GROWTH
AND
NUTRITION
OF
INFANTS
The Influence
of
Diet
and
Other
Factors
on Growth
Roberto Rueda-Williamson, M.D., M.Sc., and Hedwig E. Rose, M.B., Ch.B.
From tiac Department of Pediatrics, Harvard Medical School, tile Child Health Dicision, Children’s
hospital Medical Center, and tile Department of Nutrition, Harcard School of Public Health
(Submitted for publication June 20, 1961; accepted June 19, 1962.)
Supported in part l)\ grants-in-aid from the Nutrition Foundation, New York, and the Fund for Research and Teaching, Department of Nutrition, Harvard School of Public Health.
R. R-W. is holder of a Fellowship from Cyanamid International Lederle Division.
PRESENT ADDRESS: I)epartamento de Nutricion, Escuela de Salud Publica. Universidad Nacional de
Go-lombia, Bogota, Colombia, South America.
639
PEDIAi’sucs, October 1962
G
ROWTH and nutritional requirementshave been extensively investigated.’
However, apart from those carried out
tin-(icr hospital conditions, growth and
nu-trition studies of tile first year of life ilave
been either separate investigations of one
Or other of tilese two parameters or
insuffi-ciently detailed to permit close analyses of
tile inteITelationsilips between food intake
and the progress of morphological growth
of individual infants. The present
longitudi-nal study of 67 infants from 2 to 15 months
of age relates growth and nutrient intake
simultaneously.
Stuart et al. in the Longitudinal Studies
of Child Health and Development,
consid-ered nutrition as well as several aspects of
growtil, but description of dietary intake
during the first year of life was limited to
the statement tilat “approximately 66 of
the infants were breast fed during a
vary-ing number of months after h59 Beal
published detailed studies of the nutrient
intake of 46 children during tileir first 5
years of life.1h1
Mn in Africa and
Perez-Nava-rrete’ in Mexico studied tile growth of
groups of infants in tilese countries. They
analyzed the weight curves in relation to
the local feeding practices, quality of
sup-plementary feeding, social conditions, and
incidence of disease, and found that a
defi-nite slow-down in the rate of growth
oc-curred after 6 months due to difficulties
which arose over mixed feeding, weaning,
and intere’ ‘rrent infections. Jelliffe’
re-viewed several similar investigations of
growth in relation to group feeding
prac-tices. Others have reviewed tile
compara-tive studies of infants’ progress on breast
versus nonbreast feeding’ ‘ and on early
versus late introduction of “solids.” These
studies all suggest that, provided basic
re-quirements are met, infants do equally well
on different feeding regimens. However,
none of them provide data on tile diet and
progress of the individual.
OBJECTIVES
It seemed worthwhile, therefore, to study
concomitantly the growth and nutrient
in-take of individual, home-dwelling infants
whose physical and developmental status
and life experiences were regularly
docu-mented in sufficient detail to permit
corn-parison of the progress of individual
in-fants under differing circumstances.
The infants studied were from the same
geograpilic area and mainly from the same
ethnic group as those who participated in
tile Harvard Longitudinal Studies of Child
Health and Development of approximately
30 years ago.5 Comparative study of tile
tvo groups would, therefore, indicate
\viletiler changes in growth, whicil might
be related to alterations in feeding
pat-terns, had occurred.
Other objectives were to establish and
correlate growth and food intake patterns;
to examine tile influence of activity, illness,
and environment on tilese; to correlate iron
640
DIET
AND
GROWTH
and protein intake to serum cholesterol
1ev-els; and to compare present nutrient
con-sumption with that of other studies and
with the Recommended Allowances of the
National Research Council.
MATERIAL
The infants in this study were regular
attendants at two well-baby clinics, The
Child Health Division of the Children’s
Hospital Medical Center and the Bromley
Park Clinic, a Boston Health Department
clinic associated with the Department of
Pediatrics, Harvard Medical School, and
the Department of Maternal and Child
Health, Harvard School of Public Health.
The first clinic serves the area described
by Stuart,8 the second a similar but slightly
more depressed area.
Infants under 3 months of age were
en-rolled without selection until a total of 83
babies was obtained. Five of these left the
area; one left the clinic, while remaining
in the area; four did not attend regularly;
and five mothers of six infants did not
co-operate. This paper deals with the 67
healthy, full-term infants, 25 males and 42
females, who remained in the study until
15 months of age. Most of the parents were
of low socioeconomic groups, and 88% were
of North European stock.
METHOD OF STUDY
Physical Growth
The study of physical growth embraced
a series of monthly anthropometric
meas-urements of recumbent length, naked
weight, circumference of head, chest, and
arm; width of hip and thickness of
skin-folds of abdomen, inferior angle of scapula
and anterior and posterior arm. All physical
measurements were made by the same
ob-server (RRW). The recumbent length was
measured on a board with one fixed and
one sliding upright.8 It was taken at the
be-ginning and repeated at the end of each
observation. The skinfolds were measured
with a Franzen type spring caliper. The
circumferences were taken with a narrow
width metal tape. Measurements were
made, as far as possible, exactly at the end
of each month of life. When this could not
be done, measurements were calculated by
linear interpolation between actual
meas-urements made during the months. In the
rare instances in which a month’s
meas-urements were missed altogether, the linear
interpolation was made between the
pre-ceding and following month’s
measure-ments.
