How to Calculate Energy Needs for a Baby
(introductory text...)
Nancy F Butte
Children'south Nutrition Research Center, Section of Pediatrics, Baylor Higher of Medicine, Houston, Texas, USA
Descriptors: energy requirements, energy intake, energy expenditure, energy cost of growth, infancy
The Advisory Group of IDECG recommended that select parts of the 1985 FAO/WHO/UNU Report on energy and protein requirements be reviewed for possible revision and updating. The specific questions posed were:
1. Practise the 1985 recommendations need to be revised: what are the primary arguments for or against a revision ?
ii. What would your recommendations be at this indicate in time?
3. What boosted work would need to be washed to resolve problems that persist in this area?
Energy requirements of infants based on energy intake
'The energy requirement of an individual is the level of energy intake from nutrient that will remainder energy expenditure when the private has body size and body composition, and level of physical action, consistent with long-term good health; and that will allow for the maintenance of economically necessary and socially desirable physical action. In children the free energy requirement includes the energy associated with the deposition of tissues at rates consistent with adept health.' (FAO/WHO/UNU, 1985). This bones tenet set forth by the 1985 FAO/WHO/UNU Expert Consultation should exist upheld.
Because information technology was not possible to specify with whatsoever conviction the allowance for a desirable level of concrete activity, the 1985 FAO/WHO/UNU energy requirements from birth to ten years were derived from the observed intakes of healthy infants and children growing usually. For infants energy requirements were based on energy intakes compiled by Whitehead et al (1981). Estimated energy requirements were set five% higher than observed free energy intakes to compensate for underestimation of intake (Table 1). Implicit in this approach is the assumption that advertising libitum intakes reflect desirable intakes for infants. Although infant intake is largely self-regulated, it can exist influenced by external factors.
Correspondence: NF Butte.
Compilation of energy intakes published before and subsequently 1980
Whitehead et al (1981) compiled free energy intakes of infants from the literature predating 1940 and up to 1980. The work represented 9046 information points during infancy, weighted to account for sample size. Analysis of the energy intake data revealed a highly significant curvilinear relation betwixt free energy intake per body weight in kg and age in months:
Energy intake (kcal/kg/d) = 120 - 10.4 age + 0.76 historic period2
rtwo = 0.41 (1)
The quadratic term was significant (P = 0.001). No differences were seen between sexes. The authors attributed the sharp fall in energy intake from O to 6 months of historic period to the rapidly decelerating velocity of growth, a reduction in the rate of fatty storage, and a decrease in energy needed for maintenance per kg body weight. The rise in energy intake from 6 to 12 months of age was ascribed to the increase in physical activity equally infants begin to crawl and so walk.
Because of possible secular trends in infant feeding practices, we examined free energy intakes of presumably well-nourished infants reported afterwards 1980. An assay was performed on the mean energy intakes from xix longitudinal or cross-sectional studies comprising 3574 information points (Table 2, Figures 1 and 2). As noted in Tabular array 2, dietary methodology varied across studies.
Table ane Energy requirements of infants from birth to l twelvemonth (FAO/ WHO/UNU 1985)
| | Total requirement | ||
| Age (months) | | Boys (kcal/d) | Girls (kcal/d) |
| 0.5 | 124 | 470 | 445 |
| 1-2 | 116 | 550 | 505 |
| 2-3 | 109 | 610 | 545 |
| three-four | 103 | 655 | 590 |
| 4-5 | 99 | 695 | 630 |
| 5-6 | 96.5 | 730 | 670 |
| six-7 | 95 | 765 | 720 |
| vii-8 | 94.5 | 810 | 750 |
| 8-9 | 95 | 855 | 800 |
| 9-x | 99 | 925 | 865 |
| 10 11 | 100 | 970 | 905 |
| 11-12 | 104.5 | 1050 | 975 |
Figure i Mean energy intakes (kcal/d) of formula-fed, breast-fed and mixed-fed infants reported in 1982-1994.
Effigy 2 Mean energy intakes (kcal/kg/d) of formula-fed, breast-fed and mixed-fed infants reported in 1982-1994
Weighed dietary records, dietary retrieve methods, or the test-weighing method for chest milk intake were used. Food intakes were converted to metabolizable energy intakes using food composition tables, or macro nutrients were analyzed and converted to gross or metabolizable energy using Atwater factors. Bomb calorimetry was used to measure the gross energy content of chest milk and formula in a few studies. Hateful energy intakes every bit reported were used in the present assay. Mean total energy intakes (inclusive of solids) of breast fed and formula-fed infants were weighted past sample size at each monthly interval yielding 107 weighted mean values used in the regression analysis (BMDP1R: Dixon, 1990). The multiple regressions of energy intake per kg body weight on age and ageii are summarized below.
All: Energy intake (kcal/kg/d)
= 119 - 9.9 age + 0.82 historic periodtwo
rii = 0.29; due north = 107 (2)
BF: Energy intake (kcal/kg/d)
= 118 - 12.8 age + 0.89 historic period2
r2 = 0.66; northward = 59 (3)
FF: Free energy intake (kcal/kg/d)
= 122 - viii.five historic period + 0.73 ageii
r2 = 0.36; n = 48 (four)
Each of these three equations was tested against the before curvilinear equation published by Whitehead et al (1981). We do non take prove for a strong secular tendency in energy intakes of infants before and after 1980, since the regression coefficients did not differ significantly betwixt the Whitehead and present databases. The ~ test for equality of the regression lines across feeding groups was significant, indicating differences in the relationship of energy intake and age between breast-fed and formula-fed infants (P = 0.001) (Figure 3).
