1. Non-milk feedings Solids Beikost Table foods

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. Feeding Practices and Transitions Developmental Social Cultural Nutritional Public Health

6. Development of Feeding Behavior AgeRefelxesBehavior B-3 monthsRoot, suck-swallow- breath Suckling pattern of feeding 4-6 monthsFading root/bite reflexMature suck, brings objects to mouth, munching pattern 7-9 monthsNormal gag development Munching, rotary chewing, sits alone, holds bottle alone 10-12 monthsBites, brings food to mouth, drinks from cup, spoon feeds

8. 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)

9. 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?

10. Feeding behavior of infants Gessell A, Ilg FL

11. 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

12. 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”

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

14. 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)

15. 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.

16. 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.

17. 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.

18. 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

19. Solids: Weight Gain Weight gain: Forsyth (BMJ 1993) found early solids associated with higher weights at 8-26 weeks but not thereafter

20. 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.

21. 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.

22. 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.

23. 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

24. 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

25. The Use and Misuse of Fruit Juice in Pediatrics - AAP, May 2001 Conclusions Recommendations

26. 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.

27. 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

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

29. 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.

30. 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

31. 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

32. 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

33. 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

34. 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

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

37. 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

38. 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.

39. 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

40. 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

41. Sources of Energy: 6-11 Months RankFood group% of Total 1Infant formula43.1 2Breast milk10.7 3Infant cereal6.5 4100% juice4.4 5Milk (cow’s/goat’s/soy)3.4 6Baby food dinners3.2 7Bananas2.7 8Cookies1.8 9Apples/applesauce1.7 10Baby food desserts1.6 11Bread/rolls/biscuits/bagels/tortilla1.2 12Crackers/pretzels/rice cakes1.2 13Noninfant cereals1.2 14Pears1.2 15Cheese1.1

42. Sources of Energy: 4-5 months RankFood group% of Total 1Infant formula56.1 2Breast milk32.1 3Infant cereal5.3 4100% juice1.5

43. Percentage of Hispanic and non-Hispanic infants and toddlers consuming desserts, sweets, sweetened beverages, and salty snacks on a given day Age 4-5 MonthsAge 6-11 MonthsAge 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 13.25.957.047.188.886.8 Desserts and candy8.33.550.940.762.168.9 Baby food desserts7.02.017.415.53.22.1 Cakes, pies, cookies and pastries 1.31.138.728.351.054.1 Baby cookies1.31.124.8 * 14.59.113.4 Other cookies——11.612.536.935.2 Ice cream——3.24.413.015.4 Other sweets4.11.84.87.633.932.3 Sugar, syrups, preserves3.51.84.55.017.825.6 Sweetened beverages——13.96.753.5 * 35.8 Carbonated sodas——1.7—17.08.1 Fruit flavored drinks——13.2 * 5.447.0 * 29.5 Any type of salty snack——3.13.518.922.7 *Significantly different from non-Hispanics at P<.05.

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

45. 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.

46. 12-24 mos, cont. 14Bananas2.1 15Beef2.0 16Infant formula1.9 17White potatoes1.9 18Cakes/pies/other baked goods1.7 19Breast milk1.6 20Yogurt1.5 21Eggs1.5 22Pancakes/waffles/french toast1.5 23Chips/other salty snacks1.3 24Ice cream/frozen yogurt/pudding1.2 25Sugar/syrups/jams/jellies/other sweeteners1.1 26Rice1.1

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

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

49. 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

50. 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

51. 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

52. 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

53. Early Childhood Caries: Cost $1,000 - $3,000 for repair Increased risk of developing new lesions in primary and permanent teeth

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

55. 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 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)

57. 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.

58. 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.)

59. 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

60. 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.

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

62. 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

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

64. 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

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

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

67. 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