$Unique_ID{PAR00205} $Pretitle{} $Title{Birth to 6 Months: Nutrition and Feeding} $Subtitle{} $Author{ Editors of Consumer Guide Mendelson, Robert A Mendelson, Lottie M Meyerhoff, Michael K Ames, Louise Bates} $Subject{Birth to 6 Months Nutrition Feeding breast-feed bottle-feed formula feeding feed feeds Breast milk immunities allergies allergic immunity nurse diet foods seborrhea Caffeine alcohol narcotic narcotics drug drugs medication medications breasts nipple cracked nipples Emotional bond bonds bonding nutrition Microwave Microwaves iron vitamin supplement supplements plump overfed overfeeding nighttime crib schedule burp burps burping spit up spitting up diarrhea stool stools vitamins fluoride water calories weight fat solid foods allergenic Chocolate nuts Honey botulism poisoning pacifier thumb sucking playing NURSING POSITIONS position STERILIZING BOTTLES sterilize bottle} $Log{ Nursing Positions: Introduction*0020501.tif Nursing Positions: Side-Lying Position*0020502.tif Nursing Positions: Sitting Position (Cradle)*0020503.tif Nursing Positions: Sitting Position (Football Carry)*0020504.tif Offering the Breast: Introduction*0020505.tif Offering the Breast: Step 1*0020506.tif Offering the Breast: Step 2*0020507.tif Offering the Breast: Step 3*0020508.tif Sterilizing Bottles and Formula (Terminal Heating Method): Introduction*0020509.tif Sterilizing Bottles and Formula (Terminal Heating Method): Step 1*0020510.tif Sterilizing Bottles and Formula (Terminal Heating Method): Step 2*0020511.tif Sterilizing Bottles and Formula (Terminal Heating Method): Step 3*0020512.tif Sterilizing Bottles and Formula (Terminal Heating Method): Step 4*0020513.tif Sterilizing Bottles and Formula (Terminal Heating Method): Steps 5 and 6*0020514.tif Sterilizing Bottles and Formula (Terminal Heating Method): Steps 7 and 8*0020515.tif Sterilizing Bottles and Formula (Single Bottle Method)*0020516.tif Giving the Bottle: Step 1*0020517.tif Giving the Bottle: Step 2*0020518.tif Giving the Bottle: Step 3*0020519.tif Burping Positions: Head on Shoulder*0020520.tif Burping Positions: On Stomach*0020521.tif Burping Positions: Sitting*0020522.tif Breast-feeding has always been the preferred method of feeding newborns*0058201.tif Breast-feeding can be a wonderful experience that bonds the family*0059701.tif Nursing mothers need a nutritious well-balanced diet, but not a special one*0059801.tif} The New Parents' Question & Answer Book Birth to 6 Months: Nutrition and Feeding Is it better to breast-feed my baby than to feed him formula? The decision to breast-feed or bottle-feed is a highly personal one. Since you will be taking care of the baby, you need to feel comfortable with whichever method you choose. There are, however, some factors you should consider when making the decision. Breast-feeding has always been and remains the preferred method of feeding newborns for several reasons. First, breast-feeding gives your baby the best possible nutrition. Breast milk is the perfect food for babies, with a perfect balance of all the nutrients your baby needs (except, perhaps, for fluoride). And while manufacturers have brought formulas closer in composition to breast milk, they have not been able to duplicate it exactly. Second, breast-feeding can transfer some of your immunities against disease to your newborn. Many studies have shown that breast-fed newborns tend to have fewer and milder illnesses than those who are not breast-fed. These immunities are something that formulas just cannot provide. Third, when the baby nurses, it causes your uterus to contract, which can help it return more quickly to its prepregnancy size. Fourth, breast milk is free, readily available, and at the perfect temperature for your baby. In addition, breast-feeding can be a wonderful and satisfying experience for both you and your baby. Having taken all of these factors into account, you may still feel that you'll be more comfortable bottle-feeding. In that case, you are better off using formula. Remember that, on the whole, babies do well whichever way you decide to feed them. And if bottle-feeding makes you more comfortable, you'll be better prepared to give him the loving attention that he really needs. Do I need to start my baby out on formula if I intend to go back to work within a couple months of the birth or can I breast-feed him? You do not have to forego breast-feeding just because you need to return to work soon after the birth. You can breast-feed your baby whenever you are at home. When you are at work, you can use a breast pump to express milk into bottles (as long as you have a way to refrigerate the bottles of breast milk at work). Then the bottled breast milk can be given to your baby the following workday by whomever takes care of him. If expressing milk while at work is uncomfortable or impossible for you, you can leave formula for the baby during your work hours and then nurse him when you are at home. If you don't express milk during the day, however, your milk supply will gradually decrease. My husband and I both have allergies, so is it wise for me to breast-feed my baby? Although there are special formulas available on the market for babies from allergic families, it can make a significant difference to your baby if