Development, Relationship, and Transitions

1. Development, Relationship, and Transitions

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

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

4. Sociology of Food • Food Choices • Availability • Cost • Taste • Value • Marketing Forces • Health • Significance

5. Foods for infants and young children • Nurturing • Nourishing • Learning • Supports developmental tasks • Relationship • Development • Emotion and temperament

6. Development

7. Stages of Development: Neurophysiological • Homeostasis • Attachment • Separation and individuation

8. Stages

9. 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”

10. Developmental Changes • Oral cavity enlarges and tongue fills up less • Tongue grows differentially at the tip and attains motility in the larger oral cavity. • Gag locus moves from mid-portion to posterior tongue (3-7 months) • Elongated tongue can be protruded to receive and pass solids between the gum pads and erupting teeth for mastication. • Mature feeding is characterized by separate movements of the lip, tongue, and gum pads or teeth

11. Feeding developmentGessell A, Ilg FL

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

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

14. Maternal-Infant Feeding dyad • Indicates hunger (I) • Presents milk (M) • Consumes milk by suckling (I) • Indicates satiety, stops suckling (I) • Ends feeding (M)

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

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

17. Infant and Caregiver Interaction • Readability • Predictability • Responsiveness

18. 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

19. Play, Learning, Exploration

20. Feeding Practices and Obesity • Birch et al Learning to overeat:maternal use of restrictive feeding practices promotes girls’ eating in absence of hunger, Am J Clin Nutr 2003;78: 215-20 • Anzma and Birch, Low inhibitory control and Restrictive Feeding Practices Predict Weight Outcome J Pediatrics 2009:155:651-6

21. 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

22. Transitions: Non Milk feedings • Solids • Beikost • Table foods • Complimentary foods

23. Complementary Foods - definitions • “Any energy-containing foods that displace breastfeeding and reduce the intake of breast milk.” (AAP) • “any nutrient containing foods or liquids other than breastmilk given to young children during the periods of complementary feeding….[when] other foods or liquids are provided along with breastmilk.” (WHO) • “any foods or liquids other than human milk or formula that are fed during the first 12 months of life.” (Healthy Start Guidelines)

24. Growth, nutritional, and developmental factors form the basis of feeding transitions and recommendations for complimetary foods.

25. Successful introduction of complementary foods presupposes the ability of the infant to be nourished by, safely ingest, and accept such foods. • Key factors: digestion and absorbtion, neuromuscular development, taste and texture acceptance.

26. Development: Factors • Oral motor changes • Truncal stability • Change in gag loci from midportion to posterior of tongue (3-7 months) • Experiential • Repeat exposure

27. Factors: Growth and Nutrition • Growth • Growth faltering observed between 3-6 months • WHO/CDC deceleration in weight/length 3-12 months in breast fed infants • “Weanling dilemma” • Nutrition • Energy, Iron, Zinc

28. 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.

29. Growth and Energy • Exclusive breastfeeding • Complimentary foods replace breastmilk • “weanling dilemma” described in 1970-80 in developing countries: • Risk of infection with intro of contaminated complimentary food vs suboptimal growth with exclusive breast feeding

30. Growth faltering in exclusively breastfed infants between 3-12 months • Accelerated weight gain in the first few months associated with less deceleration in growth

31. 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

32. Complementary Foods • Energy • Iron • Zinc

33. Too Early diarrheal disease & risk of dehydration decreased breast-milk production Allergic sensitization? developmental concerns Too Late potential growth failure iron deficiency developmental concerns Some Considerations in Complementary feedings

34. Iron • Iron Status • Maternal status • Stores at birth • Growth rate • Dietary source

35. Iron U.S. date estimates prevalence in 18 month old infant/toddler 8-11%

36. Zinc • AI • 0-6 months: 2 mg/d • 7 months-3 years: 3 mg/d Breast milk content declines from 8-12 mg/L in first month to 1-3 mg/L 4-6 months Bioavailability of Zn greater in breastmilk than formula Endowment at birth, birthweight, maternal status and growth rate

37. 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)

38. 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

39. Complimentary Foods • Respiratory/Allergy • Juice • Dental Health • Safety • other

40. Allergies: Areas of Recent Interest • Early introduction of dietary allergens and atopic response • atopy is allergic reaction/especially associated with IgE antibody • examples: atopic dermatitis (eczema), recurrent wheezing, food allergy, urticaria (hives) , rhinitis • Prevention of adverse reactions in high risk children

41. Allergies: Early Introduction of Foods(Fergussson et al, Pediatrics, 1990) • 10 year prospective study of 1265 children in NZ • Outcome = chronic eczema • Controlled for: family hx, HM, SES, ethnicity, birth order • Rate of eczema with exposure to early solids was 10% Vs 5% without exposure • Early exposure to antigens may lead to inappropriate antibody formation in susceptible children.

42. Allergies: Prevention by Avoidance (Marini, 1996) • 359 infants with high atopic risk • 279 in intervention group • Intervention: breastfeeding strongly encouraged, no cow’s milk before one year, no solids before 5/6 months, highly allergenic foods avoided in infant and lactating mother

43. Allergies: Prevention by Avoidance (Marini, 1996)

44. Allergies: Prevention by Avoidance (Zeigler, Pediatr Allergy Immunol. 1994) • High risk infants from atopic families, intervention group n=103, control n=185 • Restricted diet in pregnancy, lactation, Nutramagen when weaned, delayed solids for 6 months, avoided highly allergenic foods • Results: reduced age of onset of allergies

45. Allergies: Prevention by Avoidance(Zeigler, Pediatr Allergy Immunol. 1994)

46. 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.

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

48. The Use and Misuse of Fruit Juice in Pediatrics - AAP, May 2001 • In the evaluation of children with malnutrition (overnutrition and undernutrition), the health care provider should determine the amount of juice being consumed. • In the evaluation of children with chronic diarrhea, excessive flatulence, abdominal pain, and bloating, the health care provider should determine the amount of juice being consumed. • In the evaluation of dental caries, the amount and means of juice consumption should be determined. • Pediatricians should routinely discuss the use of fruit juice and fruit drinks and should educate parents about differences between the two.

49. The Use and Misuse of Fruit Juice in Pediatrics - AAP, May 2001 • Juice should not be introduced into the diet of infants before 6 months of age. • Infants should not be given juice from bottles or easily transportable covered cups that allow them to consume juice easily throughout the day. Infants should not be given juice at bedtime. • Intake of fruit juice should be limited to 4 to 6 oz/d for children 1 to 6 years old. For children 7 to 18 years old, juice intake should be limited to 8 to 12 oz or 2 servings per day. • Children should be encouraged to eat whole fruits to meet their recommended daily fruit intake. • Infants, children, and adolescents should not consume unpasteurized juice.

50. 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.