Equations (2), (3) and (iv) were derived from energy intake data equally reported. 2 technical issues with reported data ascend in the case of the chest-fed infants. Breast milk intakes measured by the examination-weighing method were corrected for insensible water loss (IWL) during the course of the measurement in a few studies just (Heinig et al, 1993; Michaelsen et al, 1994). The systematic negative bias caused by not correcting for IWL during, the examination-weighing is well recognized: the difficulty has been to determine the magnitude of correction necessary to adequately represent the ranges of metabolic rates, ambient temperatures, humidities, and air circulation rates probable to exist encountered. Rates of IWL measured past a number of investigators were as follows: 1.5g/kg/h, Levine et al (1929); 0.83g/kg/h, Kajtar et al (1976); 0.4-0.six g/kg/h, Doyle & Sinclair (1982); 2.5 g/kg/h, Orr-Ewing & Heywood (1982); 1.9g/kg/h, Hendrikson et al (1985); 1.14 g/kg/h, Butte et al (1990b); 3 grand/kg/h, Dewey et al (1991). Most of the measurements were performed under thermoneutral conditions. Levine et al (1929) noted that rates of weight loss may increase threefold to a higher place basal levels in temperatures sufficiently high to induce visible perspiration.
Table 2 Free energy intakes of infants reported in the first year of life (kcal/kg/d). Mean ± south.d. (N)
| Reference | Country | Design/Subjects | N | Blazon of nutrient | Dietary method |
| McKillop & Durnin (1982) | Scotland | Cross-exclusive Low-high SESa | 162 | formula solids | 5d weighed record FCT, ME |
| Hofvander et al (1982) | Sweden | Cantankerous-sectional | 150 | chest milk formula solids | 1 d weighed tape FCT, ME 0.75 kcal/ml |
| Dewey & L�nnerdal (1983) | U.S.A. | Longitudinal | twenty | chest milk solids | ii d weighed record, FCT, ME macronutrients 0.76 kcal/ml breast milk |
| Butte et al (1984) | U.S.A. | Longitudinal Middle SES | 45 | breast milk minimal solids | i d weighed tape bomb calorimetry GE 0.66 kcal/k breast milk |
| Dewey et al (1984) | U.S.A. | Longitudinal | 12 | breast milk solids | ii d weighed tape, FCT, ME macronutrients 0.65 kcal/ml chest milk |
| Kohler et al (1984) | Sweden | Longitudinal Suburban | 59 | breast milk cow's formula soy formula solids | 2 d weighed tape 0.seventy kcal/g breast milk |
| Martinez et al (1985) | UsA. | Cross-exclusive Low-heart | 442 | formula solids | 24h retrieve FCT, ME |
| Forsum & Sadurskis (1986) | Sweden | Longitudinal Middle SES | 22 | chest milk | 1 d weighed record 0.67 kcal/k breast milk |
| Hoffmans et al (1986) | Kingdom of the netherlands | Longitudinal | 124 | formula breast milk solids | 24h recall test-weighing FCT, ME |
| Horst et al (1987) | The Netherlands | Cross-sectional | 308 | chest milk formula solids | 24h recall test-weighing FCT, ME |
| Leung et al (1988) | Hong Kong | Longitudinal | 174 | formula weaning foods | 24h call up FCT, ME |
| Wood et al (1988) | United statesA. | Longitudinal | 22 | chest milk | 1 d weighed record flop calorimetry GE 0.60 kcal/ml chest milk |
| Stuff & Nichols (1989) | U.S.A. | Longitudinal Middle SES | 58 | breast milk solids | v d weighed tape bomb calorimetry GE 0.65 kcal/one thousand chest milk |
| Butte et al (1990b) | U.S.A. | Cross-exclusive Heart SES | 65 | chest milk formula minimal solids | 3 d weighed record 0.65 kcal/grand breast milk GE |
| Butte et al (1990a) | U.s.A. | Cross-exclusive Middle SES | 40 | chest milk formula minimal solids | 5 d weighed tape flop calorimetry GE 0.64 kcal/thou breast milk |
| Stuff et al (1991) | U.Southward.A. | Longitudinal Heart SES | twoscore | formula solids | 5 d weighed tape FCT, ME |
| Sauve and Geggie (1991) | Canada | Longitudinal | 114 | formula solids | iii d food diaries FCT ME |
| Michaelsen et al (1994) | Kingdom of denmark | Longitudinal | lx | chest milk | i d test-weighing; IWL macronutrients GE 0.72 kcal/ml breast milk |
| Heinig et al (1993) | USA | Longitudinal Middle SES | 119 | breast milk formula solids | four d weighed tape; IWL macronutrients GE 0.seventy kcal/ml breast milk |
| Age (months) | |||||
| ane | 2 | iii | 4 | 5 | 6 |
| | | | 97.0 (71) | | |
| B-112 (25) | 108 (25) | 96 (25) | | | |
| 113 ± xix (17) | 105 ± 25 (xx) | 93 ± 26 (19) | 93 ± thirty (19) | 85 ± twenty (17) | 89 ± 24 (18) |
| 110 ± 24 (37) | 83 ± nineteen (forty) | 74 ± 20 (37) | 71 ± 17 (41) | | |
| B-113 (26) | | 96 (21) | | 87 (13) | 83 (12) |
| 116 ± 27 (22) 114 ± 19 (22) | 98 ± 26 (22) 97 ± 16 (22) | 92 ± 15 (22) | | | |
| | | | 95 ± 20 (124) | | |
| | | | B-91 ± 13 (39) | | F-97 ± 61 (96) |
| 121 (128) | 109 (150) | | 88 (151) | | 85 (153) |
| 128 ± 37 (8) | 97 ± 18 (12) 99 ± 15 (14) | 91 ± 18 (17) | 74 ± sixteen (16) | 62 ± 12 (xv) | |
| | | | 76 ± thirteen (19) | seventy ± fourteen (nineteen) | 75 ± 16 (xix) |
| B-99 ± 17 (17) | | | 74 ± 12 (15) 101 ± 9 (16) | | |
| B-101 ± 16 (10) | | | 72 ± 9 (10) | | |
| | | F-104 ± 17 (xl) | 100 ± 10 (40) | 95 ± 11 (40) | 90 ± xi (twoscore) |
| | | | 110 (29) | | |
| | 102 ± 20 (lx) | | 91 ± 18 (36) | | |
| | | B-86 ± 11 (71) | | | 80 ± 13 (56) |
| Age (months) | |||||
| vii | 8 | 9 | 10 | 11 | 12 |
| | | 96.0 (91) | | | |
| 79 ± 12 (8) | 74 ± vii (7) | 70 ± 14 (5) | 75 ± 17 (5) | 72 ± 15 (6) | 77 ± 5 (2) |
| 119 ± 41 (54) | 110 ± 42 (84) | 126 ± 44 (103) | 120 ± 44 (92) | 120 ± forty (73) | 119 ± 50 (36) |
| | | F-99 ± 25 (32) | | | |
| 77 ± sixteen (19) 73 ± fourteen (18) 65 ± 16 (eight) | | 69 ± 19 (viii) | | | |
| 86 ± 11 (23) | 82 ± xi (7) | | | | |
| | 108 (26) | | | | 103 (31) |
| | | 84 ± 19 (46) | | | 90 ± 18 (40) |
a Abbreviations: Social economic status (SES); food composition tables (FCT); metabolizable energy (ME); gross energy (GE).