you can nurse him for even a few months after birth. This way, you'll be passing on some of your immunities to your newborn through your breast milk. In addition, while very few babies are allergic to breast milk, a significant number of babies from allergic families develop allergic reactions to formula. I'm breast-feeding, and I'd like to know if I should be on a special kind of diet. What about taking medications if I get sick? Nursing moms do not need a special diet, just a nutritious, well-balanced one. You should be eating a variety of foods from the four major food groups (meat, dairy, grains, and fruits and vegetables) each day. Some obstetricians like to keep new moms on a multiple vitamin plus iron as added insurance. Now is not the time to seriously limit calories or reduce weight. While you can be careful, especially regarding desserts and fats, remember that you are using more than 500 calories each day for milk production alone. You also need to drink two to three quarts of liquid each day. Any woman who has nursed a baby can tell you how thirst becomes overwhelming the minute you start to breast-feed. So, whenever you nurse, keep a glass of water, milk, or juice within reach. Be sure to get plenty of fluids throughout the day as well. If you are not taking a calcium supplement, you'll need to be sure you're getting enough from your diet. Since milk products are a major dietary source of calcium, contact your doctor if you can't or don't drink milk. While some nursing mothers can eat almost anything without getting indigestion or upsetting their baby's tummy, other nursing mothers can't. It's recommended that you avoid highly spiced foods while nursing, since they can give your baby gas. Some doctors suggest avoiding chocolate, because it may bother your baby's digestion and may contribute to the development of seborrhea (an abnormal increase in skin-oil production). Foods that are high in fat may also be a factor in seborrhea and cradle cap. Fortunately, as breast-feeding babies get older, they tend to become more tolerant of their mother's diet. Whenever you are ill, you should check with your doctor or your baby's pediatrician before taking any medication. Remember, anything you eat or drink is likely to be found in some increment in your breast milk. Caffeine and alcohol both filter into breast milk, although very small amounts probably have little effect on the baby. On occasion, however, caffeine (from coffee, tea, and colas) in mom's diet can cause the baby to be especially jittery. Also, any kind of narcotic substance, in addition to being harmful to you, is damaging to your baby. If you are using any drug or addicted to any drug or narcotic, give your baby a better deal and get some help. Meanwhile, don't breast-feed; give your baby formula instead. In addition to getting adequate nutrition and fluids and avoiding drugs, there are other factors that affect the health and well-being of a nursing mother. Appropriate exercise is important for your overall well-being. You also need adequate rest to maintain your milk supply. How to get it? Rest when your baby is resting, and enlist help with baby care and daily chores so you can have some time each week to take care of your own emotional and physical needs. Since I'm breast-feeding, how will I know if my baby is getting enough milk? Babies who are not getting enough to eat are usually easy to spot. They let you know by demanding feedings too frequently and by not sleeping for any reasonable length of time; they're unhappy babies. On the other hand, babies who are getting enough breast milk act satisfied; they look full and content (at least for a while). As a nursing mother, there are clues you can look for to determine if your milk supply is sufficient. Your breasts should feel heavy and full before nursing, and softer after nursing. You should be able to hear the slurpy, sucking noises of the baby and see and hear him swallow. You'll also probably observe milk dribble from his mouth when you stop to burp him. Most nursing moms also leak milk from time to time; this is a clue to supply, too. As a test, you might try expressing breast milk into a bottle after a feeding if you can. This can be offered to the baby after a feeding; if he seems to need it, you may need to continue expressing milk after feedings in order to stimulate greater milk production. Another test you can use is to offer formula after breast-feeding him; if he drinks a few ounces or more, he probably isn't being satisfied at his usual feedings. Offering formula regularly as a supplement, however, is likely to decrease your milk production; better to try expressing milk between feedings to help stimulate production. Anytime you are truly concerned about not having an adequate supply of milk, however, you should contact your pediatrician or breast-feeding consultant. Your pediatrician will be keeping track of your baby's growth and development through regular checkups and can advise you as to whether the baby is gaining weight as expected. If he isn't, you will be advised regarding ways to increase your milk supply. I'm breast-feeding my baby. Can you give me some tips on breast care during this time? The single most important factor for maintaining