Transitions in infant feeding during the first year of life

Infants with cystic fibrosis have altered fecal functional capacities with potential clinical and metabolic consequences

Background

Infants with cystic fibrosis (CF) suffer from gastrointestinal (GI) complications, including pancreatic insufficiency and intestinal inflammation, which have been associated with impaired nutrition and growth. Recent evidence identified altered fecal microbiota taxonomic compositions in infants with CF relative to healthy infants that were characterized by differences in the abundances of taxa associated with GI health and nutrition. Furthermore, these taxonomic differences were more pronounced in low length infants with CF, suggesting a potential link to linear growth failure. We hypothesized that these differences would entail shifts in the microbiome’s functional capacities that could contribute to inflammation and nutritional failure in infants with CF.

Results

To test this hypothesis, we compared fecal microbial metagenomic content between healthy infants and infants with CF, supplemented with an analysis of fecal metabolomes in infants with CF. We identified notable differences in CF fecal microbial functional capacities, including metabolic and environmental response functions, compared to healthy infants that intensified during the first year of life. A machine learning-based longitudinal metagenomic age analysis of healthy and CF fecal metagenomic functional profiles further demonstrated that these differences are characterized by a CF-associated delay in the development of these functional capacities. Moreover, we found metagenomic differences in functions related to metabolism among infants with CF that were associated with diet and antibiotic exposure, and identified several taxa as potential drivers of these functional differences. An integrated metagenomic and metabolomic analysis further revealed that abundances of several fecal GI metabolites important for nutrient absorption, including three bile acids, correlated with specific microbes in infants with CF.

Conclusions

Our results highlight several metagenomic and metabolomic factors, including bile acids and other microbial metabolites, that may impact nutrition, growth, and GI health in infants with CF. These factors could serve as promising avenues for novel microbiome-based therapeutics to improve health outcomes in these infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-021-02305-z.

Infant feeding pattern in the first six months of age in USA: a follow-up study

Background

Infant feeding may consist of direct breastfeeding (DBF), pumping and bottle feeding (P&F), formula feeding (FF), solid food feeding (SFF), and any combination. An accurate evaluation of infant feeding requires descriptions of different patterns, consistency, and transition over time.

Methods

In United States of America, the Infant Feeding Practice Study II collected information on the mode of feeding on nine occasions in 12 months. We focused on the first 6 months with six feeding occasions. To determine the longitudinal patterns of feeding the latent class transition analyses was applied and assessed the transition probabilities between these classes over time.

Results

Over 6 months, 1899 mothers provided feeding information. In month 1 the largest latent class is FF (32.9%) followed by DBF (23.8%). In month 2, a substantial proportion of the FF class included SFF; which increases over time. A not allocated class, due to missing information was identified in months 1-3, transitions to SFF starting in month 4 (8.9%). In month 1, two mixed patterns exist: DBF and P&F combined with FF (13.9%) and DBF combined with P&F (18.7%). The triple combination of DBF, P&F, and FF (13.9%) became FF in month 2 (transition probability: 24.8%), and DBF in combination with P&F (transition probability: 49.1%). The pattern of DBF combined with P&F is relatively stable until month 4, when at least 50% of these infants receive solid food. Only 23-26% of the infants receive direct breastfeeding (DBF) in months 1-4, in month 5-6 SFF is added. Mothers who used FF were less educated and employed fulltime. Mothers who smoke and not residing in the west of the United States were also more likely to practice formula feeding.

Conclusion

Infant feeding is complex. Breastfeeding is not predominant and we additionally considered the mixed patterns of feeding. To facilitate direct breastfeeding, a substantial increase in the duration of maternal leave is necessary in the United States.

Infant Feeding Practices in a Multi-Ethnic Asian Cohort: The GUSTO Study

The optimal introduction of complementary foods provides infants with nutritionally balanced diets and establishes healthy eating habits. The documentation of infant feeding practices in multi-ethnic Asian populations is limited. In a Singapore cohort study (GUSTO), 842 mother-infant dyads were interviewed regarding their feeding practices when the infants were aged 9 and 12 months. In the first year, 20.5% of infants were given dietary supplements, while 5.7% took probiotics and 15.7% homeopathic preparations. At age 9 months, 45.8% of infants had seasonings added to their foods, increasing to 56.3% at 12 months. At age 12 months, 32.7% of infants were given blended food, although 92.3% had begun some form of self-feeding. Additionally, 87.4% of infants were fed milk via a bottle, while a third of them had food items added into their bottles. At both time points, more than a third of infants were provided sweetened drinks via the bottle. Infants of Indian ethnicity were more likely to be given dietary supplements, have oil and seasonings added to their foods and consumed sweetened drinks from the bottle (p < 0.001). These findings provide a better understanding of variations in infant feeding practices, so that healthcare professionals can offer more targeted and culturally-appropriate advice.

Junk food seen at pediatric clinic visits: is it a problem?

OBJECTIVE

To document the prevalence of junk foods seen at clinic visits.

DESIGN

A cross-sectional 23-item survey of observed food items were completed by medical staff using a convenience sample of families from June 2, 2011 to March 2, 2012.

SETTING

The study was conducted in pediatric clinics affiliated with the University of Texas Medical School at Houston.

PARTICIPANTS

A convenience sample consisting of 738 families with children from 4 months to 16 years old presenting for visits were included in the study. Children exclusively breast and formula fed was excluded.

RESULTS

Junk food was observed 20.9% at the clinic visits.

CONCLUSIONS AND RELEVANCE

Junk food was often seen at clinic visits. There was a trend toward higher body mass index in patients whose families had junk food at the visit.

