Trial on timing of introduction to solids and food type on infant growth

Optimal timing of introduction of complementary feeding: a systematic review and meta-analysis

CONTEXT

The timing of introducing complementary feeding (CF) is crucial because premature or delayed CF can be associated with adverse health outcomes in childhood and adulthood.

OBJECTIVE

This systematic review aims to evaluate the impact of the timing of CF introduction on health, nutrition, and developmental outcomes among normal-term infants.

DATA SOURCES

Electronic databases and trial registries were searched, along with the reference lists of the included studies and relevant systematic reviews.

DATA EXTRACTION

Two investigators independently extracted data from the included studies on a standardized data-extraction form.

DATA ANALYSIS

Data were meta-analyzed separately for randomized controlled trials (RCTs) and observational studies on the basis of early introduction of CF (< 3 months, < 4 months, < 6 months of age) or late introduction of CF (> 6 months, > 8 months of age). Evidence was summarized according to GRADE criteria. In total, 268 documents were included in the review, of which 7 were RCTs (from 24 articles) and 217 were observational studies (from 244 articles). Evidence from RCTs did not suggest an impact of early introduction, while low-certainty evidence from observational studies suggested that early introduction of CF (< 6 months) might increase body mass index (BMI) z score and overweight/obesity. Early introduction at < 3 months might increase BMI and odds of lower respiratory tract infection (LRTI), and early introduction at < 4 months might increase height, LRTI, and systolic and diastolic blood pressure (BP). For late introduction of CF, there was a lack of evidence from RCTs, but low-certainty evidence from observational studies suggests that late introduction of CF (> 6 months) might decrease height, BMI, and systolic and diastolic BP and might increase odds of intestinal helminth infection, while late introduction of CF (> 8 months) might increase height-for-age z score.

CONCLUSION

Insufficient evidence does suggest increased adiposity with early introduction of CF. Hence, the current recommendation of introduction of CF should stand, though more robust studies, especially from low- and middle-income settings, are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020218517.

Infant eating behaviors and Milk feeding independently predict infant size

OBJECTIVES

This study investigates the association of infant eating behaviors with infant size, and if those associations are mediated by infant feeding.

METHODS

Mothers with infants less than 12 months of age and living in Central North Carolina were enrolled (N = 61). Data were collected at baseline and at 3- and 6-month follow up visits. Modified constructs from the Baby Eating Behavior Questionnaire (BEBQ) and Child Eating Behavior Questionnaire (CEBQ) measured parents' perceptions of infant eating behaviors related to food approach (enjoyment of food, and food responsiveness) and food avoidance (food fussiness, satiety responsiveness, and slowness in eating). Linear mixed effects models tested longitudinal associations among infant eating behavior ratings, infant feeding (breastfeeding intensity, timing of introduction of complementary foods), and anthropometry (weight, length, and weight-for-length z-scores). Path analyses were stratified by age and tested for direct and indirect effects of mothers' ratings of infant eating behaviors and infant feeding on infant anthropometry.

RESULTS

Linear mixed models showed that general appetite was associated with higher weight-for-age, and satiety responsiveness was associated with lower length-for-age. Path analyses showed that infant milk feeding did not mediate associations. Breastfeeding intensity was independently associated with lower weight- and length-for-age z-scores. Age at complementary feeding initiation was associated with lower length-for-age z-scores.

CONCLUSIONS

Associations between parental perceptions of general appetite, satiety responsiveness, and infant weight and length are observed early in life. These findings suggest that parental perceptions of infant eating behaviors may contribute to the early developmental programming of later health outcomes.

First Bites-Why, When, and What Solid Foods to Feed Infants

Humans are the only mammals who feed our young special complementary foods before weaning and we are the only primates that wean our young before they can forage independently. There appears to be a sensitive period in the first several months of life when infants readily accept a wide variety of tastes and this period overlaps with a critical window for oral tolerance. As a result, infants should be exposed to a wide variety of flavors while mother is pregnant, while mother is nursing and beginning at an early age. There also appears to be a sensitive period between 4 and 9 months when infants are most receptive to different food textures. There remains debate about when it is best to begin introducing solid foods into an infant's diet however, the available evidence suggests that provided the water and food supply are free of contamination, and the infant is provided adequate nutrition, there are no clear contraindications to feeding infants complementary foods at any age. There is emerging evidence that introduction of solid foods into an infant's diet by 4 months may increase their willingness to eat a variety of fruits and vegetables later in life, decrease their risk of having feeding problems later in life, and decrease their risk of developing food allergies, and the early introduction of solid foods into an infant's diet does not appear to increase their risk of obesity later in childhood.

Supplementation with Fortified Lipid-Based and Blended Complementary Foods has Variable Impact on Body Composition Among Rural Bangladeshi Children: A Cluster-Randomized Controlled Trial

BACKGROUND

Complementary food supplementation enhances linear growth and may affect body composition in children.

OBJECTIVE

We aimed to determine the effect of complementary food supplements provided from the age of 6 to 18 mo on fat-free mass (FFM) and fat mass (FM) gain among children in rural Bangladesh.

METHODS

In an unblinded, cluster-randomized, controlled trial we tested the effects of 4 complementary food supplements for 1 y [chickpea, rice lentil, Plumpy'doz, and wheat-soy-blend++ (WSB++)] compared with no supplements on linear growth. Body composition was estimated using weight-length-based, age- and sex-specific equations at 6, 9, 12, 15, and 18 mo and postintervention aged 24 mo. Generalized estimating equations (GEEs) were applied to estimate the effect of each complementary food on mean FFM and FM from 9 to 18 and 24 mo compared with the control, adjusting for baseline measures. Sex interactions were also explored.

RESULTS

In total, 3592 (65.9% of enrolled) children completed all anthropometric assessments. Estimated FFM and FM (mean ± SD) were 5.3 ± 0.6 kg and 1.4 ± 0.4 kg, respectively, at the age of 6 mo. Mean ± SE FFM and FM from 9 to 18 mo were 75.4 ± 14.0 g and 32.9 ± 7.1 g, and 61.0 ± 16.6 g and 30.0 ± 8.4 g, higher with Plumpy'doz and chickpea foods, respectively, than the control (P < 0.001). Estimated FFM was 41.5 ± 16.6 g higher in rice-lentil-fed versus control (P < 0.05) children. WSB++ had no impact on FFM or FM. A group-sex interaction (P < 0.1) was apparent with Plumpy'doz and rice-lentil foods, with girls involved in the intervention having higher estimated FFM and FM than control girls compared with no significant effect in boys. At 24 mo, FFM and FM remained higher only in girls eating Plumpy'doz compared with the controls (P < 0.01).

CONCLUSIONS

In this randomized trial, supplementation effected small shifts in apparent body composition in rural Bangladeshi children. Where seen, FFM increments were twice that of FM, in proportion to these compartments, and more pronounced in girls. FFM increased in line with reported improvements in length. This trial was registered at clinicaltrials.gov as NCT01562379.

