHS 2008), the 68.9% of the infants between 0-1 months are exclusively breastfed. When they are 2-3 months-old this ratio decreases to 42%. Moreover, the ratio in which the newborn infants are breastfed within the first 1 hour is 39%, that within the first day is 73.4%, and the ratio of those who are fed with other nutrients before mother's milk is 23.2% (www.scribd.com/doc/ 21717405/ TNSA-

Malnutrition problems in Turkey are particularly observed during the infancy. The 12.2% of the infants under the age of five suffer acute and chronic malnutrition (TDHS 2003). Anemia can also be considered among malnutrition problems. In our country an average of 50% in preschool age, the 30% of school children, and 50% of the pregnant or breastfeeding women are anemic. Primary causes of anemia are the iron deficiency, vitamin B6, vitamin B12 and folic acid intake or their low bioavailability (TUIK, 2006). Furthermore, unbalanced nutrition is an important health concern in the World as it is in Turkey. The widespread availability of fast-food style, nutrition with monotype food, and sedentary lifestyles led the increase in adiposity caused by unbalanced nutrition (Aslan, 2007; TDHS, 2003). Adiposity in childhood

period draws attention as a growing concern both in the world and in our country.

To raise healthy and productive generations, the childhood period that lasts from impregnation to the end of adolescence along with the growth-development within this period are crucial for the future of societies. While Maslow places nutrition to forefront among required physical needs (in Hierarchy of Basic Human Needs) Henderson underlines the importance of the subject by claiming that adequate and balanced nutrition comes in the

Whatever the long-term benefits of nutrition are, ensuring people they would have good nutrition falls to the international laws. This law issue has been expressed in various ways at international declarations and documents about human rights since the Declaration on The requirements stated below should be met in order to determine the adequateness of nutrition, and to discuss clinical adequacy of the nutrition:

As the concept of adequateness in nutrition is searched, the problem of what kind of nutrition the human organism needs in various age periods under the environmental and living conditions has come up. The most practical standard to determine the adequateness in nutrition is that the child keeps his/her birth weight and height within the percentile channel where he/she begins to live (Arcasoy et al, 1994).

In order to overcome the nutrition problems, the importance of eliminating social inequalities which are the basic source of the problem should be emphasized by highlighting that health services constitute an equal, costless, qualified and reachable right. Also preventive health services should be prioritized among the health services.

#### **2. Nutrition requirements**

The foods include 3 essential nutrients which are protein, carbohydrate and fat, in different ratios. All the energy (calorie requirement), building blocks (amino acids, fatty acids), vitamins and minerals are taken to the organism by means of the nutrients. Requirement of each one changes depending on the environment where the individual lives and his/her daily activity. The suggested values in numerical expression of the requirement are given according to the age, body surface (m2), weight (kg) and height (cm) of the individual. Although it is advocated that the ideal evaluation is the rating of body surface to weight or to height and the second rank belongs to m2, the most commonly used one is the criteria of age-weight in practice. Example: The calorie requirement of 0-3 month-old infant is 120 Kcal/kg (Arcasoy et al, 1994).

In the first 4-6 months of life, breast milk and various infant formulas can provide with the complete nutrition to a growing infant. Still, breast milk is recommended nearly for all infants as the source of nutrient. However, very few numbers of infants are fed through only breastfeeding for more than 2-3 months. In this regard, all kind of efforts should be made to encourage breastfeeding. Another option is iron-fortified formulas which support sufficient growth of infants. These formulas are not the only ways to give nutritional supplements. Following the months 4-6, solid foods and fruit juice are being introduced in a manner such that they will gradually substitute the nutrients and calories that came from breast milk or formula. Because infants' activities increase in this period (despite a decrease in growth rate) their energy requirements also increase. A diet (milk) which has relatively high fat content and high calories is required to provide them with adequate energy. Nutritional supplements start forming a source for some important nutrients (iron) within the second 6 months. Genetic coordination of neoplasm is remarkable. However, a variety of nutritional

1. *Nourishment through breastfeeding:* It is the most ideal diet for the newborn infant (Coskun, 1996). World Health Organization (WHO) and American Pediatry Association (APA) suggest that the newborn infants should be breastfed exclusively, nutritional supplements should start as of the sixth month, and the breastfeeding period should