Repeated exposure of infants at complementary feeding to a vegetable puree increases acceptance as effectively as flavor-flavor learning and more effectively than flavor-nutrient learning

Children's vegetable consumption is below the public health recommendations. This study aimed to compare learning mechanisms to increase vegetable acceptance in infants at complementary feeding, namely repeated exposure (RE), flavor-flavor learning (FFL), and flavor-nutrient learning (FNL); measure the stability of the learning effect; and examine the impact of infants' feeding history on vegetable acceptance. The study was composed of a preexposure test, an exposure period, a postexposure test, and tests at 2-wk, 3-mo, and 6-mo follow-ups. At pre- and postexposure, a basic artichoke purée and carrot purée were presented to 95 French infants (6.4 ± 0.8 mo). During the exposure period, infants were randomly split into 3 groups and were exposed 10 times to the basic (RE group; 2 kJ/g; n = 32), a sweet (FFL group; 2 kJ/g; n = 32), or an energy-dense (FNL group; 6 kJ/g; n = 31) artichoke purée 2 or 3 times/wk. To evaluate acceptance, intake (g) and liking were recorded at home by parents. Between pre- and postexposure, intake of the basic artichoke purée significantly increased in the RE (+63%) and FFL (+39%) groups but not in the FNL group; liking increased only in the RE group (+21%). After exposure, artichoke was as much consumed and as much liked as carrot only in the RE group. Learning of artichoke acceptance was stable up to 3 mo postexposure. Initial artichoke intake was significantly related to the number of vegetables offered before the study started. RE is as effective as and simpler to implement than FFL and more effective than FNL for increasing vegetable acceptance at complementary feeding.

Complementary foods and flavor experiences: setting the foundation

Increased fruit and vegetable consumption early in life may lead to life-long intake of fruits and vegetables, which in turn may be beneficial for weight control and other health outcomes in later life. Although health officials worldwide recommend delaying solid foods until 6 months of age, younger infants often receive solid food, which may affect later obesity rates. The timing of introduction to solid foods is important both nutritionally and developmentally and may affect acceptance of foods both in infancy and later in life. Infants can clearly discriminate the flavors of different fruits and vegetables. Repeated flavor experiences promote the willingness to eat a variety of foods: infants will consume more of foods that have a familiar flavor and are more accepting of novel flavors if they have experience with flavor variety. Many flavors that the mother either ingests or inhales are transmitted to her milk and/or amniotic fluid. Mothers can help the transition from a diet exclusively of milk or formula to a mixed diet by providing the infant familiar flavors in both milk or formula and solid foods. Exposure to a variety of flavors during and between meals appears to facilitate acceptance of novel foods. Providing novelty in the context of a familiar food might prove to be an optimal combination to progressively accustom infants to a diversity of novel foods. When repeatedly exposing infants to flavors of some vegetables that have bitter tastes, mothers should focus not on infants' facial expressions but on their willingness to eat the food and should continue to provide repeated opportunities to taste the food. Introducing children repeatedly to individual as well as a variety of fruits and vegetables, both within and between meals, might help them be more accepting of fruits and vegetables, which is difficult to enhance beyond toddlerhood.

Prevention of obesity in preschool children

Obesity is a serious problem that affects children from diverse ethnic backgrounds in both industrialised and developing countries. Worldwide, an estimated twenty-two million children <5 years of age were overweight in 2007. In the UK if current trends continue an estimated one-quarter of all children <16 years of age will be obese by 2050. Recent evidence suggests that most obesity is established during the preschool years, and because one in five obese 4 year olds will become obese adults this situation has major implications for public health. The causes of obesity in preschool children are complex and multifactorial. Although 30–50% of the predisposition towards obesity in preschool children can be explained by genetic factors, environmental influences also play a crucial role. The preschool period in particular is a pivotal time during which long-term dietary and physical activity habits are established, with potential lifelong effects on health. However, research in this age-group is limited. Previous studies have aimed to improve diet, increase physical activity and achieve behavioural change. However, few of these studies have been successful and there is an urgent need, therefore, for the development of evidence-based interventions aimed at the prevention of preschool obesity.

Pooled energy budget and human life history

Human life history contains a series of paradoxes not easily explained by classical life history theory. Although overall reproductive output is higher than in related primates, juvenile growth is slower and age-specific reproductive rates decline faster with age. A simple energetic model would predict that growth and reproductive rates should be positively correlated and that reproductive effort should not decelerate with age. The pattern of negative correlations in humans suggest the presence of trade-offs among peak reproductive rate, childhood growth, and reproductive rate at older ages. To address this puzzle, we propose a synthesis of reproductive ecology and behavioral ecology focused on intra- and inter-somatic energy transfers. This integration includes three concepts: the mother as final common pathway through which energy must pass to result in offspring; a distinction between direct and indirect reproductive effort, proposing the latter as a novel net energy allocation category relative to growth and direct reproductive effort; and a pooled energy budget representing the energetic contributions and withdrawals of all members of a breeding community. Individuals at all reproductive life stages are considered in light of their contributions to the pooled energy budget.

Early milk feeding influences taste acceptance and liking during infancy

BACKGROUND

We identified a model system that exploits the inherent taste variation in early feedings to investigate food preference development.

OBJECTIVE

The objective was to determine whether exposure to differing concentrations of taste compounds in milk and formulas modifies acceptance of exemplars of the 5 basic taste qualities in a familiar food matrix. Specifically, we examined the effects of consuming hydrolyzed casein formulas (HCFs), which have pronounced bitter, sour, and savory tastes compared with breast milk (BM) and bovine milk-based formulas (MFs), in which these taste qualities are weaker.

DESIGN

Subgroups of BM-, MF- and HCF-fed infants, some of whom were fed table foods, were studied on 6 occasions to measure acceptance of sweet, salty, bitter, savory, sour, and plain cereals.

RESULTS

In infants not yet eating table foods, the HCF group ate significantly more savory-, bitter-, and sour-tasting and plain cereals than did the BM or MF groups. HCF infants displayed fewer facial expressions of distaste while eating the bitter and savory cereals, and they and BM infants were more likely to smile while they were eating the savory cereal. In formula-fed infants eating table foods, preferences for the basic tastes reflected the types of foods they were being fed. In general, those infants who ate more food displayed fewer faces of distaste.

CONCLUSIONS

The type of formula fed to infants has an effect on their response to taste compounds in cereal before solid food introduction. This model system of research investigation sheds light on sources of individual differences in taste and perhaps cultural food preferences.