healthy nipples is to make certain that your baby is taking all of the nipple and as much of the areola into his mouth whenever he nurses. If he latches onto only a small amount of nipple and is allowed to suck for some length of time, you're likely to wind up with sore, cracked nipples that can easily become infected. This is also true if you allow him to tug at the nipple when you remove him from the breast. So, be sure to follow the instructions for proper nursing technique (see "Offering the Breast," below). Start a feeding on one breast, and finish on the other. At the next feeding, start with the breast that you finished with the last time. Soon, you'll be able to tell which you started with at the last feeding by the amount of fullness in each breast. (The less full being the one you started with last time). To keep track in the beginning, put a safety pin or ribbon on the bra strap on the side that you started with, and move it at each feeding. Gradually increase the nursing time on each breast from five minutes, to seven, to ten. Once your milk is in, 15 to 20 minutes should be the maximum on each breast. You'll need to use your judgment about when the baby has finished feeding and wants to suck only. When his sucking slows and he shows signs of being content, gently remove him from the breast. After your milk supply is totally established, there will be times when your baby is satisfied with one breast only. When this occur's, try to stop sooner the next time, and use the other breast to finish the feeding. This way, you'll be continually stimulating the milk production of both breasts at each feeding. If your breasts become uncomfortably engorged, you may need to express milk in between frequent feedings. Some moms require ice packs for a while to reduce discomfort. Avoid allowing the nipples to remain moist, which can promote cracking and bacterial growth. Try not to use nursing pads, since these tend to trap moisture against the breast. Instead, take frequent showers to allow leakage from overfull breasts to be washed away (avoid using soap on the nipples, however, since this may increase irritation). Change nursing bras as often as necessary to ensure dryness. Some professionals also advise nursing mothers to keep the nipples clean by wetting a cotton swab, cotton ball, or soft washcloth with clean water and swabbing around the nipples before each feeding. If your nipples start to feel sore or you see the beginning of a crack, applying a small amount of lubricating ointment or cream may clear it up. Anything more severe should be checked by your doctor. Do not ignore breast soreness or cracking. If an infection has developed, your doctor can treat it while you continue to nurse. I'm bottle-feeding instead of breast-feeding. Will this affect my emotional bond with my baby? Only if you worry about it too much. Emotional concerns about breast-feeding should be considered in the same way as nutritional concerns. Clearly, breast-feeding has certain advantages in providing your baby with key nutrients and immunities, but proper formula preparation can compensate for most of these if bottle-feeding is chosen or required. Furthermore, there are instances when breast-feeding may supply insufficient or inappropriate nutrition, so bottle-feeding is preferred. The same is true when it comes to establishing emotional bonds. Most women find the act of breast-feeding to be tremendously helpful in this regard, but it certainly is not the only way in which a solid, loving relationship can be formed between parent and child. In fact, most fathers manage to establish emotional bonds of enormous strength despite their inability to breast-feed. Moreover, if breast-feeding presents a problem, trying to force it is very likely to be counterproductive. Therefore, as long as you provide prompt, nurturing care to your baby in the best way you can, you may rest assured that you and your baby will develop emotional bonds that are as strong as they can possibly be. Is it okay to warm the baby's bottle in the microwave? Sorry, but nothing that you intend to feed your baby should be warmed in a microwave. Microwave ovens may warm foods unevenly, leaving "hot spots" that can burn your baby's mouth or lips. It is really not possible to test for these local hot areas, so it's best to use the tried-and-true, warm-water methods for warming bottles and food (see "Giving the Bottle"). Why did my pediatrician tell me to give my baby an iron-containing formula? Will the iron upset my baby's stomach or cause constipation? Because of their rapid growth rate, many babies outgrow their natural iron supply in the first months of life and may become anemic from iron deficiency. Breast-fed babies generally receive enough usable iron in the breast milk, but many formulas, especially those made from cow's milk, lack this important mineral. Therefore, most pediatricians recommend iron-fortified formulas for bottle-fed babies. Careful studies indicate that the amount of iron in these formulas does not cause constipation or stomach upset. My three month old is getting a commercial formula, and he loves his bottle. He's very plump, and I'm wondering if I'm feeding him too much. Although babies can be overfed, it's generally not