Infant Feeding and Transitions

Sociology of food Feeding relationship Development and feeding Nutritional Considerations Safety Public Health vs Individualized approach

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

Why Transition to solid food? Factors/Considerations? Need?

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

Foods for infants and young children Nurturing Nourishing Learning Relationship Development Emotion and temperament

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

Sociology of Food Food Acceptance Taste/Preference Hunger/Satiety Feeding Relationship Development Experience Repeat exposure ??????

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

Temperament Easy: approaches novelty, positive mood, adaptable, regular, active, low intensity Slow to warm: withdraws from novelty, low mood, low activity, moderate to low intensity, cautious Difficult: withdrawing, low adaptability, high intensity, low regularity, negative mood

Experience

Taste and Smell Initial experiences of flavors occur prior to birth Amniotic fluid flavors---  maternal diet Breast milk odor/flavor--  maternal diet Sweet preference (Lactose) – More frequent and stronger sucking behavior in response to sucrose – Ability to detect other flavors (ie salt) emerges later (~ 4 months)

Experience Familiarity plays a significant part in food acceptance Research indicates it may take up to exposures to a new food for an infant to readily accept a food Other modifiers: caregivers attitude, positive experience, observation of others eating

Mechanisms of Appetite Regulation Poorly and incompletely understood Genetics Pleasure-seeking and hedonic responses to feed intake are mediated by humoral substances (endorphins, dopamine, etc) Interaction between hormones, nutrients, and neuronal signals with the CNS Appetite stimulus: ghrelin Appetite inhibition: CCK, leptin, GLP-1 etc) GI volume sensitive feedback loops (ie distention)

The feeding relationship Nourishing and nurturing Supports developmental tasks Learning Relationship Development Emotion and temperament

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.

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

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

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

Development Oral- Motor development Neurophysiologic development Homeostasis Attachment Separation and individuation

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

Feeding behavior of infants Gessell A, Ilg FL

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. 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 GI development Renal maturation – RSL

Transitions When Why What Safety and other considerations

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

Why 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 Developmental Readiness Experience ↔ Development

AAP: Cow’s Milk in Infancy Objections include: – Cow’s milk poor source of iron – GI blood loss may continue past 6 months – Bovine milk protein and Ca inhibit Fe absorption – Increased risk of hypernatremic dehydration with illness – Limited essential fatty acids, vitamin C, zinc – Excessive protein intake with low fat milks

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.

Solids: Some studies find exclusive breastfeeding for 9 months supports adequate growth. Some infants may need additional energy sources earlier. Factors determining energy adequacy include – Individual needs – Maternal production – Breastfeeding management Iron needs have individual variation.

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 Energy Iron Zinc Safety and Health Considerations Choking Allergies Mercury Honey/Botulism Other contaminants Nitrates feeding

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

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 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.

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.

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

Safety Honey Nitrates Other

Honey Honey or honey containing products may be contaminated with C. botulina spores. Infant GI track cannot destroy these spores When consumed by infants <12 months toxin produced by these spores cause infant botulism

Nitrates: Methemoglobinemia in Nitrates in food and water – 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

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

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

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 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 Desserts and candy Baby food desserts Cakes, pies, cookies and pastries Baby cookies * Other cookies—— Ice cream—— Other sweets Sugar, syrups, preserves Sweetened beverages—— * 35.8 Carbonated sodas——1.7— Fruit flavored drinks——13.2 * * 29.5 Any type of salty snack—— *Significantly different from non-Hispanics at P<.05.

Early introduction Late introduction Readiness allergy Weight gain

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

Allergy Updates Early introduction (<4 months) Late introduction (>6 months) Dose dependent New AAP statement

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.

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

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

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

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

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 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 Desserts and candy Baby food desserts Cakes, pies, cookies and pastries Baby cookies * Other cookies—— Ice cream—— Other sweets Sugar, syrups, preserves Sweetened beverages—— * 35.8 Carbonated sodas——1.7— Fruit flavored drinks——13.2 * * 29.5 Any type of salty snack—— *Significantly different from non-Hispanics at P<.05.