To correct test-weighing values for IWL, the number and duration of breastfeedings also must exist known. The systematic bias caused by IWL may be estimated for 1-iv calendar month-old (Butte et al 1985) and 12 month-old breast-fed infants (Dewey et al 1991). Based upon the published weights, milk intakes, number of feedings, and duration of feedings (20 min was assumed for the Dewey report), and an estimated average rate of IWL of 2 g/kg/d, IWL would cause a 4 and 6% underestimation of intake in the 1-4 calendar month-quondam and 12 calendar month-quondam chest-fed infants, respectively.
Figure iii Energy intake (kcal/kg/d) of infants predicted from equation (2) - (4).
Published intakes of chest-fed infants are in terms of metabolizable free energy in some reports, and gross energy in others. Gross energy intake may exist converted to metabolizable energy intake using Atwater factors (Watt & Merrill, 1963). Awarding of the Atwater factors to man milk components (Butte et al, 1984), indicates that human milk would exist 96.iv% metabolizable. The applicability of the Atwater factors to infants has been questioned, since the original studies were performed on adults (Schulz & Decombaz, 1987). Balance data on 10 chest-fed infants fed unpasteurized human milk are available from ane study (Southgate & Barrett, 1966). Metabolizable energy averaged 92%.
If not already corrected, the energy intakes of breast fed infants presented in Table ii were corrected uniformly for IWL and metabolizable energy. A 5% correction was applied to compensate for IWL, and metabolizable energy was causeless to be 94% of gross energy intake. The energy intakes reported by Martinez et al (1985) differed substantially from those of the other formula-fed infants. These half-dozen mean values were eliminated from the database.
All: Energy intake (kcal/kg/d)
= 121 - 10.2 historic period + 0.72 age2
r 2 = 0.43; n = 101 (2a)
BF: Free energy intake (kcal/kg/d)
= 116 - 12.3 historic period + 0.83 age2
r 2 = 0.66; n = 59 (3a)
FF: Energy intake (kcal/kg/d)
= 125 - 9.iii historic period + 0.64 age2
r two = 0.67; n = 42 (4a)
The curvilinearity of the equation of energy intake on historic period has important ramifications for energy requirements during infancy. The to a higher place analysis confirms White head's earlier observations of decreasing need in the offset half of infancy, followed by increasing need in the latter half of infancy. However, the in a higher place analysis may exist misleading because of a mathematical antiquity. Free energy intake standardized past body weight was regressed on age, which was highly correlated with weight (rhistoric period, weight = 0.97). Past dividing the ordinate (energy intake) past the abscissa value (age) or in this instance a proxy (weight) for the abscissa, a curvilinear relation is created mathematically with this quadratic equation, irrespective of the bodily data (Tanner, 1949). Information technology is misleading to describe the relationship of energy intake on age, with energy intake divided by weight.
To circumvent this artifact, another model relating energy intake (kcal/d) to age with weight as a covariate was adult. Mode refers to chest-fed (coded 0) or formula-fed (coded 1). Data were weighted for sample size.
All: Energy intake (kcal/d)
= 100 - 57.7 historic period + 3.3 agetwo + 92.8 weight + 43.6 way + xiii.8 age × manner
r ii = 0.81; n = 101 (five)
BF: Energy intake (kcal/d)
= 581 - 21.seven age + ane.1 age2 + 24.8 weight
r 2 = 0.63; n = 59 (6)
FF: Free energy intake (kcal/d)
= 11.8 - 71.8 age + four.0 historic periodii + 130 weight
r 2 = 0.94; n = 42 (7)
In the regression model of all cases at that place was both a negative linear term (age) and a positive quadratic term (age2) (P = 0.001). A significant interaction between age and feeding mode was encountered (P = 0.006). Splitting on feeding mode, the ageii terms for breast-fed and formula-fed infants were significant (P = 0.04 and 0.001, respectively). A curvilinear trend in energy intake was evident. Further assay revealed that the curvature could exist explained by a significant interaction betwixt historic period and weight. Free energy intake (kcal/d) can best be described by the post-obit regression equations weighted by sample size:
All: Free energy intake (kcal/d)
= 210 - 59.two age + 37.2 mode + 63.ane weight + fourteen.0 historic period × mode + 5.six age × weight
r 2 = 0.lxxx; due north = 101 (8)
BF: Free energy intake (kcal/d)
= 640 + 25.six age-forty.ane weight + 1.seven historic period × weight
r two = 0.62; due north = 59 (9)
FF: Free energy intake (kcal/d)
= 101 - 89.6 age + 105 weight + 7.7 age × weight
r 2 = 0.87; due north = 42, (10)
In the overall model, weight (P = 0.001) and the interactions of age × mode and historic period × weight were pregnant (P = 0.01 and 0.002). The older the baby the greater the positive contribution of age × weight term to energy intake becomes. Energy intake of infants across the 1st yr of life is all-time described in this multiple regression, with weight treated every bit a covariate.
