Are There Sensitive Periods for Food Acceptance in Infancy?

Infant feeding-a scoping review for Nordic Nutrition Recommendations 2023

The 2012 edition of the Nordic Nutrition Recommendations (NNR) included recommendations on breastfeeding, based on the most recent guidelines and recommendations from major national food and health authorities and organizations, systematic reviews, and some original research. For NNR 2023, the scope has been expanded and also includes formula feeding and the introduction of solid food. The main focus in this scoping review is on infants aged 0-12 months but also considers parts both before and beyond the first year, as the concept of 'the first 1000 days' emphasizes the importance of factors during pregnancy and the first 2 years of life for immediate and later health: physical as well as emotional and mental health. Breastmilk is the natural and sustainable way to feed an infant during the first months of life. Numerous studies have indicated immediate as well as long-term beneficial effects of breastfeeding on health for both the infant and the breastfeeding mother, and from a public health perspective, it is therefore important to protect, support, and promote breastfeeding. For full-term, normal weight infants, breastmilk is sufficient as the only form of nutrition for the first 6 months, except for vitamin D that needs to be given as supplement. The World Health Organization (WHO) and several other authoritative bodies therefore recommend exclusive breastfeeding during the first 6 months. Starting solids at about 6 months is necessary for both nutritional and developmental reasons. According to the European Food Safety Authority (EFSA) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), solid foods are safe to give from 4 months although exclusive breastfeeding until 6 months is the desirable goal. Breastfeeding can continue together with complementary foods as long as it is mutually desired by the mother and child. If breastfeeding is not enough or for some reason discontinued before the infant is 4 months of age, the infant should be fed infant formula, and, when possible, breastfeeding should be continued alongside the formula feeding. If the infant is 4 months or older, starting with solids together with continued breastfeeding and/or formula feeding is an option. Infant formulas have been developed for infants who are not breastfed or do not get enough breastmilk. Home-made formula should not be given.

Food oral processing and eating behavior from infancy to childhood: evidence on the role of food texture in the development of healthy eating behavior

Eating behaviors develop in early life and refine during childhood, shaping long-term food choice and dietary habits, which underpin optimum growth and health. The development of Food Oral Processing (FOP) is of major importance in the establishment of eating behaviors at two scale levels: for the initial acceptance of food texture and for the longer-term development of eating behaviors associated to food intake. To date, both processes have been studied as independent topics and the current review proposes a parallel vision on their development from the onset of complementary feeding to later childhood. Individual factors affecting these FOP-related behaviors as they relate to food texture acceptance are discussed, alongside examples of interventions aiming at modifying them. Opportunity to better consider food textures when designing foods for children is addressed. Altogether, the review demonstrates the critical role of food texture in the development of a child's FOP skills, eating habits, and dietary patterns. These scientific knowledges need to be considered for the development of healthier eating behavior. We identify research gaps that need to be addressed and highlight the need to design foods that can support the development of healthy oral processing and eating behaviors among infants and children.

Cognitive behaviour therapy (CBT) as a psychological intervention in the treatment of ARFID for children and young people

Avoidant Restrictive Food Intake Disorder (ARFID) is a condition characterised by a disturbance in eating behaviour that leads to a significant negative impact on physical, social and nutritional health. The diagnosis of ARFID relies on a comprehensive, multi-disciplinary assessment to understand the individual’s history, physical, social and mental health risk, and any co-occurring mental health difficulties. Consensus guidance suggests that psychological treatment, alongside medical and dietetic input is delivered with consideration of any appropriate adaptions to accommodate developmental stage and/or common co-occurring presentations. This paper has been authored by clinicians working in an out-patient setting for children and adolescents with ARFID, and focuses on the presentation and assessment of ARFID and cognitive behavioural therapy (CBT) approaches that can help children, young people and their families. After an introductory section, the paper is split into four sections: assessment of ARFID; drivers of avoidant restrictive eating behaviour; multi-disciplinary formulation and intervention planning; and treatment. The treatment section provides an overview of the available research on CBT for ARFID, and a brief summary of the broader evidence base for CBT in children and young people with anxiety. Following a review of the evidence base, three case descriptions are provided to illustrate the clinical application of CBT where fear-based avoidance is the main driver. The paper concludes with practice points for clinicians to take forward when working with children and young people with ARFID.

Key learning aims

(1)

A review on children's oral texture perception and preferences in foods

Texture properties of foods are particular drivers for food acceptance and rejection in children. The texture preferences follow the developmental progression of the child and these changes modulate the present and future food habits. This paper reviews the development and factors influencing texture preferences in children and the methods in food texture research with children. The child's acceptance of more complex food textures is age-dependent. The progression is indorsed by the development of oral processing skills at an early age and bolstered by repeated exposures to foods with varying textures. Children generally reject foods containing pieces or bits (i.e., geometrical textural properties); however, the impact of mechanical textural properties on food acceptance is less clear. Child characteristics such as food neophobia, picky eating, and tactile over-responsivity, negatively affect the acceptance of more diverse food textures. Depending on the child's age, the prevailing methods of characterizing food texture preferences in children include observational techniques and self-reported questionnaires. Despite knowledge of children's development of masticatory skills, learning, and cognitive abilities, the relationships of these changes to food texture acceptance and the recommended test methodology for evaluating product texture acceptance in this period of life are still limited.

