Nonmilk feedings

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Non-milk feedings

• Solids
• Beikost
• Table foods

2

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

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Sociology of Food

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

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Sociology of Food

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

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Feeding Practices and Transitions

• Developmental
• Social
• Cultural
• Nutritional
• Public Health

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Development of Feeding Behavior
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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)

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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?

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Feeding behavior of infants Gessell A, Ilg FL
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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

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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

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Analytical framework for the Start Healthy
Guidelines for Complementary foods (JADA, 2004)
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Foman S. Feeding Normal Infants Rationale for
Recommendations. JADA 1011102

• 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)

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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.

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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.

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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.

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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

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Solids Weight Gain

• Weight gain Forsyth (BMJ 1993) found early
  solids associated with higher weights at 8-26
  weeks but not thereafter

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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.

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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.

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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.

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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

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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

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

• Conclusions
• Recommendations

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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.

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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

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Complementary Foods Healthy Start Guidelines for
Infants and Toddlers (JADA, 2004)
Based on an extensive evidence-based review of
current science
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AAP Specific Recommendations for Infant Foods

• Start with introduction of single ingredient
  foods at weekly intervals.
• Sequence of foods is not critical, iron fortified
  infant cereals are a good choice.
• Home prepared foods are nutritionally equivalent
  to commercial products.
• Water should be offered, especially with foods of
  high protein or electrolyte content.

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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

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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

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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

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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

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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

35
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

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Feeding Infants and Toddlers Study (n2,515)

• Journal of the American Dietetic Association,
  January 2006

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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

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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.

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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

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How?

• Establish healthy feeding relationship
• Recognize childs developmental abilities
• Balance childs 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

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Sources of Energy 6-11 Months
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Sources of Energy 4-5 months
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Percentage of Hispanic and non-Hispanic infants
and toddlers consuming desserts, sweets,
sweetened beverages, and salty snacks on a given
day
 Significantly different from non-Hispanics at
Plt.05.
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Analytical framework for the Start Healthy
Guidelines for Complementary foods (JADA, 2004)
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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.

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12-24 mos, cont.
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• Provide guidance consistent with family/childs
• Development
• Temperament
• Preferences
• Culture
• Nutritional needs

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Early Childhood Caries

• AKA Baby Bottle Tooth Decay
• Rampant infant caries that develop between one
  and three years of age

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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

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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

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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

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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

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Early Childhood Caries Cost

• 1,000 - 3,000 for repair
• Increased risk of developing new lesions in
  primary and permanent teeth

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

56
Foman S. Feeding Normal Infants Rationale for
Recommendations. JADA 1011102

• 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)

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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.

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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.)

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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

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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.

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Early Introduction of Foods(Fergussson et al,
Pediatrics, 1990)
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Allergies Prevention by Avoidance (Marini, 1996)

• 359 infants with high atopic risk
• 279 in intervention group
• Intervention breastfeeding strongly encouraged,
  no cows milk before one year, no solids before
  5/6 months, highly allergenic foods avoided in
  infant and lactating mother

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Allergies Prevention by Avoidance (Marini, 1996)
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Allergies Prevention by Avoidance (Zeigler,
Pediatr Allergy Immunol. 1994)

• High risk infants from atopic families,
  intervention group n103, control n185
• Restricted diet in pregnancy, lactation,
  Nutramagen when weaned, delayed solids for 6
  months, avoided highly allergenic foods
• Results reduced age of onset of allergies

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Allergies Prevention by Avoidance (Zeigler,
Pediatr Allergy Immunol. 1994)
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Methemoglobinemia in vegetables

• Nitrates in homemade baby food
• Beets, carrots, pumpkin, green beans
• Case reports of cyanosis, tachycardia,
  irritability, diarrhea, and vomiting

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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