Complementary feeding: new styles versus old myths

Early life feeding habits may potentially alter future metabolic programming and body composition. Complementary feeding is the period of time when infants introduce food different from milk in their diet, together with a gradual reduction of the intake of milk (either breast milk or formula), to finally acquire the diet model of their family. This period is important in the transition of the infant from milk feeding to family foods, and is necessary for both nutritional and developmental reasons. The timing for introducing complementary foods and the method of feeding have changed over time. Available literature data show increasing interest and concerns about the impact of complementary feeding timing and modality on the onset of later non-communicable disorders, such as overweight and obesity, allergic diseases, celiac disease, or diabetes. While international scientific guidelines on complementary feeding have been published, many baby food companies' websites, blogs, and books, in most European countries exist. The aim of this manuscript is to look over current recommendations, and to revise "old myths." The adoption of an adequate weaning method is a cornerstone in the development of life-long health status. A correct strategy could reduce the risk of feeding disorders and other health problems later in life.

Appropriate age range for introduction of complementary feeding into an infant's diet

Following a request from the European Commission, the Panel on Nutrition, Novel Foods and Food Allergens (NDA) revised its 2009 Opinion on the appropriate age for introduction of complementary feeding of infants. This age has been evaluated considering the effects on health outcomes, nutritional aspects and infant development, and depends on the individual's characteristics and development. As long as foods have an age-appropriate texture, are nutritionally appropriate and prepared following good hygiene practices, there is no convincing evidence that at any age investigated in the included studies (< 1 to < 6 months), the introduction of complementary foods (CFs) is associated with adverse health effects or benefits (except for infants at risk of iron depletion). For nutritional reasons, the majority of infants need CFs from around 6 months of age. Infants at risk of iron depletion (exclusively breastfed infants born to mothers with low iron status, or with early umbilical cord clamping (< 1 min after birth), or born preterm, or born small-for-gestational age or with high growth velocity) may benefit from earlier introduction of CFs that are a source of iron. The earliest developmental skills relevant for consuming pureed CFs can be observed between 3 and 4 months of age. Skills for consuming finger foods can be observed in some infants at 4 months, but more commonly at 5-7 months. The fact that an infant may be ready from a neurodevelopmental perspective to progress to a more diversified diet before 6 months of age does not imply that there is a need to introduce CFs. There is no reason to postpone the introduction of potentially allergenic foods (egg, cereals, fish and peanut) to a later age than that of other CFs as far as the risk of developing atopic diseases is concerned. Regarding the risk of coeliac disease, gluten can be introduced with other CFs.

Standard and Specialized Infant Formulas in Europe: Making, Marketing, and Health Outcomes

Infant formulas are the only suitable substitute for human milk. The most common infant formulas are standard formulas based on cow's milk. In addition, there are formulas for infants showing signs and symptoms of intolerance and for clinical conditions such as allergy, prematurity, and gastrointestinal diseases. A comprehensive review of the literature was made to review the composition of standard and specialized infant formulas and analyze indications for use, real or presumed nutrition differences and properties, and impact on infant growth. A brief consideration on costs is outlined for each formula. Over the past few years, industrial production and advertising of infant formulas have increased. Human milk still remains the most complete source of nutrition for infants and should be continued according to the current recommendations. Few differences exist between infant formulas, both for the nutrition action and the macronutrient/micronutrient composition. Specialized infant formulas have limited indications for use and high costs. The role of the pediatrician is crucial in the management of infant nutrition, promotion of breastfeeding, and prescribing of specialized formulas only in specific clinical conditions.

Age at Introduction of Solid Food and Obesity Throughout the Life Course

OBJECTIVE

This study aimed to examine the association between age at solid food (SF) introduction and obesity throughout the life course.

METHODS

Among 31,816 mother- nurse daughter dyads in the Nurses' Mothers' Cohort Study and the Nurses' Health Study II, information was collected on age at SF introduction, body somatotype at ages 5 and 10, and Body Mass Index at age 18 and in adulthood. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for obesity throughout life were estimated using logistic regression models with adjustment for parental and nurse daughter covariates.

RESULTS

Nurse daughters introduced to SF at ≥ 9 months versus 6 to 9 months had marginally higher age-adjusted (OR: 1.21; 95% CI: 1.01, 1.47) and covariate-adjusted (OR: 1.22; 95% CI: 1.01, 1.47) odds of obesity at age 5. Age at SF introduction was not related to obesity at ages 10 and 18 or in adulthood.

CONCLUSIONS

Late age at SF introduction was marginally associated with obesity at age 5, but this association did not persist throughout the life course.

Early introduction of complementary foods and childhood overweight in breastfed and formula-fed infants in the Netherlands: the PIAMA birth cohort study

Purpose

To investigate whether early introduction of complementary foods (CF) is associated with an increased risk of overweight during childhood, and whether this association differs between formula-fed and breastfed infants.

Methods

We included 2611 participants that were born at term from a Dutch population-based birth cohort (n = 3963) designed to investigate the development of asthma and allergies. Parents kept records of their infant’s age when CF were first introduced. Weight and height were parent reported yearly from age 1 to 8 years, and at ages 11, 14 and 17 years. We used multivariate generalized estimating equations analysis to investigate the association between timing of CF introduction (before 4 months vs at or after 4 months of age) and overweight at ages 1–17 years.

Results

Children with CF introduction before 4 months had higher odds of being overweight during childhood than children with CF introduction at or after 4 months (OR 1.32, 95% CI 1.19, 1.47). This association was observed in formula-fed infants (OR 1.51, 95% CI 1.17, 1.94) and breastfed infants (OR 1.32, 95% CI 1.19, 1.47). The duration of breastfeeding modified the association between CF introduction and overweight: children breastfed for shorter than 4 months, but not children breastfed for 4 months or longer with CF introduction before 4 months had higher odds of being overweight (OR 1.37, 95% CI 1.19, 1.57 and 1.07, 95% CI 0.87, 1.32, respectively), compared to those with CF introduction at or after 4 months.

Conclusions

In children born at term, formula-fed infants and infants who were breastfed for shorter than 4 months, but not infants who were breastfed for 4 months or longer, had a higher risk of being overweight during childhood when being introduced to CF before 4 months of age.

Electronic supplementary material

The online version of this article (10.1007/s00394-018-1639-8) contains supplementary material, which is available to authorized users.

Does the early introduction of solids promote obesity?

Childhood obesity is a major public health challenge across the developed world, and it is vital to understand the modifiable factors that contribute to it. The influence of early-life nutrition on predisposition to later obesity and metabolic disease is now well established. Much research has concentrated on the preventative effects of breastfeeding in relation to childhood obesity risk, but the optimal timing of introducing solid foods has received far less attention. This remains a much-debated and contentious issue, and differing guidelines from international bodies have caused confusion among parents. There is no conclusive evidence from current research that introducing solids before six months of age is associated with an increased risk of obesity in infancy or childhood. Current studies suggest that the most clearly established risk factor for childhood obesity is maternal body mass index. There is a need for continued research in this area.

Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition

This position paper considers different aspects of complementary feeding (CF), focussing on healthy term infants in Europe. After reviewing current knowledge and practices, we have formulated these recommendations: Timing: Exclusive or full breast-feeding should be promoted for at least 4 months (17 weeks, beginning of the 5th month of life) and exclusive or predominant breast-feeding for approximately 6 months (26 weeks, beginning of the 7th month) is a desirable goal. Complementary foods (solids and liquids other than breast milk or infant formula) should not be introduced before 4 months but should not be delayed beyond 6 months.

CONTENT

Infants should be offered foods with a variety of flavours and textures including bitter tasting green vegetables. Continued breast-feeding is recommended alongside CF. Whole cows' milk should not be used as the main drink before 12 months of age. Allergenic foods may be introduced when CF is commenced any time after 4 months. Infants at high risk of peanut allergy (those with severe eczema, egg allergy, or both) should have peanut introduced between 4 and 11 months, following evaluation by an appropriately trained specialist. Gluten may be introduced between 4 and 12 months, but consumption of large quantities should be avoided during the first weeks after gluten introduction and later during infancy. All infants should receive iron-rich CF including meat products and/or iron-fortified foods. No sugar or salt should be added to CF and fruit juices or sugar-sweetened beverages should be avoided. Vegan diets should only be used under appropriate medical or dietetic supervision and parents should understand the serious consequences of failing to follow advice regarding supplementation of the diet.

METHOD

Parents should be encouraged to respond to their infant's hunger and satiety queues and to avoid feeding to comfort or as a reward.

Associations of breast-feeding patterns and introduction of solid foods with childhood bone mass: The Generation R Study

Breast-feeding has been associated with later bone health, but results from previous studies are inconsistent. We examined the associations of breast-feeding patterns and timing of introduction of solids with bone mass at the age of 6 years in a prospective cohort study among 4919 children. We collected information about duration and exclusiveness of breast-feeding and timing of introduction of any solids with postnatal questionnaires. A total body dual-energy X-ray absorptiometry scan was performed at 6 years of age, and bone mineral density (BMD), bone mineral content (BMC), area-adjusted BMC (aBMC) and bone area (BA) were analysed. Compared with children who were ever breast-fed, those never breast-fed had lower BMD (-4·62 mg/cm2; 95 % CI -8·28, -0·97), BMC (-8·08 g; 95 % CI -12·45, -3·71) and BA (-7·03 cm2; 95 % CI -12·55, -1·52) at 6 years of age. Among all breast-fed children, those who were breast-fed non-exclusively in the first 4 months had higher BMD (2·91 mg/cm2; 95 % CI 0·41, 5·41) and aBMC (3·97 g; 95 % CI 1·30, 6·64) and lower BA (-4·45 cm2; 95 % CI -8·28, -0·61) compared with children breast-fed exclusively for at least 4 months. Compared with introduction of solids between 4 and 5 months, introduction <4 months was associated with higher BMD and aBMC, whereas introduction between 5 and 6 months was associated with lower aBMC and higher BA. Additional adjustment for infant vitamin D supplementation did not change the results. In conclusion, results from the present study suggest that ever breast-feeding compared with never breast-feeding is associated with higher bone mass in 6-year-old children, but exclusive breast-feeding for 4 months or longer was not positively associated with bone outcomes.

Associations Between Breast Milk Feeding, Introduction of Solid Foods, and Weight Gain in the First 12 Months of Life

BACKGROUND AND OBJECTIVES

Breast milk feeding and solid food introduction can influence infant growth, but are rarely examined together. The objectives were to describe relationships between feeding practices, feeding practices and weight gain, and how the relationship of breast milk feeding and growth may change when breastfed infants start solid foods before 6 months.

METHODS

Data were analyzed on 438 infants from the Moms2Moms Study (2011-2012, Ohio), using multivariable linear and logistic regression models to explore each of the relationships.

RESULTS

For each additional month of breast milk feeding, solid food introduction was delayed by 1.32 days (95% CI 0.11 to 2.53) and average weight gain per month decreased by 5.05 g (95% CI 7.39 to 2.17). There was no association between solid food introduction and growth.

CONCLUSIONS

Longer breastfeeding duration was associated with slower growth regardless of solid food introduction. Age at solid food introduction was not associated with growth.

Age of introduction of first complementary feeding for infants: a systematic review

Background

Despite a World Health Organization recommendation for exclusive breastfeeding of all full-term infants to 6 months of age, it is not clear what the health implications may be. Breast milk alone may not meet the nutrition needs for all growing infants, leaving them at risk for deficiencies. The objective of this study was to investigate the relationship between moderate (4 months) versus late (6 months) introduction of complementary foods to the full-term breastfed infant on iron status and growth.

Methods

An electronic search of peer-reviewed and gray-literature was conducted for randomized control trials (RCTs) and observational studies related to the timing of introduction of complementary foods. Iron status and growth data from the relevant RCTs were analyzed using RevMan 5.2.11.

Results

Three RCTs and one observational study met the inclusion criteria. Meta-analysis showed significantly higher hemoglobin levels in infants fed solids at 4 months versus those fed solids at 6 months in developing countries [mean difference [MD]: 5.0 g/L; 95 % CI: 1.5, 8.5 g/L; P = 0.005]. Meta-anaysis also showed higher serum ferritin levels in the 4-month group in both developed and developing countries [MD: 26.0 μg/L; 95 % CI: -0.1, 52.1 μg/L, P = 0.050], [MD: 18.9 μg/L; 95 % CI: 0.7, 37.1 μg/L, P = 0.040]. Short follow-up periods and small sample sizes of the included studies were the major limitations.

Conclusions

RCT evidence suggests the rate of iron deficiency anemia in breastfed infants could be positively altered by introduction of solids at 4 months.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0409-5) contains supplementary material, which is available to authorized users.

Age at Weaning and Infant Growth: Primary Analysis and Systematic Review

OBJECTIVE

To test whether earlier age at weaning (age 3-6 months) may promote faster growth during infancy.

STUDY DESIGN

Weaning at age 3.0-7.0 months was reported by 571 mothers of term singletons in a prospective birth cohort study conducted in Cambridge, UK. Infant weight and length were measured at birth and at age 3 months and 12 months. Anthropometric values were transformed into age- and sex-adjusted z-scores. Three linear regression models were performed, including adjustment for confounders in a stepwise manner. Measurements at age 3 months, before weaning, were used to consider reverse causality.

RESULTS

Almost three-quarters (72.9%) of infants were weaned before age 6 months. Age at weaning of 3.0-7.0 months was inversely associated with weight and length (but not with body mass index) at 12 months (both P ≤ .01, adjusted for maternal and demographic factors). These associations were attenuated after adjustment for type of milk feeding and weight or length at age 3 months (before weaning). Rapid weight gain between 0 and 3 months predicted subsequent earlier age at weaning (P = .01). Our systematic review identified 2 trials, both reporting null effects of age at weaning on growth, and 15 observational studies, with 10 reporting an inverse association between age at weaning and infant growth and 4 reporting evidence of reverse causality.

