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Infant feeding involves more than just meeting basic nutrient requirements. It must also consider the timely introduction of appropriate forms of food, ever-evolving self-feeding skills and food preferences, and laying the foundation for a lifetime of healthy eating habits.
The youngest consumers are arguably the most challenging. Infants do not make their own food choices and cannot tell their parents or other caregivers exactly what they want or need to eat. Toddlers, on the other hand, feel quite free to express their preferences. What two-year-old hasn’t begged to eat the same food three times a day, day after day, for a week—then begged to never eat it again! That’s where adults come in: parents to offer nutritious foods, medical practitioners to recommend healthful feeding practices, and manufacturers to produce convenient, healthy meal and snack options that are in sync with the growth and development of infants and young children.
In this article, we’ll look at the key nutrient issues in infant and toddler feeding, specifically which nutrients are most critical and why. Then we’ll address unique, age-related feeding issues—from the non-nutritive advantages of breastfeeding, to which foods make the best first foods for older infants, to picky eating in toddlers. Finally, we will look at how this early period of infant and toddler feeding and nutrition fits in the context of building a lifetime of healthy eating habits.
Key Nutrition Issues in Infants and Toddlers
A mother’s milk is the ideal first food for her infant in terms of nutrition and immunologic and emotional benefits. It’s a dynamic fluid that changes composition to meet her young, growing infant’s evolving nutritional needs. In recognition of human milk’s role as the “perfect food,” the Dietary Reference Intakes (DRIs) from the National Academy of Sciences Institute of Medicine patterned the Adequate Intake (AI) values during the first six months of life after the nutrient content of human milk for all nutrients except vitamin D. (More on the reason for this below.) Health professionals concerned with infant nutrition enthusiastically support and promote breastfeeding for at least the first 12 months of life, and beyond the first birthday for as long as is mutually desired (AAP, 1997; ADA, 2001).
At some point, however, breastfeeding alone cannot support the nutrient needs of rapidly growing and developing older infants, particularly requirements for iron, zinc, and calcium. Solid foods that are nutritional complements of breast milk must be added to the diet. In her infinite wisdom, Mother Nature has linked the need for significant increases in nutrient intakes with the infant’s physiological and developmental readiness for solid foods. In other words, a baby’s readiness to eat foods in addition to breast milk dovetails nicely with the development of a critical nutritional need for them.
• Iron, Zinc, and Vitamin D. The first period of nutritional vulnerability occurs around six months of age, when infants’ neonatal iron stores, a gift from their healthy mothers during the third trimester of pregnancy, have been utilized. This depletion occurs just as the infant’s body begins experiencing a substantial increase in erthrocyte mass, and to a lesser extent, myoglobin in lean issue (Dallman, 1988). Additional sources of dietary iron must be introduced at this time to prevent iron-deficiency anemia (IOM, 1993; AAP, 1998; Centers for Disease Control, 1998).
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The consequences of iron deficiency with or without anemia during infancy—developmental delay, cognitive impairment, lower mental and motor test scores, and behavioral alterations—can be subtle (Lozoff et al., 1982, 1985, 1987, 1996; Nokes et al., 1998; Walter et al., 1989; Idjradinata and Pollitt, 1993). The American Academy of Pediatrics (AAP), the Centers for Disease Control, and the Institute of Medicine all recognize the importance of preventing the depletion of infant iron stores and have issued recommendations emphasizing sound iron nutrition for exclusively breast-fed infants, preferably from complementary foods such as iron-fortified infant cereals or pureed meats. Pre-term infants weighing even a little less than 2,500 g at birth are at risk of developing iron deficiencies earlier than term infants, which is why the AAP recommends providing therapeutic iron supplements to these infants starting at two months of age, while continuing breastfeeding (AAP, 1998).
In contrast to iron, zinc concentrations in human milk are initially quite high in the early weeks postpartum (Siimes and Salmenpera, 1989), but then decline sharply over the early weeks of breastfeeding (Krebs et al., 1995). Human milk alone appears unlikely to adequately meet the zinc needs of infants beyond approximately six months of age (Krebs et al., 1994).