Energy requirements of infants take been estimated from dietary intake using equations (2a), (3a), (4a) and (8)-(10) (Tabular array 3). NCHS median weights were used to calculate energy requirements. For the interpretation of the energy requirements of all infants, it was assumed that half the infants were breast-fed and half were formula fed. The current FAO/WHO/UNU energy requirements for infants are 2-15% college than these estimates based on free energy intakes recorded later 1980. The discrepancy is partially due to the 5% increment added to the 1985 FAO/WHO/UNU energy requirements to compensate for assumed underestimation of energy intakes.
Total free energy expenditure of infants
The energy requirements of older children have been estimated from multiples of basal metabolic rates (BMR), reflecting various levels of physical activeness (FAO/WHO/UNU, 1985). Even though information on the BMR of infants has been available, this approach was non applicable to infants because reasonable allowances for concrete activity were undefined. Newly emerging data on total energy expenditure (TEE), yet, may exist used to derive free energy requirements of infants. TEE encompasses BMR, thermoregulation, synthetic cost of growth, and physical activity.
The doubly labeled water method for the measurement of TEE has been used and validated in a number of studies in preterm infants and hospitalized term infants. Although these validation studies were non conducted nether free-living atmospheric condition of term infants, the high rates of water turnover and loftier percentages of body water common to all infants were tested. Mean errors betwixt the doubly labeled h2o method and respiration calorimetry were 0.3 ± ii.6% (Roberts et al, 1986), - 0.ix ± 6.2% (Jones et al, 1987), - 4.5 ± half-dozen.0% (Westerterp et al, 1991), and �0.4 + xi.v% (Jensen et al, 1992). Although errors for individuals may exist large the doubly labeled water method provides an accurate, unbiased measurement of total energy expenditure for groups and may be used for recommendations of free energy intakes of infants. Available data on the TEE of infants are summarized in Table 4. The data published by Davies et al (1989, 1991) have been updated to include more infants (Davies, 1993 private communication). There are 268 information points available on presumably well nourished infants studied in Cambridge, United kingdom of great britain and northern ireland and Houston, The states. The majority (xc%) of the infants studied were £ half dozen months of historic period (specific ages given in Table 4). TEE of infants living in The Gambia (n = 59) (Prentice et al, 1988; Vasquez-Velasquez, 1987, 1988), rural Mexico (north= 38) (Butte, 1993), and Peru (n= nineteen) (Fjeld et al, 1989) likewise take been studied.
Table iii Energy requirements of infants estimated from dietary free energy intake
| | Free energy intake | |||||
| Age | All (kcal/d) | BF* | FF* | All | BF* | FF* |
| Boys: | ||||||
| 0-one | 453 | 504 | 470 | 116 | 110 | 120 |
| ane-two | 490 | 500 | 520 | 107 | 99 | 112 |
| ii-3 | 530 | 503 | 573 | 100 | 90 | 106 |
| 3-4 | 571 | 513 | 625 | 94 | 83 | 100 |
| 4 5 | 612 | 528 | 675 | ninety | 77 | 96 |
| 5-vi | 650 | 549 | 721 | 87 | 73 | 93 |
| 6 9 | 730 | 600 | 812 | 85 | 70 | 91 |
| 9-12 | 863 | 693 | 963 | 93 | 78 | 98 |
| Girls: | ||||||
| 0-one | 440 | 512 | 448 | 116 | 110 | 120 |
| 1-2 | 461 | 515 | 474 | 107 | 99 | 112 |
| ii-3 | 487 | 523 | 504 | 100 | xc | 106 |
| three-4 | 517 | 535 | 540 | 94 | 83 | 100 |
| 4 5 | 554 | 549 | 585 | xc | 77 | 96 |
| 5-6 | 594 | 567 | 632 | 87 | 73 | 93 |
| 6 ix | 675 | 614 | 726 | 85 | 70 | 91 |
| 9-12 | 784 | 707 | 842 | 93 | 78 | 98 |
* BF Breast-fed; FF Formula-fed infants.
First, we performed an assay on the group hateful values for TEE of presumably well-nourished infants (Table 4). Hateful TEE was 449 ± 161 kcal/d for infants who were 4.0 ± iii.0 months quondam and weighed 6.1 ± ane.v kg. Weighted for sample size, TEE was regressed on age (months), feeding mode (breast-fed, coded 0, and formula-fed, coded 1) and weight (kg) (BMDP1R: Dixon, 1990).
TEE (kcal/d) = 73.viii + 38.half dozen age + 40.four mode + 35.iv weight
See = 25.7
r 2 = 0.98;
due north = 14. (xi)
TEE (kcal/d) was significantly affected by age (P = 0.005), feeding mode (P = 0.01), but non weight. Weight was highly correlated with age (r = 0.98). Interactions between historic period, mode and weight were not significant. Mean TEE for the breast-fed and formula-fed infants were 420 ± 151 and 495 ± 190 kcal/d, respectively. The high rtwo does non imply that the TEE of individual infants tin be predicted with such a loftier degree of certainty. It should be remembered that the analysis was performed on group mean values. The SEE provides an indication of the error for predicting group hateful values of TEE.