CONCLUSION

In high-income countries, weaning between 3 and 6 months appears to have a neutral effect on infant growth. Inverse associations are likely related to reverse causality.

The timing of solid introduction in an 'obesogenic' environment: a narrative review of the evidence and methodological issues

OBJECTIVE

To evaluate the evidence for association between obesity risk outcomes >12 months of age and timing of solid introduction in healthy term infants in developed countries, the large majority of whom are not exclusively breastfed to six months of age.

METHODS

Studies included were published 1990 to March 2013.

RESULTS

Twenty-six papers with weight status or obesity prevalence outcomes were identified. Studies were predominantly cohort design, most with important methodological limitations. Ten studies reported a positive association. Of these, only two were large, good-quality studies and both examined the outcome of early (<4 months) introduction of solids. None of the four good-quality studies that directly evaluated current guidelines provided evidence of any clinically relevant protective effect of solid introduction from 4-5 versus ≥6 months of age.

CONCLUSION

The introduction of solids prior to 4 months of age may result in increased risk of childhood obesity but there is little evidence of adverse weight status outcomes associated with introducing solids at 4-6 rather than at six months.

IMPLICATIONS

More and better quality evidence is required to inform guidelines on the 'when, what and how' of complementary feeding.

Timing of solid food introduction and obesity: Hong Kong's "children of 1997" birth cohort

BACKGROUND

Some observational studies in Western settings show that early introduction of solid food is associated with subsequent obesity. However, introduction of solid food and obesity share social patterning. We examined the association of the timing of the introduction of solid food with BMI and overweight (including obesity) into adolescence in a developed non-Western setting, in which childhood obesity is less clearly socially patterned.

METHODS

We used generalized estimating equation models to estimate the adjusted associations of the timing of the introduction of solid food (<3, 3-4, 5-6, 7-8, and >8 months) with BMI z score and overweight (including obesity) at different growth phases (infancy, childhood, and puberty) in 7809 children (88% follow-up) from a Chinese birth cohort, "Children of 1997." We assessed if the associations varied with gender or breastfeeding. We used multiple imputation for missing exposure and confounders.

RESULTS

The introduction of solid food at <3 months of age was associated with lower family socioeconomic position (SEP) but was not clearly associated with BMI or overweight (including obesity) in infancy [mean difference in BMI z score: 0.01; 95% confidence interval (CI): -0.14 to 0.17], childhood (0.14; 95% CI: -0.11 to 0.40), or at puberty (0.22; 95% CI: -0.07 to 0.52), adjusted for SEP and infant and maternal characteristics.

CONCLUSIONS

In a non-Western developed setting, there was no clear association of the early introduction of solid food with childhood obesity. Together with the inconsistent evidence from studies in Western settings, this finding suggests that any observed associations might simply be residual confounding by SEP.

A community-based intervention to prevent obesity beginning at birth among American Indian children: study design and rationale for the PTOTS study

Eating and physical activity behaviors associated with adult obesity have early antecedents, yet few studies have focused on obesity prevention interventions targeting very young children. Efforts to prevent obesity beginning at birth seem particularly important in populations at risk for early-onset obesity. National estimates indicate that American Indian (AI) children have higher rates of overweight and obesity than children of other races/ethnicities. The Prevention of Toddler Obesity and Teeth Health Study (PTOTS) is a community-partnered randomized controlled trial designed to prevent obesity beginning at birth in AI children. PTOTS was developed to test the effectiveness of a multi-component intervention designed to: promote breastfeeding, reduce sugar-sweetened beverage consumption, appropriately time the introduction of healthy solid foods, and counsel parents to reduce sedentary lifestyles in their children. A birth cohort of 577 children from five AI tribes is randomized by tribe to either the intervention (three tribes) or the comparison condition (two tribes). The strengths and weaknesses of PTOTS include a focus on a critical growth phase, placement in the community, and intervention at many levels, using a variety of approaches.

The Effect of Breast-Feeding with and without Formula Use on the Risk of Obesity at 4 Years of Age

OBJECTIVE

To determine the minimal duration of breast-feeding required to protect against later obesity, whether the concurrent use of formula lessened any protective effect of breast-feeding, and what maternal or child characteristics might modify the association between breast-feeding and child obesity.

RESEARCH METHODS AND PROCEDURES

This was a retrospective cohort study. Participants were 73,458 white and black low-income children followed from birth through 4 years of age. Obesity at age 4 years was defined as measured BMI >or= 95th percentile. Feeding exposure was based on breast-feeding duration and the age of formula initiation. Covariates were obtained from the children's birth certificates.

RESULTS

At age 4 years, the prevalence of obesity was 11.5%. Only 16% of children were breast-fed 8 weeks or longer. Breast-feeding was associated with a reduced risk of obesity only in white children whose mothers had not smoked in pregnancy. In this subgroup, the reduction in obesity risk (adjusted odds ratio, 95% confidence interval), compared with those never breast-fed, occurred only for children who were breast-fed at least 16 weeks without formula (0.71, 0.56 to 0.92) or at least 26 weeks with concurrent formula (0.70, 0.61 to 0.81). Among whites whose mothers smoked in pregnancy and among blacks, breast-feeding was not associated with a reduced risk of obesity at age 4 years.

DISCUSSION

In a population of low-income children, breast-feeding was associated with a reduced risk of obesity at age 4 years only among whites whose mothers did not smoke in pregnancy and only when breast-feeding continued for at least 16 weeks without formula or at least 26 weeks with formula.

Weight change before and after the introduction of solids: results from a longitudinal birth cohort

We studied the association, and its direction, between the introduction of solids and weight-for-height (WFH) change between birth and 45 months. Pregnant women were asked to participate in a birth cohort during their first antenatal visit. Data from 3184 children were used. The timing of the introduction of solids was reported by the mother from a questionnaire at 12 months postpartum, and categorised into very early (0-3 months), early (3-6 months) and timely (after 6 months) introduction of solids. Anthropometric data were collected during standardised child health centre visits. WFH was converted into a z-score. Repeated-measurements analyses with splines positioned according to the moments of solid introduction were used to obtain estimates for WFH change before and after the introduction of solids. Analyses were adjusted for educational level, ethnicity, smoking during pregnancy, mother's BMI, breast-feeding, history of food allergy and infant's hospital admission. Before solids were introduced, weight gain was higher in children introduced to solids early (z= 0.65, 95 % CI 0.34, 0.95) than in children introduced to solids very early (z= 0.02, 95 % CI -0.03, 0.08) and timely (z= -0.04, 95 % CI -0.05, -0.03). Shortly after the introduction of solids, children introduced to solids very early and early showed a relative decrease in WFH. WFH change did not differ between the solid introduction groups after 12 months, and at that time, weight change was as expected (i.e. z= 0). We therefore conclude that differences in WFH in childhood are not the result of early introduction to solids.

