Complementary Feeding

Transcription

1 Complementary Feeding Raanan Shamir, MD ESPGHAN Goes Africa Capetown, October 2013

2 Definition and Concepts Nutritional Adequacy Allergy ESPGHAN recommendations Safety (lack of) Specific Regulation Taste and food preference

3 Definitions & Concepts

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5 Definition complementary feeding embrace all solid and liquid foods other than breast milk or infant formula and/ or follow-on formula

6 LISA Birth Cohort 1 st introduction of any solids 0-4 mo 32% 5-6 mo 49.3% >6 mo 18.8% Solids 4 mo No solid food 69.6% 1-2 groups 17.3% 3-8 groups 13.1% Zutavern A et al. Pediatrics 2008;121:e44-52

7 Current Practices Introduction of CF in 5 EU Countries Solid 4 mo: 37% of FF 17% of BF Complementary feeding is introduced earlier than recommended in a sizeable number of infants, particularly among FF infants

8 Prevalence and Reasons for Early Introduction of CF Variations by Milk Feeding Type 40.4% of mothers in the US ( ), introduced solid foods before age 4 months. Prevalence varied by milk feeding type: 24.3% BF 52.7%, FF 50.2% Mixed Clayton HB, et al. Pediatrics. April 2013

9 Prevalence and Reasons The most commonly cited reasons for early introduction of solid food were as follows: "My baby was old enough" "My baby seemed hungry" "I wanted to feed my baby something in addition "My baby wanted the food I ate" "A doctor or other health care professional said my baby should begin eating solid food" "It would help my baby sleep longer at night Clayton HB, et al. Pediatrics. April 2013

10 Why should we introduce complementary feeding?

11 Volume of human milk with exclusive about 6 months becomes insufficient to meet the requirements of calories, protein, iron, zinc and some fat-soluble vitamins (A & D). Issues of texture and oral skills are not EBM Possible prevention of allergy, celiac disease and obesity

12 When? Gastrointestinal and renal function are sufficiently mature by around 4 months of age There is a range of ages when infants attain the necessary motor skills to cope safely with CF

13 Appropriate CF Timely: Foods are introduced when the need for energy and nutrients exceeds what can be provided through exclusive and frequent breastfeeding; Adequate: Foods provide sufficient energy, protein, and micronutrients to meet a growing child s nutritional needs; Safe: Foods are hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats WHO. Complementary feeding 201 1

14 Appropriate CF properly fed : Foods are given consistent with a child s signals of appetite and satiety, and that meal frequency and feeding method actively encouraging the child to consume sufficient food using fingers, spoon or self-feeding are suitable for age WHO. Complementary feeding 201 1

15 Appropriate CF The consistency of complementary foods should change from semisolid to solid foods and the variety of foods offered should increase By 8 months, infants can eat finger foods and by 12 months, most children can eat the same types of food as the rest of the family WHO. Complementary feeding 201 1

16 Summary of ESPGHAN Recommendations Exclusive or full BF for about 6 months is a desirable goal Complementary feeding should not be introduced in any infant before 17 weeks, and all infants should start complementary feeding by 26 weeks

17 Nutrition Adequacy

18 Nutrition Adequacy With average breast-milk intake, CF should provide about : 200 kcal/day at aged 6 8 months 300 kcal/day for infants aged 9 11 months 550 kcal/day for children aged months WHO. Complementary feeding 201 1

19 Nutrition Adequacy On a population basis, suggested # of meals (assuming a diet with energy density of 0.8 kcal/gr or above and low breast milk intake: mo mo. and children mo. Additional nutritious snacks may be offered 1 2 times a day, as desired WHO. Complementary feeding 201 1

20 Do We Provide Adequate Nutrition in Low Income Countries? WHO 2011: Adequate Protein Thiamine Deficiency in Some Vitamin A Folate Ubiquitous Deficiency Diets of infants and young Riboflavin B6 B12 Calcium children in most populations in Zinc low-income countries are Iron consistently deficient in some nutrients, including iron, zinc and vitamin B6 Vossenaar M, et al. Am J Clin Nutr 201 2; 95:

21 AJCN October NGG infants had significantly higher red meat intake and higher Hemoglobin with no significant differences in linear growth from 6 to 12 mo of age or in serum ferritin or zinc

22 CF and attained linear growth among 6-23-month-old children DESIGN: Secondary analysis of Phase V Demographic and Health Surveys data ( ). SETTING: Twenty-one countries (4 Asian, 12 African, 4 from the Americas and one European). SUBJECTS: Sample sizes ranging from 608 to Onyango AW, et al. Public Health Nutr Sept 2013

23 CF and attained linear growth among 6-23-month-old children RESULTS: Less than 50% of countries met minimum meal frequency and minimum dietary diversity, Minimum dietary diversity was the indicator most consistently associated with attained length Length-for-age declined with age in all countries, and the greatest declines in its Z-score were seen in countries where dietary diversity was persistently low or increased very little with age. Onyango AW, et al. Public Health Nutr Sept 2013

24 CF and attained linear growth among 6-23-month-old children CONCLUSIONS: poor complementary feeding contributes to the characteristic negative growth trends observed in developing countries and therefore needs focused attention and its own tailored interventions Dietary diversity has the potential to improve linear growth. Onyango AW, et al. Public Health Nutr Sept 2013

25 Allergy

26 Allergy Some studies suggest that delayed introduction of certain foods did not reduce, and may actually increase the risk of allergic sensitization Zutavern A, et al. Arch Dis Child 2004;89: Zutavern A, et al. Pediatrics 2006;117: Kull I, et al. Allergy 2006;61: Filipiak B, et al. J Pediatr 2007;151: (GINI). Du Toit, Katz Y, et al. J Allergy Clin Immunol 2008;122: Zutavern A, et al. Pediatrics 2008;121:e44-52 (LISA) Snijders et al. Pediatrics 2008;122:e (KOHALA)

27 Prospective Birth Cohort Studies Study N Conclusions GINI Study 4753 Germany No evidence supporting a delayed introduction of solids >4 m or delayed inroduction of most potentially allergenic solids >6 mo for the prevention of eczema LISA Study 2073 Germany No effect of age introduction of solids on longer term outcomes (asthma or allergic rhinitis) at 6 y. Higher risk of food sensitisation when solid foods >6 mo KOALA Study Chuang et al Holland Taiwan Delayed introduction of cow s milk products and other food products higher risk for eczema. Delayed introduction of other food products higher risk for recurrent wheeze No relationship between the age of introduction of solid foods and the risk of eczema at 18 mo.

28 Generation R Study 6905 preschool children were evaluated for timing of introduction of cow's milk, hen's egg, peanuts, tree nuts, soy, and gluten collected by questionnaires at 6 and 12 months of age. Introduction of all items was not significantly associated with eczema or wheezing at any age after adjustment for potential confounders (P >.10 for all comparisons). Tromp II, et al. Arch Pediatr Adolesc Med 201 1

29 ESPGHAN, AAP and NIAID Recommendations ESPGHAN and both the American Academy of Pediatrics (AAP) and the National Institute of Allergy and Infectious Diseases (NIAID) support: The introduction of solids between 4-6 months of age Avoiding delayed introduction of allergenic foods

30 Summary of ESPGHAN Recommendations During the CF period, >90% of the iron requirements of a BF infant must be met by CF. Cow s milk is a poor iron source. It should not be used as the main drink before 12 months, although small volumes may be added to CF.