The physical growth was assessed against
Stuart’s percentiles and also on the
corn-bined chart of one of the authors (RRW).
The latter assessment will be presented
elsewhere as a demonstration of the use and
advantages of the Combined Auxornetric
Method”2#{176} developed by its author as a
step toward the establishment of a
univer-sal auxometric system. It includes a weight
on length regression standard, similar to
that of Wetzel2l and others, over which the
weight and length deviations of De Toni22
are applied for measuring position and
speed of growth in units of equal
signifi-cance regardless of the age at which they
occur.
Food Intake
The longitudinal dietary survey was
con-ducted by the same person throughout
(HER).
No attempt was made to prescribefeeding, but minor modifications to the diet
were suggested when necessary in the
in-terest of the child. Food intake was
re-corded in terms of feeding patterns,
in-eluding kind and quantity of food taken at
and between meals, and also in terms of
quantity of specific items of food consumed.
The information was obtained from dietary
histories and records, and from personal
oh-servations in the ilomes. Dietary histories
were taken twice a month during the first
5 or 6 months, and montilly thereafter.
Ad-ditional histories were taken when changes
in feeding could be expected, namely,
dur-ing and after illness and at times of other
stresses, including social problems. They
were mostly obtained during clinic visits in
follow-up, but some were taken in the
homes. This afforded an opportunity to
oh-serve mother and child in their natural
en-vironment, to see \vilat and how the cilild
was eating, and to become acquainted Witil
tile usual food supplies in the home and
vith the sizes of cups, dishes, and spoons
in common use. The tecilnique, although
basically the same throughout, varied from
case to case, depending on the personality
of the informant and circumstances of the
moment. The informant, usually the mother,
was encouraged to talk freely and to
pre-sent her information in iler own way.
From tile histories taken and observations
made during each month, the average daily
food intake for that month was estimated.
The daily nutrient intake was calculated
from tilis, using food composition tables
based on information from infant food
man-ufacturers, milk companies, and the
Agri-culture Handbook No. 323 Average daily
ilutrient intakes per kilogram of body
weight (actual and expected#{176}) were
cal-culated, using tile interpolated mid-month
weight as denominator.
Activity, Illness, and Environment
A general ilistory was taken concurrently
\Titil the diet history. A record was kept of
each cililds health and developmental
sta-ttis, moods and temperament, sleep and cry
rhythm, exercise and behavior patterns,
ill-ness experience, family relations, and
phys-ical and emotional environment. Activity
was assessed, not merely on degree of
phys-ical exercise, but also on sleep, cry, and
tempo of movements.
Tile observer, as the child’s pediatrician,
Ilad tile benefit of the trust and confidence
usually placed in a physician. She also
profited from consultation and discussion
with the Department of Nutrition and with
the multidisciplinary teams of the broadly
oriented clinics before mentioned. These
0 “Expected” weight was taken to be that
weight which would give a child the same percen-tile position in weight as he has in length; i.e., standard weight for length on the regression line of the Wetzel channel system.”
benefits gave tile study some of the
advan-tages of multidisciplinary approach without
the disadvantages of a direct team approacil
in which a mother has no one particular
person to whom she can relate.
Blood Components
Three times during the year cholesterol
and hemoglobin levels in serum were
de-termined. Hemoglobin was measured on
the Evelyn photoelectric hemoglobinometer.
Cholesterol was estimated by the method of
Carpenter et al.24 Blood was collected from
the big toe.
RESULTS
The infants and their parents are
gen-erally representative of the clinic
popula-tion, since they were enrolled without
selec-tion. The mothers were no more nor less
intelligent or conscientious than tile
aver-age. They co-operated well, some
sponta-neously and others only with considerable
encouragement and persuasion, because
they received, in return, free individual and
special attention from the physician
inves-tigator. In view of this and the fact that no
feedings were prescribed, the growtil and
feeding patterns of the study infants can he
considered to be generally representative of
these patterns in the areas, as a whole.