The ingredients of breast milk make mother milk as the most suitable nutrient for infants. This is due to the fact that the ingredients of mother milk change according to the requirements of newborn, besides it is protective against the infections, while it is affordable, as well. Mother milk, thus, meets all the physiological and psychosocial requirements of an infant alone by itself within the first 4-6 months (Dallar et al, 2007;

 *Exclusively breastfeeding:* The infant is fed only with breast milk of its mother or a wet nurse. Otherwise, any liquid food (except vitamin drops and syrups, drugs) or solid

 *Nutrition in which breastfeeding is dominant*: The essential nutrition source of the infant is breast milk. Additionally, liquid beverages, sugared water, tea, fruit juice, vitamin

 *Nutrition in weaning period:* It is the period which follows the breastfeeding for 4-6 months, breastfeeding is kept but nutritional supplements are also newly added to meet

2. *Artificial Nourishment:* It is the diet in which the infant cannot be breastfed due to the problems arising from itself or its mother as a result of misfortune (Coskun, 1996). If it is possible in this nutrition, infant formula milk (industrial milk) which is very similar to breastmilk should be used. Under the clean and proper preparation conditions, digestion problems are seen scarcely and the drawbacks of artificial nutrition are minimized in use of infant formula milk. However, it should be known that these

**Age Amount Meal/day**

1-2 weeks 50-70 ml. 7-8 2-6 weeks 75-110 ml. 6-7 2 months 110-180 ml. 5-6 3 months 170-220 ml. 5 6 months 220-240 ml. 4

The infant should pass 3 consecutive periods which have the terms and characteristics compatible with the growth physiology of the child. These are: Exclusively breastfeeding,

drops and syrups, medicine can also be given (Beaudry, 1995; Coskun, 1996). Mixed Nutrition: In addition to breast milk, semi-solid and solid foods are given to

last beyond two years and more (1 year and more-APA) (APA, 2003).

food is not given (Beaudry, 1995; Coskun, 1996).

nutrients will create economic burden for the family.

Table 1. Artificial nourishment (Tuncdogan & Tuncdogan, 2005).

weaning, nutrition with modified foods for adults (Ozalp, 1996).

**2.2 Nutrition types for infants**

Tuncel et al, 2005).

child.

the infant's requirements.

deficiencies may be restrictive on one of these growth functions. Energy and nutrition requirements are generally proportional to Body Muscle Mass (BMM); as the child grows up, these requirements increase and reach to higher BMM. These requirements are very low for women compared to men, because mass of fat is higher and BMM is lower in women. In terms of some nutrients, the requirements of girls may be more than the requirements of boys or they may be equal like iron or vitamin C. In order to meet the requirements of suggested daily nutrients, a girl should have a richer diet in terms of nutrients compared to a boy. Hence the deficiency risk of some nutrients is higher for girls (Tershakovec, & Stallings, 1996).

*Nutrition requirements:* The minimum nutrition requirement of any food is determined as the amount below the consumed level that would show deficiency. It is determined that the daily nutrient requirement is 2-6 times of the minimum requirement, and the daily nutrient requirement is calculated by taking weight, gender, age and the requirements in pregnancy and lactation into consideration. Calorie requirement is calculated more frequently depending on the requirements below: 100 kcal/kg for the first 10 kg, 50 kcal/kg for 10-20 kg and 20 kcal/kg for over 20 kg (Tershakovec, & Stallings, 1996).

#### **2.1 Energy requirement**

The measure of the organism's energy requirement is the units of "calorie" or "joules". "Kcal" is practically used both in the world and in our country (Arcasoy et al, 1994). One kilocalorie is the required energy amount to raise the temperature of one kilogram of water from 15ºC to 16 ºC. Fats, carbohydrates and proteins are used as the source of energy. 1 gram of oils, 1 gram of carbohydrates and 1 gram of proteins generate 9 kcal, 4 kcal and 4 kcal, respectively. It is desired in a well-balanced prepared diet that each contribution of the carbohydrates, fats and proteins to total energy is 50%, 35% and 15%, respectively (Coskun, 1996).

In general, 4 criteria are used to determine either the energy requirement or other requirements.