necessary to worry about a plump three month old. Thirty to thirty five ounces a day is the maximum amount of formula babies should receive. Few three month olds need more than this. If your baby takes this amount or less, then he's probably doing fine. If you think your baby may be taking formula when he's no longer hungry but still needs to suck, you might introduce a pacifier. Pacifiers can satisfy a baby's sucking needs. However, if your baby, is truly hungry, a pacifier won't satisfy him. Keep in mind that sometimes we can be too quick to offer feedings or pacifiers when our babies really are asking for other kinds of fulfillment or stimulation. Although at three months of age babies spend most of their time eating and sleeping, when they are awake, they need lots of one-to-one eye contact, cuddling, and interaction with you. If you are providing prompt feedings and plenty of attention, and your baby still consistently cries for more formula, discuss it with your pediatrician. On occasion, your doctor may advise you to begin offering a small amount of rice cereal. Three month olds are usually not ready for cereals (or any other solid foods), although cereals are occasionally used in especially large and demanding babies. I like to give my baby his nighttime bottle in his crib. Is that okay? Professionals agree that bottles should not be propped. You should hold your baby when you give him his bottle; then, put him to bed without it. If you put him to bed with the bottle and he is allowed to suck at will, milk may pool in his mouth, promoting tooth decay. Also, because of the proximity of the eustachian tubes, babies who go to bed with their bottles have a greater tendency to develop ear infections. Although I'm a nursing mother, I'm trying to introduce my six week old to a bottle so I can leave feedings for him when I return to work. He's refusing to take a bottle and screams until I nurse him. Any suggestions? Although a six-week-old baby may be more easily introduced to a bottle than an older baby, you're likely to have greater success if you have someone else give him the bottle. He would naturally prefer his mother's soft, warm breast to the foreign baby-bottle nipple. So enlist someone else to give your baby the bottle. Try to do this when the baby is truly hungry but before he's in a rage because of it. Another option is to try giving him a bottle a little earlier than you would usually breast-feed him; this not-so-hungry time will allow him to experiment with the nipple and get used to it. Another option is to express milk into a bottle from which he can be fed while you are at work. While the nipple may still seem odd, the liquid inside will be the breast milk that he is accustomed to drinking. This option also allows you to maintain your milk supply by stimulating milk production the way sucking does. Should I keep my baby on a rigid feeding schedule? All families develop parenting skills and philosophies tailored to their individual personalities, preferences, and lifestyles. What will work well for one family doesn't necessarily work well for another. When it comes to nurturing your baby, you may want to lean towards flexibility. Especially for young babies, feeding on demand, within reason, is preferred. By promptly answering his cries for food, warmth, and other physical needs during these first few months, you will be teaching your baby one of the most fundamental lessons of his life--that there are people who love him and will take care of him. If a baby appears to want hourly feedings, then something is wrong. On the other hand, a baby can be on a rigid four-hour feeding schedule and do well, but there will be days when he'll be hungry every three hours or every five hours. Your goal is to satisfy your baby's needs, so you'd want to feed him when he is hungry. The answer, therefore, is that healthy scheduling for babies should be neither entirely flexible nor inflexible. When should I burp my baby? If you're breast-feeding, stop to burp your baby when his sucking slows down. If you're bottle-feeding, about midway through the feeding is a good time to stop and burp him. No matter which method you use, if your baby starts to fuss during the feeding, he probably feels an air bubble and needs to be burped. Hungry babies who are fed after they've been crying will have swallowed air already and may need to be burped sooner. If the baby starts to doze and you think he hasn't had enough, stop to burp, and he may begin again and finish his feeding. It's not necessary, however, for the baby to empty his bottle at each feeding. He may require different amounts at different feeding times, depending on his appetite and on how long it's been since the last feeding. When the baby turns away, stops sucking, or otherwise lets you know he's full, try for another burp. If he's sleeping and doesn't burp, put him down on his tummy or prop him up in an infant seat, and the bubble may come up by itself. I can't always get the baby to burp. Should he burp after each feeding? When nursing babies are sucking well and getting most of the areola plus the nipple in their mouths, they may not be swallowing much air and may not have to burp every time. The same is true for bottle-fed babies who are