From food preference development to responsive feeding - Selective studies to commemorate the life and work of Dr Leann Birch

Dr Leann Birch was a pioneer in conducting research on infant and child eating behaviour. At the beginning of her research career, Leann recognised a significant gap in the developmental psychology literature, namely that few studies had been conducted to understand infant eating and feeding behaviours. This seems an unusual omission given that food intake is essential and that developmental milestones from milk to solids, and from being fed to becoming an autonomous eater, are obvious to most caregivers. Leann paved the way for interdisciplinary research from psychology, paediatrics and public health to explore and apply this knowledge to infant and child appetite, eating behaviour, dietary patterns, food preferences, and obesity risk. Early studies in her laboratory demonstrated that children form food preferences through experience and socialisation. Experiments published in 1979 tested the role of familiarisation through repeat exposure, and the impact of instrumental and social learning on the acquisition of food preferences. In 1984, a presentation given to the British Feeding and Drinking Group (BFDG) in Brighton set out three organising principles for understanding how children acquire food preferences: genetically pre-programmed behavioural propensities; social constraints on experience with food; and social transmission resulting from direct social interaction. Building on these three organising principles, research on child eating behaviour has flourished, including the intersection between individual differences, food experience and environmental influences on children's food preferences, energy regulation, and weight outcomes. In this review, the initial groundwork set out by Leann Birch on food preference development in children is considered followed by a discussion of how this has since inspired an interdisciplinary, international and expanding field of research on children's food intake, appetite and body weight regulation.

Starting complementary feeding with vegetables only increases vegetable acceptance at 9 months: a randomized controlled trial

BACKGROUND

Starting complementary feeding (CF) with vegetables only may improve vegetable acceptance throughout childhood.

OBJECTIVES

We aimed to test whether exposure to vegetables only during the first 4 wk of CF increases later vegetable acceptance compared with a control group receiving fruit and vegetables.

METHODS

In this randomized, controlled, parallel-group study, 117 Auckland infants received either vegetables only (veg-only, n = 61) or a combination of fruit and vegetables (control, n = 56) for a duration of 4 wk, starting from the first day of CF at ∼4-6 mo of age. The primary outcome measure was intake of target vegetables (broccoli, spinach) provided by the study at 9 mo of age. Daily intake of vegetables (FFQs) at 9 mo was a supporting measure. Infants' iron status (serum ferritin, hemoglobin) was examined at all time points.

RESULTS

The veg-only infants consumed more broccoli and spinach than controls [mean difference (95% CI): 11.83 (0.82, 22.84) g, P = 0.036 and 10.19 (0.50, 19.87) g, P = 0.039, respectively]. Intake of pear was comparable among intervention groups (P = 0.35). At 9 mo, veg-only infants consumed target vegetables at a faster rate [mean difference (95% CI): broccoli, 3.37 (1.26, 5.47), P = 0.002; spinach, 4.12 (0.80, 7.45), P = 0.016] and showed greater acceptance for target vegetables [mean difference (95% CI): broccoli, 0.38 (0.07, 0.70), P = 0.019; spinach, 032 (0.04, 0.60), P = 0.024] than controls. The rate of eating and acceptance of pear was comparable among intervention groups (P = 0.42 and P = 0.98, respectively). Also, veg-only infants consumed more vegetables than controls [86.3 (52.5, 146.3) compared with 67.5 (37.5, 101.3) g, respectively, P = 0.042]. Introducing vegetables as the first food was not associated with 9-mo iron status.

CONCLUSIONS

Providing vegetables as first foods increased vegetable intake at 9 mo of age and may be an effective strategy for improving child vegetable consumption and developing preferences for vegetables in infancy.

Weaning children from prolonged enteral nutrition: A position paper

Enteral nutrition (EN) allows adequate nutritional intake in children for whom oral intake is impossible, insufficient or unsafe. With maturation and health improvements, most children ameliorate oral skills and become able to eat orally, therefore weaning from EN becomes a therapeutic goal. No recommendations currently exist on tube weaning, and practices vary widely between centres. With this report, the French Network of Rare Digestive Diseases (FIMATHO) and the French-Speaking Group of Paediatric Hepatology, Gastroenterology and Nutrition (GFHGNP) aim to develop uniform clinical practice recommendations for weaning children from EN. A multidisciplinary working group (WG) encompassing paediatricians, paediatric gastroenterologists, speech-language therapists, psychologists, dietitians and occupational therapists, was formed in June 2018. A systematic literature search was performed on those published from January 1, 1998, to April 30, 2020, using MEDLINE. After several rounds of e-discussions, relevant items for paediatric tube weaning were identified, and recommendations were developed, discussed and finalized. The WG members voted on each recommendation using a nominal voting technique. Expert opinion was applied to support the recommendations where no high-quality studies were available.

Implementing a 'Vegetables First' Approach to Complementary Feeding

Purpose of Review

To provide a rationale for promoting a vegetables first approach to complementary feeding (CF), building on prior exposure to vegetable flavours experienced in utero and via breastfeeding (chemosensory continuity).

Recent Findings

Vegetables confer selective health benefits but population intakes are below recommendations globally; maternal intake of vegetables during both pregnancy and lactation promotes familiarity with some vegetable flavours. Building on this exposure, vegetables as a first food during CF further promote acceptance. However, experiments testing efficacy of a vegetables first approach to CF demonstrate increased liking and intake, some evidence of generalisability but little evidence of sustained effects beyond infancy.

Summary

The aim to increase the quantity and variety of vegetables eaten by children is both desirable, to improve nutrient quality of the diet, and achievable. However, longer, larger, randomised control trials are needed to evidence any longer term, sustainable benefits to liking and intake of vegetables.

