British Journal of Nutrition

Full Papers

Human and Clinical Nutrition

Validation of energy requirement references for exclusively breast-fed infants

Susan B. Nielsena1 c1, Jonathan C. K. Wellsa2, Mary S. Fewtrella2, Simon Eatona3, James Grinhama2 and John J. Reillya4

a1 University of Glasgow, School of Medicine, Centre of Population and Health Sciences, Yorkhill Hospitals, Tower 1st Floor, Glasgow G3 8SJ, Scotland, UK

a2 UCL Institute of Child Health, Childhood Nutrition Research Centre, London, UK

a3 Department of Surgery, UCL Institute of Child Health, London, UK

a4 University of Strathclyde, Physical Activity and Health Research Group, School of Psychological Sciences and Health, Glasgow, UK


In paediatric practice, mean reference energy requirements for groups are often used to predict individual infant energy requirements. References from the FAO/WHO/United Nations University are based on infants not fed according to the current infant feeding recommendations. The objective of the present study was to measure total energy expenditure (TEE) and determine energy requirements using criterion methods, and validate the use of TEE prediction equation and mean energy requirement references for predicting individual TEE and energy requirements, respectively, in infants who were exclusively breast-fed (EBF) to 6 months of age. EBF infants were included from Greater Glasgow for measurements at 3·5 (n 36) and 6 (n 33) months of age. TEE was measured using doubly labelled water and energy requirements were determined using the factorial approach. TEE and energy requirements were also predicted using equations based on body weight. Relationships between criterion methods and predictions were assessed using correlations. Paired t tests and Bland–Altman plots were used to assess agreement. At the population level, predicted and measured TEE were similar. The energy requirement reference significantly underestimated energy requirements by 7·2 % at 3·5 months at the population level, but there was no bias at 6 months. Errors at individual levels were large and energy requirements were underestimated to a larger extent for infants with higher energy requirements. This indicates that references presently used in clinical practice to estimate energy requirements may not fully account for the different growth pattern of EBF infants. More studies in infants EBF to 6 months of age are needed to understand how growth of EBF infants influences energy requirements.

(Received February 11 2012)

(Revised August 03 2012)

(Accepted August 06 2012)

(Online publication November 13 2012)

Key Words:

  • Energy metabolism;
  • Exclusive breast-feeding;
  • Growth;
  • Infant health;
  • Nutritional requirements


c1 Corresponding author: S. B. Nielsen, fax +44 141 201 0674, email


  Abbreviations: EBF, exclusive breast-feeding; FFM, fat-free mass; FM, fat mass; TEE, total energy expenditure; UNU, United Nations University