Transcript Infant Feeding transition to solid and table food

Development, Relationship, and
Transitions
• What factors
influence food
choices, eating
behaviors, and
acceptance?
Sociology of Food
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Hunger
Social Status
Social Norms
Religion/Tradition
Nutrition/Health
Sociology of Food
• Food Choices
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Availability
Cost
Taste
Value
Marketing Forces
Health
Significance
Foods for infants and young
children
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Nurturing
Nourishing
Learning
Supports developmental tasks
• Relationship
• Development
• Emotion and temperament
Development
Stages of Development:
Neurophysiological
• Homeostasis
• Attachment
• Separation and
individuation
Stages
Age
Development
1-3 months Homeostasis
2-6 months Attachment
6-36
months
Separation and
individuation
* State regulation
* Neurophysiologic
stability
* “falling in love”
* Affective engagement
and interaction
* Differentiation
* Behavioral organization
and control
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”
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
Feeding development
Gessell A, Ilg FL
Age
1-3
months
Reflexes
Rooting and suck
and swallow
reflexes are
present at birth
4-6
months
Rooting reflex
fades
Bite reflex fades
7-9
months
10-12
months
Oral, Fine, Gross Motor Development
Head control is poor
Secures milk with suckling pattern, the tongue projecting
during a swallow
By the end of the third month, head control is developed
Changes from a suckling pattern to a mature suck with
liquids
Sucking strength increases
Munching pattern begins
Grasps with a palmer grasp
Grasps, brings objects to mouth and bites them
Gag reflex is less Munching movements begin when solid foods are eaten
strong as chewing Rotary chewing begins
of solids begins
Sits alone
and normal gag is Has power of voluntary release and resecural
developing
Holds bottle alone
Choking reflex
Develops an inferior pincer grasp
can be inhibited
Bites nipples, spoons, and crunchy foods
Grasps bottle and foods and brings them to the mouth
Can drink from a cup that is held
Tongue is used to lick food morsels off the lower lip
Finger feeds with a refined pincer grasp
Relationship
• Feeding is a
reciprocal process
that depends on the
abilities and
characteristics of
both caregiver and
infant/child
Relationship
• The feeding
relationship is both
dependent on and
supportive of infants
development and
temperament.
Maternal-Infant Feeding dyad
• Indicates hunger (I)
• Presents milk (M)
• Consumes milk by
suckling (I)
• Indicates satiety,
stops suckling (I)
• Ends feeding (M)
Tasks
• Infant
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time
how much
speed
preferences
• Parent
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food choices
support
nurturing
structure and limits
safety
Relationship
• Children do best with
feeding when they
have both control and
support
Infant and Caregiver Interaction
• Readability
• Predictability
• Responsiveness
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
Play, Learning, Exploration
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
• 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
Transitions: Non Milk feedings
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Solids
Beikost
Table foods
Complimentary foods
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)
• Growth, nutritional, and developmental
factors form the basis of feeding
transitions and recommendations for
complimetary foods.
• 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.
Development: Factors
• Oral motor changes
• Truncal stability
• Change in gag loci from midportion to
posterior of tongue (3-7 months)
• Experiential
• Repeat exposure
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
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.
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
• Growth faltering in exclusively breastfed
infants between 3-12 months
• Accelerated weight gain in the first few
months associated with less deceleration
in growth
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
Complementary Foods
• Energy
• Iron
• Zinc
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
Iron
• Iron Status
– Maternal status
– Stores at birth
– Growth rate
– Dietary source
Iron
U.S. date estimates prevalence in 18 month
old infant/toddler 8-11%
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
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)
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
Complimentary Foods
– Respiratory/Allergy
– Juice
– Dental Health
– Safety
– other
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)
% of Children With Any Allergic
Manifestations (cummulative incidence)
80
70
60
50
40
30
20
10
0
non-intervention
intervention
1 yr
2 yrs
3 yrs
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
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
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.
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.
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
Complementary Foods: Healthy Start
Guidelines for Infants and Toddlers
(JADA, 2004)
Based on an extensive evidence-based review of
current science
Analytical framework for the Start Healthy
Guidelines for Complementary foods (JADA, 2004)
The Start Healthy Feeding Guidelines for
Infants and Toddlers (JADA, 2004)
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.
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
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
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
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 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:
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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
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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
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.
AAP Recommendations
• Introduce 1 “single ingredient” new food at a
time (3-5 days).
– Allergy
– Rice cereal least likely to cause allergic rx
• Choose 1st 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 1st
year
– 8-15 exposures for acceptance
• Withhold cows milk in 1st year
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
Jackson
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8 month old formula fed infant
Takes 40 ounces of formula
Weight gain appropriate.
All growth parameters tracking at the 50-75th
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.
Myra
• Exclusively breastfed 6 month old infant.
• Growth from birth to 4 months tracking at
25th percentile for all parameters. At 6
months, weight decreased to between 510th percentile. Hct is 30.
• Mother is concerned about “decreasing
milk supply”