Infant Appetitive Phenotypes: A Group-Based Multi-Trajectory Analysis

Background: Examining appetitive traits with person-centered analytical approaches can advance the understanding of appetitive phenotype trajectories across infancy, their origins, and influences upon them. The objective of the present study was to empirically describe appetitive phenotype trajectories in infancy and examine the associations with infant and parent factors.

Materials and Methods: In this longitudinal cohort study of Australian infants, parents completed three online surveys ~3 months apart, beginning when the infant was <6 months. Appetitive traits were assessed with the Baby Eating Behavior Questionnaire (BEBQ) and parent feeding practices with the Feeding Practices and Structure Questionnaire (FPSQ) infant and toddler version. Parent demographics and cognitions were also collected. Infant weight and length were transcribed from health records and converted to a BMI z-score. Group-based trajectory modeling identified appetitive phenotype trajectories using the BEBQ. Multilevel modeling examined change in feeding practices and child BMI z-score over time by appetitive phenotype trajectories.

Results: At time 1, 380 participants completed the survey (mean infant age 98 days), 178 at time 2 (mean infant age 198 days), and 154 at time 3 (mean infant age 303 days). Three multi-trajectory appetitive phenotype groups were identified and labeled as (Phenotype 1) food avoidant trending toward low food approach (21.32% of infants), (Phenotype 2) persistently balanced (50.53% of infants), and (Phenotype 3) high and continuing food approach (28.16% of infants). Formula feeding was more common in Phenotype 1 (p = 0.016). Parents of infants in Phenotype 1 were more likely to rate them as being more difficult than average, compared to infants with phenotypes 2 or 3. Phenotype 2 had the greatest increase in persuasive feeding over time [0.30; 95% CI (0.12, −0.47)].

Conclusions: Distinct multi-trajectory appetitive phenotype groups emerge early in infancy. These trajectories appear to have origins in both infant and parent characteristics as well as parent behaviors and cognitions. The infant multi-trajectory appetitive phenotype groups suggest that for some infants, difficulties in self-regulating appetite emerge early in life. Investigation of infant multi-trajectory appetitive phenotype groups that utilize a range of measures, examine relationships to key covariates and outcomes, and extend from infancy into childhood are needed.

Timing of Introduction to Solid Food, Growth, and Nutrition Risk in Later Childhood

OBJECTIVE

To evaluate the relationship between the timing of infant cereal introduction between 4 and 6 months of age and growth and dietary intake in later childhood.

STUDY DESIGN

A longitudinal cohort study was conducted among healthy children 0-10 years of age participating in The Applied Research Group for Kids cohort study between June 2008 and August 2019 in Toronto, Canada.

RESULTS

Of 8943 children included, the mean (SD) age of infant cereal introduction was 5.7 (2.1) months. In the primary analysis, children who were introduced to infant cereal at 4 vs 6 months had 0.17 greater body mass index z score (95% CI 0.06-0.28; P = .002) and greater odds of obesity (OR 1.82; 95% CI 1.18-2.80; P = .006) at 10 years of age. In the secondary analysis, children who were introduced to infant cereal at 4 vs 6 months had 0.09 greater height-for-age z score (95% CI 0.04-0.15; P = .002) at 1 year of age, an association that was not observed at 5 or 10 years of age. Children who were introduced to infant cereal at 4 vs 6 months had greater nutrition risk which was primarily determined by a less-favorable eating behavior score at 18 months to 5 years of age (0.18 units higher; 95% CI 0.07-0.29; P = .001).

CONCLUSIONS

Introduction of infant cereal at 4 vs 6 months was associated with greater body mass index z score, greater odds of obesity, similar height-for-age z score, and less favorable eating behavior. These findings support recommendations for introducing solid food around 6 months of age.

Food Preparation Practices for Infants Aged From 7 to 13 Months

OBJECTIVE

To examine infant food preparation practices at age 7, 9, 11, and 13 months overall and by sociodemographic characteristics.

DESIGN

Data from a longitudinal study from the US Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Infant and Toddler Feeding Practices Study-2 (ITFPS-2) were used.

PARTICIPANTS

A sample of 1,904 infants (970 males and 934 females) enrolled in WIC who had been introduced to solid foods and were consuming food prepared at home.

MAIN OUTCOME MEASURES

Food preparation practices included pureeing, mashing, chopping/dicing, and prechewing. Estimates were provided overall and by sociodemographics.

ANALYSIS

Prevalence estimates were calculated for each survey month overall and by sociodemographics. Chi-square tests for independence were used to test for differences.

RESULTS

Food preparation practices changed as infants aged. Pureeing and mashing were common in month 7 (57.8% and 59.6%, respectively), but chopping/dicing were the most prevalent by month 13 (85.4%). Food preparation practices did not vary by education status, but statistical differences were consistently observed by race and ethnicity and inconsistently observed by maternal age at birth.

CONCLUSIONS AND IMPLICATIONS

Exposing children to a range of food textures at an appropriate age is important for developmental progress. Continued culturally relevant efforts by WIC educators and health care providers can emphasize the importance of early experiences with food textures.

