Non-milk feedings

• Solids• Beikost• Table foods

• What factors influence food choices, eating behaviors, and acceptance?

Sociology of Food

• Hunger• Social Status• Social Norms• Religion/Tradition• Nutrition/Health

Sociology of Food

• Food Choices– Availability– Cost– Taste– Value– Marketing Forces– Health– Significance

Feeding Practices and Transitions

Developmental

Social

Cultural

Nutritional

Public Health

Complementary Foods - definitions

• “Any energy-containing foods that displace breastfeeding and reduce the intake of breast milk.” (AAP)

• “any nutrient containing foods or liquids other than breastmilk given to young children during the periods of complementary feeding….[when] other foods or liquids are provided along with breastmilk.” (WHO)

• “any foods or liquids other than human milk or formula that are fed during the first 12 months of life.” (Healthy Start Guidelines)

Complementary Foods – The Nutrition issues

• When are they needed?

• What nutrients and foods are important?

• When is the gut ready?

• What about allergies?

• What about juice?

Feeding behavior of infants Gessell A, Ilg FL

Age Reflexes Oral, Fine, Gross Motor Development1-3months

Rooting and suckand swallowreflexes arepresent at birth

Head control is poorSecures milk with suckling pattern, the tongue projectingduring a swallowBy the end of the third month, head control is developed

4-6months

Rooting reflexfadesBite reflex fades

Changes from a suckling pattern to a mature suck withliquidsSucking strength increasesMunching pattern beginsGrasps with a palmer graspGrasps, brings objects to mouth and bites them

7-9months

Gag reflex is lessstrong as chewingof solids beginsand normal gag isdevelopingChoking reflexcan be inhibited

Munching movements begin when solid foods are eatenRotary chewing beginsSits aloneHas power of voluntary release and resecuralHolds bottle aloneDevelops an inferior pincer grasp

10-12months

Bites nipples, spoons, and crunchy foodsGrasps bottle and foods and brings them to the mouthCan drink from a cup that is heldTongue is used to lick food morsels off the lower lipFinger feeds with a refined pincer grasp

Developmental Changes

• Oral cavity enlarges and tongue fills up less• Tongue grows differentially at the tip and attains motility

in the larger oral cavity. • Elongated tongue can be protruded to receive and pass

solids between the gum pads and erupting teeth for mastication.

• Mature feeding is characterized by separate movements

of the lip, tongue, and gum pads or teeth

Development of Infant Feeding Skills

• Birth– tongue is disproportionately large in comparison with

the lower jaw: fills the oral cavity – lower jaw is moved back relative to the upper jaw,

which protrudes over the lower by approximately 2 mm.

– tongue tip lies between the upper and lower jaws. – "fat pad" in each of the cheeks: serves as prop for

the muscles in the cheek, maintaining rigidity of the cheeks during suckling.

– feeding pattern described as “suckling”

Analytical framework for the Start Healthy Guidelines for Complementary foods (JADA, 2004)

The Basics from AAP: Timing of Introduction of Non-milk Feedings

• Based on individual development, growth, activity level as well as consideration of social, cultural, psychological and economic considerations

• Most infants ready at 4-6 months• Introduction of solids after 6 months may delay

developmental milestones.• By 8-10 months most infants accept finely

chopped foods.

Some Issues: Foman, 1993• “For the infant fed an iron-fortified formula,

consumption of beikost is important in the transition from a liquid to a nonliquid diet, but not of major importance in providing essential nutrients.”

• Breastfed infants: nutritional role of beikost is to supplement intakes of energy, protein, perhaps Ca and P.

• Nutrient content of breastmilk is a compromise between maternal and infant needs. Most human societies supplement breastmilk early in life.

Foman S. Feeding Normal Infants: Rationale for Recommendations. JADA

101:1102• “It is desirable to introduce soft-cooked red

meats by age 5 to 6 months. “

• Iron used to fortify dry infant cereals in US are of low bioavailablity. (use wet pack or ferrous fumarate)