Psychosocial Determinants of the Early Introduction of Complementary Foods

Infant feeding guidelines recommend exclusive breast-feeding to the age of 6 months; complementary foods should not be introduced before this age. This study examined parent and infant psychosocial determinants of the early introduction of complementary foods. Analyses were conducted on a representative sample of children born in Québec (Canada) in 1998 ( n = 2,223), surveyed through the Québec Longitudinal Study of Child Development. Of the children, 61% received complementary foods prior to the age of 4 months. A multiple logistic regression analysis revealed the early introduction of complementary foods was more likely when mothers were younger, less educated, of lower socioeconomic class, and when they felt they had little influence on their child's development. Higher parental confidence in caring for the infant was also associated with the early introduction of complementary foods ( p ≤ .05). Future research must carefully consider the psychosocial aspects involved in adhering to infant feeding guidelines.

Measuring the effects of nutritional counseling on total infant diet in a randomized controlled intervention trial

OBJECTIVES

To examine the effects of nutritional counseling for the infant diet focused on complementary feeding and total diet by use of dietary scores.

PATIENTS AND METHODS

In a randomized controlled intervention trial, 183 mothers of full-term infants were allocated to 4 intervention groups (IG0-IG3). Intervention consisted of dietary counseling based on the food-based guidelines for infant nutrition in Germany. Counseling was done in 3 different forms: a telephone hotline (IG1), then written information (IG2), followed by additional personal telephone counseling (IG3). The IG0 group was not counseled at all. The actual diet of the infants was assessed by telephone interviews when the infants were 2, 4, 6, 9, and 12 months old and evaluated by food-based and meal-based dietary scores.

RESULTS

Plausible, although often not statistically significant, effects of counseling were found for several single scores at various age points. Total diet during the first year of life was significantly closer to the recommendations in the most intensively counseled group than in the non-counseled and lowest-counseled groups. Telephone counseling proved to be more effective than distribution of written material.

CONCLUSIONS

The measured effects of the innovative approach of personal telephone counseling point to the advantages of giving dietary advice to mothers of infants by means of personal contacts and suggest that positive effects on dietary habits may even be greater by face-to-face talks between mothers and experts.

Food-related sensory experience from birth through weaning: contrasted patterns in two nearby European regions

This study describes infant feeding practices among mothers from two European regions from the perspective of early sensory experiences. Two groups of mothers, one in Dijon , France (n=139), the other in Aalen , Germany (n=157) with infants aged 4-9 months were interviewed using a structured questionnaire. Clear between- and within-group differences in weaning practices were found, particularly with respect to breastfeeding duration (Aalen>Dijon) and exposure to flavour variety early in weaning (Dijon>Aalen). By 4 months, 65% of infants in Dijon and 20% in Aalen, had received their first non-milk, solid foods. Before beginning to wean, 39% of mothers in Dijon offered their infant a variety of foods "just for a taste". This was the case for only 25% of mothers in Aalen. During the first 28 days of weaning, infants in Dijon were offered a greater number of vegetables compared to those in Aalen and more frequent changes from day-to-day. Thus, while Aalen infants were likely to be exposed for a longer period to different sensory experiences via breast milk, Dijon infants tended to be exposed to a greater flavour variety during the first weeks of weaning.

Vegetable acceptance by infants: effects of formula flavors

Individual differences in acceptance patterns are evident as early as the child's first experiences with a particular food. To test hypothesis that the flavor of formula fed to infants modifies their acceptance of some foods, we conducted a within- and between-subjects design study in which two groups of 6- to 11-month-old infants were tested on two separate days. One group was currently feeding a milk-based formula whereas the other was feeding a protein hydrolysate formula, a particularly unpleasant tasting formula to adults that contains similar flavor notes (e.g., sulfur volatiles) with Brassica vegetables such as broccoli. In counterbalanced order, acceptance of pureed broccoli/cauliflower was determined during one test session and pureed carrots on the other. Although there were no group differences in the amount of carrots consumed, hydrolysate infants consumed significantly less broccoli/cauliflower relative to carrots when compared to those who were currently fed milk based formulas (F(1,72 df)=4.43; p=0.04). The mothers of hydrolysate infants were significantly more likely to report that their infants did not enjoy feeding the broccoli/cauliflower (54.2%) when compared to mothers of infants being fed milk-based formulas (28.0%; Chi-Square (1 df)=4.79; p=0.03). Such findings are consistent with prior research that demonstrated a sensory specific satiety following repeated exposure to a particular flavor in milk. We hypothesize that when infants are experiencing a flavor in milk or formula, in the short term, the preference that develops is specific to the context it is experienced in (e.g., milk). Over the longer term, the preference may generalize to other contexts such as solid foods. Hydrolysate infants were also significantly more likely to be judged by their mothers as being more active (F(1,69 df)=3.95; p=0.05) and hesitant (F(1,69 df)=6.55; p=0.01) when compared to those infants who were feeding milk-based formulas, a finding that further supports the hypothesis that mother-child dynamics surrounding early feeding impacts upon mothers' perception of their children's temperament.

Feeding Infants and Toddlers Study: meal and snack intakes of Hispanic and non-Hispanic infants and toddlers

OBJECTIVE

To describe meal and snack patterns of Hispanic and non-Hispanic infants and toddlers.

DESIGN

A cross-sectional telephone survey in which mothers or other primary caregivers reported their infants' and toddlers' food and beverage intake for a 24-hour period.

SUBJECTS/SETTING

Subjects were a subset of the national random sample of children aged 4-24 months who participated in the 2002 Feeding Infants and Toddlers Study. The Feeding Infants and Toddlers Study includes a stratified random sample of 3,022 infants and toddlers aged 4-24 months. Three hundred seventy-one Hispanic and 2,637 non-Hispanic children who had 24-hour dietary recalls are included in the subset.

ANALYSES

Means+/-standard errors of daily intakes of energy, nutrients, and nutrient densities were calculated, as were percentages of children consuming foods at each eating occasion.