Longitudinal effects of fat and lean mass on bone accrual in infants

There are conflicting reports on the influence of lean and fat mass on bone accrual during childhood. No infant's studies have been reported that describe the influence of changes in body composition with changes in bone accrual during the first year of life. The objective of this research was to test the hypothesis that greater gains in lean mass will have a positive effect on bone mineral content (BMC) accrual, while greater gains in fat mass will have a negative effect on BMC accrual in infants. Longitudinal data from 3 previous infant studies were used. Linear mixed models, adjusting for age, sex, dietary calcium, and length were used to investigate longitudinal and cross-sectional associations between total body BMC and lean and fat mass in the individual studies and in a combined analysis. In both individual and combined analyses, we found that lean and fat mass were positively associated with whole body BMC accrual (all, P<0.001). The cross-sectional association of BMC and dietary calcium was negative in one study (P<0.05). No differences in BMC change between sexes were observed in three studies. Our results showed positive cross-sectional and longitudinal associations between total body BMC and lean mass in infants. In contradiction to our hypothesis for fat mass, we found a positive cross-sectional and longitudinal association between total body BMC and fat mass in infants.

Prevention of Overweight in Infancy (POI.nz) study: a randomised controlled trial of sleep, food and activity interventions for preventing overweight from birth

BACKGROUND

Rapid weight gain during the first three years of life predicts child and adult obesity, and also later cardiovascular and other morbidities. Cross-sectional studies suggest that infant diet, activity and sleep are linked to excessive weight gain. As intervention for overweight children is difficult, the aim of the Prevention of Overweight in Infancy (POI.nz) study is to evaluate two primary prevention strategies during late pregnancy and early childhood that could be delivered separately or together as part of normal health care.

METHODS/DESIGN

This four-arm randomised controlled trial is being conducted with 800 families recruited at booking in the only maternity unit in the city of Dunedin, New Zealand. Mothers are randomised during pregnancy to either a usual care group (7 core contacts with a provider of government funded "Well Child" care over 2 years) or to one of three intervention groups given education and support in addition to "Well Child" care: the Food, Activity and Breastfeeding group which receives 8 extra parent contacts over the first 2 years of life; the Sleep group which receives at least 3 extra parent contacts over the first 6 months of life with a focus on prevention of sleep problems and then active intervention if there is a sleep problem from 6 months to 2 years; or the Combination group which receives all extra contacts. The main outcome measures are conditional weight velocity (0-6, 6-12, 12-24 months) and body mass index z-score at 24 months, with secondary outcomes including sleep and physical activity (parent report, accelerometry), duration of breastfeeding, timing of introduction of solids, diet quality, and measures of family function and wellbeing (parental depression, child mindedness, discipline practices, family quality of life and health care use). This study will contribute to a prospective meta-analysis of early life obesity prevention studies in Australasia.

DISCUSSION

Infancy is likely to be the most effective time to establish patterns of behaviour around food, activity and sleep that promote healthy child and adult weight. The POI.nz study will determine the extent to which sleep, food and activity interventions in infancy prevent the development of overweight.

TRIAL REGISTRATION

Clinical Trials NCT00892983. Prospective meta-analysis registered on PROSPERO CRD420111188. Available from http://www.crd.york.ac.uk/PROSPERO.

The introduction of solid food and growth in the first 2 y of life in formula-fed children: analysis of data from a European cohort study

BACKGROUND

Early introduction of solid food has been suspected to induce excessive infant energy intake and weight gain.

OBJECTIVE

The objective of this study was to test whether introduction of solid foods influences energy intake or growth.

DESIGN

Healthy, formula-fed infants who were recruited in 5 European countries were eligible for study participation. Anthropometric measurements were taken at recruitment and at 3, 6, 12, and 24 mo. Time of introduction of solid foods and energy intake were determined by questionnaires and 3-d weighed food records at monthly intervals. Age at introduction of solid food was categorized into 4 groups: ≤ 13 wk, 14-17 wk, 18-21 wk, and ≥ 22 wk.

RESULTS

Of 1090 recruited infants, 830 (76%) had data available for age at first introduction of solid food, and 671 (61%) completed the study until 24 mo of age. The median age at introduction of solid food was 19 wk. The time of introduction of solid foods was associated with country, sex, birth weight, parental education and marital status, and maternal smoking. Energy intake was higher in the first 8 mo of life in children with solid-food intake. Solid-food introduction did not predict anthropometric measures at 24 mo. Growth trajectories differed significantly: children with solid-food introduction in the first 12 wk experienced early catch-up growth, whereas those introduced to solid food at >22 wk of age grew more slowly and stayed on lower trajectories.

CONCLUSIONS

Solid foods do not simply replace infant formula but increase energy intake. Time of introduction of solid food has little influence on infant growth. This trial was registered at clinicaltrials.gov as NCT00338689.

Association between timing of introducing solid foods and obesity in infancy and childhood: a systematic review

Determining early-life risk factors for obesity in later life is essential in order to effectively target preventative interventions to reduce obesity. The aim of this systematic review was to investigate current evidence to determine whether the timing of introducing solid foods is associated with obesity in infancy and childhood. Relevant randomized and observational studies from developed countries were identified by searching the following six bio-medical databases (Medline, Embase, British Nursing Index, CINAHL, Maternity and Infant Care, and PsycINFO) and hand-searching reference lists. Studies of pre-term or low birthweight infants were excluded. Twenty-four studies met the inclusion criteria for the systematic review. Data from over 34,000 participants were available for interpretative analysis. No clear association between the age of introduction of solid foods and obesity was found. It is likely that a whole family approach to obesity prevention will be most effective and health professionals should continue to promote healthy infant feeding in line with national recommendations.

Timing of solid food introduction and risk of obesity in preschool-aged children

OBJECTIVE

To examine the association between timing of introduction of solid foods during infancy and obesity at 3 years of age.

METHODS

We studied 847 children in Project Viva, a prospective pre-birth cohort study. The primary outcome was obesity at 3 years of age (BMI for age and gender ≥ 95th percentile). The primary exposure was the timing of introduction of solid foods, categorized as <4, 4 to 5, and ≥ 6 months. We ran separate logistic regression models for infants who were breastfed for at least 4 months ("breastfed") and infants who were never breastfed or stopped breastfeeding before the age of four months ("formula-fed"), adjusting for child and maternal characteristics, which included change in weight-for-age z score from 0 to 4 months-a marker of early infant growth.

RESULTS

In the first 4 months of life, 568 infants (67%) were breastfed and 279 (32%) were formula-fed. At age 3 years, 75 children (9%) were obese. Among breastfed infants, the timing of solid food introduction was not associated with odds of obesity (odds ratio: 1.1 [95% confidence interval: 0.3-4.4]). Among formula-fed infants, introduction of solid foods before 4 months was associated with a sixfold increase in odds of obesity at age 3 years; the association was not explained by rapid early growth (odds ratio after adjustment: 6.3 [95% confidence interval: 2.3-6.9]).

CONCLUSIONS

Among formula-fed infants or infants weaned before the age of 4 months, introduction of solid foods before the age of 4 months was associated with increased odds of obesity at age 3 years.