Issues

• Energy

• Iron

• Respiratory/Allergy

• Juice

• Dental Health

• Safety/other

Some Considerations in Complementary feedings

Too Early• diarrheal disease & risk

of dehydration• decreased breast-milk

production• Allergic sensitization? • developmental

concerns

Too Late• potential growth failure• iron deficiency• developmental

concerns

Solids: Weight Gain• Weight gain: Forsyth (BMJ 1993) found

early solids associated with higher weights at 8-26 weeks but not thereafter

Sources of Energy: 4-5 months

Rank Food group % of Total

1 Infant formula 56.1

2 Breast milk 32.1

3 Infant cereal 5.3

4 100% juice 1.5

Sources of Energy: 6-11 MonthsRank Food group % of Total

1 Infant formula 43.1

2 Breast milk 10.7

3 Infant cereal 6.5

4 100% juice 4.4

5 Milk (cow’s/goat’s/soy) 3.4

6 Baby food dinners 3.2

7 Bananas 2.7

8 Cookies 1.8

9 Apples/applesauce 1.7

10 Baby food desserts 1.6

11 Bread/rolls/biscuits/bagels/tortilla 1.2

12 Crackers/pretzels/rice cakes 1.2

13 Noninfant cereals 1.2

14 Pears 1.2

15 Cheese 1.1

12-24 mos, cont.14 Bananas 2.1

15 Beef 2.0

16 Infant formula 1.9

17 White potatoes 1.9

18 Cakes/pies/other baked goods 1.7

19 Breast milk 1.6

20 Yogurt 1.5

21 Eggs 1.5

22 Pancakes/waffles/french toast 1.5

23 Chips/other salty snacks 1.3

24 Ice cream/frozen yogurt/pudding 1.2

25 Sugar/syrups/jams/jellies/other sweeteners 1.1

26 Rice 1.1

Solids: Respiratory Symptoms• Forsyth (BMJ 1993) found increased

incidence of persistent cough in infants fed solids between 14-26 weeks.

• Orenstein (J Pediatr 1992) reported cough in infants given cereal as treatment for GER.

Solids: Borrensen - (J Hum Lact. 1995)

• Some studies find exclusive breastfeeding for 9 months supports adequate growth.

• Iron needs have individual variation.

• Drop in breastmilk production and consequent inadequate intake may be due to management errors

What foods should be avoided to reduce food allergy risk?

• No restrictions if not at risk for allergy.

• If strong family history of food allergy:– Breastfeed as long as possible– No complementary foods until after 6 months– Delay introduction of foods with major

allergens: eggs, milk, wheat, soy, peanuts, tree nuts, fish, shellfish.

The Use and Misuse of Fruit Juice in Pediatrics - AAP, May 2001

• In the evaluation of children with malnutrition (overnutrition and undernutrition), the health care provider should determine the amount of juice being consumed.

• In the evaluation of children with chronic diarrhea, excessive flatulence, abdominal pain, and bloating, the health care provider should determine the amount of juice being consumed.

• In the evaluation of dental caries, the amount and means of juice consumption should be determined.

• Pediatricians should routinely discuss the use of fruit juice and fruit drinks and should educate parents about differences between the two.

The Use and Misuse of Fruit Juice in Pediatrics - AAP, May 2001

• Juice should not be introduced into the diet of infants before 6 months of age.

• Infants should not be given juice from bottles or easily transportable covered cups that allow them to consume juice easily throughout the day. Infants should not be given juice at bedtime.

• Intake of fruit juice should be limited to 4 to 6 oz/d for children 1 to 6 years old. For children 7 to 18 years old, juice intake should be limited to 8 to 12 oz or 2 servings per day.

• Children should be encouraged to eat whole fruits to meet their recommended daily fruit intake.

• Infants, children, and adolescents should not consume unpasteurized juice.

The Use and Misuse of Fruit Juice in Pediatrics - AAP, May 2001

• Excessive juice consumption may be associated with malnutrition (overnutrition and undernutrition).

• Excessive juice consumption may be associated with diarrhea, flatulence, abdominal distention, and tooth decay.

• Unpasteurized juice may contain pathogens that can cause serious illnesses.

• A variety of fruit juices, provided in appropriate amounts for a child's age, are not likely to cause any significant clinical symptoms.

• Calcium-fortified juices provide a bioavailable source of calcium but lack other nutrients present in breast milk, formula, or cow's milk.

Allergies: Areas of Recent Interest

• Early introduction of dietary allergens and atopic response– atopy is allergic reaction/especially associated

with IgE antibody– examples: atopic dermatitis (eczema),

recurrent wheezing, food allergy, urticaria (hives) , rhinitis

• Prevention of adverse reactions in high risk children

Allergies: Early Introduction of Foods

(Fergussson et al, Pediatrics, 1990)

• 10 year prospective study of 1265 children in NZ• Outcome = chronic eczema• Controlled for: family hx, HM, SES, ethnicity,

birth order• Rate of eczema with exposure to early solids

was 10% Vs 5% without exposure• Early exposure to antigens may lead to

inappropriate antibody formation in susceptible children.