Since the growth rate is high in the first years of the childhood period, the requirements for energy and the other nutritional elements are unexpectedly higher than the body mass. For example, whereas the energy and protein requirement of a moderately active woman at a weight of 40 kg is 40 kcal/kg and 1 g/kg, respectively, these requirements for an infant in the first six months of life are three times of the stated values (Coskun, 1996).

deficiencies may be restrictive on one of these growth functions. Energy and nutrition requirements are generally proportional to Body Muscle Mass (BMM); as the child grows up, these requirements increase and reach to higher BMM. These requirements are very low for women compared to men, because mass of fat is higher and BMM is lower in women. In terms of some nutrients, the requirements of girls may be more than the requirements of boys or they may be equal like iron or vitamin C. In order to meet the requirements of suggested daily nutrients, a girl should have a richer diet in terms of nutrients compared to a boy. Hence the deficiency risk of some nutrients is higher for girls (Tershakovec, &

*Nutrition requirements:* The minimum nutrition requirement of any food is determined as the amount below the consumed level that would show deficiency. It is determined that the daily nutrient requirement is 2-6 times of the minimum requirement, and the daily nutrient requirement is calculated by taking weight, gender, age and the requirements in pregnancy and lactation into consideration. Calorie requirement is calculated more frequently depending on the requirements below: 100 kcal/kg for the first 10 kg, 50 kcal/kg for 10-20

The measure of the organism's energy requirement is the units of "calorie" or "joules". "Kcal" is practically used both in the world and in our country (Arcasoy et al, 1994). One kilocalorie is the required energy amount to raise the temperature of one kilogram of water from 15ºC to 16 ºC. Fats, carbohydrates and proteins are used as the source of energy. 1 gram of oils, 1 gram of carbohydrates and 1 gram of proteins generate 9 kcal, 4 kcal and 4 kcal, respectively. It is desired in a well-balanced prepared diet that each contribution of the carbohydrates, fats and

In general, 4 criteria are used to determine either the energy requirement or other

1. The requirement for basal metabolism (BM): is calculated according to m2'. The shares that the organs take from BM according to the age period are different in childhood period. For example: the brain of an infant uses 2/3 of BM energy, whereas this ratio is

3. Specific-dynamic effect (SDE) of the nutrients: While the energy use of the organism is

4. The required energy for growth-development (G/D): It is calculated that 3.5-5 Kcal are needed in order to increase the weight of an organism by one gram. Rapid growth during infancy requires rapid energy consumption. It is estimated that 1/4-1/3 of the total energy taken within the first months of life is used for G/D (Arcasoy et al, 1994). Since the growth rate is high in the first years of the childhood period, the requirements for energy and the other nutritional elements are unexpectedly higher than the body mass. For example, whereas the energy and protein requirement of a moderately active woman at a weight of 40 kg is 40 kcal/kg and 1 g/kg, respectively, these requirements for an infant in

kg and 20 kcal/kg for over 20 kg (Tershakovec, & Stallings, 1996).

proteins to total energy is 50%, 35% and 15%, respectively (Coskun, 1996).

2. A requirement obedient to physical activity should be calculated.

calculated, SDE of the nutrients accounts for a low ratio such as 5-10%.

the first six months of life are three times of the stated values (Coskun, 1996).

Stallings, 1996).

**2.1 Energy requirement**

requirements.

1/4 for adults.

#### **2.2 Nutrition types for infants**

1. *Nourishment through breastfeeding:* It is the most ideal diet for the newborn infant (Coskun, 1996). World Health Organization (WHO) and American Pediatry Association (APA) suggest that the newborn infants should be breastfed exclusively, nutritional supplements should start as of the sixth month, and the breastfeeding period should last beyond two years and more (1 year and more-APA) (APA, 2003).

The ingredients of breast milk make mother milk as the most suitable nutrient for infants. This is due to the fact that the ingredients of mother milk change according to the requirements of newborn, besides it is protective against the infections, while it is affordable, as well. Mother milk, thus, meets all the physiological and psychosocial requirements of an infant alone by itself within the first 4-6 months (Dallar et al, 2007; Tuncel et al, 2005).

Table 1. Artificial nourishment (Tuncdogan & Tuncdogan, 2005).