Physical Growth
The weight and length values of the study
infants are summarized in Table I. Their
patterns of growth in these dimensions are
similar to those of Stuart’s infants of about
30 years ago (Fig. 1). The median boy’s
weight lies on Stuart’s 50th percentile at 2
months, follows his 75th percentile from 3
to 6 months, and his 50th percentile from
7 to 12 months. The median girl’s weight
lies on Stuart’s 2th percentile at 2 months,
reaches the 50th percentile at 4 months,
remains approximately on this line until 10
months, and then deviates toward but does
not reach the 25th percentile. The 10th and
90th percentile weight values for girls are
very close to Stuart’s corresponding values,
Age
____
(mo)
Low
Percentiles
10 25 50 7#{244} 90 High
3.4
5.8
7.8
9.3
10.0
0 1.99 ‘2.61 ‘2.84 3.10 3.47 3.89 4.06 4’2 3.09 3.4
‘2 4.00 4.’20 4.39 4.69 5.04 5.50 6.60 4’2
3 4.40 4.90 5.’21 5.48 5.95 6.’20 7.90 4’2 5.54 5.6
4 5.’2’2 5.65 5.87 6.’25 6.70 7.05 8.’25 4’2
5 5.70 6.10 6.43 6.81 7.2’2 7.80 9.30 4’2
6 6.07 6.40 6.73 7.’25 7.74 8.46 10.’20 4’2 7.35 7.9
7 6.40 6.85 7.10 7.6’2 8.’21 8.75 10.50 4’2
8 6.60 7.15 7.43 8.03 8.65 9.07 11.15 4’2
9 6.70 7.30 7.73 8.33 8.88 9.55 11.47 4’2 8.46 8.9 10 6.9’2 7.57 7.94 8.80 9.36 9.85 11.78 4’2
11 7.45 7.80 8.’25 9.04 9.63 10.50 1’2.03 4’2
U 7.63 8.15 8.63 9.’25 10.20 11.05 1’2.38 4’2 9.41 9.9
15 8.’29 8.84 9.43 9.81 10.75 11.90 13.40 4’2 10.1’2
TABLE I
WEIGHTS AND LENGTHS OF 67 INFANTS
Boys’ Weight, in Kilograms
Cases Stuarts
.llean
(no) Mean
0 .58 .73 2.73
3.75 4.03 4.47
S 4.75 4.96 5.45
4 5.15 5.49 6.87
5 6.10 6.41 7.00
6 6.80 7.16 7.50
7 7.55 7.76 8.05
8 8.00 8.13 8.3
9 8.50 8.57 8.70
10 8.75 8.88 9.05
11 9.03 9.08 9.30
12 9.5 9.31 9.60
15 9.70 9.73 10.00
8.38 3.81 4.14 4.40 5.15 5.70 6.10 6.18 6.0 6.60 6.80 7.00
6.90 7.7 7.70 8.00
7.50 8.07 8.60 8.80
7.98 8.45 9.11 9.70
8.30 9.10 9.80 10.45
8.75 9.40 10.48 11.05
8.95 10.00 10.88 11.35
9.45 10.45 11.38 F1.05
9.90 10.90 11.84 1L35 10.15 11.30 1I.31 1.50 11.5 1.70 13.10 13.40
25 3.’32
5 6.03
25
5 8.0
‘25 ‘25
25 9.41 ‘25
‘25
‘25 10.44
‘25 11.34
Girls’ Weight, in Kilograms
Boys’ Lengths, in Centimeters
‘2 53.6 54.6 55.3 57.6 59.5 60.7 61.4 ‘25
3 56.6 56.7 58.1 60.7 6’2.7 63.6 63.8 ‘25 60.5 60.4 4 58.7 59.9 60.5 63.0 64.8 66.! 66.5 ‘25
5 6’2.0 6’2.4 63.0 65.3 67.0 68.3 68.5 ‘25
6 64.3 64.5 65.’2 67.’2 68.8 69.9 71.5 ‘25 67.’2 67.0
7 65.5 66.5 67.’2 69.0 70.’2 71.4 7’2.5 ‘25
8 67.0 68.0 68.4 70.6 7’2.4 73.7 74.6 ‘25
9 67.9 69.0 69.5 71.5 73.5 74.3 76.’2 ‘25 71.5 71.5 10 69.9 70.1 70.9 7Q.8 75.0 75.4 78.0 ‘25
11 70.9 71.1 7’2.4 74.0 76.’2 77.1 79.’2 ‘25
1’2 71.8 7’2.0 73.9 75.0 77.5 78.1 80.6 25 75.4 75.5 15 75.0 75.9 77.0 77.7 80.4 8’2.3 88.8 ‘25 78.7
Girls’ Lengths, in Centimeters
‘2 51.7 53.8 54.7 56.0 57.6 58.4 60.3 4’2
3 54.8 56.0 57.5 58.9 60.5 61.8 64.0 4’2 58.9 59.4 4 57.7 58.3 59.7 61.1 6’2.6 64.0 67.4 4’2
5 59.6 61.’2 61.7 63.4 65.8 66.5 69.0 4’2
6 61.1 6’2.7 63.7 65.’2 66.6 68.5 71.0 4’2 65.3 65.7
7 6’2.3 63.8 65.5 67.1 68.4 70.1 73.3 4’2
8 64.4 65.3 66.8 68.1 70.4 7’2.’2 75.5 4’2
9 65.9 66.6 68.1 69.7 71.4 73.6 76.9 4’2 69.9 70.1 10 66.7 67.6 69.3 71.1 7’2.9 75.0 78.’2 4’2
11 67.7 68.9 70.6 7’2.1 74.0 76.4 80.0 4’2
1’2 70.0 70.3 71.4 73.4 75.0 77.8 8’2.0 4’2 73.7 74.3
ICM o
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Fic. 1. Percentile weight and length positions of 67 infants (25 boys and
42 girls). The fiftieth (x) tenth, and ninetieth percentile values are plotted on a condensed form of the Children’s Hospital Medical Center, Boston Anthropometric Chart. The percentiles of this chart are based on Stuart’s
measurements.
ilis 10th and 25th and his 90th and 97th
percentiles respectively. This latter
sug-gests a tendency for male infants in the
present study to be heavier than those of
Stuart’s study. However, the actual weight
differences are small and were not
consid-ered to be significant in view of the small
sample size and the fact that the means of
the two studies were very similar. The
lengtil percentiles of the present study are
generally very close to those of Stuart’s
study.