Table 4 Total free energy expenditure of infants past doubly-labeled water method
| Reference | north | Age | Fx a | RQ | TEE | TEE (kcal/kg/d) | Comments |
| Lucas et al (1987) | 12BF | 0.9-one.4 | 0.13 | 0.85 | 306 (26)b | 66.nine (24) | BF infants, Cambridge,UK |
| Roberts et al (1988) | eighteen | three | 0.thirteen | 0.87 | 408 (28) | 72 (5) | MF infants, Cambridge, UK TEE/SMR= i.15 |
| Vasquez-Velasquez (1987) | viii | 0-3 | | | 381 (88) | 82 (23) | MF Gambian infants |
| Fjeld et al (1989) | 22FF | 16 | | | 629 (84) | 90 (12) | FF infants, Lima, Peru Early on recovery from malnutrition Belatedly recovery from malnutrition |
| Davies et al (1989) | 39c | 1.2 | 0.13 | 0.87 | 306 (93) | 64.5 (xvi.7) | BF and FF infants, Cambridge, Great britain |
| Butte et al (1990a) | 10BF | 1 4 | 0.xvi | 0.94 | 291 (48) | 64 (7) | BF and FF infants, Houston, TX TEE/SMR = ane.28, 1,26 TEE/SMR = 1.34, 1.36 |
| Davies et al (1991) | 33c | 2.8 | 0.13 | 0.86 | | 69 (17.nine) | Same infants as 1989 paper |
| Davies (unpublished 1993) | 20BFc | 1.4 | | | 283 (80) | 61.1 (17.eight) | BF and FF infants, Cambridge, UK |
| Davies (unpublished 1993) | 24 | one.4 | | | | 74.five (12.1) | BF (north = 11) and FF (north = 13) infants, Cambridge, Great britain |
| Butte et al (1993) | 19BF | 4 | 0.23 | 0.88 | 446 (97) | 74.1 (13.9) | BF infants, Capulhuac, Mexico |
a Abbreviations: Fx = isotope fractionation; RQ = respiratory quotient; TEE = full free energy expenditure; BF = breast-fed; FF = formula-fed; MF = mixed-fed; SMR = sleeping metabolic rate.
b Mean (southward.d.).
c 1993 unpublished compilation of data used.
Standardized past torso weight, TEE averaged 72.6 ± eight.one kcal/kg/d overall, and 69.2 ± 7.8 and 76.six ± nine.3 kcal/kg/d for the breast-fed and formula-fed infants, respectively. TEE (weighted past sample size, kcal/kg/d) was significantly affected by historic period (P = 0.001) and feeding mode (P = 0.01); the interaction between historic period and feeding mode was non significant. Within studies, the TEE of breast-fed infants has been shown to be lower than that of formula-fed infants (Butte, 1990a; Davies, 1992).
TEE (kcal/kg/d) = threescore.1 + ii.6 age + 6.5 mode
SEE = 3.seven
r2 = 0.83; due north = 14. (12)
We calculated BMR according to the Schofield equation for children under the age of 3 years (1985). Hateful BMR was 54.6 ± 1.half-dozen kcal/kg/d for the boys and 52.8 ± 1.vii kcal/kg/d for the girls. The physical activeness level of the infants (TEE/BMR) increased from 1.three at 1 month to 1.vii at 12 months of age. TEE rose steadily and gradually as action increased through infancy.
Second, we examined the TEE data from infants living nether harsh environmental atmospheric condition. We compiled 88 data points on Gambian and Mexican infants nether 12 months of age (Vasquez-Velasquez, 1987; Butte, 1993). The hateful TEE of these infants (5.seven ± 3.i months) was 513 ± 101 kcal/d or 79.ii ± 4.0 kcal/kg/d. The TEE (kcal/kg/d) of infants living under harsh environmental weather condition was significantly higher than that of the more than sheltered infants (t = 2.6, P = 0.02), merely the Gambian and Mexican infants were older. The regression of TEE (kcal/kg/d) on age did not differ between the sheltered and unsheltered infants. Prentice did non find any significant differences in TEE (kcal/kg/d) between Gambian and British infants, aged 0 to 36 months (Prentice, 1993). However, we institute the TEE (kcal/kg/d) of the Mexican infants to exist higher than that of predominantly chest-fed infants studied in Houston (Butte et al, 1993). More data from different geographic locations are needed to resolve putative differences in TEE of infants exposed to infection and other environmental stresses.
Currently available data on TEE of infants are express in number, age range, and geographic distribution. All the same, TEE data provide stiff bear witness for the need to revise current recommendations for energy intake of infants. Prudently, more than data should exist sought, particularly in the 2nd 6 months of life.
Energy requirement for growth
Although the free energy requirement for growth relative to maintenance is pocket-size, except for the get-go months of life, satisfactory growth is a sensitive indicator of whether needs are being met. To determine the energy cost of growth, the energetics of growth must be understood and satisfactory growth velocities must be defined. The 1985 requirements were based on the growth reference published for international use by WHO (1983), which were derived from the United States National Middle for Health Statistics growth curves (NCHS, 1977). What constitutes appropriate infant growth is a topic of controversy and is currently under debate at WHO. Considering of policy implications, the findings of the WHO Proficient Committee on 'Physical Condition: The Use and Interpretation of Anthropometry During Infancy' should be considered if the FAO/WHO/UNU Energy and Protein Requirements are revised. Quantitatively, revision of babe growth curves will minimally bear upon estimated free energy requirements. If growth curves were revised to reflect the growth velocities of chest-fed infants, energy requirements would decrease by 10, 16, 24 and 12 kcal/d for 0-3 months, 3-6 months, six-ix months and 9-12 months, respectively.
