Timing of introduction of complementary foods and beverages and growth, size, and body composition: a systematic review

Infant feeding practices and body mass index up to 7.5 years in the French nationwide ELFE study

BACKGROUND/OBJECTIVES

The infant diet represents one of the main modifiable determinants of early growth. This study aimed to investigate the associations of infant feeding practices with body mass index (BMI) until 7.5 years.

SUBJECTS/METHODS

Analyses were based on data from the French nationwide ELFE birth cohort. Data on breastfeeding (BF) and complementary feeding (CF) were collected monthly from 2 to 10 months. Infant feeding practices were characterized using principal component analyses (PCA) and hierarchical ascendant classification. BMI z-score was computed at 1, 2, 3, 5 and 7.5 years, from data collected in the child's health booklet; 7.5-year overweight was defined according to IOTF references. Associations between infant feeding practices and BMI were investigated by linear regression models adjusted for main confounders.

RESULTS

Ever breastfeeding was not associated with BMI up to 7.5 years. Compared to intermediate breastfeeding duration (1 to <3 months), longer breastfeeding duration (≥6 months) was related to lower 1-year BMI, but not at older ages. Compared to the recommended age at CF introduction (4-6 months), early CF (<4 months) was related to higher BMI up to 5 years with a similar trend at 7.5 years, but not to the risk of overweight. The PCA patterns characterized by early baby cereal introduction and late food pieces introduction or by frequent intake of main food groups were related to a lower BMI up to 7.5 years.

CONCLUSION

Breastfeeding was related with a lower BMI in infancy but not thereafter, whereas an early CF initiation (<4 months) was associated with a higher BMI in childhood.

Early feeding and nutritional status of Portuguese children in the first 36 months of life: EPACI Portugal 2012-a national representative cross-sectional study

Background

Early feeding practices have a critical role in the future not only in health but also in modulating eating habits. This study aimed to assess breastfeeding and complementary feeding practices and the nutritional status of Portuguese toddlers aged 0-36 months.

Methods

EPACI Portugal 2012 is a cross-sectional study of a national representative sample. Trained interviewers collected data about early feeding practices and anthropometrics. Body mass index was classified according to World Health Organization criteria. Frequencies and survival analysis were used to characterize variables.

Results

More than 90% of children were initiated breastfeeding, around 20% were exclusively breastfed for six months, and about 20% were breastfed at 12 months while complementary feeding was taking place. Exclusive breastfeeding was determined by maternal prepregnancy body mass index (HR 1.01; 95% CI 1.00, 1.03, P=.03) and low birth weight (HR 1.61; IC 95% 1.21, 2.15, P=.001) of the infants. About 90% were initiated complementary feeding between four and six months, and almost 10% were introduced to cow's milk before 12 months. In the second year of life, 83.2% and 61.6% of toddlers have already consumed nectars and sweet desserts, respectively. About one-third of Portuguese toddlers showed a body mass index z-score >1, and 6.6% were overweight/obese (z-score >2). No association was found between the duration of breastfeeding or timing of complementary feeding and the body mass index z-score in children.

Conclusions

Despite the low prevalence of exclusive breastfeeding at six months, Portuguese infants effectively comply with dietary recommendations during the first year of life. The transition to the family diet must be carefully made. There is a high prevalence of Portuguese toddlers at least at overweight risk. The duration of breastfeeding or timing of complementary feeding was not associated with the expression of overweight/obesity.

A Review on Maternal Parenting, Child's Growth Stunting, and Oral Health

Stunting has gained global attention as one of the most critical problems in public health. As the first and dominant figure in a child's life, the mother is responsible for determining the proper parenting behaviors to apply to maintain the child's physical health. Stunting is often associated with early childhood caries (ECC) and molar incisor hypomineralization, which can be manifested into each other through various mechanisms. Therefore, it is crucial to explore how far maternal parenting behaviors affect stunting and oral health. This study aims to determine which maternal parenting behaviors can affect stunting and oral health. A systematic search was used through PubMed and Google Scholar to search for published articles between 2011 and 2021. The articles analyze maternal parenting behaviors with stunting and poor oral health. Final analysis was used on 21 articles containing 18 cross-sectional studies, 2 cohort studies, and 1 randomized controlled trial. The result implied that the high prevalence of stunting and ECC is the combined result of prolonged breastfeeding practices (7 articles), poor complementary feeding practice (6 articles), high consumption of sugar (5 articles), and poor oral hygiene practices (5 articles). Maternal parenting styles in the aspect of fulfilling nutrition and maintaining oral health affect the occurrence of stunting and ECC in children.

