Transcript Infant Feeding transition to solid and table food

Non-milk feedings
• Solids
• Beikost
• Table foods
• 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
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
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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
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
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
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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 Months
Rank
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)
% 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
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
Hispanic
(n=84)
Any type of dessert, sweet,
or sweetened beverage
Age 6-11 Months
NonHispanic
(n=538)
Hispanic
(n=163)
Age 12-24 Months
NonHispanic
(n=1,228)
Hispanic
(n=124)
NonHispanic
(n=87)
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 before 1.00
4 months
1-3 types of food
before 4 months
1.69
4+ types of foods
before 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