There are relatively rare reports of frank severe zinc deficiency—with characteristic skin rash, diarrhea, and growth failure—in breast-fed babies in the U.S. More common but less dramatic is a mild, growth-limiting zinc deficiency, seen as a slowing of weight gain and/or linear growth, loss of appetite, and normal or slightly low plasma zinc concentrations. The risks of zinc deficiency are considerably greater in environments with higher morbidity due to infectious illnesses, especially for diarrheal illnesses, which have been associated with excessive zinc losses. In these settings, zinc supplementation has led to improved growth, fewer infectious illnesses, and recovery from acute diarrhea (Black, 1998).
Despite their excellent bioavailability in human milk, the naturally low levels of iron and declining levels of zinc cannot support the demands of older, exclusively breast-fed infants. Solid foods must be introduced as a complement to breast milk to prevent nutritional deficiencies during this period of rapid infant growth and development. The infant’s gastrointestinal tract is essentially mature by this time, and gross and fine motor skills have developed to a point where the infant can eat solid foods from a spoon. Importantly, an infant’s energy requirements—not micronutrient requirements—will drive milk intake. Feedings are discontinued when a baby feels “full,” which could be long before micronutrient requirements are met. Complementary foods are key to meeting the breast-fed infant’s nutritional need for iron and zinc.
Vitamin D has always been recognized as a critical nutrient for breast-fed infants, particularly dark-skinned infants and those who do not receive supplemental vitamin D or adequate sunlight exposure (AAP, 2003). These infants are all at increased risk of developing vitamin D deficiency or rickets. Until very recently, sunlight exposure was traditionally hailed as an effective rickets preventative for breast-fed infants. However, the AAP and the American Cancer Society have recently launched a major public health campaign that urges limited exposure to ultraviolet light to decrease the risk of skin cancer. The initiative includes guidelines to decrease exposure for infants younger than six months of age. While sunscreens are effective for reducing exposure to ultraviolet light, their use also markedly reduces vitamin D production in the skin.
In light of these new recommendations, the AAP and National Academy of Sciences have issued a concurrent recommendation that all infants, including those who are exclusively breastfed, receive a minimum intake of 200 IU of vitamin D per day beginning during the first two months of life. Human milk typically contains a vitamin D concentration of 25 IU/L or less, which does not meet the recommended adequate intake (AI) of vitamin D. In addition, since most vitamin D in older children and adolescents is supplied by sunlight exposure, it is recommended that the 200 IU of vitamin D per day recommendation be continued throughout childhood and adolescence.
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• Calcium. A second period of nutritional vulnerability occurs when toddlers are weaned from a mixed diet of milk and infant foods to an exclusive table-food diet. During this period, human milk and/or infant formula intakes decrease substantially and with them so do dietary calcium intakes. This dietary shift could lead to calcium deficiency if other sources of calcium are not introduced.
Nutritionists agree that it is very difficult to meet calcium needs without a source of milk in the diet (Margarey et al., 1991). Milk and milk products are calcium-dense foods providing about 300 mg of calcium per serving. These foods also contain other nutrients important to bone health such as vitamin D (if fortified), phosphorus, and magnesium. Calcium intake is a particular concern in children who have low intakes of dairy products and high intakes of unfortified juice drinks, soft drinks, and other beverages. While healthier, low-fat milks are replacing higher-fat milks in children’s diets (USDA, 1996), their overall milk consumption has declined by 36% in the past 30 years (Cavadini et al., 2000). Establishing an early “milk habit” of 3 servings a day of milk or dairy products (USDA, 1992) is important because milk—and therefore calcium—consumption during childhood tracks over time. Among a sample of elderly adults, the frequency of milk consumption during childhood was found to be the strongest predictor of current milk intake (Elbon et al., 1996).