Associations of infant feeding practices with abdominal and hepatic fat measures in childhood in the longitudinal Healthy Start Study

BACKGROUND

Infant feeding patterns have been linked with obesity risk in childhood, but associations with precise measures of body fat distribution are unclear.

OBJECTIVE

We examined associations of infant feeding practices with abdominal fat and hepatic fat trajectories in childhood.

METHODS

This study included 356 children in the Healthy Start Study, a prospective prebirth cohort in Colorado. Infant feeding practices were assessed by postnatal interviews and categorized as any human milk <6 mo compared with ≥6 mo; complementary foods introduced ≤4 mo compared with >4 mo; soda introduced ≤18 mo compared with >18 mo. Abdominal subcutaneous (SAT) and visceral adipose tissue (VAT) areas and hepatic fat (%) were assessed by magnetic resonance imaging in early and middle childhood (median 5 and 9 y old, respectively). We examined associations of infant feeding with adiposity trajectories across childhood using linear mixed models.

RESULTS

In the sample of children, 67% consumed human milk ≥6 mo, 75% were introduced to complementary foods at >4 mo, and 81% were introduced to soda at >18 mo. We did not find any associations between duration of any human milk consumption and childhood adiposity trajectories. Early introduction to complementary foods (≤4 mo) was associated with faster rates of change for SAT and VAT during childhood (Slope [95% CI]: 15.1 [10.7,19.4] cm2/y for SAT; 2.5 [1.9,2.9] cm2/y for VAT), compared with introduction at >4 mo (5.5 [3.0,8.0] cm2/y and 1.6 [1.3,1.9] cm2/y, respectively). Similarly, early introduction to soda (≤18 mo) was associated with faster rates of change for all 3 outcomes during childhood (Slope [95% CI]: 20.6 [15.0,26.1] cm2/y for SAT, 2.7 [2.0,3.3] cm2/y for VAT, 0.3 [0.1,0.5] %/year for hepatic fat) compared with delayed introduction (5.4 [2.8,8.0] cm2/y, 1.7 [1.3, 2.0] cm2/y, -0.1 [-0.2,0.0] %/y, respectively).

CONCLUSIONS

The timing of introduction and quality of complementary foods in infancy was associated with rates of abdominal and hepatic fat accrual during childhood. Experimental studies are needed to assess underlying mechanisms.

Breastfeeding and less healthy beverage intake during the first year of life

BACKGROUND AND OBJECTIVES

Breastfeeding during infancy is associated with healthier beverage consumption later in childhood, but little is known about this relation during infancy. This was a longitudinal study of breastfeeding and less healthy beverage consumption during the first year of life, in a birth cohort study conducted 2013-2018 in the Southeastern United States (n = 666).

METHODS

We estimated monthly rates of 100% juice and sugar-sweetened beverage (SSB) consumption comparing infants who were exclusively or partially breastfed, versus those who were not, in multivariable adjusted models.

RESULTS

Mothers had a median age of 26.5 years, 71% identified as Black/African-American, and 61% reported household incomes <$20 000/year. The prevalence of any breastfeeding during the first month was 78.2% and 18.7% at month 12. By age 12 months, infants consumed juice a mean (SD) 9.1 (10.1) times per week and SSBs 3.6 (9.5) times per week. Breastfed infants had a 38% lower incidence rate of weekly juice consumption (95% CI 52%, 15%, p = 0.003) and a 57% lower incidence rate of weekly SSB consumption (95% CI 76%, 22%, p = 0.006), compared with infants who were not breastfed.

CONCLUSIONS

Research on early-life correlates of dietary health should focus on the earliest beverages, given evidence that consumption of obesogenic beverages may begin prior to age 1 year.

Optimal timing of introduction of complementary feeding: a systematic review and meta-analysis

CONTEXT

The timing of introducing complementary feeding (CF) is crucial because premature or delayed CF can be associated with adverse health outcomes in childhood and adulthood.

OBJECTIVE

This systematic review aims to evaluate the impact of the timing of CF introduction on health, nutrition, and developmental outcomes among normal-term infants.

DATA SOURCES

Electronic databases and trial registries were searched, along with the reference lists of the included studies and relevant systematic reviews.

DATA EXTRACTION

Two investigators independently extracted data from the included studies on a standardized data-extraction form.