RESULTS

Hispanic and non-Hispanic infants and toddlers, on average, were fed seven times per day. Overall, the percentages of children who ate snacks increased with age, and more than 80% of toddlers aged 12-24 months consumed afternoon snacks, with more than 90% of Hispanic children consuming an afternoon snack. In each age group, there were significant differences between ethnic groups in nutrient intakes by eating occasion. No significant difference was seen for energy across all meal occasions. At age 6-11 months, Hispanic children had a significantly lower intake of carbohydrate at dinner and lower intake of saturated fat at afternoon snacks compared with non-Hispanic children (P<.05). The main difference between Hispanic children's and non-Hispanic children's intakes by eating occasion is at age 12-24 months. Hispanics aged 12-24 months had significantly (P<.05) lower percentages of energy from fat and saturated fat and a significantly (P<.05) higher percentage of carbohydrate at lunch compared with non-Hispanic children. For dinner, Hispanic toddlers had significantly (P<.05) lower intakes of total fat and saturated fat compared with non-Hispanic toddlers at age 12-24 months. Overall fiber intake contributed 2 g/meal for both ethnic groups. Snacks contributed, on average, less than 1 g fiber, except Hispanic toddlers had significantly higher fiber intake at afternoon snacks (1.5 g) than non-Hispanic toddlers. Foods frequently consumed at meals and snacks were lacking in whole grains, vegetables, and fruits. Most nutrients were not significantly different between Hispanics and non-Hispanics for meals and snacks.

CONCLUSIONS

Considering the sizeable contribution that snacks make toward overall energy, parents and caregivers should plan toddlers' snacks to complement meals by including additional fruits, vegetables, and whole grains that are culturally appropriate rather than fruit drinks, cookies, and crackers. This will increase fiber intake and limit fat and sugar intakes. To develop healthful eating patterns, introduce toddlers to foods eight to 10 times to increase food acceptance and the likelihood of establishing healthful eating patterns. Dietetics professionals need to consider cultural differences when developing meal and snack patterns for Hispanic and non-Hispanic infants and toddlers.

[Feeding practices in infants: a 6-month prospective cohort study]

The aims of this work were to assess timing of complementary feeding in infants and to precise the underlying factors that may cause inappropriate complementary feeding.

PATIENTS AND METHODS

A cohort of 167 newborns, born in the same maternity ward during a 6 week-period, was prospectively analyzed. Only healthy neonates were included in the study. A phone questionnaire was filled at 4 and 6 months of age to evaluate modality of complementary feeding. Multivariate analysis (segmentation tree, analyse by multiple correspondence) was used to study factors associated with inappropriate diversification.

RESULTS

Out of the 167 neonates included in the study, 132 mothers could be contacted at 4 months and 116 at 6 months of age. Sixty-seven per cent of mothers started breast feeding at birth. Among these, 33% still breastfed -at least partially- at 4 months and 17% at 6 months. Fifty-two percent of mothers started complementary feeding before 4 months, and 24% of infants received gluten at 4 months of age. Multi-gravida mothers, mothers aged more than 35 years old and mothers who gave infant or follow-up formulae before 4 months, started complementary feeding significantly earlier (P<0.05). Infants who were formula fed received more frequently complementary feeding before the age of 4 months than breast fed infants (57% vs 33%, P<0.05).

CONCLUSION

Our study showed that half of infants were introduced solid food too early and allowed to identify a population at risk that could benefit from nutritional intervention programs.

What Do Québec Children Eat During Their First Six Months?

Study objectives were to describe the introduction of foods and beverages and the use of vitamin and/or mineral supplements among infants aged six months, and to identify factors associated with following Québec recommendations on introducing foods and beverages. Study subjects were primiparous women interviewed by phone when their infants were approximately six months old. Data were gathered on foods and beverages offered to infants, the age at which these were introduced, and supplements. The use of each food, beverage, and supplement was evaluated according to recommendations. Mean age at which foods were introduced and proportions of women who followed recommendations were calculated. Multivariate logistic regression models were used to identify the factors associated with following recommendations. Results indicated that among the 1,937 interviewed mothers, 212 (10.9%) exclusively breast-fed their infants before age four months, 1,073 (55.4%) breast-fed their infants at birth but gave them formula or foods before age four months, and 652 (33.7%) formula-fed their infants at birth. Factors associated with adherence to recommendations were breast-feeding exclusively, being older than 30 years, an annual family income of at least $60,000, and being a non-smoker. Few mothers followed all the recommendations.

Introduction of food during the infant's first year: a study with emphasis on introduction of gluten and of egg, fish and peanut in allergy-risk families

AIM

The aim of the current study was to retrospectively examine introduction of food during the first year in a representative sample of Swedish children. A secondary aim was to study how parents with history of atopy introduced food to their infants.

METHODS

Data derive from 467 infants who visited child health centres in three different counties in Sweden for health check-up at 12 mo of age. The parents were asked to fill in a questionnaire about breastfeeding and/or formula feeding, time of introduction of weaning food focusing on cow's milk, follow-on formula, porridge, fish and egg. Questions regarding hypersensitivity in the family, peanut consumption of mother as well as in the child, and questions about number of siblings, ethnic background and parental education were included.

RESULTS

Compliance with suggested introduction of gluten-containing food was low; as many as 45% had avoided gluten until 6 mo of age, instead of introducing gluten between 4 and 6 mo. Only 33% of parents with stated family hypersensitivity avoided giving their child fish and 23% avoided egg during the first year, even though this recommendation was present at the time of the study. Almost 50% of all mothers had avoided peanuts during pregnancy even though there was no such advice. The avoidance of peanut was not connected to hypersensitivity in the family.

CONCLUSION

These results suggest that time of introduction of gluten was not in accordance with the current recommendation. The results imply that there is a need to follow up if and how this feeding information is distributed to parents with infants and also to sharpen the information to the right target groups, otherwise implementation of preventive strategies will be less useful.

Longitudinal calcium intake is negatively related to children's body fat indexes

OBJECTIVE

To determine if dietary calcium was negatively related to children's body fat (BF), if BF indexes and calcium intakes changed over time, and to identify variables related to BF and calcium intake.

DESIGN

Percent BF and kg BF were assessed by dual energy x-ray absorptiometry (DEXA) in 8-year-old children. In a prospective design, height, weight, dietary intakes, and related variables were monitored longitudinally from ages 2 months to 8 years during in-home interviews.