The Iowa babies46 wilose food intake
x
0
KG.
CM.
8-
70-7-
65-6-
60--Study Infonts
5
-55
- --* Iowa Infants‘I Stuart’s Mean
1 Study
Mean
4 . . . . . .
-50
I I I 1 1I
23456
MONTHS
FIG. 2. s1edian 2-to-6-month weights and lengths of the 67 study infants and the 18 Iowa infants who were followed for more than 60 days in the studies of Fomon and Mav.4
644 DIET AND GROWTH
The protein intakes of the Boston
(pres-WEIGHT
I I I I I I
1
23456
MONTHS
this study had from 2 to 6 months lower
median weight values than our infants,
despite tlleir higher median length values
in the 3-to-6-month age period (Fig. 2).
Food Intake
More than 50 different foods and food
combinations are available as “baby food”
and in regular use. However, milk was
usu-ally the main source of nutrients until 9
months, and in many cases it continued to
be so, even up to 15 months. Few of the
many brands of milk and milk substitutes
on the rnarket2 were in common use. Only
3 of the 67 babies in the study were breast
fed for longer than 3 months.
Approxi-mately 80% of them had whole cow’s milk
or the equivalent in evaporated milk, and
95% consumed some “solid” food before 3
months of age. This is consistent with
cur-rent pediatric practice throughout the
United States.26 About 60% of the infants
were on “demanding feeding,” 35% on a
flexible schedule, and 5% on a fairly rigid
schedule. Although new foods, including
whole egg, and many kinds of cereal and
LENGTH
fruit were introduced early and suddenly,
definite allergic reactions were observed in
one case only. A child with mild chronic
atopic dermatitis ilad severe and repeated
reactions to egg, both yolk and white.
Calories
Table II and Figure 3 present, for
corn-parison, the Recommended Allowances of
the National Research Council27 and the
average daily calorie per kilogram intakes
of the Denver (Beal, 19461951)1th1 and the
present study (Boston, 1959-1960) infants.
The 50th percentile values of Boston are
slightly above, and those of Denver are
slightly below, the Recommended
Allow-ances. Both the highest and the lowest
Bos-ton values are usually above the Denver
highest and lowest values. The 50th
per-centile intake of the Iowa infants (Fomon
and May, 1958) is well above the
Rec-omrnended Allowances at 6 weeks and well
below them during the sixth month (Fig. 3).
4-lu’,
(1110)
.V.ILC. ,
\ umber of (uses
.lIl0llUflCeX
Ih’(il 1(11. Be(l1
Calories per Kilogram of Body Weight
Lowest .50th Pereentile
1’LR. Real
highest
I?.!?. Real 11.11.
3 1() 6 67 8!) 90 119 1’24
3-4 U() 29 67 92 89 110 117
4-3 Ho ‘28 67 83 85 104 114
5-6 1() 67 75 S’2 10’2 115
6-7 10() . . 67 . . 83 .. 114
7-H 100 . 67 .. 81 .. 114
8-9 10(1 . 67 8(1 108
9-1(1 10(1 . 67 . . 78 109
10-li 10(1 . . 67 . 73 .. 107
11-’?1 1(8) .. 67 . . 73 .. 104
6-9 lOt) 3() 67 6.5 81 101 1l’2
9-H 1(11) ‘31 67 74 7.5 101 107
1’-i5 .. 33 67 73 73 103 106
141 140
136
139
153 15’2
159 156 146 163 166
154
15’2 15’2 140 150 157 152
143
ISO - “
‘4
4
-*4(“0 \
FOMON-’. MAY
140
I 20
I-I 0 ‘U
4
1-U
4
II.
0
4
0
0
-J
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0. (S
‘U 0
-J
4 I.)
K’
100-80
-I I
FOMON -MAY
U Modifi#{149}d cow’s milk
D Srsost milk
‘FABLE II
(‘oII’.IuoN OF’ CI.oI4IE INTAKE OF INFANTS IN THE PRESENT (R-R) AND IN BEAL’S STUDY’#{176} VITII
RECOMMENDED ALLOWANCES OF NATIONAL RESEA14cII COUNCIL’7
645
ent study) and the Denver (Beal) infants
were both very high at all ages (Table III,
Fig. 4). Tile highest intakes (6.7 gm/kg to
8.3 gm/kg) exceeded by more than 100%
tile considered allowances of tile National
Research Council. #{176}They were four to five
ISO
-times higher than both minimum
require-ments as estimated by Hegsted2s and mean
0 “Levels of intake of 3.5 grams per kilogram
from age 1 month to 6 months, and of 3.0 grams
per kilogram during the remainder of the first year, are undoubtedly well in excess of minimum
require-I,,’, -S _
----K
50th p.rwitlle - RUEDA-ROSc
‘4#{149}.-- OU FOMONM RcommIIId.d Allo.o,c..-N.R.C.