Specific Issues by Feeding Period
Fulfilling nutritional requirements is only half the story. The actual feeding of infants and young children is the second half. Their foods should provide age-appropriate nutrition, while exposing them to age-appropriate textures and flavors. Alert parents who learn to recognize their infants’ behavioral cues for hunger and satiety, as well as their developmental readiness for new and increasingly complex flavors and textures, can help their children learn healthy eating habits right from the start.
• Breastfeeding. The great news for infants in the U.S. is that breastfeeding rates at birth have steadily climbed over the past 30 years from 25% in 1971 to just over 70% in the year 2000. Moreover, 50% of infants continue to breastfeed through the first three months of life, just under 40% at six months, and 20% at one year of age. These rates, which still fall short of national goals (National Center for Health Statistics, 2000), represent significant gains and mean that more and more infants are reaping the nutritional, immunological, and emotional benefits of breastfeeding.
Increased breastfeeding rates means that more infants are also learning to appreciate the foods of their culture sooner, since many flavors of the mother’s diet are transmitted through her breast milk. Some suggest that the breast-fed infant’s willingness to accept new foods more readily than formula-fed infants may be due to their greater experience with the variety of flavors in their mother’s milk.
Importantly, beginning solid foods should not mean an end to breastfeeding. Iron-rich solid foods are appropriate complements to breast milk that ensure continued healthy growth and development once infant body stores of iron have been depleted. Mothers should be encouraged to breastfeed as long as possible throughout their infant’s first year of life and can be assured that breast milk and iron-fortified infant cereals are a healthy and nutritious mealtime combination.
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• Introducing Solids—Which Are Best? Developmentally, infants’ physical and emotional abilities dovetail nicely with their nutritional need for foods in addition to breast milk. For example, the disappearance of the extrusion reflex and the appearance of neck and trunk control coincide with the infant’s biological need for additional dietary sources of micronutrients, especially iron and zinc. Single-grain, iron-fortified infant cereals are traditionally recommended for the older infant’s first complementary food. Recently, zinc has also been added to some of these cereals, which are usually well-tolerated by infants. They can also be mixed with breast milk to create a flavor bridge that facilitates the introduction of other solid foods.
Fruits and vegetables are recommended and commonly introduced as early solid foods. While they contribute fiber and certain vitamins, as opposed to the protein, iron, or zinc contributed by infant cereals and meats, fruits and vegetables are also extremely important in terms of the early opportunities they provide for infants to learn about dietary variety. Studies on infant food acceptance patterns have shown that infants’ taste experience with foods increases their subsequent intake and acceptance of these foods, as well as foods that are categorically similar—e.g., other fruits or other vegetables (Birch et al., 1998). At least one study has shown that early experiences with dietary variety lead to increased acceptance of other novel foods—e.g., early dietary experience with carrots increased infants’ acceptance of chicken (Gerrish and Mennella, 2001). Moreover, breastfeeding duration, early taste experiences with fruits and vegetables, and a mother’s own food preferences all have been positively linked to children’s fruit and vegetable intakes in later life (Skinner et al., 2002).
Pennington (1989) describes the protein, iron, and zinc content of fruits, iron-fortified rice cereal, beef, and poultry. Iron-fortified infant cereals obviously contribute substantial amounts of iron; and those that are zinc fortified contribute significant amounts of zinc. Beef and chicken contribute several-fold more protein, moderately more zinc, and much less iron, compared to the cereal. While meats contain less iron, iron from meat is more bioavailable than that from cereal, so meat can be an important source of iron. Serving cereal with a source of vitamin C, such as fruit, enhances the absorption of iron from cereal. Both meat and poultry are good sources of protein; beef, however, is considerably higher than chicken in zinc. The two are approximately equivalent in iron. While traditional infant feeding practices and cultural preferences may cause parents to shy away from meats as first foods, AAP (AAP, 1998), IOM (1993), and the LaLeche League (Gotsch and Torgus, 1997) all recommend meat as one of the first complementary foods for infants.