The infant should pass 3 consecutive periods which have the terms and characteristics compatible with the growth physiology of the child. These are: Exclusively breastfeeding, weaning, nutrition with modified foods for adults (Ozalp, 1996).

half an hour following the birth is encouraged, anything like fake breast or infant pacifier is not given to the breastfeeding infant, exclusively breastfeeding is kept up to the first 4-6 months and then breastfeeding with nutritional supplements is applied in the following period (Arcasoy et al, 1994; Bellamy, 1998; T.R. Ministry of Health General Directorate of

Breastfeeding is the most appropriate diet for infants to let them grow and develop healthily. The first year of the infant is extremely important in terms of laying the foundations of a healthy life. Adequate and balanced nutrition is provided in infanthood period through the breast milk of each infant's own mother. It is exclusively sufficient for 4- 6 months to give the infant breast milk of its mother without giving water beginning from the birth and observe the growth (Bertan & Guler, 1995). Since 87% of breast milk consists of liquid, in the first six months the infant does not need anything like water or similar liquid

We can summarize the superiorities of breast milk: it is suitable for the growth rate of the infant in terms of its composition, it is digested easily and there is not any loss in digestion, it is non-allergic, economic, clean and sterilized, furthermore it does not require special preparation, it has protective elements against the microbes, toxic elements that will give harm to the infant are at minimum level in breast milk, it strengthens the affection relation between the mother and the child, it assists the mental health of both to be protected (Baysal, 1993; Ozalp, 1996). In breast milk, there are different growth factors having effects in infant's growth that are demonstrated by means of in vivo and in vitro studies. Tiny molecules such as taurine, ethanolamine, phosphoethanolamine, and proteins such as "epidermal growth factor", "nerve growth factor" which look like hormones and interferon affect the growth and development by affecting the mammary gland or distinct organs of infants (Ozalp, 1991). Besides that taurine is one of the factors in breast milk that orders the growth, it is known that it provides the coherence of cell membrane and prevents the

Breast milk is the unique ideal and physiological nutrient for the newborn. It supplies all feeders according to requirement of the infant in an organized and sterilized manner. Moreover when breast milk is compared with the infant formulas which are sterilized but "inert" because of enabling the mother to adapt to the microbial environment where she is, and providing the infant both general and specific anti-infective factors, breast milk is a "living" biological liquid. Even though macro-feeders are imitated for their concentration and content in the sense of "static", supplying the micro-feeders at-will cannot be always guaranteed. For example, the existence of a different whey casein ratio in the formula affects the infant's cholesterol levels in blood. While whey casein ratio in breast milk is 63:37, this is 18:82 in cow's milk. Although the ratio of 60:40 in infant formulas that are regarded as "humanize" is adopted nowadays, rich formulas (20:80) have been generated from the casein within last 10 years because of its affordability. It was found that blood cholesterol levels of the infants who had been fed with these formulas were high, in which only the protein ratio

MCH/FP, 1997; Tuncel et al, 2005).

destruction of retina (Ozalp, 1996).

**<IP_ADDRESS> Content of breast milk**

**<IP_ADDRESS> Characteristics of the breast milk**

nutrients, except the breast milk (Gokcay & Garibagaoglu, 2002).

was modified and lipids remained the same (Civi et al, 1997).

#### **2.2.1 Energy and nutrient needs of infants**

Nutrient and energy needs of the children differ from the adults'. Due to the generation of new tissues within infant's body, the need for proteins, minerals and vitamins is high. Significant amount of energy is necessary in growth period. Because the children have not learnt eating food by themselves yet, the diets that will be prepared for their nutrition should be in conformity with the child and include definite nutrient elements (Netsel, 2003).

Energy Needs of Infants:

Majority of the calories are provided from fats and carbohydrates. The carbohydrate (lactose) and fats within the breast milk are absorbed easily (Netsel, 2003).

Infant's need for protein is substantially high. Intake of qualified and adequate protein is a requirement, since the growth of body tissues requires continuous protein synthesis. Breast milk has the characteristics of sample protein. The digestion rate of the sample protein accounts for 95%.