sucking well from nipples kept full of formula. If he really does need to burp, he'll let you know. When babies feel air bubbles, they get cranky. They make funny faces or grunt and cry to let you know they are uncomfortable. My baby seems to spit up whenever he's been fed. How can I prevent this? If your baby is eating well and developing as expected, it's nothing to be concerned about. There are, however, some helpful hints to employ with babies who are "spitters," or who burp up milk after feeding. First, keep plenty of cloth diapers handy; lay one on your shoulder or lap when you burp your baby, and hand one to guests who want to hold him. There are some other strategies, too. You might try burping him more frequently during feedings. Check the nipple flow from the bottle to make certain he isn't getting the formula too quickly. After feeding, gently lift him, in an upright position, to your shoulder, and burp him; then, lay him in a carrier or infant chair that keeps his head higher than the rest of his body. In addition, try not to change his diaper or bathe him immediately after feeding. If you are worried about his spitting up, discuss it with your pediatrician. My newborn always has diarrhea. Will this stop when he starts eating solid foods? The normal bowel movement of a newborn is loose and has a large fluid content. It is normal for a newborn to pass as many as one stool per feeding. The definition of diarrhea, therefore, is more than one loose stool per feeding. If you notice this occurring or if your baby is acting ill, consult your pediatrician. Since the first solid food that most babies receive is cereal, which is a stool-firming food, the loose, soft stools will become firmer. After that, the new foods added to your baby's diet may make the stools firmer or looser or have no effect at all, depending on the food. How long should I give my baby supplemental vitamins and fluoride? Most babies are given supplemental vitamins beginning in the first month of life. These may be contained in the formula or given as drops to the breast-fed baby. Many say that if a nursing mother is healthy, her baby will get adequate vitamins in the breast milk. Often, however, a pediatrician will prescribe a supplement of vitamins A, D, and C for the first year or so of life, just to he sure. Your pediatrician will let you know when it is no longer necessary to give these supplements, but it is generally agreed that no child over 18 to 24 months of age who is eating a varied, nutritious diet needs supplemental vitamins. In areas where there is no fluoride in the water, it is recommended that infants, children, and young adolescents receive fluoride daily. This is usually given as a vitamin/fluoride combination in children under two, and later as a single daily chewable fluoride tablet. The fluoride promotes improved dental health by decreasing the rate of cavities. In areas where there is fluoride in the drinking water, it is not necessary to provide fluoride supplements. Is it necessary for babies to drink water? Both formula and breast milk have a high water content. Many babies, therefore, do just fine without water until they are old enough to use a cup. If your baby takes the maximum amount of formula and wants more, you might try offering water. If you're nursing your baby, it's more difficult to know when he's had enough, so you might try offering water from time to time. All babies should be offered extra water in hot weather. If your baby is wetting several diapers a day, he's most likely getting enough fluids. We work hard at keeping our weight down and want to be certain that our baby is slim. How do we go about this? You are to be congratulated on your weight-conscious lifestyle. It will be of great benefit to your child, but not for a year or two. Babies are not little adults; they should not be on restrictive diets. Indeed, in recent years, experts have seen an increasing number of children who are failing to thrive because well-meaning parents have overly restricted their babies' diets. Babies require a much greater number of calories per pound of body weight and a greater percentage of calories from fat compared to adults if they are to grow and develop normally. Many pediatricians prefer to keep a baby on breast milk or formula until he is ready to take a cup (at about nine to 16 months of age). If your baby drinks from a cup before his first birthday, you can offer him two-percent milk unless advised differently by your pediatrician. Skim milk is lacking in sufficient fat to maintain adequate growth. Is there a difference of opinion regarding when to introduce solid foods? Most pediatricians believe that six months is an optimum time to introduce solid foods. If your baby is very large and is still hungry after getting the maximum amount of formula, you might start as early as four months. Still, at this stage, the important calories and nutrition should be supplied by breast milk or formula, and the solid food should be looked upon as a supplement. Parents who have allergies or allergic family histories will probably want to start later and be more cautious when introducing solids. Even if there are no allergies in the family, early exposure to some foods may produce a reaction