In addition to the growth velocity, the energy toll of growth must be known. This price consists of the energy content of the newly synthesized tissues and the free energy expended in synthesis. In the 1985 report the energy toll of weight gain was reviewed in Annex four (FAO/ WHO/UNU, 1985) The value proposed for healthy term infants was 5.vi kcal/g gained. We measured the energy cost of growth in term infants and arrived at an estimate, iv.8 kcal/thousand (Butte et al, 1989). An additional written report appeared on the free energy cost of growth of infants recovering from malnutrition; the total energy price of growth was 6-seven kcal/g (Fjeld et al, 1989). The estimated free energy cost of growth is more accurate when the carve up costs of protein and fat degradation are taken into business relationship, since the components of weight proceeds alter dramatically through the first year of life. However, the practicality of this signal is significantly diminished by the fact that the energy cost of growth as a pct of total energy requirement decreases from 35% at one month to three% at 12 months.
The total free energy cost of growth and its components is presented in Table five (Figure iv). For the present discussion, the rates of weight proceeds and components of weight gain, as described by Fomon et al (1982), take been used. For lack of specific information on the composition of weight proceeds of breast-fed and formula-fed infants, no distinction was made with respect to potential differences in the free energy cost of growth between feeding groups. Median NCHS weights were used to standardize the data. The energetic efficiencies of synthesizing protein and fat were taken to exist 42% (ane kcal deposited/2.38 kcal used) and 85% (ane kcal deposited/ i.17 kcal used), respectively (Roberts & Immature, 1988). Free energy equivalents for fat and protein were nine.25 kcal/g and 5.65 kcal/g, respectively.
Table five Free energy cost of growth through infancy
| | | | Fat deposition | Protein deposition | | | Total energy price growth | |||
| Age | Weight (kg) | Weight proceeds a (g/d) | (g/d) b | (kcal/d) c | (chiliad/d) b | (kcal/d) c | Fat synthesis (kcal/d) d | Protein synthesis (kcal/d) d | (kcal/d) | (kcal/kg/d) |
| Boys: | ||||||||||
| 0-one | 380 | 29 | 6 | 56 | 4 | 21 | 10 | 29 | 115 | xxx |
| one-ii | iv.75 | 35 | xiv | 130 | iv | xx | 23 | 27 | 201 | 42 |
| 2-3 | 5.60 | xxx | 13 | 119 | 3 | 17 | 21 | 23 | 181 | 32 |
| iii-4 | half dozen.35 | 21 | 8 | 77 | 2 | 13 | fourteen | 18 | 121 | 19 |
| 4 5 | seven.00 | 17 | half dozen | 51 | two | xi | 9 | 16 | 87 | 12 |
| five-half dozen | vii.55 | 15 | 4 | 38 | 2 | xi | 7 | 16 | 72 | 9 |
| 6 9 | 8.50 | 13 | 2 | 17 | 2 | 11 | 3 | 16 | 46 | 5 |
| ix-12 | ix.70 | xi | 1 | nine | 2 | 10 | ii | xiv | 35 | iv |
| Girls: | ||||||||||
| 0-ane | 3.60 | 26 | half dozen | 52 | 3 | 19 | 9 | 26 | 105 | 29 |
| 1-2 | 4.35 | 29 | 13 | 118 | 3 | 16 | 21 | 22 | 177 | 41 |
| two-3 | 5.05 | 24 | ten | 93 | iii | 15 | 16 | xx | 145 | 29 |
| three-4 | v.70 | 19 | 7 | 68 | two | 12 | 12 | 16 | 108 | xix |
| four-five | six.35 | xvi | 6 | 55 | 2 | eleven | 10 | fifteen | 90 | xiv |
| v-6 | half dozen.95 | xv | 5 | 45 | 2 | 11 | viii | fifteen | 79 | eleven |
| 6-9 | seven.97 | xi | two | 16 | ii | x | three | 14 | 43 | five |
| ix-12 | 9.05 | ten | ane | 11 | two | ten | 2 | thirteen | 36 | 4 |
a Monthly rates of weight proceeds (Fomon et al, 1982).
b Monthly rates of &t and protein deposition (Fomon et al, 1982).
c Energy equivalents for fat and protein degradation were taken as 9.25 kcal/g and 5.65 kcal/g, respectively.
d Energetic efficiencies of synthesizing protein and fat were taken to be 42% (1 kcal deposited/ii.38 kcal used) and 85% (one kcal deposited/i.17 kcal used), respectively (Roberts & Young, 1988).
As calculated, the energy cost of growth displays an abrupt increase at one-two months, followed by a gradual decline through 12 months. The abrupt increase in fat deposition may be an artifact due to interpolation of data compiled from dissimilar studies by Fomon et al (1982). Unpublished information of Southgate were used to guess torso limerick at nascency. Body fat was assumed to be linearly related to subscapular and infra-iliac skinfolds between the ages of 3 months and 10 years. A smoothed bend was synthetic relating the percentage body fat to age from 1 month to 10 years.
Energy requirements of infants predicted from full energy expenditure and growth
We estimated energy requirements of infants from nativity to 12 months of age from full energy expenditure and energy deposition as protein and fat (Tabular array 6, Figures five and half-dozen). The energy costs of poly peptide and fat synthesis are covered in the estimate of total energy expenditure and therefore take been excluded from this gauge of free energy deposition. The relatively low free energy degradation at 0-1 months and high estimate at 1-two months may be in mistake. Because fatty deposition probably does not increase so abruptly betwixt ane and 2 months, the average energy deposition for the interval 0-2 months was used in calculating energy requirements. The 1985 FAO/WHO/UNU free energy requirements are nine-39% higher than these estimates. These discrepancies are not trivial and could lead to overfeeding of infants.
