1. Development, Relationship, and Transitions

2. What factors influence food choices, eating behaviors, and acceptance?

3. Sociology of Food Hunger Social Status Social Norms Religion/Tradition Nutrition/Health

4. Sociology of Food Food Choices –Availability –Cost –Taste –Value –Marketing Forces –Health –Significance

5. Foods for infants and young children Nurturing Nourishing Learning Supports developmental tasks Relationship Development Emotion and temperament

6. Development

7. Stages of Development: Neurophysiological Homeostasis Attachment Separation and individuation

8. Stages AgeDevelopment 1-3 monthsHomeostasis* State regulation * Neurophysiologic stability 2-6 monthsAttachment* “falling in love” * Affective engagement and interaction 6-36 months Separation and individuation * Differentiation * Behavioral organization and control

9. 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”

10. Developmental Changes Oral cavity enlarges and tongue fills up less Tongue grows differentially at the tip and attains motility in the larger oral cavity. Gag locus moves from mid-portion to posterior tongue (3-7 months) 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

11. Feeding development Gessell A, Ilg FL

12. Relationship Feeding is a reciprocal process that depends on the abilities and characteristics of both caregiver and infant/child

13. Relationship The feeding relationship is both dependent on and supportive of infants development and temperament.

14. Maternal-Infant Feeding dyad Indicates hunger (I) Presents milk (M) Consumes milk by suckling (I) Indicates satiety, stops suckling (I) Ends feeding (M)

15. Tasks Infant –time –how much –speed –preferences Parent –food choices –support –nurturing –structure and limits –safety

16. Relationship Children do best with feeding when they have both control and support

17. Infant and Caregiver Interaction Readability Predictability Responsiveness

18. Emotion/Temperament Temperament theory categorizes enduring personality styles based on activity, adaptability, intensity, mood, persistence, distractibility, regularity, responsivity, approach/withdraw from novelty Chess and Thomas 1970

19. Play, Learning, Exploration

20. Feeding Practices and Obesity Birch et al Learning to overeat:maternal use of restrictive feeding practices promotes girls’ eating in absence of hunger, Am J Clin Nutr 2003;78: 215-20 Anzma and Birch, Low inhibitory control and Restrictive Feeding Practices Predict Weight Outcome J Pediatrics 2009:155:651-6

21. Problems established early in feeding persist into later life and generalize into other areas Ainsworth and Bell –feeding interactions in early months were replicated in play interactions after 1st year

22. Transitions: Non Milk feedings Solids Beikost Table foods Complimentary foods

23. 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)

24. Growth, nutritional, and developmental factors form the basis of feeding transitions and recommendations for complimetary foods.

25. Successful introduction of complementary foods presupposes the ability of the infant to be nourished by, safely ingest, and accept such foods. Key factors: digestion and absorbtion, neuromuscular development, taste and texture acceptance.

26. Development: Factors Oral motor changes Truncal stability Change in gag loci from midportion to posterior of tongue (3-7 months) Experiential Repeat exposure

27. Factors: Growth and Nutrition Growth –Growth faltering observed between 3-6 months –WHO/CDC deceleration in weight/length 3-12 months in breast fed infants –“Weanling dilemma” Nutrition –Energy, Iron, Zinc

28. 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.

29. Growth and Energy Exclusive breastfeeding Complimentary foods replace breastmilk “weanling dilemma” described in 1970-80 in developing countries: –Risk of infection with intro of contaminated complimentary food vs suboptimal growth with exclusive breast feeding

30. Growth faltering in exclusively breastfed infants between 3-12 months Accelerated weight gain in the first few months associated with less deceleration in growth

31. 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

32. Complementary Foods Energy Iron Zinc

33. 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

34. Iron Iron Status –Maternal status –Stores at birth –Growth rate –Dietary source

35. Iron U.S. date estimates prevalence in 18 month old infant/toddler 8-11%

36. Zinc AI – 0-6 months: 2 mg/d –7 months-3 years: 3 mg/d Breast milk content declines from 8-12 mg/L in first month to 1-3 mg/L 4-6 months Bioavailability of Zn greater in breastmilk than formula Endowment at birth, birthweight, maternal status and growth rate

37. 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)

38. 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

39. Complimentary Foods –Respiratory/Allergy –Juice –Dental Health –Safety –other

40. 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

41. 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.

42. 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

43. Allergies: Prevention by Avoidance (Marini, 1996)

44. 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

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

46. 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.

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

48. 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.

49. 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.

50. 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.

51. 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.

52. Early Childhood Caries AKA Baby Bottle Tooth Decay Rampant infant caries that develop between one and three years of age

53. 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

54. 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

55. 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

56. 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

58. Complementary Foods: Healthy Start Guidelines for Infants and Toddlers (JADA, 2004) Based on an extensive evidence-based review of current science

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

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

61. How Introducing new foods –Repeated exposures may be needed (8-15) –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.

62. 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

63. 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

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

65. 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.

66. 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.)

67. 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

68. Methemoglobinemia in vegetables Nitrates in homemade baby food –Beets, carrots, pumpkin, green beans –Case reports of cyanosis, tachycardia, irritability, diarrhea, and vomiting

69. 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

70. 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

71. Feeding Infants and Toddlers Study (n=2,515) Journal of the American Dietetic Association, January 2006

72. 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

73. 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

74. 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

75. 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

76. 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.

77. AAP Recommendations Introduce 1 “single ingredient” new food at a time (3-5 days). –Allergy –Rice cereal least likely to cause allergic rx Choose 1 st foods that provide key nutrients and help meet energy needs –Iron fortified cereal, pureed meats Introduce a variety of foods by the end of the 1 st year –8-15 exposures for acceptance Withhold cows milk in 1 st year

78. AAP recommendations Ensure adequate calcium intake when transitioning to complimentary foods Avoid fat or cholesterol restrictions <2 years of age Do not introduce fruit juice during first 6 months. Upper limit 4-6 oz for 1-6 year olds Ensure safe ingestion and adequate nutrition when choosing and preparing homemade foods

79. Jackson 8 month old formula fed infant Takes 40 ounces of formula Weight gain appropriate. All growth parameters tracking at the 50-75 th percenile since birth. Attempt to introduce solids unsuccessful. Initially gagged on solids. After several attempts to introduce and move to more textures, Jackson, is showing food refusals.

80. Myra Exclusively breastfed 6 month old infant. Growth from birth to 4 months tracking at 25 th percentile for all parameters. At 6 months, weight decreased to between 5- 10 th percentile. Hct is 30. Mother is concerned about “decreasing milk supply”