31 Safety

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33 Safety Aspects in the Introduction of CF Family and Child Consumer behavior Environmental Contaminants Regulatory Bodies

34 Safety Aspects in the Introduction of CF Family and Child Home environment is not regulated Failure to remove hazardous/non healthy items (bones, skin, fat) Prolonged thawing and delayed cooking of meat, poultry, fish and milk products increase the risk of bacterial contamination

35 Safety Aspects in the Introduction of CF Family and Child Risk of Allergy Timely introduction of allergenic foods Introduction of single ingredients at a time with adequate interval Risk of choking grains (granola bars, seeds, nut pieces) food items that are too big or not soft enough to be chewed (hot dogs, non sliced food items) Risk of Contamination and poisoning

36 Safety Aspects in the Introduction of CF Family and Child

37 Risk of choking An estimated 111,914 children ages 0 to 14 years were treated in US hospital EDs from for nonfatal food-related choking, (12,435 children annually ). Mean age was 4.5 years. 37.8% of cases where in Children 1 y of age Pediatrics 201 3

38 Risk of choking Of all food types, hard candy was most frequently (15.5% [ cases]) associated with choking, followed by: other candy (12.8% [13 324]) meat (12.2% [12 671]) bone (12.0% [12 496]). Meyli M, et al. Pediatrics 201 3

39 What are safe levels of contaminats in food? Animal studies (rats, mice, etc.): - NOAEL : «No observed adverse effect level» In humans : - ADI=acceptable daily intake (daily dose in mg/kg for a 60 kg adult exposed all life long) - ADI= NOAEL/100 («safety factor») - 100=10 (inter species variability) x 10 (intra species variability )

40 Environmental Contaminants Children are not Small Adults Infants have different metabolism, immature defense mechanisms (i.e. permeable membranes including gut and brain barriers) and sensitive developing organs (i.e. CNS) Short duration exposure may have long term effects Adverse effects may go un noticed until much later in life

41 Environmental Contaminants Children are not Small Adults Diversity of food intake is limited Intestinal absorption is different (i.e. lead absorption is much higher) Tissue distribution is different Enzymatic biotransformation (important in detoxification) is immature Small body: some food items such as apples, intake by infants, may be up to X 20 higher than for adults

42 Environnemental Contaminants Farming Storage Processing Packaging Retailing Food preparation Agrochemicals (e.g. pesticides) Packaging migrants (e.g. phtalats) Packaging migrants Contact materials Industrial contaminants (e.g. heavy metals, PCB s) Contact materials Veterinary drugs Industrial contaminants Natural toxicants (e.g. mycotoxines, plant toxins) Chemicals formed during processing

43 Biological hazards Bacterial contamination Methylmercury and pesticides in fish and other food products Antimicrobials used as animal food additives Genetically modified organisms (GMOs)

44 Risk analysis 1. Develop an estimate of the risks to human health and safety («risk assessment») 2. Identify and implement appropriate measures to control the risks («risk management») 3. Communicate the risks and measures applied («risk communication»)

45 However, there Codex are alimentarius no specific regulations for complementary food Food Service, Israel Ministry of Health

46 Safety Aspects in the Introduction of CF Health care providers, especially pediatricians: Family and Child Consumer behavior Environmental Contaminants - We need to educate families for adequate nutrition and safety of CF Regulatory Bodies - Act as safe guards and identify safety holes

47 Development of Taste and Food Preferences Longitudinal follow-up studies suggest that early flavor experiences and food preferences during infancy even track into childhood and adolescence Skinner JD, et al. J Am Diet Assoc 2002;102:

48 Development of Taste and Food Preferences Beauchamp and Moran (Appetite 1982;3: ) examined preference for sweet solutions versus water in about 200 infants: At birth: all of the infants preferred sweet solutions to water By 6 months of age: the preference for sweetened water was linked to the infants dietary experience:

49 Development of Taste and Food Preferences Infants who were routinely fed sweetened water by their mothers (25%) showed greater preference for it than did infants who were not. Parents can thus play a critical role in the development of food preferences.

50 Development of Taste and Food Preferences Forcing a child to eat a particular food will decrease the liking for that food Restricting access to particular foods increases preferences. By contrast, repeated exposure to initially disliked foods may break down resistance. Benton D. Int J Obes Relat Metab Disord 2004;28:

51 Development of Taste and Food Preferences ESPGHAN recommendations Offering complementary foods without added sugars and salt may be advisable not only for shortterm health but also to set the infant s threshold for sweet and salty tastes at lower levels later in life.

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