SUBJECTS

Fifty-two white children, (n=25 boys, 27 girls) participated in a longitudinal study with their mothers. At 8 years of age, mean BMI was 17.3+/-2.1 (standard deviation) for boys and 17.1+/-2.5 for girls.

ANALYSES

Regression analysis of all variables, followed by further regression analysis on selected models.

RESULTS

At 8 years, percent BF was 22.7+/-6.7 for boys and 26.2+/-7.9 for girls, as assessed by DEXA. Dietary calcium (mg) and polyunsaturated fat intake (g) were negatively related to percent BF (P=.02 to.04) in 3 statistical models, which predicted 28% to 34% of the variability in BF among children. Variables positively associated with percent BF were total dietary fat (g) or saturated fat (g), female gender, sedentary activity (hours/day), father's BMI, and mothers' percent BF. Calcium intakes were significantly correlated over time. Dietary variety was positively related to calcium intake, and intakes of carbonated beverages and other sweetened beverages were negatively related.

APPLICATIONS/CONCLUSIONS

Children should be strongly encouraged to regularly include calcium-rich foods and beverages in their diets.

Transitions in infants’ and toddlers’ beverage patterns

OBJECTIVE

To describe transitions and patterns in infants' and toddlers' beverage intakes, with focus on nonmilk beverages.

DESIGN

A cross-sectional study was conducted by telephone to obtain a 24-hour dietary recall of infants' and toddlers' food intakes, as reported by mothers or other primary caregivers.

SUBJECTS

A nationwide sample of infants and toddlers (n=3,022) ages 4 to 24 months, who participated in the Feeding Infants and Toddlers Study (FITS).

ANALYSES

Beverages were categorized as total milks (ie, breast milk, infant formulas, cow's milk, soy milk, goat's milk), 100% juices, fruit drinks, carbonated beverages, water, and "other." Analyses included means +/- standard deviations, percentages, frequencies, nutrient densities, and linear regression.

RESULTS

Beverages provided 84% of total daily food energy for infants 4 to 6 months of age, decreasing to 36% at ages 19 to 24 months. Apple juice and apple-flavored fruit drinks were the most frequently consumed beverages in the 100% juice and fruit drink categories, respectively. Juices, fruit drinks, and carbonated beverages appeared to displace milk in toddlers' diets (P<.0001).

APPLICATIONS/CONCLUSIONS

This research shows that beverages make important contributions to infants' and toddlers' energy and nutrient needs, but they must be wisely chosen. Registered dietitians should advise parents and caregivers that excessive intakes of any beverage, including milks and 100% juices, may displace other foods and beverages in the diet and/or contribute to excess food energy (kcal). Further research is needed to define excessive amounts in each beverage category, and such guidance could be very useful to parents and caregivers of infants and toddlers.

Feeding infants and toddlers study: what foods are infants and toddlers eating?

OBJECTIVE

To describe the food consumption patterns of US infants and toddlers, 4 to 24 months of age.

DESIGN

Descriptive analysis of data collected in the 2002 Feeding Infants and Toddlers study based on telephone interviews and 24-hour dietary recalls.

SUBJECTS

A national random sample of 3,022 infants and toddlers age 4 to 24 months.

STATISTICAL ANALYSES PERFORMED

The percentage of infants and toddlers consuming foods from specific food groups was estimated for six age groups, using a single 24-hour recall.

RESULTS

Infants as young as 7 months of age showed food patterns that have been observed in older children and adults. From 18% to 33% of infants and toddlers between ages 7 and 24 months consumed no discrete servings of vegetables, and 23% to 33% consumed no fruits. French fries were one of the three most common vegetables consumed by infants 9 to 11 months of age. By 15 to 18 months, french fries were the most common vegetable. Almost half (46%) of 7- to 8-month-olds consumed some type of dessert, sweet, or sweetened beverage, and this percentage increased as age increased. By 19 to 24 months, 62% of toddlers consumed a baked dessert, 20% consumed candy, and 44% consumed a sweetened beverage.

APPLICATIONS

Parents and caregivers should be encouraged to offer a wide variety of vegetables and fruits daily, with emphasis on dark green, leafy, and deep yellow vegetables and colorful fruits. They should offer desserts, sweets, sweetened beverages, and salty snacks only occasionally, offering nutrient-dense, age-appropriate foods as alternatives (eg, fruit, cheese, yogurt, and cereals). Water, milk, and 100% fruit juices should be offered as alternative beverages. Because family food choices influence what foods are offered to children, family-based approaches to developing healthy eating habits may be helpful.

Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children?

OBJECTIVE

To determine if food-related experiences in the first 2 years of life predict dietary variety in school-aged children.

DESIGN/SETTING

Child/mother pairs were interviewed 7 or 8 times when children were 2 to 24 months using a randomized incomplete block design to schedule interviews. Each child/mother pair was interviewed when the child was ages 6, 7, and 8 years.

PARTICIPANTS

Child/mother pairs (n = 70) were continuous participants in the longitudinal study.

MAIN OUTCOME MEASURES

Dependent variables were children's vegetable and fruit dietary variety, assessed from 3 days of dietary data at ages 6, 7, and 8 years. Independent variables from the first 2 years of life were selected from the longitudinal data set.

ANALYSES

General linear models. Adjustments for age that vegetables (or fruits) were introduced in the diet.

RESULTS

Vegetable variety in the school-aged child was predicted by mother's vegetable preferences, R2 =.084. Fruit variety in the school-aged child was predicted by breast-feeding duration and either early fruit variety (R2 =.254) or fruit exposure (R2 =.246).

CONCLUSIONS/IMPLICATIONS

Nutrition education messages for mothers should emphasize the importance of early food-related experiences to school-aged children's acceptance of a variety of vegetables and fruits.

Determination of macronutrients, by chemical analysis, of home-prepared milk feeding bottles and their contribution to the energy and protein requirements of infants from high and low socioeconomic classes

OBJECTIVES

To determine the macronutrients composition of home-prepared milk feeding bottles, by chemical analysis, and assess their contribution to the energy and protein requirements of children under two years of age from high (HSE) and low (LSE) socioeconomic classes.