#### **2.2.2 Vitamins and minerals**

The daily average need of an infant for vitamins and minerals are:

Breast milk can meet an infant's need for vitamins and minerals up to 4th-6th month under normal conditions. Afterwards the need should be met by means of the nutritional supplements (Koksal, 2007).

#### **2.2.3 Nutrition of infants in the first 6 months**

The ideal nutrition for infants is exclusively breastfeeding the first 6 months, then starting to get proper nutritional supplements and the continuation of breastfeeding for two years. It is estimated that breastfeeding will be able to prevent 1.3 million infants from dying every year. If inartificial nutrition cannot be provided, artificial nutrition or mixed nutrition are applied (APA, 2003).

#### **<IP_ADDRESS> Breastfeeding**

With respect to "*The Innocenti Declaration*" that WHO and UNICEF published in 1990, it is suggested that the conditions are created to enable the women to breastfeed commonly, the necessary information about this subject can be reached easily, to begin breastfeeding within

Nutrient and energy needs of the children differ from the adults'. Due to the generation of new tissues within infant's body, the need for proteins, minerals and vitamins is high. Significant amount of energy is necessary in growth period. Because the children have not learnt eating food by themselves yet, the diets that will be prepared for their nutrition should be in conformity with the child and include definite nutrient elements (Netsel, 2003).

Majority of the calories are provided from fats and carbohydrates. The carbohydrate

Infant's need for protein is substantially high. Intake of qualified and adequate protein is a requirement, since the growth of body tissues requires continuous protein synthesis. Breast milk has the characteristics of sample protein. The digestion rate of the sample protein

**2.2.1 Energy and nutrient needs of infants**

 120 calories per kilogram between 1-3 months 110 calories per kilogram between 4-9 months

105 calories per kilogram between 10-12 months (Netsel, 2003).

The daily average need of an infant for vitamins and minerals are:

**Vitamin A** : 1500 I.U. **Calcium:** 500 mg

**Vitamin C** : 20- 30 mg **Iodine :** 50 mcg **Vitamin B 6** : 0.3-0.6 mg **Phosphorus :** 400 mg **Vitamin B12** : 1- 2 mcg **Zinc :** 5–10 mg

**Vitamin D** : 400 I.U. **Iron:** 5-10mg (after 6th month)

**Folic acid:** 40- 60 mcg **Potassium:** 4- 8 mg (Koksal, 2007).

Breast milk can meet an infant's need for vitamins and minerals up to 4th-6th month under normal conditions. Afterwards the need should be met by means of the nutritional

The ideal nutrition for infants is exclusively breastfeeding the first 6 months, then starting to get proper nutritional supplements and the continuation of breastfeeding for two years. It is estimated that breastfeeding will be able to prevent 1.3 million infants from dying every year. If inartificial nutrition cannot be provided, artificial nutrition or mixed nutrition are

With respect to "*The Innocenti Declaration*" that WHO and UNICEF published in 1990, it is suggested that the conditions are created to enable the women to breastfeed commonly, the necessary information about this subject can be reached easily, to begin breastfeeding within

(lactose) and fats within the breast milk are absorbed easily (Netsel, 2003).

Energy Needs of Infants:

accounts for 95%.

**2.2.2 Vitamins and minerals**

supplements (Koksal, 2007).

applied (APA, 2003). **<IP_ADDRESS> Breastfeeding**

**2.2.3 Nutrition of infants in the first 6 months**

half an hour following the birth is encouraged, anything like fake breast or infant pacifier is not given to the breastfeeding infant, exclusively breastfeeding is kept up to the first 4-6 months and then breastfeeding with nutritional supplements is applied in the following period (Arcasoy et al, 1994; Bellamy, 1998; T.R. Ministry of Health General Directorate of MCH/FP, 1997; Tuncel et al, 2005).

#### **<IP_ADDRESS> Characteristics of the breast milk**

Breastfeeding is the most appropriate diet for infants to let them grow and develop healthily. The first year of the infant is extremely important in terms of laying the foundations of a healthy life. Adequate and balanced nutrition is provided in infanthood period through the breast milk of each infant's own mother. It is exclusively sufficient for 4- 6 months to give the infant breast milk of its mother without giving water beginning from the birth and observe the growth (Bertan & Guler, 1995). Since 87% of breast milk consists of liquid, in the first six months the infant does not need anything like water or similar liquid nutrients, except the breast milk (Gokcay & Garibagaoglu, 2002).