FIGURE 4 Energy toll of fat and poly peptide degradation in infants (kcal/d).(Boys)
FIGURE 4 Energy cost of fat and protein deposition in infants (kcal/d).(Girls)
A comparison of FAO/WHO/UNU energy requirements and estimations based on energy intakes recorded later on 1980 and on TEE and growth is graphically displayed in Figures 7 and viii.
FIGURE v Free energy requirements of infants estimated from full energy expediture and energy degradation (kcal/d).
Recommendations
The 1985 FAO/WHO/UNU recommendations for dietary energy intake of healthy infants seem too high based on reported measurements of energy intake or energy expenditure and estimates of the energy deposited for growth. Considering observed energy intakes may not reverberate desirable intakes, measurements of energy expenditure are preferred as the ground for estimating free energy requirements. Estimated energy requirements of infants based on total energy expenditure and growth are 9-39% lower than the 1985 FAO/WHO/UNU recommendations and provide potent show that current estimates should be revised. However, confirmation of this observation will require expansion of the available database on total energy expenditure of healthy infants, in terms of sample size, historic period range and geographic distribution beyond the unabridged age range of infancy. Data are particularly deficient in the second half-dozen months of infancy. Estimated free energy requirements should be consequent with the growth reference endorsed by WHO. To better ascertain the energy deposited during growth, changes in torso composition during infancy must be confirmed.
Given the relative uniformity of behavior, physical activity and growth of healthy infants from different geographic origins, estimates of energy requirements can be applied universally to good for you infants. It should be appreciated that energy requirements of infants are a function of age, gender, body size and feeding manner. Stipulation of estimated energy requirements by these factors volition depend on the awarding.
More data must be sought on the energy expenditure of infants in populations at take chances of loftier rates of infection and exposed to other environmental sources of stress to determine if energy requirements are altered under these circumstances. The free energy needs for adequate take hold of-upward growth likewise must be considered.
Tabular array 6 Energy requirement estimated from full energy expenditure and energy toll of growth
| | Total energy expenditure | Energy degradation | ||||||
| Age | ALL | BF a | FF a | ALL | BF a | FF a | (kcal/d) | (kcal/kg/d) |
| Boys | ||||||||
| 0-ane | 248 | 228 | 268 | 65 | 61 | 68 | 113 | 26 |
| one-2 | 320 | 300 | 340 | 67 | 64 | 70 | 113 | 26 |
| two-3 | 389 | 368 | 409 | lxx | 67 | 73 | 136 | 24 |
| 3-iv | 454 | 434 | 474 | 72 | 69 | 76 | ninety | xiv |
| 4-v | 516 | 495 | 536 | 75 | 72 | 78 | 62 | 9 |
| 5-6 | 574 | 553 | 594 | 78 | 74 | 81 | 49 | half-dozen |
| half-dozen-ix | 684 | 664 | 705 | 83 | 80 | 86 | 28 | 3 |
| 9-12 | 843 | 822 | 863 | 91 | 87 | 94 | 19 | 2 |
| Girls: | ||||||||
| 0-1 | 241 | 220 | 261 | 65 | 61 | 68 | 102 | 22.5 |
| one-2 | 306 | 286 | 326 | 67 | 64 | 70 | 102 | 22.5 |
| 2-3 | 369 | 349 | 389 | seventy | 67 | 73 | 108 | 20 |
| 3-four | 431 | 411 | 451 | 72 | 69 | 76 | 79 | 13 |
| four-5 | 492 | 472 | 513 | 75 | 72 | 78 | 65 | ten |
| five-6 | 552 | 532 | 573 | 78 | 74 | 81 | 56 | 8 |
| 6-9 | 666 | 645 | 686 | 83 | 80 | 86 | 26 | three |
| nine-12 | 820 | 799 | 840 | 91 | 87 | 94 | 21 | 2 |
| Energy requirement | |||||
| Age | BF a | FF a | ALL | BF a | FF a |
| Boys | |||||
| 0-1 | 341 | 381 | 91 | 87 | 94 |
| 1-2 | 413 | 453 | 93 | 90 | 96 |
| 2-3 | 504 | 545 | 94 | 91 | 97 |
| 3-4 | 524 | 564 | 86 | 83 | ninety |
| 4-5 | 557 | 598 | 84 | 81 | 87 |
| 5-6 | 602 | 643 | 84 | 80 | 87 |
| 6-nine | 692 | 733 | 86 | 83 | 89 |
| ix-12 | 841 | 882 | 93 | 89 | 96 |
| Girls: | |||||
| 0-i | 322 | 363 | 88 | 84 | ninety |
| ane-2 | 388 | 428 | 90 | 86 | 92 |
| 2-3 | 457 | 497 | 90 | 87 | 93 |
| 3-iv | 490 | 530 | 85 | 82 | 89 |
| four-5 | 537 | 578 | 85 | 82 | 88 |
| 5-6 | 588 | 629 | 86 | 82 | 89 |
| 6-9 | 671 | 712 | 86 | 83 | 89 |
| 9-12 | 820 | 861 | 93 | 89 | 96 |
a BF = breast-fed; FF = formula-fed infants.
FIGURE vi Energy requirements if infants estimated from total energy expenditure and energy deposition (kcal/kg/d).
Effigy 7 FAO/WHO/UNU energy requirements compared confronting requirements (i) based on energy intakes observed afterward 1980 and (2) total energy expenditure (TEE) and energy degradation during growth (kcal/d).
FIGURE 8 FAO/WHO/UNU energy requirements compared confronting requirements (1) based on free energy intakes observed afterwards 1980 and (2) total energy expenditure (TEE) and energy degradation during growth (kcal/kg/d).