• The Next Steps. One of the common myths about eating is that it is easy and instinctive (Toomey, 2002). Eating is actually the most complex physical task humans engage in. It is the only physical task that utilizes all the body’s organ systems: the brain and cranial nerves; the heart and vascular system; the respiratory, endocrine, and metabolic systems; all the muscles of the body; and the entire gastrointestinal tract. Eating is also the only task children do that requires the simultaneous coordination of all of the sensory systems. The ability to manage this physical coordination begins instinctively, but only for the first month of life. Between the first and sixth months of life, the primitive motor reflexes (rooting, sucking, swallowing) take over as the older infant lays down pathways in the brain for the voluntary motor and sensory control over eating. Beyond this period, eating becomes a learned behavior.
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Because learning to eat involves the development and interplay of so many body systems and activities, providing the appropriate foods at the appropriate times helps the older infant and toddler master the incremental skills needed to transition from pureed baby foods to complex, textured table foods. Young children lead the way through this transition by indicating the unique timing of their readiness. Importantly, physical development and acquisition of different gross and fine motor skills happens over a range of ages. The same skills and capabilities do not occur at exactly the same time for every child. Each child is an individual and develops at his or her own rate. Parents and other caregivers can feel comfortable allowing their children to show them what they need and when.
The skills acquired and needed over this period include (1) postural stability, which is affected by the type of chair used to support the growing infant; (2) oral motor skills, which need to progress from a sucking movement for purees to the side-to-side tongue movements needed for eating table foods; (3) jaw skills, which will progress from a suck to a munch to a rotary chewing motion so that foods with textures can be properly broken apart; (4) sensory skills, so an older infant and toddler can tolerate the “feel” of foods in their mouth, to learn to like the taste of table foods, and to track where the food is in the mouth at any given time; (5) hand-to-mouth skills, which allow the child to learn to self feed; and (6) parenting skills, which encourage the infant to enjoy a variety of foods and the feeding experience throughout the formative years (Toomey, 2002).
The foods offered during this critical period should have sensory attributes that encourage both acceptance and skill development. Gerber has designed a line of foods that specifically addresses the evolving needs of young children during this stage of development and helps promote the acquisition of these skills. Generally the progression is from a thin puree, such as a thin cereal mixture, or a Gerber® 1st Foods™ fruit or vegetable, to increasingly thicker purees, such as Gerber 2nd Foods™ fruits, vegetables, and dinners. When the child is ready, soft lumps that are easily mashed can be added to the food (Gerber 3rd Foods™); very soft dices of fruits and vegetables (Gerber Graduates™ Dices) are also appropriate. At about this same time, the child may be ready for finger foods, such as a Gerber Biter Biscuit™, which melt easily in the mouth. Gerber has developed an entire line of Gerber Finger Foods. As the child is ready to handle more complex foods, Gerber Graduates™ fill the need for more complex and nutritious foods that bridge the way to table foods and provide just the right serving sizes for these little stomachs.
• Picky Eating. Of all the troublesome behaviors at meal-times, “picky eating” is clearly the most exasperating for parents. “Why won’t he try new foods?” “She eats like a sparrow!” “If I have to make one more peanut butter sandwich, I’ll scream!” Most of the time, these are all normal mealtime behaviors for infants and young children. Problems can arise, however, when parents fail to respond appropriately to these “teachable moments.” Because if a child is not exposed on a regular basis to a wide variety of fruits, vegetables, and whole grain, he or she will not learn to appreciate these flavors, limiting the opportunity to learn to like a wide variety of nutritious foods.
Food preferences are related to our experiences with them. So the more frequently a food is tasted, the more likely a baby or child will learn to like it. The good news for parents is that food neophobia—the fear of trying new foods—diminishes with age. In other words, their three-year-old is least likely to try a new food, but their child at age five, and later at 15, will be more willing. Before they know it, their 18-year-old will have gone off to college and become a vegetarian!