Allergies: Prevention by Avoidance (Marini, 1996)

• 359 infants with high atopic risk

• 279 in intervention group

• Intervention: breastfeeding strongly encouraged, no cow’s milk before one year, no solids before 5/6 months, highly allergenic foods avoided in infant and lactating mother

Allergies: Prevention by Avoidance (Marini, 1996)

01020304050607080

1 yr 2 yrs 3 yrs

% of Children With Any Allergic Manifestations (cummulative incidence)

non-interventionintervention

Allergies: Prevention by Avoidance (Zeigler, Pediatr Allergy Immunol. 1994)

• High risk infants from atopic families, intervention group n=103, control n=185

• Restricted diet in pregnancy, lactation, Nutramagen when weaned, delayed solids for 6 months, avoided highly allergenic foods

• Results: reduced age of onset of allergies

Allergies: Prevention by Avoidance (Zeigler, Pediatr Allergy Immunol. 1994)

Definite or Probable Food Allergy

Age Intervention Control p

12 mo 5% 16% 0.007

24 mo 7% 20% 0.005

48 mo 4% 6% ns

The Use and Misuse of Fruit Juice in Pediatrics - AAP, May 2001

The Use and Misuse of Fruit Juice in Pediatrics - AAP, May 2001

• Fruit juice offers no nutritional benefit for infants younger than 6 months.

• Fruit juice offers no nutritional benefits over whole fruit for infants older than 6 months and children.

• One hundred percent fruit juice or reconstituted juice can be a healthy part of the diet when consumed as part of a well-balanced diet. Fruit drinks, however\ are not nutritionally equivalent to fruit juice.

• Juice is not appropriate in the treatment of dehydration or management of diarrhea.

AAP: Specific Recommendations

• Home prepared spinach, beets, turnips, carrots, collard greens not recommended due to high nitrate levels

• Canned foods with high salt levels and added sugar are unsuitable for preparation of infant foods

• Honey not recommended for infants younger than 12 months

Early Childhood Caries

• AKA Baby Bottle Tooth Decay

• Rampant infant caries that develop between one and three years of age

Early Childhood Caries: Etiology

• Bacterial fermentation of cho in the mouth produces acids that demineralize tooth structure

• Infectious and transmissible disease that usually involves mutans streptococci

• MS is 50% of total flora in dental plaque of infants with caries, 1% in caries free infants

Early Childhood Caries: Etiology

• Sleeping with a bottle enhances colonization and proliferation of MS

• Mothers are primary source of infection

• Mothers with high MS usually need extensive dental treatment

Early Childhood Caries: Pathogenesis

• Rapid progression

• Primary maxillary incisors develop white spot lesions

• Decalcified lesions advance to frank caries within 6 - 12 months because enamel layer on new teeth is thin

• May progress to upper primary molars

Early Childhood Caries: Prevalence

• US overall - 5%

• 53% American Indian/Alaska Native children

• 30% of Mexican American farmworkers children in Washington State

• Water fluoridation is protective

• Associated with sleep problems & later weaning

Early Childhood Caries: Cost

• $1,000 - $3,000 for repair

• Increased risk of developing new lesions in primary and permanent teeth

What?

• After 6 months most breastfed infants need complementary foods to meet DRIs for energy, iron, vitamin D, vitamin B6, niacin, zinc, vitamin E, and others

• In US Iron and vitamin D need special emphasis due to prevelance of deficiency.

• Little room for foods with low energy density in the diets of infants

When?

• GI readiness: 3-4 months

• Developmental readiness: varies, between 4 and 6 months

• Nutritional needs beyond breastmilk: not before 6 months, after that varies

• Need for variety and texture: within first year, order not important

Complementary Foods: Healthy Start Guidelines for Infants and Toddlers

(JADA, 2004)

Based on an extensive evidence-based review of current science

How

• Introducing new foods– Repeated exposures may be needed– No evidence for benefit to introducing foods in

any sequence or rate– Meat and fortified cereals provide many

nutrients identified as needed after 6 months.

How

• Safety issues:– Safe food handling for formula and

expressed breast milk– Guidance about choking, lead poisoning,

nonfood eating, high intakes of nitrates, nitrites and methylmurcury

How?