44%%44%%%
--60 . . . - - -4 1il I I I I . . I 11
Birth 2 4 6 S 10 (2 4 6 IS
AGE - MONTHS
---. Highist OvId Iosst vslvis- RUEDA-ROSE group ‘----K #{149} #{149} #{149} . - SEALS
Ftc. .3. Average daily calorie intake per kilogram of actual weight of three groups of infants as compared with the Recommended Allowances of the National
‘4
A
8
7
6
5
4
3
2
I-I
0
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A 0 ‘----;r Recommended Allowances-N.R.C.
- %F0MON-MAY
‘L,4
‘4;w:4_._,Q__ . Theoretical Minimum Requirements - HEGSTED
I I I I I 1 ;__a__I#{149}.__.r_..._r.h!_r__..I__.._r.._i.__i_I04I I I
4 6 8 0 2 14 6 lB
AGE - MONTHS
‘4. --0 Highst oiid lowest volues - RUEDA-ROSE group
5.4--K #{149} #{149} #{149} . - SEALS group
FIG. 4. Average daily protein intake per kilogram of actual weight of three groups of infants as compared with Recommended Allowances of National Research
Council and Hegsted’s minimal requirements.
Birth 2
646
DIET
AND
GROWTH
intake of tile Iowa infants fed human milk4
(Fig. 4). The 50th percentile values of both
studies range from 5.1 gm/kg during the
third month to 4.4 gm/kg during the
9-to-12-month period, but the Boston values are
slightly higher during the intervening
months. They exceed the Denver values by
0.5, 0.6, 0.5, and 0.3 gm/kg during the
fourth, fifth, and sixth months and the
6-to-9-rnonth period, respectively. The mean
protein intake of the human milk-fed
in-fants of Iowa4 is almost identical with the
estimated minimum requirements of
Heg-sted, while that of the modified cow’s
milk-fed infants of Iowa6 is close to the
sug-gested allowances of the National Research
Council.
ments and afford ample allowances to meet the needs of healthy infants. Allowances for the arti-ficially fed infant may lie in the range of 2.5 to 3.5 grams per kilogram from 2 to 6 months, and 2.0 to 3.0 grams per kilogram during the remainder of the first year. In current practice, diets furnishing 3.5 grams of protein and more per kilogram are in
common use.
FOMON-MAY S Modifisd cow’s milk
C Breast milk
Iron Intake and Hemoglobin Level
Table IV gives the average hemoglobin
levels of the infants in the present study at
three age periods. They are within the
nor-ma! range, 10.5 to 12.5 gm/100 ml.29 Very
few infants had hemoglobin levels below
10.5 and only one had levels below 9.3 grn/
100 ml (a twin girl with 8.5 gm/100 ml at
4 months and 8.9 gm/100 ml at 7 months).
The iron intake of these infants was
gen-erally comparable with that of infants with
higher hemoglobin levels. Table V presents
the daily iron intakes. The median intake
during the third month (2.47 mg) was
be-low the recommended allowances (5 mg).
At all other periods it was higiler than these
allowances, usually by 50%. Individual
in-takes two or three times higher than
rec-ommended were not uncommon.
The wide range of iron intake, from 0.5
to 9.7 mg/day, during the third and from
2.2 to 31.9 mg/day during the ninth
month, was related to the wide range in
TABLE III
ColpA14IsoN OF PIIOTEIN INTAKE OF INFANTS IN TIlE PRESENT (R-R) AND IN BEAL’S’0 STUDY WITH HEGSTED’S
EsTIIATED MINIMAL REQUIREMENTS” AND CONSIDERED ALIAWANCES OF THE N.R.C.’7
Total Grams per Kilogram of Body Weight
N.R.C. $
\ 0. of ( uses
Cons. _41l.
lieu! B-k
Lowest ,501h Percentile
Real B-Il ..lg’. (mo) 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-1’2 6-9 9-1’2 1’2-15 highest Real B-Il Ilegsted’s Mi,m. Req. I. 1,5 I.S I .4 I ‘3 1.3 I .3 1.’2 1.’2 1.2 1.3 1.2 Real Il-Il ‘2.5-3.5 ‘2.5-3.5 ‘2.5-3.5 ‘2.5-3.5 ‘2.0-3.0 ‘2.0-3.0 ‘2.0-3.0 ‘2.0-3.0 ‘2.0-3.0 ‘2.0-3.0 ‘2.0-3.0 ‘2.0-3.0 26 67 29 67 28 67 ‘29 67
- . 67
. . 67
-. 67
.. 67
.. 67
.. 67
30 67 31 67 33 67 ‘2.7 1.6 ‘2.6 1.6 2.4 1.7 ‘2.3 ‘2.5
.- ‘2.9
-. 3.0
.- 3.1
..