that wouldn't occur if the food was introduced at a later age. In terms of which foods to introduce, it's probably best to begin with cereals and less tasty foods like vegetables, and progress gradually to tastier foods, like fruit and desserts. Avoid sweetening cereal or mixing it with fruit; babies naturally have a sweet tooth and have no need to acquire a taste for sweets. Never mix cereal in the bottle either. Although the cereal will be fairly watery, it should be offered with a spoon. It's messy at first, but one of the important goals of introducing solids is to gradually teach the baby how to eat them. Foods that are not naturally soft and watery should be pureed with a small amount of water before being served to the baby. Introduce no more than one new food a week. This allows time for you to see if the baby has an unfavorable reaction to a particular food. Many times, the same food can be introduced again later, when the child's digestive system is more mature. Avoid foods that have pieces that can break off and cause choking. Honey should never be given to babies less than a year old because of the risk of botulism (food poisoning). Egg yolks shouldn't be offered until the baby is at least six months old; egg whites shouldn't be offered until the baby is a year old because of the likelihood of allergic reaction. Chocolate and nuts should be avoided because they are both highly allergenic; nuts are also dangerous because of the risk of choking, and therefore should not be given to children under four to five years of age. For more information on introducing solids, see the next age group. My six month old won't take a pacifier, but lately he's been sucking his thumb constantly--even between bites when I'm feeding him. What can I do about this? Your six month old will eventually become more skilled at eating. One of the things he'll learn is to keep his thumb out of his mouth between spoonfuls. For now, gently remove his thumb from his mouth when you offer a bite. Your baby may have more time to stick his thumb in his mouth if you're feeding him too slowly. On the other hand, you may he feeding him too quickly, and he may be putting his thumb in his mouth to give himself a break. Experiment with the pace and see what happens. Most of the time, babies just stick their thumb in their mouth because they want to, regardless of what else is going on. Don't make a big deal of it, or he'll enjoy your reaction and have an added reason to do it. Summon your patience and sense of humor. You'll need more of both before he's eating nicely. When I feed my baby, he often seems more interested in playing with his food than eating it. Should I stop him from doing this? Unless it gets totally out of hand and starts to interfere with his getting proper nutrition, you might consider giving your baby a little slack here. As far as he's concerned, his food is just like anything else in his environment--brand new and very exciting. As a result, his initial inclination may be to explore it rather than eat it. At first, the different colors of the foods you serve him and the different sounds that are made by the spoon will intrigue him. Once he learns to move his hands under the direction of his eyes and becomes adept at using his fingers, he will become fascinated by the varying temperatures and textures of the food as well. Although it may make feeding your baby a bit more inconvenient and time-consuming, you may want to acknowledge his educational needs as well as his nutritional needs. Permit mealtime to be a learning session at least to a certain extent as well as a way to give him the nutrition be needs. Lately, my baby appears to be trying to feed himself, but he's not very good at it. Should I stop him until he gets older? Toward the end of this period, your baby will be attempting to do more things for himself, and of course, he will be having a tough time in the beginning. When it comes to something like feeding, you certainly will have to step in at some point to make sure that he gets sufficient nutrition. However, if you don't allow him to try it himself for a little while, he'll never have a chance to get better. While this can seem obvious, it often is overshadowed by the need to get things done, particularly if parents are busy. This can become a real problem, especially at later stages of development. Therefore, now is a good time to start allotting more time for things like feeding, dressing, bathing, etc. so you can begin to include your baby's efforts without creating stress for yourself. SUGGESTED INTRODUCTION OF SOLID FOODS You can start introducing solid foods when your baby is four to six months old. Begin with cereals unless directed otherwise by your pediatrician. Be sure to refer first to the question regarding when to introduce solid foods. 1. Cereal: Rice, then barley, then oatmeal 2. Yellow vegetables: Carrots, then squash, then sweet potatoes 3. Green vegetables: Peas, then beans, then spinach 4. Meats: Lamb, beef, veal, poultry, pork, fish (order not important); then egg yolk 5. Noncitrus fruits 6. Noncitrus juices (only after nine months of age) 7. Citrus fruits (orange, tomato, grapefruit, etc.) 8. Citrus juices 9. NO EGG WHITE OR HONEY UNTIL AFTER 12 MONTHS OF AGE