Development and application of specific questions to classify a child as food texture sensitive

Understanding food texture sensitivity in children is important in guiding food selection. The objective of this work was to develop a short questionnaire that could be completed by parents in nonclinical settings to provide a categorization for food texture sensitivity in children. This study evaluated the distribution of children as texture sensitive (TS) or non-texture sensitive (NTS) and the predictive validity of these questions to explain rejection of specific food textures. Three sets of survey data were examined, including data from a home-use test (HUT) in children with and without Down syndrome (DS), and lingual tactile sensitivity measured by grating orientation task (GOT). From three parent-completed surveys, the use of the questionnaire yielded a similar distribution of children in the TS category (16-22%) as previously reported. TS children (4-36 months) were more likely to reject specific food textures, including chewy, hard, lumpy, and "tough meat" (p < .05). A higher percentage of children with a diagnosis of DS were TS (36.9%). Children who were TS showed increased negative behaviors to foods and ate less than NTS children. In older children (5-12 years), TS children were fussier than NTS children (p < .001). Lingual tactile sensitivity was not significantly different by TS/NTS categorization (p = .458). This study demonstrated that the use of these five questions specific to food texture provides a useful tool in categorizing a child as TS/NTS, with this information being useful in selecting preferred food textures. Future studies involving these TS questions should perform psychometric assessments and measures of criterion validity using other questionnaires.

Impact of a "vegetables first" approach to complementary feeding on later intake and liking of vegetables in infants: a study protocol for a randomised controlled trial

BACKGROUND

Vegetables as first complementary foods for infants may programme taste preferences that lead to improved vegetable intake in children. Yet few studies have investigated the impact of a "vegetables first" approach to complementary feeding, especially in New Zealand. The purpose of this randomised control trial is to investigate the effect of starting complementary feeding with vegetables only on infants' later intake and liking of vegetables, compared to those starting with fruit and vegetables.

METHODS/DESIGN

One-hundred and twenty mother-infant pairs living in Auckland, New Zealand, will be randomised to receive either vegetables only (intervention) or fruit and vegetables (control) for 28 days, starting from the first day of complementary feeding at around 4-6 months of age. Infants will be presented with a brassica (broccoli), followed by a green leafy vegetable (spinach) and sweet fruit (pear) at 9 months of age. The primary outcome measures of intake of each food will be assessed using a weighed food diary. Secondary outcome measures of overall intake, liking and wanting of vegetables will be assessed using a food frequency questionnaire, liking tool and video coding tool, respectively, at 9, 12, and 24 months of age. Infant growth and iron status will be assessed as part of health screening and monitoring at baseline, post intervention and 9 months of age. Other biological samples to be collected include infant stool samples, vitamin D (mother and infant), iron status (mother), and mothers' diet.

DISCUSSION

This randomised, controlled trial will be the first to our knowledge to investigate a "vegetables first" approach to complementary feeding on infants' liking and intake of vegetables in New Zealand. Comparison against standard practice (fruit and vegetables as first foods) should complement other trials underway, such as the Baby's First Bites and Nordic OTIS trial. Results may contribute to the evidence supporting complementary feeding guidelines in New Zealand and worldwide.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12619000737134 . Registered on 16 May 2019.

Utilising an integrated approach to developing liking for and consumption of vegetables in children

Children eat too few vegetables and this is attributed to disliked flavours and texture as well as low energy density. Vegetables confer selective health benefits over other foods and so children are encouraged to eat them. Parents and caregivers face a challenge in incorporating vegetables into their child's habitual diet. However, liking and intake may be increased through different forms of learning. Children learn about vegetables across development from exposure to some vegetable flavours in utero, through breastmilk, complementary feeding and transitioning to family diets. Infants aged between 5 and 7 m are most amenable to accepting vegetables. However, a range of biological, social, environmental and individual factors may act independently and in tandem to reduce the appeal of eating vegetables. By applying aspects of learning theory, including social learning, liking and intake of vegetables can be increased. We propose taking an integrated and individualised approach to child feeding in order to achieve optimal learning in the early years. Simple techniques such as repeated exposure, modelling, social praise and creating social norms for eating vegetables can contribute to positive feeding experiences which in turn, contributes to increased acceptance of vegetables. However, there is a mismatch between experimental studies and the ways that children eat vegetables in real world settings. Therefore, current knowledge of the best strategies to increase vegetable liking and intake gained from experimental studies must be adapted and integrated for application to home and care settings, while responding to individual differences.

A quasi-experimental intervention protocol to characterize the factors that influence the acceptance of new foods by infants: mothers' diet and weaning method. Dastatuz project

BACKGROUND

Children usually refuse to eat and taste fruits and vegetables; and turning unhealthy eating habits around is an important social challenge in industrialized countries. The Dastatuz project aims to study children food neophobia and to enhance fruit and vegetable acceptance.

METHODS

A quasi-experimental, multicentre, controlled and prospective intervention study is proposed, in which early factors influencing new food acceptance will be studied. Mothers in the third trimester of pregnancy (n = 144) and their infants will be the study population. Experimental groups will be established based on mothers´ fruit and vegetable intake (standard or high intake) and weaning method (baby lead weaning vs spoon feeding). The project will assess the possible impact of maternal diet and complementary feeding on infants eating behaviour until 18 months of age. Outcome measures will comprise maternal diet and psychological features during pregnancy and breast-feeding (validated questionnaires). Compositional and physicochemical analysis of milk during breastfeeding will also be carried out. During weaning, until 18 months of age, children's diet will be assessed with 24 h recalls and acceptance of new fruits and vegetables will be studied using video recording.

DISCUSSION

If the intervention is effective, this research work would have a high potential to be transferred to future public health programs or nutrition guidelines, as a feasible solution to achieve a higher intake of fruits and vegetables among children.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov. Identifier: NCT04262102 . Registration date: February 10, 2020 - Retrospectively registered.