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Parents need to know that infants and children grow in fits and spurts, and their eating behaviors mirror these patterns. They eat more during a growth spurt and eat less during periods of no growth. Parents may view these changing eating patterns as erratic and unconventional, as a normally “picky eater” becomes ravenous, or a normally “good eater” becomes picky. These changes are in fact normal patterns driven by metabolic necessity. Children’s weight and linear growth should be monitored at regular well-child checkups, particularly for those who are truly “picky eaters.” Poor weight-gain can signal a serious condition that requires further intervention or medical attention.
Another challenge of feeding older infants and especially toddlers is their increasing interest in exploring the world around them rather than eating. If meals and the food are enjoyable extensions of a child’s exploration of the world, there will be incentive to come to the table to eat. Serving foods with different colors and textures to create foods and meals that look interesting and appealing to eat can help. Letting a child explore foods (texture, temperature, consistency, pliability) will help the child get to know foods—especially new foods—teaching him the “physics of food” or how the food will feel, break apart, and move in his mouth. Allowing the older infant and toddler to get messy and “play” with their food is especially helpful for gaining and maintaining a child’s interest in food and eating.
Teaching Healthy Habits
Researchers have repeatedly shown that if young children are allowed to choose from a wide range of nutritious foods, they will eat the right amounts of a varied diet to grow and develop normally. They may not eat a variety of foods at each meal, but over the course of several weeks, they will eat a healthy diet rich in variety.
Of course, the results would be quite different if large quantities of foods high in fat and sugar and low in micronutrients were included in the offering, which is why the parents’ role as “nutrition gatekeeper” in the home is so important. A healthy and enjoyable diet is all about variety, balance, and moderation. There is room for all foods in a healthy diet; it is the frequency and amount that is important. Yet, significant quantities of fruits and vegetables as well as whole grains form the base of a healthy diet. But there is also room for the occasional “treat”—those foods that provide more calories than nutrition—as long as they are not the basis of the diet. It is important to teach children how to incorporate a variety of foods—including “treats”—into their diet because, just like the forbidden fruit, if parents restrict highly palatable foods at all times these foods become even more desirable and nutrient-rich foods even less desirable (Fisher and Birch, 1999). Bottom line: Fruits and vegetables as well as whole grains form the base of a healthy diet, but there’s room for a treat now and then.
Not to be confused with occasional treats are routine healthy snacks or “mini-meals,” which are as important to older infants and young children as the three square meals. Their rapidly growing bodies rely on the calories and nutrition provided throughout the day by delicious and nutritious snacks, such as yogurt or cheese with fruit or vegetable dices, cereal with a cup of milk or juice, crackers with peanut butter.
So, if young children should be allowed to choose what and how much to eat, what role do parents play during mealtimes? Their job is to provide a variety of healthy foods during pleasant, regularly scheduled meals and snacks, then allow their children to choose what and how much to eat from the foods offered. This simple strategy helps children learn to listen to their internal hunger and satiety cues as they learn to accept and enjoy a variety of nutritious foods.
Importantly, before parents can teach their children to be healthy eaters, parents need to be aware of the messages they might be sending to their children about particular foods and/or about their own food preferences. If parents are concerned that their older infant or toddler may not be able to handle a particular food and then look worried about it, the child will get the message that that food is not safe and should be rejected. Similarly, parents need to be good role models for their infants and toddlers. This applies to modeling how to eat, as well as what to eat. If parents make a face and complain that they don’t like broccoli, it’s doubtful that their child will eat broccoli either. Recent research suggests parents’ own food preferences play a large role in whether or not their children learn to eat particular foods during their lifetime (Nicklas and Fisher, 2003).
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A century ago, vitamin and mineral fortification and under-nutrition were the critical nutrition issues that affected public health and challenged the food industry. Today, while we may find pockets of vulnerable children experiencing micronutrient deficiencies in this country, notably iron, unlimited access to an over-abundance of food has created a new set of challenges, including an epidemic of childhood obesity. Today, 15% of school-age children and adolescents are overweight and at an increased risk for a number of chronic diseases including diabetes, heart disease, cancer and arthritis (National Center for Health Statistics, 2002). In fact, 45% of newly diagnosed cases of type II diabetes—previously thought of as an adult disease—are associated with childhood obesity. Risk factors for heart disease, such as high cholesterol and high blood pressure, also occur at greater frequency in overweight children. Moreover, these children have a 75% chance of being overweight or obese as adults, who will also be at great risk of chronic disease (Goran, 2001). Developing healthy eating habits around appropriate amounts and varieties of nutritious foods is more important than ever.