Is baby-led weaning feasible? When do babies first reach out for and eat finger foods?

The baby-led weaning philosophy proposes that when solids are introduced, infants should be encouraged to self-feed with solid food, as opposed to spoon-feeding purees. We used data from the Gateshead Millennium Study (GMS) to define the range of ages at which infants reach out for and eat finger foods and related this to developmental status. GMS recruited infants shortly after birth and followed them prospectively using postal questionnaires. Of the 923 eligible children, 602 had data on when they first reached out for food, and 340 (56%) had done so before age 6 months, but 36 (6%) were still not reaching for food at age 8 months. Infants who had not reached out for food by 6 months were less likely to be walking unaided at age 1 year (85 out of 224, 38%) compared with those who did (155 out of 286, 54%; P < 0.001). For the 447 parents who completed a diary of the first five occasions when their child ate finger foods, the first finger food eaten was before age 6 months for 170 (40%) and before age 8 months for 383 (90%); foods offered were mainly bread, rusks or biscuits. Of the 604 with information at age 8 months about current intake, all but 58 (9.6%) were having some finger foods at least daily, but only 309 (51%) were having them more than once per day. Baby-led weaning is probably feasible for a majority of infants, but could lead to nutritional problems for infants who are relatively developmentally delayed.

Canadian infants' nutrient intakes from complementary foods during the first year of life

Background

Complementary feeding is currently recommended after six months of age, when the nutrients in breast milk alone are no longer adequate to support growth. Few studies have examined macro- and micro-nutrient intakes from complementary foods (CF) only. Our purpose was to assess the sources and nutritional contribution of CF over the first year of life.

Methods

In July 2003, a cross-sectional survey was conducted on a nationally representative sample of mothers with infants aged three to 12 months. The survey was administered evenly across all regions of the country and included a four-day dietary record to assess infants' CF intakes in household (tablespoon) measures (breast milk and formula intakes excluded). Records from 2,663 infants were analyzed for nutrient and CF food intake according to 12 categories. Mean daily intakes for infants at each month of age from CF were pooled and compared to the Dietary Reference Intakes for the respective age range.

Results

At three months of age, 83% of infants were already consuming infant cereals. Fruits and vegetables were among the most common foods consumed by infants at all ages, while meats were least common at all ages except 12 months. Macro- and micro-nutrient intakes from CF generally increased with age. All mean nutrient intakes, except vitamin D and iron, met CF recommendations at seven to 12 months.

Conclusions

Complementary foods were introduced earlier than recommended. Although mean nutrient intakes from CF at six to 12 months appear to be adequate among Canadian infants, further attention to iron and vitamin D intakes and sources may be warranted.

Late introduction of complementary feeding, rather than duration of breastfeeding, may protect against adult overweight

BACKGROUND

Early nutrition may affect the risk of overweight in later life.

OBJECTIVE

The objective was to explore the effect of the duration of breastfeeding (BF) and age at introduction of complementary feeding (CF) on body mass index (BMI) during childhood through adulthood.

DESIGN

The study was based on a subsample of the Copenhagen Perinatal Cohort established in 1959-1961 (n = 5068). Information on BF and available information on CF (age of introduction of "spoon-feeding," "vegetables," "egg," "meat," and "firm food") and several covariates were collected in infancy and linked with information on BMI from follow-up examinations in childhood and adulthood at age 42 y.

RESULTS

The median (10th, 90th percentiles) durations of any BF and age at introduction of spoon-feeding were 2.50 (0.23, 6.50) and 3.50 (2.00, 6.00) mo, respectively. After 1 y of age and throughout childhood and adolescence, no association between BF and BMI was found in regression models also adjusted for age at introduction of spoon-feeding and covariates. The risk of overweight at age 42 y decreased or tended to decrease with increasing age (in mo) at introduction of spoon-feeding [odds ratio (OR): 0.94; 95% CI: 0.86, 1.02], vegetables (OR: 0.90; 95% CI: 0.81, 0.98), meat (OR: 0.93; 95% CI: 0.87, 1.00), and firm food (OR: 0.92; 95% CI: 0.86, 0.98) but not egg (OR: 0.98; 95% CI: 0.91, 1.05).

CONCLUSION

The findings of this study suggest that introduction of CF at a later age (within the range of 2 to 6 mo) is protective against overweight in adulthood but do not support a protective effect of a longer duration of BF.

Introduction of solid foods: do mothers follow recommendations?

PURPOSE

Infant age at introduction of solid foods was examined, as were maternal characteristics associated with adherence to recommendations.

METHODS

In a telephone survey, 2153 mothers living in Ontario were asked questions about the age at which foods were introduced to their infants.

RESULTS

Eighteen percent of respondents introduced infant cereal before age four months, while 5% introduced it at age seven months or later. Mothers who introduced cereal either earlier or later than recommended had a lower household income and were less likely to have attended prenatal classes than were those who followed recommendations. Mothers who introduced cereal before their infants were four months old were more likely than were other mothers to be younger, not to be breastfeeding at three months, to have smoked during pregnancy, and to have someone who smoked inside the home. Mothers who introduced infant cereal after age seven months were more likely to be older, breastfeeding at three months, and mothering their second or later-born child than were mothers who introduced infant cereal as recommended.

CONCLUSIONS

Small but distinct groups of mothers are introducing solid foods earlier or later than recommended. Educational and informational initiatives that target these parents may help increase the number of infants being fed as recommended.

Early weaning is related to weight and rate of weight gain in infancy

BACKGROUND

Evidence relating to the effect of early weaning on infant weight and weight gain is conflicting. The aim of this paper is to compare weight and weight gain in two groups of infants; one group weaned before 4 months (early weaned), the other weaned at 4 months or after.

METHODS

Feeding practices were assessed through semistructured interviews with mothers of 1-year-old infants. Weight at birth, 8 weeks and 7 months were taken from an administrative database (Child Health System), and an additional measure of weight was taken at 14 months.

RESULTS

Infants weaned early were heavier at 7 and 14 months, and gained more weight between 8 weeks and 14 months, even after breastfeeding was controlled for.

CONCLUSION

Early weaning is related to rapid weight gain in infancy. This may have implications for childhood obesity.

Optimizing the introduction of complementary foods in the infant's diet: a unique challenge in developing countries

Being one of a series of technical support papers pertaining to the South African paediatric food-based dietary guidelines, this paper specifically deals with two of the guidelines proposed for the age group 6-12 months regarding the introduction of complementary foods in the infant's diet. Studies have shown that most of South African infants receive solid foods at the age of 4 months or earlier while only a small percentage are breastfed exclusively until 6 months. The untimely and inappropriate introduction of complementary foods have been shown to be risk factors for both under- and over-nutrition with resultant under- or overweight, stunting and micronutrient deficiencies. Optimal timing for the introduction of complementary foods will depend on the infant's physiological and developmental status. Small, frequent meals of easily digestable, smooth, semisolid nutrient- and energy-dense complementary foods should initially be offered while gradually increasing variety in both the type and texture of food. Protein and carbohydrate intake should increase with the infant's age while preference should be given to foods rich in micronutrients. It should be observed that certain foods, such as fresh cow's milk and egg white, because of their allergenic properties, as well as fat-free and high-fibre foods, excessive fruit juice and low nutrient value drinks such as tea are not recommended. Timely introduction of appropriate complementary foods is vital for the immediate and long-term health of the infant and caregivers should be accordingly advised on feeding at this age.

