Development, Relationship, and Transitions

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

Sociology of Food

• Hunger• Social Status• Social Norms• Religion/Tradition• Nutrition/Health

Sociology of Food

• Food Choices– Availability– Cost– Taste– Value– Marketing Forces– Health– Significance

Foods for infants and young children

• 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 * State regulation

* Neurophysiologic stability

2-6 months Attachment * “falling in love”

* Affective engagement and interaction

6-36 months

Separation and individuation

* 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 Reflexes Oral, Fine, Gross Motor Development 1-3 months

Rooting and suck and swallow reflexes are present at birth

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

4-6 months

Rooting reflex fades Bite reflex fades

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

7-9 months

Gag reflex is less strong as chewing of solids begins and normal gag is developing Choking reflex can be inhibited

Munching movements begin when solid foods are eaten Rotary chewing begins Sits alone Has power of voluntary release and resecural Holds bottle alone Develops an inferior pincer grasp

10-12 months

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– 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

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

• 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)

01020304050607080

1 yr 2 yrs 3 yrs

% of Children With Any Allergic Manifestations (cummulative incidence)

non-interventionintervention

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:

– 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

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

• 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 5-10th percentile. Hct is 30.

• Mother is concerned about “decreasing milk supply”