Oral motor disorder and feeding difficulty during the introduction of complementary feeding in preterm infants

PURPOSE

To investigate the association between oral-motor disorder and feeding difficulty during the process of introducing complementary feeding in preterm infants.

METHODS

This is a cross-sectional, observational, and quantitative study. Preterm infants who had already begun complementary feeding and were up to 24 months corrected gestational age, were followed up at an outpatient clinic for high-risk newborns. The feeding difficulty was assessed using the mother's perception of the presence of defensive behaviors in their child. The measurement of the oral motor skills performance was obtained through the application of an adaptation of the Clinical evaluation protocol of pediatric dysphagia (PAD-PED).

RESULTS

The sample consisted of 62 dyads of children with a mean corrected gestational age (CGA) of 13.5 months. Complementary feeding was introduced at the sixth month CGA by almost half of the mothers and most of them reported some sort of difficulty with this activity. Extreme prematurity revealed an association with defensive feeding behavior (p = 0.005), as well as with the initial introduction of food with liquid consistency (p = 0.001), the extended period of time using enteral tube feeding (p = 0.044), the continuous positive airway pressure (CPAP) (p = 0.013) and parenteral nutrition (p = 0.039).

CONCLUSION

There was no significant association between oral motor disorder and feeding difficulty.

Optimising Repeated Exposure: Determining Optimal Stimulus Shape for Introducing a Novel Vegetable among Children

Although it is well evident that a healthy diet rich in fruit and vegetables could prevent a number of major chronic diseases, national and international guidelines concerning their intake are not being reached by a large percentage of the population, including children. Thus, it is of interest to investigate how the consumption of this food group by children could be increased. The aim of this study was to examine the impact of serving style on the consumption of a raw snack vegetable (daikon) and the influence of its exposure on liking and intake of the vegetable. A group of 185 children 3–5 years old participated in the study. Two kindergartens served as intervention groups, while the third was assigned to be the control group of the study (n = 50). The intervention groups were repeatedly exposed to one of three different serving styles of daikon: sticks (n = 42), triangles (n = 46) or grated (n = 47), and they were all visited 7 times during the exposure period, on the same frequency (twice per week). Familiarity and liking of the target vegetable, daikon, and six other vegetables (cucumber, celery, celeriac, broccoli, cauliflower and beetroot) were measured at baseline, post-intervention and two follow up sessions (3- and 6-month) to investigate the likelihood of generalisation effects. Intake of daikon was measured at all control sessions and exposures. Moreover, children were asked to rank their favourite serving style of daikon and beetroot, among triangle, stick and grated, towards understanding the influence of shape on the efficacy of the exposure. The results revealed significant changes between liking and intake of daikon for the groups of triangles and sticks and the control group (p < 0.05). The group that received grated daikon did not show significant differences in liking and at intake levels during the exposures but performed well in the long-term. Throughout the exposure period, intake levels followed an overall increasing pattern, with all the groups to demonstrate a decrease of their intake at the last session, which was not found significant for the triangle group. Mere exposure was efficient towards increasing liking and intake of the novel vegetable with all the shapes to deliver positive results, but based on this study no particular serving style can be recommended.

Child Involvement in Choosing a Recipe, Purchasing Ingredients, and Cooking at School Increases Willingness to Try New Foods and Reduces Food Neophobia

OBJECTIVE

To investigate the effect of involving children in their feeding process (choosing a recipe, purchasing the ingredients, and cooking) on their lunch food choice in a school environment.

DESIGN

Quasi-experimental.

SETTING

Two schools in Bilbao, Spain.

PARTICIPANTS

A total of 202 children (aged 8-9 years) participated in the study (43% girls), with 99 in the nutrition education (NE) group and 103 in the hands-on (HO) group.

INTERVENTION

Three 1-hour workshops (1 workshop/wk), different for each group: HO, cooking-related activities, and NE, healthy habits promotion through nutrition education activities.

MAIN OUTCOME MEASURES

Food neophobia, diet quality, cooking self-efficacy and attitudes toward cooking, and food intake and selection of the experimental lunches.

ANALYSIS

Chi-square test of independence, ANCOVA, and t tests were performed.

RESULTS

Students from the HO group selected and ate more spinach/broccoli (P < 0.001 and P = 0.02, respectively) for the first lunch; and selected more spinach/broccoli (P = 0.04) for the second lunch. After the intervention, improvements were observed for spinach liking and neophobia for the HO group and cooking self-efficacy and KidMed score for both groups.

CONCLUSIONS AND IMPLICATIONS

Both interventions succeeded in improving children's diet quality, but only the HO group reduced food neophobia levels. Therefore, involving children in choosing a recipe, purchasing ingredients, and cooking may promote changing eating behaviors toward healthy habits such as increasing vegetable consumption.

Factors Associated With Food Texture Acceptance in 4- to 36-Month-Old French Children: Findings From a Survey Study

Food texture plays an important role in food acceptance by young children, especially during the complementary feeding period. The factors driving infant acceptance of a variety of food textures are not well-known. This study summarizes maternal reports of children's ability to eat foods of different textures (here: acceptance) and associated factors. Mothers of 4- to 36-month-old children (n = 2,999) answered an online survey listing 188 food-texture combinations representing three texture levels: purees (T1), soft small pieces (T2), hard/large pieces, and double textures (T3). For each offered combination, they reported whether it was spat out or eaten with or without difficulty by the child. A global food texture acceptance score (TextAcc) was calculated for each child as an indicator of their ability to eat the offered textured foods. The results were computed by age class from 4-5 to 30-36 months. The ability to eat foods without difficulty increased with age and was ranked as follows: T1> T2 > T3 at all ages. TextAcc was positively associated with exposure to T2 (in the age classes between 6 and 18 months old) and T3 (6-29 months) and negatively associated with exposure to T1 (9-36 months). Children's developmental characteristics, as well as maternal feeding practices and feelings with regard to the introduction of solids, were associated with texture acceptance either directly or indirectly by modulating exposure. Children's ability to eat with their fingers, gagging frequency, and to a lesser extent, dentition as well as maternal feelings with regard to the introduction of solids were the major factors associated with acceptance. This survey provides a detailed description of the development of food texture acceptance over the complementary feeding period, confirms the importance of exposure to a variety of textures and identifies a number of additional person-related associated factors.