Nature and strength of epidemiological evidence for origins of childhood and adulthood obesity in the first year of life

Increased interest in early life origins of chronic disease, a concept often referred to as programming, has resulted in several studies investigating the origins of childhood or adulthood obesity during infancy. Rapid infancy weight gain as a risk factor and breastfeeding as a protective factor for later obesity have been most thoroughly studied. The association between rapid infancy weight gain and later obesity is supported by several observational studies, but not by the two, relatively small, randomized trials. This association is strong, suggests a dose-response effect and has biological plausibility, but is not consistent between study designs. Rapid infancy weight gain as a risk factor for later obesity has been experimentally reproduced in animal models, but not in humans. The protective effect of breastfeeding on obesity is also supported by several observational studies, but randomized trials are not available. Considering the potential for residual confounding factors, current evidence is insufficient to demonstrate origins of obesity during infancy or to change public health recommendations, but the potential for obesity prevention during infancy is promising.

Breastfeeding, introduction of complementary foods, and adiposity at 5 y of age

BACKGROUND

Although dual-energy X-ray absorptiometry (DXA) is considered the most accurate measure of adiposity in children, it has rarely been used to examine the relation between infant feeding and adiposity during childhood.

OBJECTIVE

The objective was to ascertain whether adiposity at age 5 y was related to breastfeeding, to the timing of the introduction of complementary foods during infancy, or to both.

DESIGN

Body composition was measured in 313 children at age 5 y by using DXA. Data on breastfeeding, formula feeding, and the timing of the introduction of complementary foods were obtained from the mothers when the children were 3 y old. Regression analysis was used to examine the relation between infant feeding and fat mass after adjustment for lean body mass, sex, birth weight, maternal obesity, race, and other sociodemographic variables.

RESULTS

Fifty-three percent of the children were boys, 80% were white, and 20% were black. There was no significant difference in adjusted fat mass between those ever breastfed and those never breastfed (x +/- SE: 4.48 +/- 0.09 and 4.76 +/- 0.17 kg, respectively; P = 0.17). Children who were breastfed for a longer duration and those who were breastfed without concurrent formula feeding did not have significantly lower fat mass than did those children who were never breastfed. Children did not differ significantly in fat mass if they were introduced to complementary foods before or after 4 mo of age (4.49 +/- 0.12 and 4.63 +/- 0.12 kg, respectively; P = 0.42).

CONCLUSION

Neither breastfeeding nor the timing of the introduction of complementary foods was associated with adiposity at age 5 y.

Dietary recommendations for children and adolescents: a guide for practitioners

Since the American Heart Association last presented nutrition guidelines for children, significant changes have occurred in the prevalence of cardiovascular risk factors and nutrition behaviors in children. Overweight has increased, whereas saturated fat and cholesterol intake have decreased, at least as percentage of total caloric intake. Better understanding of children's cardiovascular risk status and current diet is available from national survey data. New research on the efficacy of diet intervention in children has been published. Also, increasing attention has been paid to the importance of nutrition early in life, including the fetal milieu. This scientific statement summarizes current available information on cardiovascular nutrition in children and makes recommendations for both primordial and primary prevention of cardiovascular disease beginning at a young age.

Dietary Recommendations for Children and Adolescents

Since the American Heart Association last presented nutrition guidelines for children, significant changes have occurred in the prevalence of cardiovascular risk factors and nutrition behaviors in children. Overweight has increased, whereas saturated fat and cholesterol intake have decreased, at least as percentage of total caloric intake. Better understanding of children’s cardiovascular risk status and current diet is available from national survey data. New research on the efficacy of diet intervention in children has been published. Also, increasing attention has been paid to the importance of nutrition early in life, including the fetal milieu. This scientific statement summarizes current available information on cardiovascular nutrition in children and makes recommendations for both primordial and primary prevention of cardiovascular disease beginning at a young age.

Why are babies weaned early? Data from a prospective population based cohort study

BACKGROUND

The recommended age of introduction of solids food to the diet of infants (weaning) has recently been increased in the UK to 6 months, but most babies are still weaned before the age of 4 months.

AIMS

To examine what predicts the age of weaning and how this relates to weight gain and morbidity using data from a population based cohort.

METHODS

Parents of 923 term infants born in a defined geographical area and recruited shortly after birth were studied prospectively using postal questionnaires, weaning diaries, and routinely collected weights, of whom 707 (77%) returned data on weaning.

RESULTS

The median age of first weaning solids was 3.5 months, with 21% commencing before 3 months and only 6% after 4 months of age. Infants progressed quickly to regular solids with few reported difficulties, even when weaned early. Most parents did not perceive professional advice or written materials to be a major influence. The strongest independent predictors of earlier age at weaning were rapid weight gain to age 6 weeks, lower socioeconomic status, the parents' perception that their baby was hungry, and feeding mode. Weight gain after 6 weeks was unrelated to age of weaning. Babies weaned before 3 months, compared to after 4 months, had an increased risk of diarrhoea.

CONCLUSIONS

Social factors had some influence on when weaning solids were introduced, but the great majority of all infants were established on solids before the previously recommended age of 4 months, without difficulty. Earlier weaning was associated with an increased rate of minor morbidity.

Dual Energy X-Ray Absorptiometry Measurements in Small Subjects: Conditions Affecting Clinical Measurements

OBJECTIVE

To document the clinical and experimental situations that may affect DXA measurements in small subjects.

METHODS

49 piglets (886g to 21100g) had measurements with either of two pencil beam densitometers (QDR 1000W and QDR 2000 Plus, Hologic Inc, Waltham, MA) using commercial infant (IWB) and adult whole body (AWB) software v5.71p and v5.71 respectively. AWB scans were analyzed with three additional software versions. 35 infants (2115 to 11564g) had IWB measurements.

RESULTS

DXA measurements of total weight, bone mineral content, bone area, bone mineral density, fat and lean mass from IWB scans (all piglets) and from AWB scans (piglets >12 kg) were highly reproducible (p < 0.001). A statistically significant change occurred in at least one of the DXA measurements from the use of different platforms, variations in the amount and placement of covering (e.g., blanket), placement of the external calibration standard, presence of radiographic contrast material, presence of movement artifact, delivery of an intravenous fluid bolus prior to scanning or improper delineation of external calibration standard during analysis. Additionally, results varied amongst different versions of software as well as between IWB and AWB softwares.

CONCLUSION

In small subjects, consistency in the DXA techniques is paramount for valid and meaningful comparison of DXA data in bone mass and body composition.

