Development, Feeding Skills and Relationships

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

Sociology of Food

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

Sociology of Food

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

Foods for infants and young children

• Nurturing

• Nourishing

• Learning

• Relationship • Development• Emotion and temperament

Feeding Practices and Transitions

Developmental

Social

Cultural

Nutritional

Public Health

The feeding relationship in infancy

• Nourishing and nurturing

• Supports developemental tasks

Relationship

• Feeding is a reciprocal process that depends on the abilities and characteristics of both caregiver and infant/child

Relationship

• The feeding relationship is both dependent on and supportive of infants development and temperament.

Tasks

• Infant– time– how much– speed– preferences

• Parent– food choices– support– nurturing– structure and limits– safety

Relationship

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

Maternal-Infant Feeding dyad

• Indicates hunger (I)• Presents milk (M)• Consumes milk by

suckling (I)• Indicates satiety,

stops suckling (I)• Ends feeding (M)

Infant and Caregiver Interaction

• Readability

• Predictability

• Responsiveness

Nurturing

• Supportive and responsive– Homeostasis– Attachment– Separation and individuation– Security– Well-being– Temperament– Needs– other

• Problems established early in feeding persist into later life and generalize into other areas

• Ainsworth and Bell– feeding interactions in

early months were replicated in play interactions after 1st year

Development

• Neurophysiologic– Homeostasis– Attachment– Separation and

individuation

• Oral Motor

Developmental Changes

• Oral cavity enlarges and tongue fills up less• Tongue grows differentially at the tip and attains motility

in the larger oral cavity. • Elongated tongue can be protruded to receive and pass

solids between the gum pads and erupting teeth for mastication.

• Mature feeding is characterized by separate movements

of the lip, tongue, and gum pads or teeth

Development of Infant Feeding Skills

• Birth– tongue is disproportionately large in comparison with

the lower jaw: fills the oral cavity – lower jaw is moved back relative to the upper jaw,

which protrudes over the lower by approximately 2 mm.

– tongue tip lies between the upper and lower jaws. – "fat pad" in each of the cheeks: serves as prop for

the muscles in the cheek, maintaining rigidity of the cheeks during suckling.

– feeding pattern described as “suckling”

Stages

Age Development

1-3 months Homeostasis * State regulation

* Neurophysiologic stability

2-6 months Attachment * “falling in love”

* Affective engagement and interaction

6-36 months

Separation and individuation

* Differentiation

* Behavioral organization and control

Feeding behavior of infants Gessell A, Ilg FL

Age Reflexes Oral, Fine, Gross Motor Development1-3months

Rooting and suckand swallowreflexes arepresent at birth

Head control is poorSecures milk with suckling pattern, the tongue projectingduring a swallowBy the end of the third month, head control is developed

4-6months

Rooting reflexfadesBite reflex fades

Changes from a suckling pattern to a mature suck withliquidsSucking strength increasesMunching pattern beginsGrasps with a palmer graspGrasps, brings objects to mouth and bites them

7-9months

Gag reflex is lessstrong as chewingof solids beginsand normal gag isdevelopingChoking reflexcan be inhibited

Munching movements begin when solid foods are eatenRotary chewing beginsSits aloneHas power of voluntary release and resecuralHolds bottle aloneDevelops an inferior pincer grasp

10-12months

Bites nipples, spoons, and crunchy foodsGrasps bottle and foods and brings them to the mouthCan drink from a cup that is heldTongue is used to lick food morsels off the lower lipFinger feeds with a refined pincer grasp

Feeding Problems

• Homeostasis– Colic, poor growth,

stressful unsatisfactory feedings

• Attachment– Vomiting, diarrhea, poor

growth, disengaged or intensely conflicted feeding interactions

• Individuation– Food refusal

Emotion/Temperament

• Temperament theory categorizes enduring personality styles based on activity, adaptability, intensity, mood, persistence, distractibility, regularity, responsivity, approach/withdraw from novelty

Chess and Thomas 1970

Temperament

• Easy: approaches novelty, positive mood, adaptable, regular, active, low intensity

• Slow to warm: withdraws from novelty, low mood, low activity, moderate to low intensity, cautious

• Difficult: withdrawing, low adaptability, high intensity, low regularity, negative mood

Feeding Practices and Transitions

Developmental

Social

Cultural

Nutritional

Public Health

Analytical framework for the Start Healthy Guidelines for Complementary foods (JADA, 2004)

How?