Acceptance of a Nordic, Protein-Reduced Diet for Young Children during Complementary Feeding-A Randomized Controlled Trial

Early life is critical for developing healthy eating patterns. This study aimed to investigate the effects of a Nordic, protein-reduced complementary diet (ND) compared to a diet following the current Swedish dietary guidelines on eating patterns and food acceptance. At 4–6 months (mo) of age infants were randomized to a Nordic group (NG, n = 41) or a Conventional group (CG, n = 40), and followed until 18 mo of age. Daily intake of fruits and vegetables (mean ± sd) at 12 mo was significantly higher in the NG compared to the CG: 341 ± 108 g/day vs. 220 ± 76 g/day (p < 0.001), respectively. From 12 to 18 mo, fruit and vegetable intake decreased, but the NG still consumed 32% more compared to the CG: 254 ± 99 g/day vs. 193 ± 67 g/day (p = 0.004). To assess food acceptance, both groups were tested with home exposure meals at 12 and 18 mo. No group differences in acceptance were found. We find that a ND with parental education initiates healthy eating patterns during infancy, but that the exposure meal used in the present study was insufficient to detect major differences in food acceptance. This is most likely explained by the preparation of the meal. Nordic produce offers high environmental sustainability and favorable taste composition to establish healthy food preferences during this sensitive period of early life.

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.

Fostering infant food texture acceptance: A pilot intervention promoting food texture introduction between 8 and 15 months

Healthy infant feeding practices form the basis of healthy eating behaviour later in life. The effect of providing parents with recommendations on textured food introduction between 8 and 15 months on children's experience with and acceptance of textured foods was studied. Sixty parent/child dyads were randomly assigned to a control group (CG) receiving current French recommendations and an intervention group (IG) receiving a brochure with supplementary advice, tips and monthly counselling on food texture introduction. After the intervention, parents completed self-report measures about the introduction of 188 food items, including purees, soft/small pieces, hard/large pieces and double textures. Children's acceptance of eight textured foods was assessed in a laboratory setting. Parents in the IG introduced more soft/small food pieces (P = 0.004) but not more complex textures (P = 0.15). There was no group difference in children acceptance for any of the textured foods offered in the laboratory. Independent of their study group, children's exposure to texture was associated with birth order, self-feeding with fingers, low gagging frequency and seldom use of commercial baby foods. Higher acceptance was associated with higher exposure to food pieces but not to pureed foods (either smooth or rough) and with children's eating behavioural traits (high food enjoyment, high food responsiveness and low food fussiness). This pilot intervention demonstrated that providing information can be effective in promoting the introduction of small and soft food pieces, but the most effective way to influence the introduction of more challenging textures (hard pieces and double texture) is uncertain. Further research should focus on the identification of barriers to complex texture introduction and on how building on this knowledge for a population-based public health intervention.

A clinical description of children with solid organ transplants who present with feeding disorder

Pediatric solid organ transplant recipients have long-standing malnutrition concerns related to their pretransplant medical status. The targeted nutrition therapy utilized pre-, peri-, and post-transplantation may have the adverse effect of impeding normally developing feeding skills, particularly in very young children. Little is known about the relationship between transplantation and feeding disorders of childhood. The purpose of this study was to describe severity of feeding disorder and parental stress in patients with transplant compared to children followed in a specialty feeding clinic and the general community. Sixty-four children, comprised of 32 children with solid organ transplant ages 2 months to 12 years and 32 matched control patients diagnosed with a feeding disorder without history of solid organ transplant, were reviewed. All children were from the Feeding, Swallowing, and Nutrition Clinic at a single children's hospital. Findings indicate that patients who received a transplant and presented with a feeding problem had worse symptoms of feeding disorder than are typically found in the general community. These feeding problems disrupt mealtime behavior, caregiver and child relationship within a mealtime context, and may result in maladaptive feeding strategies used by families. When transplanted children present with feeding disorders, they are severe and have multiple effects on both the child and the feeding dynamic between the child and the child's caregivers. Further investigation may help us to better understand the relationship between transplantation and symptoms of feeding disorder.