METHODS

72 samples were analyzed for energy density and protein, fat and carbohydrate content: 41 from the LSE group and 31 from the HSE group. The assessment of the percentages of the energy and protein requirements met by the consumption of the milk bottles was calculated as follows: the energy and protein per 100 mL obtained through chemical analysis were multiplied by the volume consumed at each feeding, then by the number of feedings per day, the results divided by the energy and protein requirements and multiplied by 100. Energy and protein requirements were those recommended by the FAO/WHO/UNU Committee and the Food and Nutrition Board. The children's weight-for-age index was assessed.

RESULTS

Unmodified cow's milk was largely consumed by both groups. The addition of sugar and other ingredients to the milk was significantly higher in the LSE group. Moisture, protein and fat content were lower in the LSE group, whereas carbohydrate and energy content were higher. The percentages of energy and protein requirements provided by feeding bottles were higher in the LSE group. Children in the LSE group had lower z-scores for weight-for-age.

CONCLUSIONS

Differences in the preparation practices led to differences in the chemical results. The feeding bottles in the LSE group were high in energy, due to the addition of sugar and cereals to the milk in the bottle. The milk feeding bottles were an important weaning food providing more than 50% and 100% of the children's energy and protein requirements, respectively. The children's weight-for-age index was within the normal limits.

Longitudinal study of energy and nutrient intakes for infants from low-income, urban families

OBJECTIVE

To assess the energy and nutrient intakes of healthy infants from low-income families and to compare intakes with current recommendations.

DESIGN

We interviewed mother-infant pairs longitudinally when the infants were 3, 6, 9, 12, 18 and 24 months old. Food intake data were obtained by 24-hour dietary recalls. Selected nutrient intakes were calculated and compared with the Recommended Dietary Allowances (RDAs).

SUBJECTS/SETTING

Infants were the offspring of low-income, pregnant women recruited at the Albany County Department of Health, New York for the Albany Pregnancy and Infancy Lead Study, a prospective investigation of factors related to blood lead levels, including nutrition. Interviews were conducted during paediatric clinic visits.

STATISTICAL ANALYSES PERFORMED

Means and standard deviations were used to describe energy and micronutrient intakes for age groups. The probability approach was utilised to examine the prevalence of inadequate intakes.

RESULTS

Mean energy and nutrient intakes generally met or exceeded the RDA. The exceptions were vitamin D and zinc for which observed means were below the RDA at several data points. Protein consumption was exceptionally high in this sample. The highest estimated prevalences of inadequate intakes were observed for iron, zinc and vitamin D at the older ages.

CONCLUSIONS

This study identified several potential concerns about the diets of infants during the transition from infant food and formula to table foods. Low intakes of vitamin D, zinc and iron, especially at 12 and 18 months, were observed. High protein intakes were noted at all ages.

What Do Infants Really Eat?

This article compares the feeding practices of healthy infants reported by their mothers in studies spanning two decades. Nutrient intakes are largely adequate and feeding practices are changing to meet recommendations, but breast-feeding rates do not meet public health guidelines.

Flavor variety enhances food acceptance in formula-fed infants

BACKGROUND

Research in humans and animal models suggests that acceptance of solid foods by infants during weaning is enhanced by early experiences with flavor variety.

OBJECTIVE

We tested the hypotheses that the acceptance of novel foods by formula-fed infants could be facilitated by providing the infants with a variety of flavors at the time when beikost is first introduced and that, contrary to medical lore, infants who had previously consumed fruit would be less likely to reject vegetables when first introduced than would infants without such an experience.

DESIGN

The infants' acceptance of a novel vegetable (puréed carrot) and a novel meat (puréed chicken) was evaluated after a 9-d exposure period in 3 groups of infants, some of whom had previously consumed fruit. During the home-exposure period, one group was fed only carrots, the target vegetable; a second group was fed only potatoes, a vegetable that differed in flavor from carrots; and a third group was fed a variety of vegetables that did not include carrots.

RESULTS

Infants fed either carrots or a variety of vegetables, but not those fed potatoes, ate significantly more of the carrots after the exposure period. Exposure to a variety of vegetables also facilitated the acceptance of the novel food, puréed chicken, and daily experience with fruit enhanced the infants' initial acceptance of carrots.

CONCLUSION

These findings are the first experimental evidence to indicate that exposure to a variety of flavors enhances acceptance of novel foods in human infants.

Home and videotape intervention delays early complementary feeding among adolescent mothers

BACKGROUND

The American Academy of Pediatrics, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the World Health Organization recommend that infants receive only breast milk or formula for the first 4 to 6 months of life, followed by the introduction of complementary foods. Despite these recommendations, many infants, particularly those with adolescent mothers, receive solid foods (often cereal mixed with formula in a bottle) and liquids other than formula or breast milk in the first few weeks of life. Decisions on early feeding are often guided by grandmothers and influenced by beliefs that infants need complementary food to counteract signals of hunger, reduce crying, and sleep through the night.

OBJECTIVE

This investigation evaluated the efficacy of an intervention to delay the early introduction of complementary feeding among first-time, black, adolescent mothers living in multigenerational households. The intervention focused on reducing the cultural barriers to the acceptance of the recommendations of the American Academy of Pediatrics, WIC, and World Health Organization on complementary feeding by highlighting 3 topics: 1) recognition of infants' cues; 2) nonfood strategies for managing infant behavior; and 3) mother-grandmother negotiation strategies. The intervention was delivered through a mentorship model in which a videotape made by an advisory group of black adolescent mothers was incorporated into a home-visiting program and evaluated through a randomized, controlled trial.

METHODS

One hundred eighty-one first-time, low-income, black mothers <18 years old, living in multigenerational households were recruited from 3 urban hospitals. Infants were born at term, with birth weight appropriate for gestational age and no congenital problems. Shortly after delivery, mothers and grandmothers completed a baseline assessment and mothers were randomized into an intervention or control group. Intervention group mothers received home visitation every other week for 1 year. At 3 months, a subset of 121 adolescent mothers reported on their infant's intake through a food frequency questionnaire. Mothers who fed their infant only breast milk, formula, or water were classified as optimal feeders. Mothers who provided complementary foods other than breast milk, formula, or water were classified as less optimal feeders.