.. ‘2.8
.. ‘2.8
3.3 ‘2.9 2.9 ‘2.8 2.9 3.’2 5.1 4.7 4.5 4.4 4.4 4.4 4.3 5.1 5.’2 5.1 4.9 4.8 4.6 4.5 4.4 4.4 4.4 4.7 4.4 4.4 6.0 7.3 6.3 7.’2 5.7 6.8 6.4 7.9
-- 8.8
-- 6.9
-. 6.7
.. 7.7
.. 6.1
.. 6.7
5.8 8.1
5.9 7.7
6.2 6.0
mg of iron per tablespoonful. The studies
of Schulz and Smith#{176} indicate that iron
absorption from fortified cereal was as good
as that from otiler sources. The correlation
coefficients of iron intake to hemoglobin
levels were extremely low possibly because
iron intake was high and hemoglobin
1ev-els were good. They were not significant.
Cholesterol Levels
Three times during the year cholesterol
levels in serum were determined for most
of the infants in the study. The mean
val-ues were 147 ± 26 mg/100 ml at 3 to 5
montilS (55 infants); 144 ± 24 mg/100 ml
at 6 to 8 months (41 infants); and 162 ±
28 mg/100 ml at 9 to 12 months (41 infants).
The 3-to-5-month value (147 mg/100 ml) is
very close to the mean value (140 mg/100
ml) of the 6-day-old infants of Rafsted and
Swahn.3’ It is lower than the mean
choles-terol value (187 mg/100 ml) of the infants
TABLE IV
HEMOGLOBIN CONCENTRATIONS IN STUDY INFANTS
Age, in Months
.3to5 6to8 9to12
Mean values (gm/ lOOmloiblood)
Per cent cases
be-low 10.5 gm/100 ml
11.7±1.111.5±1.011.7±1J2
11 9 17
TABLE V
AVERAGE DAIIY VALUES OF IRON INTAKE IN MILLIGRAMS
J’alues
2-3
Age, in Months
3-,4 4-5 5-6 6-7 7-8 8-9 9-10
Mediall #{149}‘2.5 5.9 7.8 8.3 10.5 11.1 10.9 10.1
Mean 3.3 6.4 8.3 9.8 11.5 11.7 11.4 11.’2
Lowest 0.5 0.6 0.8 1.’2 1.’2 1.0 ‘2.’2 ‘2.6
Highest 9.7 16.’2 ‘21.4 27.3 ‘28.9 30.6 31.9 ‘23.7
TABLE VI
ASSO(’IATIONS BETWEEN GROWTH AND FOOD INTAKE
(Coalt ELATION COEFFIC.IENTS)*
Calories Proteins Length
0.01
0.07
0.11
Jforpho-logical
Levels
0.43f
0.85t
Calories per Day
2toJ StoG 8to9
648
DIET AND GROWTHProteins 0.83t
Morphological
levels 0.13
I.engt Ii
increment 0.16
Weight
increment 0.31t
* Cumulative values from ‘2 to 10 months.
t Significant at the 1% level.
fed with cow’s milk and higher than the
mean cholesterol level (128 mg/100 ml) of
the SMA fed infants of Porneranze et
at 3 to 4 months. Most of our infants were
receiving “solid” food supplementation at
that age. The cholesterol levels of the cow’s
milk fed and the SMA fed infants of
Pom-eranze et al. began to approximate each
otller at 4 and 5 months, when cereal and
meat were added to their diet.
Tile association between cholesterol
1ev-els and calorie, protein, and fat intake
dur-ing tile previous 2 months were computed
for the tilree age periods. The correlations
(r 0.01 to 0.27) were not significant. The
correlation between body shape and
choles-terol level in serum at 9 months was equally
low (r = 0.12).
Association s between Growth Increments
and Food Intakes
Table VI presents the correlation
coeffi-cients among five variables : increments of
lengtll, weight, and morphological level
from 2 to 10 months, and average daily
calorie and protein intakes during those 8
months. Their values are all very low, the
highest being 0.31 for calories against
weight, significant at the 1% level. The
cor-relation coefficients of weight gain to
pro-tein intake (0.11) and length gain to calorie
(r 0.16) and to protein (r 0.07) intake
are not significant. In the 9-to-15-rnonth
age period there was a similar lack of
cor-relation, the only significant value being
r 0.33 for weight increment against
cal-one intake. At 2 to 3 months, 5 to 6 months,
and 8 to 9 months, body shape (measured
in units of weight deviation from standard
weight for length)’5#{176} was correlated to
av-erage daily calorie intake: total, calories per
kilogram of actual weight, and calories per
kilogram of expected weight. All values are
-- very low, and only three are statistically
significant: the correlation coefficients
be-0.56t tween weight deviation and calorie intake
per kilogram of actual weight at the third
and the ninth months (0.40 and 0.28,
re-spectively); and between weight deviation
and calorie intake per kilogram of expected
weight at tile sixth month (0.38) (Table
VII).