Acknowledgements - I wish to thank Drs PSW Davies, Cambridge, U.k.; KG Dewey, University of California-Davis; KF Michaelsen, The Royal Veterinarian and Agricultural University, Copenhagen,
Denmark; AM Prentice, Dunn Diet, Cambridge, UK; Every bit Ryan, Ross Laboratories, Columbus, Ohio, and JE Stuff, Children's Nutrition Research Eye, Houston, Texas for their contribution of data used in this manuscript, equally well as Dr C Garza, Cornell University, Ithaca, New York, for his thoughtful review. I would besides similar to thank I Tapper for manuscript grooming, and Fifty Loddeke and R Klein for editorial review.
This work is a publication of the USDA/ARS Children'southward Diet Inquiry Center, Department of Pediatrics Baylor College of Medicine and Texas Children'due south Infirmary, Houston, TX. Funding has been provided from the U.Southward. Department of Agriculture, Agricultural Research Service under Cooperative Agreement No. 58-6250-ane-003. The contents of this publication do not necessarily reflect the views or policies of the U.S. Department of Agronomics, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.South. Government.
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Discussion
Atwater factors indicate the average corporeality of energy yielded by one gram of ingested carbohydrate, fat or poly peptide; they are used in the calculation of the metabolizable energy content of foods, for case in food composition tables and in infant formulas. Atwater (likewise equally Durnin and Southgate after him) derived them from the heat of combustion, corrected for energy losses in the grade of unabsorbed nutrients in feces and urine of adults. The question was raised whether the aforementioned factors were also applicable to infants. The answer to this question does not affect free energy requirements per se but becomes important in a discussion of recommended dietary intakes. Several factors may influence the metabolizable energy derived from food: (i) the chemic form of the macronutrient in the food, (2) the coefficient of digestibility; (3) the extent to which the nutrients are not completely oxidized, just stored in the torso; (4) gut maturation and (5) age. In growing infants nitrogen retention will be college. Preterm infants absorb less fat than term infants, and fat is generally less well absorbed past newborn infants than by older infants. Fatty digestibility is also highly dependent upon the fat source and its processing, e.g. butterfat is poorly absorbed, whereas a mixture of vegetable oils is absorbed nearly to the aforementioned extent equally human being milk. In a study of 10 breast-fed infants fed unpasteurized milk, Southgate plant that metabolizable free energy averaged 92%. Awarding of the Atwater factors to human milk components indicated 96% metabolizable energy. Using Atwater factors in normal infants, therefore, does non seem to entail neat errors. Application of the Atwater factors in preterm or sick infants may overestimate energy availability.
In young infants the energy content of man milk is of item importance. Since it is very variable throughout days and feeds and there is no generally agreed upon, standard method for obtaining representative milk samples and for estimating their energy density, published figures vary considerably. Butte et al, using unlike methods, obtained values between 0.65 and 0.67, whereas values from Sweden (0.72) and a WHO study in Republic of hungary are considerably higher (Waterlow). In the first 2 figures of her newspaper, Butte used energy intakes as reported. Dewey pointed out that differences in fat secretion in breast milk between groups of women had been observed, even when exactly the same methods were used. Maternal body fatty can impact milk fatty (Prentice), as can fat intake in lean women (Dewey). Since pasteurization alters the fat, information technology is important to note whether pasteurized or non pasteurized milk is used. In the cease, the prevailing opinion was that Dewey and Butte had made the most rigorous assessments and that their values should therefore be relied upon primarily.
Several participants were intrigued by the depression level of the first two data points in the line representing energy requirements derived from TEE and growth in Butte's figures vii and 8. Near likely this is an antiquity due to an underestimate of the price of growth in these first ii fourth dimension periods.
Should recommendations exist the same or different for breast- and bottle-fed infants? Reeds argued that requirements and intakes should not be confused. Requirements are to be seen as a office of the organism and non of the diet, whereas recommended dietary allowances are a function of the diet and the degree to which information technology meets requirements. Dewey pointed out that in practice the picture was less clear and the feeding mode seemed to bear upon physiology. Energy expenditure is lower in breast-fed infants or, in other words, formula-fed infants appear to require more energy than breast-fed ones. These differences are most marked between iii and 6 months of age; then they gradually disappear, probably as a consequence of the phasing out of pure breast-feeding. Butte tried to derive free energy requirements from information of a mixed grouping of infants, 50% breast- and l% formula-fed. Dewey advocated separate recommendations for the 2 feeding groups in club to avoid the :impression that breast-fed infants exercise not get plenty energy and ought to be supplemented or the risk that formula fed infants will not get enough energy to comprehend their needs. Giving a wide range of requirements does not appear to exist a satisfactory solution either.
Butte et al tried to determine how much of a departure in diet-induced thermogenesis (DIT) there was between breast- and formula-fed infants. During the first 4h after the repast, DIT appeared slightly lower in breast-fed infants, but the difference was not statistically significant.
Waterlow queried the validity of 42% for the energetic efficiency of protein synthesis (Tabular array v, footnote d), and suggested that a figure of 75% would exist more in accordance with the evidence.
Do infants growing up in the more than stressful environment of developing countries or urban slums accept the same or higher free energy requirements than infants in industrialized countries? The little information that exists on this issue shows smaller differences than expected. Total energy expenditure (TEE), expressed every bit kcal/kg, was for instance very like in infants from The Gambia and the U.k. (Prentice). Butte compared TEE of small groups (n = 20) of 4-month-onetime infants from Mexico and Houston. In. Mexico it was 74 kcal/kg, in Houston 64 and 73 kcal/kg for chest- and canteen-fed infants, respectively. Several participants felt that more data was needed to decide the extent to which frequent infections and desirable catch-up growth add to free energy requirements in poor environments.
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