Nutrition influences bone development from infancy through toddler years

During the last decade a greater appreciation has developed for determining factors that influence bone accretion in healthy children. Nutritional factors that may contribute to bone accretion in infants and toddlers include maternal nutritional status during pregnancy, type of infant feeding, calcium and phosphorus content of infant formula, introduction of weaning foods, and diet during the toddler and preschool years. Maternal vitamin D deficiency during pregnancy is associated with disturbances in neonatal calcium homeostasis, and maternal calcium deficiency leads to reduced neonatal bone mineral content (BMC). Preterm infants are at increased risk of osteopenia, and, although the use of high mineral formula has reduced the risk of osteopenia in these infants, it has not eliminated it. The reason for the long-term bone deficiency among preterm infants is not clear, although lower physical activity levels have been suggested as a potential cause. Studies find that human milk-fed infants have lower bone accretion than do formula-fed infants; that the greater the mineral content of formula, the greater the bone accretion; and that the inclusion of palm olein oil in infant formula may reduce bone mineral accretion. Bone accretion is not influenced by the timing of the introduction of weaning foods, despite higher serum parathyroid hormone (PTH) concentrations among infants who receive solids earlier. There is evidence of calcium intake-by-gene and calcium intake-by-physical activity interactions among toddlers and young children. The long-term effects of these early nutritional influences on later bone health are unknown.

Interchangeability of pencil-beam and fan-beam dual-energy X-ray absorptiometry measurements in piglets and infants

BACKGROUND

Compared with the older pencil-beam (PB) dual-energy X-ray absorptiometry (DXA), the newer fan-beam (FB) DXA has the advantage of faster scan acquisition and greater accuracy of body-composition measurement in small subjects. However, no data exist on the relation between the measurements obtained with these techniques.

OBJECTIVE

The objective of the study was to investigate whether PB and FB DXA measurements in small subjects are interchangeable.

DESIGN

PB and FB DXA scans were performed on 26 piglets and 54 infants to examine the relation between the measurements obtained by using the 2 techniques.

RESULTS

The correlation between all PB and FB DXA measurements of variables (total weight, bone area, bone mineral content, bone mineral density, and lean and fat masses) approached 1.0, but there were significant differences in absolute values. The extent of the differences varied according to the variable, with the lowest value for total weight (mean difference: approximately 1% for both piglets and infants) and the highest value for bone mineral content (mean difference: 35.3% and 36.7% for piglets and infants, respectively). PB and FB DXA measurements were strongly predictive of each other after adjustment (r(2) = 0.927-1.000 for the piglet data and 0.939-0.999 for the infant data).

CONCLUSION

In small subjects, DXA measurements from PB and FB techniques were strongly predictive of each other, although their absolute values differed. Thus, group comparison of PB and FB DXA data is possible after adjustment of the data from either technique. It is advisable to generate normative data for each technique and to use the same technique throughout longitudinal studies.

The effects of infant feeding decisions on infant growth

ISSUES AND PURPOSE

To determine the effects of feeding decisions on infant growth in the first 6 months of life.

DESIGN AND METHODS

Growth measurements were collected twice during the first 6 months of infancy as part of a larger investigation of infant feeding practices (N = 52).

RESULTS

Infants who received solid foods before the age of 4 to 6 months weighed less than those who received solid foods after 4 to 6 months. There were no differences in growth measurements between formula-fed and breast-fed infants, although breast-fed infants weighed more at birth.

PRACTICE IMPLICATIONS

Emphasize the importance of feeding breast milk (preferably) or formula only for the first 6 months. Advise parents to withhold fruit juices until the infant is at least 6 months old.

Maternal feeding practices and beliefs and their relationships to overweight in early childhood

To better explore possible factors that may lead to childhood obesity, we developed and analyzed two new instruments that assess maternal feeding practices and beliefs. The Infant Feeding Questionnaire (IFQ) assesses feeding during the entire first year of life and was administered to 453 mothers of children 11 to 23 months old. The Preschooler Feeding Questionnaire (PFQ) assesses feeding of young children between the ages of 2 to 5 years and was administered to 634 mothers of children this age. Each questionnaire was factor analyzed and mean factor scores were calculated and linked with the children's measured and mothers' self-reported weight and height. Mean factor scores from the IFQ and PFQ were compared between mothers who were obese (body mass index > or = 30 kg/m2) and those who were nonobese, between those who did and those who did not have an overweight child (weight-for-height > or = 90th percentile), and between those who had a low income (< or = 185% of the poverty level) and those who had a high income. To control for confounding variables and to detect interaction among variables, hierarchical linear regression was used. Results from this study did not suggest that there is a particular "feeding style" that is associated with overweight in young children; however, there were differences found in feeding behaviors between high and low income mothers.

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.

Effect of timing of introduction of complementary foods on iron and zinc status of formula fed infants at 12, 24, and 36 months of age

OBJECTIVE

The timing of introduction of complementary food to an infant's diet is variable throughout the world. Our objective was to determine whether early introduction of complementary foods affects iron and zinc status of formulated infants at 12, 24, and 36 months of age.

DESIGN

A randomized, prospective trial was conducted. Infants were randomly assigned to receive either a) early introduction (at 3 to 4 months of age) of commercially prepared or parent's choice of complementary foods; or b) late introduction (at 6 months of age) of commercially prepared complementary foods or parent's choice of complementary foods. In addition to complementary foods, infants were fed commercial infant formula as recommended by their pediatrician. Hemoglobin, mean corpuscular volume, and serum ferritin and zinc concentrations were determined at 12, 24, and 36 months of age. Three-day diet diaries were completed at 3, 6, 12, 18, 24, 30, and 36 months of age.

SUBJECTS/SETTING

One hundred seventy-five infants younger than 3 months were recruited by mailings to parents in the Cincinnati area. Of these, 172 were enrolled, 90 in the early-introduction group and 82 in the late-introduction group. One hundred thirty-three infants (n = 67 in the early, n = 66 in the late group) completed the study.

STATISTICAL ANALYSES PERFORMED

Student t test and regression analyses were used to determine whether there were group differences and whether there was a relationship between serum parameters and dietary intake.

RESULTS

Infants fed complementary foods early had significantly greater iron intakes until 6 months of age; however, there were no differences in the iron status parameters (ferritin, hemoglobin, and mean corpuscular volume) at 12, 24, or 36 months of age. The early introduction group consumed slightly less zinc than the late introduction group at 5 months (4.4 vs 4.8 mg/day, P < .01) and 6 months (4.4 vs 4.7 mg/day, P < .01). At all other times there were no differences between the early and late group in zinc intakes. The serum zinc concentration was not associated with dietary zinc. Both groups had normal serum zinc concentrations at 12, 24, and 36 months and there were no differences between groups.

APPLICATIONS/CONCLUSIONS

The iron and zinc status of infants in this study was not influenced by the timing or type of complementary foods introduced. However, the infants were formula fed and the mean iron and zinc intakes that were equal or greater than the Recommended Dietary Allowances for the first 6 months of age.