RESULTS

Sixty-one percent of the infants received complementary foods before 3 months old. Multivariate hierarchical logistic regression was used to evaluate the determinants of being in the optimal versus less optimal feeders group. After controlling for infant age and family income, mothers of infants in the optimal feeders group were more likely to report accurate messages from WIC regarding the timing of complementary food and nearly 4 times more likely to be in the intervention group. The most common complementary food was cereal mixed with formula in the bottle.

CONCLUSIONS

The success of this relatively brief intervention demonstrates the importance of using ecological theory and ethnographic research to design interventions that enable participants to alter their behavior in the face of contradictory cultural norms. The intervention focused on interpreting infants' cues, nonfood methods of managing infant behavior, and mother-grandmother negotiations. It was delivered through methods that were familiar and acceptable to adolescent mothers-a mentorship model incorporating home visits and videotape. The skill-oriented aspects of the intervention delivered in a culturally sensitive context may have enabled the young mothers to follow the guidelines that they received from WIC and from their pediatricians. Strategies, such as those used in this intervention, may be effective in promoting other caregiving recommendations, thereby enabling providers to meet the increasing demands from parents for advice regarding children's early growth and development.

Addition of supplementary foods and infant growth (2 to 24 months)

OBJECTIVE

To determine the effect of adding supplementary foods on infant growth 2 to 8 and 12 to 24 months.

METHODS

Length (cm/month) and weight (kg/month) of white infants (n = 94) were measured five to nine times from 2 to 24 months of age. Mothers reported birth weights, infants' ages at first introduction of supplementary food, illnesses and information sources about infant feeding. Simple linear regression equations were used to compute slopes for each child (unit changes in length and in weight by age). Stepwise linear regression was used to determine the effect on weight and length slopes by the introduction of supplementary foods (e.g., an infant's age when cereal, fruit, juice, vegetables and a meat cluster were first added) to the diet. Breast feeding (months duration or ever fed), illness scores and gender were covariates in the regression models.

RESULTS

A significant model (F = 10.09, p = .002) for weight gain (2 to 8 months) showed that gender explained 10% of the variance; for length slope, the model was non-significant and gender explained 3% of the variance. Females had a slower weight gain compared to that of males. None of the covariates or supplementary foods were retained in the models. Weight prior to 12 months was the best predictor (p = .0001, 54% of the variance) of weight gain 12 to 24 months.

CONCLUSIONS

Unit changes in weight or length for an infant's age were not statistically associated with the timing of when supplementary foods were first added to the diet 2 to 8 or 12 to 24 months. Weight prior to 12 months was a significant predictor of weight gain 12 to 24 months.

Carbohydrate absorption from fruit juices in infants

OBJECTIVE

To compare the absorption of carbohydrate in particular from a lower (10 mL/kg(-1)) quantity than that previously tested, of white grape juice and pear juice after a single feeding and after ingestion twice daily for 2 weeks, and determine their respective effects on stool water content, in healthy infants.

STUDY PARTICIPANTS

Twelve healthy, well-nourished infants, 5 to 9 months of age, who were recruited from the general population.

DESIGN/METHODS

Infants underwent a breath hydrogen test after a serving of pear juice. Three to 5 days later, the test was repeated after a serving of white grape juice. Infants were randomly assigned to receive a 10 mL/kg(-1) serving of grape juice or pear juice twice daily for 2 weeks. The breath tests were repeated after the ingestion of the juices in the same sequence. With the second breath test with pear juice, a charcoal marker and 20 mg (13)C fructose, a stable, nonradioactive isotope, were mixed with the juice. Water content of the stools was compared before and after the 2-week feeding of the juice, and fecal samples were analyzed for (13)C enrichment by mass spectrometry.

RESULTS

After the ingestion of the fruit juices, only 1 infant had an abnormal peak hydrogen (H(2); >/=10 ppm), which followed the pear juice. That same infant was the only one who had H(2) levels >/=10 ppm after grape juice. There was no significant difference in the peak breath H(2) levels after grape juice and pear juice either at the beginning of the study or 2 weeks after taking the juice assigned (2.8 ppm +/- 2.9 vs 6.2 ppm +/- 9, respectively). The difference in breath H(2) response before and after the 2 weeks of fruit juice intake was not significant. Mean (+/-standard deviation) fecal (13)C enrichment at baseline was 3.0 Delta%o (+/-2.4), which was not significantly different from after 2 weeks of juice intake (2.4 Delta%o [+/-1.5]), regardless of the juice assigned: 2.7 Delta%o (+/-1.6) for grape juice and 2.2 Delta%o (+/-1.5) for pear juice. Mean (+/-standard deviation) percentage of fecal water at baseline was 24.1% (+/-5.1), which was not significantly different from after 2 weeks of juice (22.5% [+/-6]), regardless of the juice received: 21.8% (+/-5.8) for grape juice and 23.2% (+/-6.7) for pear juice.

CONCLUSION

When either grape or pear juice is administered in a dosage of 10 mL/kg/day, the carbohydrate is well absorbed, produces no adverse gastrointestinal symptoms, and has no effect on stool water in healthy infants.

Infant feeding practices of low-income, African-American, adolescent mothers: an ecological, multigenerational perspective

The early introduction of non-milk foods among African-American infants has been well documented. Several studies report the addition of semi-solids as early as 1-2 weeks of age. This study investigated, through ethnographic, repeat indepth interviews with teen mothers and grandmothers of infants, the determinants of such feeding practices and the inter-generational factors involved in infant feeding decision-making. Nineteen adolescent mothers were recruited from Baltimore City WIC programs. The teen mothers were interviewed in their homes during four separate visits and the grandmothers at least twice. Ethnographic field guides focused on questions about what, why and how infants were fed and on the 'ethnotheories' of parenting and infant care in this population. All interviews were taped and transcripts were analyzed using text retrieval software. Results confirmed that it is the cultural norm to feed cereal in the bottle and to feed other semi-solid foods within the first month of life. Most grandmothers played the dominant role in deciding what the infant should eat and the timing of the introduction of solids. This pattern occurred both because grandmothers had extensive physical access to their grandchildren and because teen mothers were dependent upon grandmothers. The use of qualitative research methods, with an ecological, multi-generational focus, provides a rich description of the context within which infant feeding decisions are made.