This general lack of correlation was also
evident in the different and sometimes
para-doxical behavior of individual growth
curves in relation to food intake.
Activity, Illness, and Environment
The influence of these factors on the
re-lationship between rate of physical growth
and quantity of calories consumed was
in-vestigated by analyzing individual growth
curves in relation not only to infant’s food
intake but also to his general ilistory,
en-vironmental experiences, and clinical
find-ings. Comparative study of these analyses
indicate that variations in energy
require-ments for illness and physical activity were
TABLE VII
DAILY CAIoI4IE INTAKE %EI4SUS WEIGhT 1)EVIATION (CORRELATION COEFFICIENTS)
-1ge, in i1OflthS
Total 0.17 0.07 0.’23
Per kilogram actual weight 0.40* 0.l’2 0.‘1St Per kilogram expected
weight 0.11 0.38* 0.’2’2
* Significant at the 1% level.
649
often directly responsible for the low growth
increment-calorie consumption correlations,
wilile physical and human environment
fac-tors seemed to be indirectly involved
inas-much as they modified degree of activity.
COMMENT
Tile study of infants in the first year of
life has two advantages. First, it considers
tile period of most rapid growth. The child
grows during his first year as much as he
does during 6 to 8 years in any period of
prepubertal childhood. Secondly, some of
the difficulties encountered in evaluating
nutrient intake are minimal during most
of this period since intakes are essentially
in ounces of milk and jars of food of
estab-lished nutrient values.
Growth
The general pattern of growth in length
and weight of tile 67 study infants during
their first year of life was similar to tilat
re-Ported by Stuart et al. for infants in the
same area about 30 years ago. This suggests
that despite change in feeding practices
from predominantly breast to predominantly
artificial feeding, there has been no
remark-able change in rate of physical growth of
2-to-12-rnonth-old infants in an area in
\vhicil infants have had regular health
so-pervision throughout this 30-year period.
The difference between the growth
pat-terns of the study infants and the Iowa
in-fants could indicate, especially if the small
sample size and the environmental
differ-ences involved are disregarded, that infants
gain more wilen “solids” are added to their
diets before 6 months of age. Such
addi-tions permit greater calorie intake without
increase of volumetric intake, an important
consideration if there is a limit to the
vol-ime which can be comfortably consumed.
This may account for the lower calorie
in-take of tile Iowa infants who received only
milk.
Calories
Most infants ill tile present study
con-stirned calories slightly in excess of
recom-mended allowances. The highest intakes
(150-160 cal/kg) exceeded these allowances
by 50%. Some intakes were even higher
when expressed in calories/kilogram
“ex-pected” weight. One infant had an intake of
188 cal/kg “expected” weight for length.
It cannot be stated at present that such high
calorie consumption in infancy always
con-stitutes “overfeeding” or that it is harmful;
fleitiler does it necessarily cause obesity
since the extra calories may be utilized for
greater physical activity. However,
atten-tion is drawn to the trend toward
ever-increasing concentrations of proteins in
in-fant formulas and foods and to the
gener-ally high calorie intakes since “overeating”
with decreased activity could result in
obes-ity in infants and may set a pattern for
obesity in later life. It is known that this is
a public ilealth problem in the well-fed
western societies. Actuarial data 5110w that
it is commonly associated with decreased
life expectancy.34’35 Evidence has
accumu-lated in tile last decades, implicating
nutri-tion as an important associative factor in
atilerosclerosis and other degenerative
dis-eases in man.3’35 Ross39 demonstrated in
experimental studies with rats that excess
intake of protein and/or calories was
asso-ciated with decrease in lifespan and a
sig-nificant increase in the incidence of
spon-taneous tumors. Silberberg and Silberberg#{176}
found tilat epiphysial aging was accelerated
in mice by lifelong feeding of a fat rich
diet. This was due in part to high calorie
intake. McCay et al.” found a definite
di-rect relationship between retarded groWtil,
as a result of food restrictions, and
longev-ity. The idea that bigger animals are better
ones is no longer an axiom in biology, and
the e(uatiflg of optimum nutrition with one
giving maximum size has also been
chal-lenged.
Protein
Protein consumption was very high. The
median intakes exceeded the amount
con-sidered adequate by the National Research
Council2? by about 60%, and the higilest
650
DIET
AND
GROWTH
Whether or not these high protein intakes
represent a metabolic burden of any
signif-icance remains to be seen. Holt et al.2
pointed out that high protein intake in early
infancy could force chemical maturity and
accumulation of tissue reserves of labile
protein, which may or may not be desirable
at this age. Infants often have to excrete
more nitrogen under conditions of increased
protein intake. Either process might require
an adaptive increase of enzyme levels and
subject young infants fed on high protein
diets, such as undiluted cow’s milk, to a
metabolic strain not encountered by
breast-fed infants. The authors suggest that, while
a return to the undue and exaggerated fears
of overfeeding of two or three decades ago
is not justified, “safe allowances” might be
advantageously re-evaluated, bearing in
mind that suboptimal nutrition might occur
not only at deficiency but also at still
un-determined excessive levels of intake. The
main factors contributing to high protein
feeding were the use of high concentration
of evaporated milk, even whole milk and
the use of “high protein” foods. High total
food intake was frequently related to the
substitution of a bottle for some other
at-tention which the child was seeking. This
was done in the guise of “demand feeding.”