We can summarize the superiorities of breast milk: it is suitable for the growth rate of the infant in terms of its composition, it is digested easily and there is not any loss in digestion, it is non-allergic, economic, clean and sterilized, furthermore it does not require special preparation, it has protective elements against the microbes, toxic elements that will give harm to the infant are at minimum level in breast milk, it strengthens the affection relation between the mother and the child, it assists the mental health of both to be protected (Baysal, 1993; Ozalp, 1996). In breast milk, there are different growth factors having effects in infant's growth that are demonstrated by means of in vivo and in vitro studies. Tiny molecules such as taurine, ethanolamine, phosphoethanolamine, and proteins such as "epidermal growth factor", "nerve growth factor" which look like hormones and interferon affect the growth and development by affecting the mammary gland or distinct organs of infants (Ozalp, 1991). Besides that taurine is one of the factors in breast milk that orders the growth, it is known that it provides the coherence of cell membrane and prevents the destruction of retina (Ozalp, 1996).

#### **<IP_ADDRESS> Content of breast milk**

Breast milk is the unique ideal and physiological nutrient for the newborn. It supplies all feeders according to requirement of the infant in an organized and sterilized manner. Moreover when breast milk is compared with the infant formulas which are sterilized but "inert" because of enabling the mother to adapt to the microbial environment where she is, and providing the infant both general and specific anti-infective factors, breast milk is a "living" biological liquid. Even though macro-feeders are imitated for their concentration and content in the sense of "static", supplying the micro-feeders at-will cannot be always guaranteed. For example, the existence of a different whey casein ratio in the formula affects the infant's cholesterol levels in blood. While whey casein ratio in breast milk is 63:37, this is 18:82 in cow's milk. Although the ratio of 60:40 in infant formulas that are regarded as "humanize" is adopted nowadays, rich formulas (20:80) have been generated from the casein within last 10 years because of its affordability. It was found that blood cholesterol levels of the infants who had been fed with these formulas were high, in which only the protein ratio was modified and lipids remained the same (Civi et al, 1997).

Breastfeeding within the first half an hour after the birth is a crucial factor for not delaying the increase in the amount of milk, and it affects the total breastfeeding period positively

The milk in the period of 5-10 day-old infant is the temporary milk. The concentration of phosphorus is higher in transitional milk than it is in the colostrum or mature milk (Ok, 1991). It contains fat, lactose and vitamin in higher rates than the colostrum and its calorie

Lactose is the most important component of the carbohydrates in breast milk. Its rate is higher in breast milk than it is in cow's milk (7.1 g/dl and 4.1 g/dl). The compounds of lactose's galactose component with lipids have a significant role in the development of brain. Also, it facilitates the calcium absorption and affects the bone mineralization positively. The indigestible part of lactose has role in the development of acidophilic bacterial flora (*Lactobacillus bifidus*) in intestines as fermented, and prevents reproduction of the pathogen microorganisms (Gokçay & Garibagaoglu, 2002; Oran & Yurdakok, 1996).

*Whey protein*, which is digestible and rich in biological value, constitutes the 60% of the protein content (which is almost 18% in cow's milk). Alfa-lactalbumine makes up the significant part of the whey proteins and has a function in the lactose synthesis in the breast alveoli. Most of the whey proteins are anti-infective proteins and protects the infant from infections. Lactoferrin, lysozyme, emunctory immunoglobulin-A and other types of immunoglobulin, nucleotides, and growth factors play key role in immunity. The rate of casein that is less digestible is lower in breast milk than it is in cow's milk (40% and 80%)

The protein content in breast milk is less than it is in cow's milk (1.1 g/dl and 3.2 g/dl), but its biological value is higher and it meets the protein requirement of the infant alone (Oran

The nucleotides in breast milk increase the protein utilization. When amino acids are insufficient through diet, nucleotides are used in the synthesis of proteins and non-essential amino acids. It is known that there are 12 distinct nucleotides in the breast milk and inosine phosphate among these increases the absorption of iron in the breast milk (Ozalp, 1996).