Infant formula preparation, handling, and related practices in the United States

OBJECTIVE

To describe practices related to infant formula feeding: diluting and concentrating formula, mixing formula with warm tap water, sterilizing, storing prepared formula, heating in a microwave oven, putting the baby to bed with a bottle, and adding cereal and sweeteners to formula; to analyze characteristics related to compliance with recommended practices; and to examine the relation between formula handling and infant diarrhea.

SUBJECTS/DESIGN

Subjects were mothers who fed their infants formula (more than 1,000 subjects at each infant age). Data are from the US Food and Drug Administration's Infant Feeding Practices Study (IFPS), a national longitudinal survey with a nonprobability sample. Data were collected by mail, and formula practices were included at infant ages 2, 5, and 7 months.

STATISTICAL ANALYSES PERFORMED

Logistic regression was conducted and percentages and odds ratios were calculated, adjusting for instruction in preparing formula from a health care professional, education, income, age, parity, work status, and breast-feeding practices.

RESULTS

Failure to comply with recommendations was high for several practices with clear health implications; 33% of mothers mixed formula with warm tap water and up to 48% heated bottles in a microwave oven. Mothers of 2-month-old infants who received instruction from a health care professional and who breast-fed showed increased compliance, but few demographic characteristics, such as education, were related. Diarrhea increased with ambient holding of formula for older infants.

APPLICATION

Advice from a health care professional can improve formula-handling behaviors. Dietitians and other health care professionals should provide information on proper preparation and handling of infant formula to all infant caregivers.

Fruit juice intake is not related to children's growth

BACKGROUND

Excessive fruit juice intake (>12 ounces/day) has been reported to be associated with short stature and obesity in preschool children.

OBJECTIVE

To confirm whether excess fruit juice intake was associated with short stature and obesity in preschool children, we assessed growth parameters and fruit juice intake in 105 white children, ages 24 to 36 months.

METHODOLOGY

Mothers were interviewed twice by a registered dietitian when children were age 24, 28, or 32 months (interview 1) and when children were age 28, 32, or 36 months (interview 2); interviews were assigned randomly. At each interview mothers provided 3 days of dietary data (one 24-hour recall and a 2-day food record) and the registered dietitian weighed the child and measured his/her height. Dietary data were analyzed using Nutritionist IV software. Each child's body mass index (wt/ht2) and ponderal index (wt/ht3) were calculated for each interview. Growth parameters of children consuming <12 ounces/day 100% fruit juice were compared with those consuming >/=12 ounces/day using the Student's t test, chi2, Fisher's exact test, and mixed model repeated measures analyses (PROC MIXED).

RESULTS

Results consistently indicated no statistically significant differences in children's height, body mass index, or ponderal index related to fruit juice intake. Intakes of soda pop were negatively related to intakes of milk and fruit juice although intakes of milk and fruit juice were not related.

CONCLUSIONS

The consistent lack of relationship between children's fruit juice intake and growth parameters in our study does not support previous recommendations to limit the intake of 100% fruit juice to <12 ounces/day.

Implications of the weaning pattern on macronutrient intake, food volume and energy density in non-breastfed infants during the first year of life

OBJECTIVES

To evaluate the implications of the patterns of weaning on the intake of macronutrients, energy intake, food volume and the energy density in healthy infants in the Mediterranean area of Spain.

SUBJECTS AND STUDY DESIGN

Cross-sectional study of 120 clinically-healthy, non-breastfed infants at the ages of 4, 6, 9 and 12 months randomly recruited from three pediatric out-patient clinics. Nutrition data were obtained from the infant's food preparer using the 24-hour dietary recall method.

RESULTS

Energy intake/kg body weight was within the recommended daily allowance and did not vary significantly with age (423 kJ/kg body weight at 4 months and 443.7 kJ/kg at 12 months). There was a progressive decrease in the intake volume (p < 0.001) in which carbohydrate-rich foodstuffs were the major factors, and an increase in the energy density (p < 0.001) in which the protein-rich items were the principal contributors. Lipid intake diminished progressively (p < 0.01) to a nadir of 26.4% of energy intake at 9 months of age. In each of the meals there was a tendency towards a progressive increase in energy intake with age. This increase was achieved by a significant increase in energy density (p < 0.001 in all meals, except dinner p < 0.05). Conversely, the intake volume of breakfast, lunch and dinner remained essentially unchanged between 6 and 12 months while that of the mid-evening meal decreased markedly.

CONCLUSION

Increased energy requirements for growth is achieved, mainly, by an increase in the energy density rather than the intake volume during food-item diversification in the non-breastfed infant. Cereals were the central food item in the weaning diet in our study sample and which adequately compensates, in terms of energy requirement, for the early reliance on the lipids contained in milk.

The phenomenon of "picky eater": a behavioral marker in eating patterns of toddlers

OBJECTIVE

To determine if toddlers who were considered "picky eaters" had lower dietary scores than non-picky eaters, and if family environment and socioeconomic status were significantly related to picky eater status and dietary scores.

METHODS

An incomplete block design provided two interviews at randomly assigned times (24, 28, 32, or 36 months) of Caucasian mothers from upper socioeconomic (n=74) and lower socioeconomic status (n=44). Using trained interviewers, 6 days of food intake, two administrations of a questionnaire about toddler's eating behavior, and one administration of the Family Environment Scales were collected in the home. MANOVA, discriminant function analysis, and logistic regression procedures were used to determine significant differences between picky and non-picky eater groups.

RESULTS

Picky eaters had lower dietary variety (p=.03) and diversity scores (p=.009) than non-picky eaters. Mothers of picky eaters compared to those of non-picky eaters used persuasion (p=.0001) and ranked their child's eating behaviors as more problematic (p=.0001).

CONCLUSION

Toddlers perceived by their mothers as picky eaters had significantly lower dietary variety and diversity scores. Parents need information and strategies to increase the number of foods acceptable to their toddlers and to develop a sound feeding plan.