• Establish healthy feeding relationship– Recognize child’s developmental abilities– Balance child’s need for assistance with

encouragement of self feeding– Allow the child to initiate and guide feeding

interactions– Respond early and appropriately to hunger

and satiety cues

How

• Safety issues:– Safe food handling for formula and

expressed breast milk– Guidance about choking, lead poisoning,

nonfood eating, high intakes of nitrates, nitrites and methylmurcury

How

• Safety issues:– Safe food handling for formula and

expressed breast milk– Guidance about choking, lead poisoning,

nonfood eating, high intakes of nitrates, nitrites and methylmurcury

How

• Introducing new foods– Repeated exposures may be needed– No evidence for benefit to introducing foods in

any sequence or rate– Meat and fortified cereals provide many

nutrients identified as needed after 6 months.

When?

• GI readiness: 3-4 months

• Developmental readiness: varies, between 4 and 6 months

• Nutritional needs beyond breastmilk: not before 6 months, after that varies

• Need for variety and texture: within first year, order not important

Some Issues: Foman, 1993• “For the infant fed an iron-fortified formula,

consumption of beikost is important in the transition from a liquid to a nonliquid diet, but not of major importance in providing essential nutrients.”

• Breastfed infants: nutritional role of beikost is to supplement intakes of energy, protein, perhaps Ca and P.

• Nutrient content of breastmilk is a compromise between maternal and infant needs. Most human societies supplement breastmilk early in life.

Solids: Borrensen - (J Hum Lact. 1995)

• Some studies find exclusive breastfeeding for 9 months supports adequate growth.

• Iron needs have individual variation.

• Drop in breastmilk production and consequent inadequate intake may be due to management errors

What?

• After 6 months most breastfed infants need complementary foods to meet DRIs for energy, iron, vitamin D, vitamin B6, niacin, zinc, vitamin E, and others

• In US Iron and vitamin D need special emphasis due to prevelance of deficiency.

• Little room for foods with low energy density in the diets of infants

Sources of Energy: 4-5 months

Rank Food group % of Total

1 Infant formula 56.1

2 Breast milk 32.1

3 Infant cereal 5.3

4 100% juice 1.5

Sources of Energy: 6-11 MonthsRank Food group % of Total

1 Infant formula 43.1

2 Breast milk 10.7

3 Infant cereal 6.5

4 100% juice 4.4

5 Milk (cow’s/goat’s/soy) 3.4

6 Baby food dinners 3.2

7 Bananas 2.7

8 Cookies 1.8

9 Apples/applesauce 1.7

10 Baby food desserts 1.6

11 Bread/rolls/biscuits/bagels/tortilla 1.2

12 Crackers/pretzels/rice cakes 1.2

13 Noninfant cereals 1.2

14 Pears 1.2

15 Cheese 1.1

12-24 mos, cont.14 Bananas 2.1

15 Beef 2.0

16 Infant formula 1.9

17 White potatoes 1.9

18 Cakes/pies/other baked goods 1.7

19 Breast milk 1.6

20 Yogurt 1.5

21 Eggs 1.5

22 Pancakes/waffles/french toast 1.5

23 Chips/other salty snacks 1.3

24 Ice cream/frozen yogurt/pudding 1.2

25 Sugar/syrups/jams/jellies/other sweeteners 1.1

26 Rice 1.1

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

The Basics from AAP: Timing of Introduction of Non-milk Feedings

• Based on individual development, growth, activity level as well as consideration of social, cultural, psychological and economic considerations

• Most infants ready at 4-6 months• Introduction of solids after 6 months may delay

developmental milestones.• By 8-10 months most infants accept finely

chopped foods.

AAP: Specific Recommendations for Infant Foods

• Start with introduction of single ingredient foods at weekly intervals.

• Sequence of foods is not critical, iron fortified infant cereals are a good choice.

• Home prepared foods are nutritionally equivalent to commercial products.

• Water should be offered, especially with foods of high protein or electrolyte content.