*Carbohydrate:* Lactose within the breast milk is almost 7% at average. Lactose of the breast milk is more digestible than the lactose in cow's milk (Arcasoy et al, 1994). Lipids which supply 50% of the calories in breast milk are more in breast milk than they are in cow's milk (4.5 g/dl and 3.8 g/dl) and they exist in the form of fat globules. Lipase in breast milk promotes the digestion of fat even in low bile level. Furthermore, the breast milk has a rich content in terms of long chain poly unsaturated fatty acids such as arachidonic acid, docosahexaenoic acid, linolenic acid and alfa linoleic acid all of which are in the structure of nerve cell and retina cell and have role in the development of the nervous system and

(Richard, 2001; TR Ministry of Health, 1996; Yurdakok, 2004).

Color of the breast milk is white and its pH is 6.97 (Arcasoy et al, 1994).

(Gokcay & Garibagaoglu, 2002; Oran & Yurdakok, 1996).

**2.2.3.b Temporary milk**

& Yurdakok, 1996).

value is also higher (Taskin, 1997). **2.2.3.c Mature milk (breast milk)**

#### **2.2.3.a Colostrum**

The breast milk which is lactated within the first 4-5 days following the birth is called *colostrum.* The milk turns into *transitional milk* in the next days by changing its structure. It takes the form of *mature milk* within thirty days (Arcasoy et al, 1994).

Colostrum is a yellowish liquid having pH 7.7 approximately. Its structure is different from the mature milk and it has the characteristics of retention liquid (Arcasoy et al, 1994; Ok, 1991; Ozalp, 1996)*.*

Colostrum has a rich content in terms of minerals, vitamin A, IgA. Its sugar and fat content is lower compared to the following milk (Ok, 1991; Özalp, 1996).

*Protein:* Its rate is an average of 2.2% g.

*Carbohydrate:* Lactose rate is lower than it is in mature milk due to the resorption of lactated liquid from the breast again. Its rate is an average of 4-5% g (Arcasoy et al, 1994). The concentration of breast milk is not affected from the mother's diet. Lactose is influential in the absorption of calcium within the milk. The compounds of lactose's galactose component with lipids are essential for the development of brain tissue (Ozalp, 1996).

Fat: The fat rate is low in the first days; afterwards it is 3% g approximately (Arcasoy et al, 1994).

As lactation increases, the total protein and mineral levels decrease and the level of fat, lactose and frequently vitamin B1 increase (Arcasoy et al, 1994).

*Energy:* It is 570 Kcal per liter approximately (Arcasoy et al, 1994).

*Immunoglobulins:* All structural factors for the development and protection of the newborn are available in colostrum. Colostrum is very rich in terms of the immunoglobulins. After the first breastfeeding, the mouth and gastrointestinal mucous is covered by secretory lgA. These interlink the toxins, bacteria and macromolecular agents and prevent their absorption from intestinal epithelium. Moreover, they have the function of stimulating infant to form its own lgAs. In the first days most of the cells in the colostrum comprise of neutrophils, and macrophages in the next days. Both cell types protect the infant from infections through the synthesis of phagocytosis and interferon. Half of the lymphocytes in colostrum are T-lymphocytes. B lymphocytes constitute lgA and also it is discovered that they are able to generate interferon when they are stimulated by viruses (Arcasoy et al, 1994).

As the volume of milk decreases through the end of lactation, immunoglobulins increase again. Thus, both the infant and the breast are protected (Arcasoy et al, 1994).

The amount of *taurine* in colostrum which is a necessary amino acid for the newborn, is 7-8 times more than the cow's milk in 3th-7th days (Arcasoy et al, 1994).

Rather than for the nutrition of newborn (in any case, the energy and water requirements of a 3-day-old infant is minimal), colostrum is beneficial for protecting the newborn from the microbes in external environment and preparing it for the function of gastro-intestinal system (Ok, 1991).

The breast milk which is lactated within the first 4-5 days following the birth is called *colostrum.* The milk turns into *transitional milk* in the next days by changing its structure. It

Colostrum is a yellowish liquid having pH 7.7 approximately. Its structure is different from the mature milk and it has the characteristics of retention liquid (Arcasoy et al, 1994; Ok,

Colostrum has a rich content in terms of minerals, vitamin A, IgA. Its sugar and fat content