A new masticatory performance assessment method for infants: A feasibility study

This study evaluated the feasibility of assessing masticatory performance in infants and toddlers. Four groups of healthy children (n = 97, 42 girls and 55 boys) participated in the study: two study groups (SG) followed at 6, 8, and 10 months old (MO) or at 12, 15, and 18 MO, and two control groups (CG) of respectively 10 and 18 MO children. Masticatory performance was determined from children's ability to comminute a model gel during videotaped lab measurements. The gel was inserted in a mesh feeder and offered to the child for a 60s oral processing duration, then gel particles were collected from the feeder and photographed. Resulting gel breakdown was assessed from the characterization of the area and number of formed particles. Children strategy to orally process the gel (sucking vs. biting/chewing) was evaluated from video recordings. Children's compliance (acceptance of the feeder in the mouth for the expected duration) was average (51%) overall. It decreased from 1 year of age and was higher in SG than in CG. The number and area of gel particles formed under oral processing increased significantly with age, demonstrating an increase in children masticatory performance as they grew up. Median particles area was positively associated with sucking behavior and negatively associated with biting/chewing. The association with teeth emergence was not significant. In conclusion, the proposed method is relevant for quantifying the development of early masticatory performance in children who accept to hold the feeder in their mouth. PRACTICAL APPLICATIONS: In this article, a method to easily quantify masticatory performance in young children aged 6-18 MO was evaluated. The method is based on a feeder and could be used for collecting boluses, as an alternative to the chew-and-spit method when it is unfeasible. Children's compliance to the method and the impact of previous study participation on compliance to the protocol are detailed, giving thus a rationale for an optimal application of this method in future experiments. Finally, the determination of masticatory performance as a function of age thanks to this method could contribute to the understanding of food oral processing and food texture acceptance in childhood in future studies.

Oral Sensory-Motor Intervention for Children and Adolescents (3-18 Years) With Dysphagia or Impaired Saliva Control Secondary to Congenital or Early-Acquired Disabilities: A Review of the Literature, 2000 to 2016

OBJECTIVES:

Dysphagia and impaired saliva control are common in children and adolescents with congenital and developmental disabilities. The aim of the present review was to investigate the evidence base for oral sensory-motor interventions in children and adolescents with dysphagia or impaired saliva control secondary to congenital or early-acquired disabilities and to make recommendations regarding methods for intervention.

METHODS:

A review of the literature from 2000 to 2016, including oral sensory-motor intervention studies for children and adolescents (3-18 years of age) with dysphagia or impaired saliva control secondary to congenital or early-acquired disabilities, was performed. The literature search included the PubMed, CINAHL, Medline, SpeechBITE, OVID, ERIC, Cochrane, and Google Scholar databases. Primary studies were evaluated on a 4-grade scale using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS:

Twenty primary studies of oral sensory-motor interventions for dysphagia and 6 studies for the treatment of impaired saliva control fulfilled the inclusion criteria. Of these, 3 were randomized, controlled trials. Five systematic reviews and 16 narrative reviews were also included. Limited and moderately strong recommendations were made on the basis of the grading results from the primary studies. The studies reported good results, but study design was often insufficient, and the study groups were small. The systematic reviews confirmed the lack of high scientific support for oral sensory-motor interventions in children and adolescents with congenital and developmental disabilities.

CONCLUSIONS:

There is an urgent need for high-quality studies that could serve as the basis for strong recommendations relating to oral sensory-motor interventions for children with dysphagia and impaired saliva control.

Therapy services and specialized devices for conjoined twins: Unique challenges with conjoined twins and the importance of physical and occupational therapy

Conjoined twins are a rare occurrence that offer unique challenges and circumstances to therapists. The overall goal of physical and occupational therapy treatment is to provide care that promotes developmental progression to two conjoined individuals with distinct personalities and potentially different physical and medical needs. The unique presentation of conjoined twins must be considered in determining therapeutic goals, interventions and plans of care. Providing therapeutic interventions throughout the NICU stay is a dynamic, evolving process, which challenges the therapy team to work together to find solutions. This paper aims to highlight the considerations, challenges, and strategies used to address barriers in the therapeutic care of conjoined twins.

Patterns and predictors of food texture introduction in French children aged 4–36 months

The aims of this study were to describe which and when food textures are offered to children between 4 and 36 months in France and to identify the associated factors. An online cross-sectional survey was designed, including questions about 188 food texture combinations representing three texture levels: purées (T1), soft small pieces (T2) and hard/large pieces and double textures (T3). Mothers indicated which combinations they already offered to their child. A food texture exposure score (TextExp) was calculated for all of the texture levels combined and for each texture level separately. Associations between TextExp and maternal and child characteristics and feeding practices were explored by multiple linear regressions, per age class. Answers from 2999 mothers living in France, mostly educated and primiparous, were analysed. Over the first year, children were mainly exposed to purées. Soft and small pieces were slowly introduced between 6 and 22 months, whereas hard/large pieces were mainly introduced from 13 months onwards. TextExp was positively associated with children’s number of teeth and ability to eat alone with their finger or a fork. For almost all age classes, TextExp was higher in children introduced to complementary feeding earlier, lower for children who were offered only commercial baby foods and higher for those who were offered only home-made/non-specific foods during the second year. Our study shows that until 12 months of age the majority of French children were exposed to pieces to a small extent. It provides new insights to further understand the development of texture acceptance during a key period for the development of eating habits.

Picky eating in Swedish preschoolers of different weight status: application of two new screening cut-offs

Background

Characteristics of picky eaters of different weight status have not been sufficiently investigated. We used two newly developed screening cut-offs for picky eating in the Food fussiness (FF) subscale of the Child Eating Behavior Questionnaire (CEBQ) to investigate the prevalence and characteristics of picky eaters in preschool-aged children with thinness, normal weight, overweight or obesity.

Methods

Data for 1272 preschoolers (mean age 4.9 years) were analyzed. The parent-reported FF subscale ranges from 1 to 5, and two screening cut-offs were applied to classify children as picky eaters (3.0 and 3.33). Structural Equation Modeling was used to study associations with other factors in the CEBQ, the Child Feeding Questionnaire (CFQ) and the Lifestyle Behavior Checklist (LBC). Scores were compared separately for each weight status group.