AAP: Specific Recommendations

• Home prepared spinach, beets, turnips, carrots, collard greens not recommended due to high nitrate levels

• Canned foods with high salt levels and added sugar are unsuitable for preparation of infant foods

• Honey not recommended for infants younger than 12 months

Methemoglobinemia in vegetables

• Nitrates in homemade baby food– Beets, carrots, pumpkin, green beans– Case reports of cyanosis, tachycardia,

irritability, diarrhea, and vomiting

Foman S. Feeding Normal Infants: Rationale for Recommendations. JADA

101:1102• “It is desirable to introduce soft-cooked red

meats by age 5 to 6 months. “

• Iron used to fortify dry infant cereals in US are of low bioavailablity. (use wet pack or ferrous fumarate)

Foman S. Feeding Normal Infants: Rationale for Recommendations. JADA

101:1102• “It is desirable to introduce soft-cooked red

meats by age 5 to 6 months. “

• Iron used to fortify dry infant cereals in US are of low bioavailablity. (use wet pack or ferrous fumarate)

Cautionary Tales

• Early introduction

• Late introduction

• Honey/Nitrates

• Juice

• Other

Some Considerations in Complementary feedings

Too Early• diarrheal disease & risk

of dehydration• decreased breast-milk

production• Allergic sensitization? • developmental

concerns

Too Late• potential growth failure• iron deficiency• developmental

concerns

Solids: Weight Gain• Weight gain: Forsyth (BMJ 1993) found

early solids associated with higher weights at 8-26 weeks but not thereafter

Solids: Respiratory Symptoms• Forsyth (BMJ 1993) found increased

incidence of persistent cough in infants fed solids between 14-26 weeks.

• Orenstein (J Pediatr 1992) reported cough in infants given cereal as treatment for GER.

What foods should be avoided to reduce food allergy risk?

• No restrictions if not at risk for allergy.

• If strong family history of food allergy:– Breastfeed as long as possible– No complementary foods until after 6 months– Delay introduction of foods with major

allergens: eggs, milk, wheat, soy, peanuts, tree nuts, fish, shellfish.

Vegan Infants

• ADA and AAP state that well planned vegan diet can meet the nutritional needs and support growth in infants and children

• Key issues– Adequate maternal diet to maintain adequate milk

volume– B12– Vitamin D– Zinc– Iron– Energy, adequate fat in diet

The Use and Misuse of Fruit Juice in Pediatrics - AAP, May 2001

• Excessive juice consumption may be associated with malnutrition (overnutrition and undernutrition).

• Excessive juice consumption may be associated with diarrhea, flatulence, abdominal distention, and tooth decay.

• Unpasteurized juice may contain pathogens that can cause serious illnesses.

• A variety of fruit juices, provided in appropriate amounts for a child's age, are not likely to cause any significant clinical symptoms.

• Calcium-fortified juices provide a bioavailable source of calcium but lack other nutrients present in breast milk, formula, or cow's milk.

Feeding Infants and Toddlers Study (n=2,515)

Journal of the American Dietetic Association, January 2006

Delayed Complementary Feeding Until 4 months

• 73% met guideline• Those who met guideline more likely to:

– Be married– Have higher income– Be college grads– Be white or Hispanic compared to African American– Live in an urban area and/or live in the west– Not be on WIC

Juice Recommendations (after age 6 mos, 100% juice, limit to 6 oz/d)

• 80% met guidelines• Those who met guidelines more likely to:

– Be college graduates– Have higher incomes– Live in the west and in urban areas– Not be on WIC– Note: no racial/ethnic differences

Percentage of Hispanic and non-Hispanic infants and toddlers consuming desserts, sweets, sweetened beverages, and salty snacks on a given day

Age 4-5 Months Age 6-11 Months Age 12-24 Months

Hispanic (n=84)

Non-Hispanic (n=538)

Hispanic (n=163)

Non-Hispanic (n=1,228)

Hispanic (n=124)

Non-Hispanic (n=87)

Any type of dessert, sweet, or sweetened beverage

13.2 5.9 57.0 47.1 88.8 86.8

Desserts and candy 8.3 3.5 50.9 40.7 62.1 68.9

Baby food desserts 7.0 2.0 17.4 15.5 3.2 2.1

Cakes, pies, cookies and pastries

1.3 1.1 38.7 28.3 51.0 54.1

 Baby cookies 1.3 1.1 24.8* 14.5 9.1 13.4

 Other cookies — — 11.6 12.5 36.9 35.2

Ice cream — — 3.2 4.4 13.0 15.4

Other sweets 4.1 1.8 4.8 7.6 33.9 32.3

Sugar, syrups, preserves 3.5 1.8 4.5 5.0 17.8 25.6

Sweetened beverages — — 13.9 6.7 53.5* 35.8

Carbonated sodas — — 1.7 — 17.0 8.1

Fruit flavored drinks — — 13.2* 5.4 47.0* 29.5

Any type of salty snack — — 3.1 3.5 18.9 22.7

 *Significantly different from non-Hispanics at P<.05.