Relationship between Physical Growth
and Food Intake
Analysis of group data gave useful
in-formation on the general trends in growth
and nutrition and enabled calculation of
correlations between these two parameters,
but separate case studies were prerequisite
to the understanding of the individual’s
progress and to appreciation of the many
interacting factors which interfere with a
direct correlation between growth
mere-ments and nutrient intakes. Every child has
his own personal and peculiar growth curve
which demonstrates graphically the extent
to which he succeeds or fails in his attempt
to maintain equilibrium at his own level.
The study of separate growth curves in
relation to food intakes suggested that
in-fants have genetically or physiologically
predetermined maximums of statural growth
which they could not exceed no matter how
much they increased calorie or protein
in-take. The consumption of calories in excess
of what was required to maintain good
physique for this “maximum” stature
re-sulted almost invariably in greater weight
gain, even to levels of marked obesity,
with-out further increase of length.
These studies also demonstrated the
in-accuracy of evaluating all intakes in
rela-tion to actual weight. Comparison of the
correlations between weight increments and
cal/kg of actual weight and weight
mere-ments and cal/kg of “expected” weight did
not show this, probably because “expected”
weight was based on actual length alone.
This would seem to have been appropriate
when length positions maintained their
1ev-els. However, it appears, in retrospect, that
declines in length positions often reflected
suboptimal growth and, therefore, that
when such declines occurred, intakes would
have been more accurately assessed in
re-lation to length or weight which the child
could be expected to have considering his
previous performance rather than to either
actual length or weight.
The study of individual growth curves in
relation to general history as well as to food
intake4l indicated that the relationship
be-tween growth increments and calories
con-sumed was often directly modified by
ill-ness and activity. It was indirectly
info-enced by physical and human
environ-mental factors inasmuch as these modified
activity. The latter, it seemed, could be
either increased or decreased by a specific
environmental factor depending on previous
conditioning, the total constellation and the
personalities involved. For example, one
infant became restless, cried more, and
slept less when her mother took on full-time
work outside of the home, while another
became apathetic, slept more, and played
less when his mother did likewise. The
fam-ily structures of these two infants were
en-tirely different; so were the personalities of
the parents and the temperaments of the
ARTICLES
651variables interacted to an extent which
made it difficult to single out any one as
having a predictable and uniform effect on
activity and therefore on growth relative to
food intake. Further study of the
relation-silip between environment, especially
ho-man, and degree of physical activity may
lead to better understanding of the influence
of environmental factors and experiences
on growth and dietary requirements.
In tile present study “bigger babies” were
not always “better babies”42, 43; neither did
their size necessarily result from greater
calorie and protein intakes than that
con-sumed by smaller infants. These
observa-tions indicate that nutrient requirements
should be, as advocated by Burke and
Stuart,44 computed on individual basis and
that besides actual and expected weight
many other factors, especially physical
ac-tivity, should be taken into account.
SUMMARY
A longitudinal study was conducted on
growth and food intake of 67 unselected
healthy, full-term infants from 2 to 15
montils of age. The length and weight
prog-ress of infants in the study was, during the
first year of life, very similar to progress as
reported in an earlier study by other
in-vestigators, indicating that no striking
change in size of 2-to-12-month-old infants
had occurred in this area during 30 years,
despite changes in feeding practices. The
study infants had high calorie and very
high protein intakes as compared with
Rec-ommended Allowances of the National
Re-search Council. The question of whether
some of the very high intakes seen in this
study could be potentially harmful or at
least beyond the range of optimum
nutri-tion was raised. The desirability of
estab-lishing nutritional ceilings was considered.
The correlation between length increment
and calorie or protein intake was not
sig-nificant. The correlation coefficients between
weight increments and calorie intake were
significant but low, indicating that other
variables beside food intake influenced size
and speed of growth. The correlations
be-tween iron intakes and hemoglobin levels
and between fat, protein, and calorie
in-takes and cholesterol levels were not
sig-nificant. Individual case studies indicated
that the most important variables in the
energy balance, beside food intake and
growth, were illness and physical activity.
Environment affected the balance indirectly
inasmuch as it influenced physical activity.
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ACKNOWLEDGMENT
This study was the result of the combined effort,
grateful to the staff of both clinics and to the moth- Center for their encouragement, advice, and
assist-ers of the infants. ance. We thank Miss Mary McCann for evaluating
We are especially grateful to Drs. Fredrick J. the diets.
Stare, D. Mark Hegsted, Martha F. Trulson of the We are indebted to Cyanamid International,
Led-Department of Nutrition, Harvard School of Public erie Division, for granting a fellowship to one of us