• Establish healthy feeding relationship– Recognize child’s developmental abilities– Balance child’s need for assistance with

encouragement of self feeding– Allow the child to initiate and guide feeding

interactions– Respond early and appropriately to hunger

and satiety cues

• Provide guidance consistent with family/child’s– Development– Temperament– Preferences– Culture– Nutritional needs

The Start Healthy Feeding Guidelines for Infants and Toddlers (JADA, 2004)

C-P-F: Possible Concerns Michaelsen et al. Eur J Clin Nutr. 1995

• Dietary Fat is ~ 50% of Kcals with exclusive breastmilk or formula intake.

• Dietary fat contribution can drop to 20-30% with introduction of high carbohydrate infant foods.

• Infants receiving low fat milks are at risk of insufficient energy intake.

• Fat intake often increases with addition of high fat family foods.

C-P-F: Low Energy Density • Low fat diet often means diet has low

energy density

• Increased risk of poor growth

• Reduction in physical activity

• Energy density of 0.67 kcal/g recommended for first year of life (Michaelson et al.)

C-P-F: Recommendations• No strong evidence for benefits from fat

restriction early in life

• AAP recommends:– high carbohydrate infant foods may be

appropriate for formula fed infants– no fat restriction in first year– a varied diet after the first year– after 2nd year, avoid extremes, total fat intake

of 30-40% of kcal suggested

Methemoglobinemia in vegetables

• Nitrates in homemade baby food– Beets, carrots, pumpkin, green beans– Case reports of cyanosis, tachycardia,

irritability, diarrhea, and vomiting

Vegan Infants

• ADA and AAP state that well planned vegan diet can meet the nutritional needs and support growth in infants and children

• Key issues– Adequate maternal diet to maintain adequate milk

volume– B12– Vitamin D– Zinc– Iron– Energy, adequate fat in diet

Feeding Practices in Infancy

Percentage of Hispanic and non-Hispanic infants and toddlers consuming desserts, sweets, sweetened beverages, and salty snacks on a given day

Age 4-5 Months Age 6-11 Months Age 12-24 Months

Hispanic (n=84)

Non-Hispanic (n=538)

Hispanic (n=163)

Non-Hispanic (n=1,228)

Hispanic (n=124)

Non-Hispanic (n=87)

Any type of dessert, sweet, or sweetened beverage

13.2 5.9 57.0 47.1 88.8 86.8

Desserts and candy 8.3 3.5 50.9 40.7 62.1 68.9

Baby food desserts 7.0 2.0 17.4 15.5 3.2 2.1

Cakes, pies, cookies and pastries

1.3 1.1 38.7 28.3 51.0 54.1

 Baby cookies 1.3 1.1 24.8* 14.5 9.1 13.4

 Other cookies — — 11.6 12.5 36.9 35.2

Ice cream — — 3.2 4.4 13.0 15.4

Other sweets 4.1 1.8 4.8 7.6 33.9 32.3

Sugar, syrups, preserves 3.5 1.8 4.5 5.0 17.8 25.6

Sweetened beverages — — 13.9 6.7 53.5* 35.8

Carbonated sodas — — 1.7 — 17.0 8.1

Fruit flavored drinks — — 13.2* 5.4 47.0* 29.5

Any type of salty snack — — 3.1 3.5 18.9 22.7

 *Significantly different from non-Hispanics at P<.05.

Early Introduction of Foods(Fergussson et al, Pediatrics, 1990)

Proportional Hazard Coefficient (p<0.01)For Risk of Chronic Eczema

No solid Food before4 months

1.00

1-3 types of foodbefore 4 months

1.69

4+ types of foodsbefore 4 months

2.87

Feeding Infants and Toddlers Study (n=2,515)

Journal of the American Dietetic Association, January 2006

Delayed Complementary Feeding Until 4 months

• 73% met guideline• Those who met guideline more likely to:

– Be married– Have higher income– Be college grads– Be white or Hispanic compared to African American– Live in an urban area and/or live in the west– Not be on WIC

Juice Recommendations (after age 6 mos, 100% juice, limit to 6 oz/d)

• 80% met guidelines• Those who met guidelines more likely to:

– Be college graduates– Have higher incomes– Live in the west and in urban areas– Not be on WIC– Note: no racial/ethnic differences

• 21% introduced solids <4 months

• 7% introduced solids >6 months

• 29% >3 new foods/week 5-10 months

• 20% gave juice before 6 months, cows milk before 12 months and 20% reduced fat milk

• 20% provided <5 meals/day after 5 months

• 15% chewed food for infant

• ½ added salt

• By 1 year of age 50% were consuming french fries, candy, cookies, or cake. (only) 15% sweetened drinks such as soda or juice drinks