Results

Nearly half of the children were classified as moderate or severe picky eaters (cut-off 3.0) and 30% as severe (cut-off 3.33). For both cut-offs, prevalence was significantly lower in the obesity group. Still, one-third of children with obesity met the cut-off of 3.0 and 17% met the cut-off of 3.33. While picky eaters displayed similar patterns across weight status groups, some differences emerged. Food responsiveness was lower for picky eaters, but the difference was significant only among children with obesity. Slowness in eating was not as pronounced among picky eaters in the obesity group. In the overweight and obesity groups, parents of picky eaters did not report as high pressure to eat, as compared to the thinness or normal weight groups; in the obesity group, parents of picky eaters also perceived their children’s weight as lower. In all weight status groups, parents of picky eaters were more likely to report their children had too much screen time, complained about physical activity, and expressed negative affect toward food.

Conclusions

Picky eating was less common but still prevalent among children with obesity. Future studies should investigate the potential influence of picky eating on childhood overweight and obesity. Moreover, as children with picky eating display higher emotional sensitivity, further research is needed to understand how to create positive eating environments particularly for children with picky eating and obesity.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0706-0) contains supplementary material, which is available to authorized users.

Scientific opinion on pesticides in foods for infants and young children

Following a request from the European Commission, the EFSA Panel on Plant Protection Products and their Residues (PPR Panel) prepared a scientific opinion to provide a comprehensive evaluation of pesticide residues in foods for infants and young children. In its approach to develop this scientific opinion, the EFSA PPR Panel took into account, among the others, (i) the relevant opinions of the Scientific Committee for Food setting a default maximum residue level (MRL) of 0.01 mg/kg for pesticide residues in foods for infants and young children; (ii) the recommendations provided by EFSA Scientific Committee in a guidance on risk assessment of substances present in food intended for infants below 16 weeks of age; (iii) the knowledge on organ/system development in infants and young children. For infants below 16 weeks of age, the EFSA PPR Panel concluded that pesticide residues at the default MRL of 0.01 mg/kg for food for infants and young children are not likely to result in an unacceptable exposure for active substances for which a health-based guidance value (HBGV) of 0.0026 mg/kg body weight (bw) per day or higher applies. Lower MRLs are recommended for active substances with HBGVs below this value. For infants above 16 weeks of age and young children, the established approach for setting HBGVs is considered appropriate. For infants below 16 weeks of age the approach may not be appropriate and the application of the EFSA guidance on risk assessment of substances present in food intended for infants below 16 weeks of age is recommended. The contribution of conventional food to the total exposure to pesticide residues is much higher than that from foods intended for infants and young children. Because of the increased intake of conventional food by young children, these have the highest exposure to pesticide residues, whereas infants 3-6 months of age generally have lower exposure. The impact of cumulative exposure to pesticide residues on infants and young children is not different from the general population and the EFSA cumulative risk assessment methodology is also applicable to these age groups. Residue definitions established under Regulation (EC) No 396/2005 are in general considered appropriate also for foods for infants and young children. However, based on a tier 1 analysis of the hydrolysis potential of pesticides simulating processing, the particular appropriateness of existing residue definitions for monitoring to cover processed food, both intended for infants and young children as well as conventional food, is questionable.

Factors Influencing Children's Eating Behaviours

Relevant factors involved in the creation of some children’s food preferences and eating behaviours have been examined in order to highlight the topic and give paediatricians practical instruments to understand the background behind eating behaviour and to manage children’s nutrition for preventive purposes. Electronic databases were searched to locate and appraise relevant studies. We carried out a search to identify papers published in English on factors that influence children’s feeding behaviours. The family system that surrounds a child’s domestic life will have an active role in establishing and promoting behaviours that will persist throughout his or her life. Early-life experiences with various tastes and flavours have a role in promoting healthy eating in future life. The nature of a narrative review makes it difficult to integrate complex interactions when large sets of studies are involved. In the current analysis, parental food habits and feeding strategies are the most dominant determinants of a child’s eating behaviour and food choices. Parents should expose their offspring to a range of good food choices while acting as positive role models. Prevention programmes should be addressed to them, taking into account socioeconomic aspects and education.

The relation between family meals and health of infants and toddlers: A review

Family meals are associated with multiple health benefits in children and adolescents including evidence that eating together as a family may play a role in reducing childhood obesity. The current review aims to investigate whether the beneficial health effects of the family meal also apply to infants and toddlers. PubMed, Web of Science, Scopus and PsycInfo were searched and 14 empirical studies were identified. The findings were discussed according to frequency of having a family meal and parental perception, associations between the family meal and health aspects (e.g., eating behaviors and diet quality) and causal influences of these associations. Descriptive data showed that mothers offer food at a structured mealtime, but that eating together as a family was not always upheld. The frequency of family meals was positively associated with more nutrient-dense food intake and a more balanced diet. Different advantages (e.g., social importance, practical considerations) and obstacles (e.g., planning, possible mess) of the family meal were mentioned by parents. Further, having structured mealtimes and family meals was associated with more food enjoyment and less fussy and emotional eating. Finally, no causal studies were identified. The limited number of studies suggests that the pattern of positive associations between family meal and child health which has been shown in older children may also exist in infants and toddlers. More specific research is needed to examine the causality of the associations between the family meal and health of the infant and toddler. The associations between the family meal and less fussiness and emotional eating, more food enjoyment and better nutrient intake suggest that the family meal is a valuable moment to promote healthy eating in toddlers and infants.