The Gerber Start Healthy™ initiative, a collaboration with the American Dietetic Association, was created in response to the global childhood obesity epidemic. The initiative is both a research and educational program aimed at filling the gaps in scientific knowledge about what children are eating, what parents are feeding, and what professionals are recommending during the transition from an all-milk diet to one patterned after family meals. This critical window in children’s growth and development can affect the development of food preferences and eating habits throughout childhood and beyond.
Importantly, right from the start babies are born knowing how much they need to eat to grow and thrive. They demonstrate this from day one during breastfeeding. The Start Healthy initiative encourages parents to become attuned to their baby’s mealtime communication during the nursing period and beyond. Honoring innate hunger and satiety cues teaches babies to eat when they are hungry and stop when they are full, decreasing their risk of developing overeating habits.
Start Healthy also stresses the importance of 5 servings a day of fruits and vegetables for everyone in the family. A colorful variety will provide vitamin A for vision and cell growth, vitamin C for healthy gums, potassium for fluid balance, and lycopene and the other phytonutrients for a multitude of preventive health benefits that we’re still discovering.
Parents also need to begin early to build their baby’s taste for a variety of food flavors and textures. Research from the University of Tennessee shows that children’s food preferences change little between ages 2-3 and ages 6-8 (Skinner et al., 2002a, b). So rather than waiting until a child is older before teaching him to like a healthy mix of foods, Start Healthy encourages parents to gradually introduce them when their children are first learning to eat solid foods.
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Other research indicates that it can take up to 10 exposures for a child to accept a new food (Birch et al., 1987). Start Healthy encourages parents to feed a food several times before deciding that their child doesn’t like the food. It’s important in those early months and years of gastronomical discovery not to limit a child’s exposure to new flavors and textures.
Parents do have an influence over their children’s food acceptance patterns, so they need to set a good example right from the start. Throughout childhood their children will watch and mimic them. If the parents are eating a healthy variety of foods, their children are likely to enjoy them, too. If parents eat a limited number of foods, or avoid certain types of foods, their children are likely to pick up the same eating pattern.
The other side of the healthy habits equation is activity. As with eating habits, experts agree that parents can influence their children’s future preferences by what they teach them now. Nurturing children’s motor skills when they are young, while making physical activity enjoyable and fun, helps ensure healthy development today and a healthy physical activity habit tomorrow.
Research from various areas of child nutrition and development tell us that starting healthy habits early on can lead to a better quality of life and health over the course of a lifetime. Importantly, whether parents are helping their young children develop healthy eating habits, good oral hygiene, or a love of reading, starting early, showing patient persistence, and modeling good behavior are key. All habits—good and bad—are formed over time and through repetition. They don’t just happen overnight. When caregivers and young children work together to develop healthy habits, they also nurture the quality of their relationship. Therefore, developing healthy habits isn’t just about nutrition, health, and safety, it’s also about developing a loving, secure environment that nurtures the emotional well-being of a child.
The two periods with greatest opportunity for helping young children learn about healthy eating habits are (1) during the transition from an all-milk diet to complementary foods from a spoon, and (2) later, when a child makes the transition from pureed baby foods to more complex foods from the family’s table.
Learning to eat should be a natural, stress-free progression for families with young children. With the right foods, at the right time, and the right information, parents can make this a wonderful learning, exploring, and fun experience, too.
by Kathleen Reidy
The author is Director of Nutrition Science and
Regulatory Affairs, Gerber Products Co.,
200 Kimball Dr., Parsippany, NJ 07054-0622.
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