DATA ANALYSIS

Data were meta-analyzed separately for randomized controlled trials (RCTs) and observational studies on the basis of early introduction of CF (< 3 months, < 4 months, < 6 months of age) or late introduction of CF (> 6 months, > 8 months of age). Evidence was summarized according to GRADE criteria. In total, 268 documents were included in the review, of which 7 were RCTs (from 24 articles) and 217 were observational studies (from 244 articles). Evidence from RCTs did not suggest an impact of early introduction, while low-certainty evidence from observational studies suggested that early introduction of CF (< 6 months) might increase body mass index (BMI) z score and overweight/obesity. Early introduction at < 3 months might increase BMI and odds of lower respiratory tract infection (LRTI), and early introduction at < 4 months might increase height, LRTI, and systolic and diastolic blood pressure (BP). For late introduction of CF, there was a lack of evidence from RCTs, but low-certainty evidence from observational studies suggests that late introduction of CF (> 6 months) might decrease height, BMI, and systolic and diastolic BP and might increase odds of intestinal helminth infection, while late introduction of CF (> 8 months) might increase height-for-age z score.

CONCLUSION

Insufficient evidence does suggest increased adiposity with early introduction of CF. Hence, the current recommendation of introduction of CF should stand, though more robust studies, especially from low- and middle-income settings, are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020218517.

Early introduction of complementary foods/drinks and milk feeding type in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

Infants younger than 4 months are not ready for complementary foods/drinks (any solid or liquid other than breast milk or infant formula). Almost half of US infants participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which provides nutrition education and support to low-income families. We describe the prevalence of early introduction (<4 months) of complementary foods/drinks and examine the association of milk feeding type (fully breastfed, partially breastfed or fully formula fed) with early introduction of complementary foods/drinks. We used data from 3310 families in the longitudinal WIC Infant and Toddler Feeding Practices Study-2. We described the prevalence of early introduction of complementary foods/drinks and modeled the association of milk feeding type at Month 1 with early introduction of complementary foods/drinks using multi-variable logistic regression. Thirty-eight percent of infants were introduced early to complementary foods/drinks (<4 months). In adjusted models, infants who were fully formula fed or partially breastfed at Month 1 were 75% and 57%, respectively, more likely to be introduced early to complementary foods/drinks compared with fully breastfed infants. Almost two in five infants were given complementary foods/drinks early. Formula feeding at Month 1 was associated with higher odds of early introduction of complementary foods/drinks. There are opportunities to support families participating in WIC to prevent early introduction of complementary foods/drinks and promote child health.

Timing of Introduction of Complementary Foods - United States, 2016-2018

The American Academy of Pediatrics (AAP) recommends introducing complementary foods (i.e., any solid or liquid other than breast milk or infant formula) to infants at approximately age 6 months (1). Although a consensus on ideal timing is lacking, most experts agree that introduction of complementary foods before age 4 months is too early because of infant gastrointestinal and motor immaturity (1,2). In addition, early introduction prevents exclusively breastfed infants from reaching the recommended 6 months of exclusive breastfeeding (1) and might be associated with increased risk for overweight and obesity (3). Nationally representative data on complementary feeding are limited; state-level estimates have been previously unavailable. CDC analyzed 2016-2018 data from the National Survey of Children's Health (NSCH) (N = 23,743) to describe timing of complementary feeding introduction and prevalence of early introduction of complementary foods before age 4 months (early introduction) among children aged 1-5 years. Prevalence of early introduction was 15.6% nationally and varied geographically and across sociodemographic and infant feeding characteristics. These estimates suggest that approximately one in six infants are introduced to complementary foods before they are developmentally ready. Efforts by health care providers and others who might influence infant feeding practices could help decrease the number of infants who are introduced to complementary foods too early.

An equitable, community-engaged translational framework for science in human lactation and infant feeding-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 5

Human milk is the ideal source of nutrition for most infants, but significant gaps remain in our understanding of human milk biology. As part of addressing these gaps, the Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project Working Groups 1-4 interrogated the state of knowledge regarding the infant-human milk-lactating parent triad. However, to optimize the impact of newly generated knowledge across all stages of human milk research, the need remained for a translational research framework specific to the field. Thus, with inspiration from the simplified environmental sciences framework of Kaufman and Curl, Working Group 5 of the BEGIN Project developed a translational framework for science in human lactation and infant feeding, which includes 5 nonlinear, interconnected translational stages, T1: Discovery; T2: Human health implications; T3: Clinical and public health implications; T4: Implementation; and T5: Impact. The framework is accompanied by 6 overarching principles: 1) Research spans the translational continuum in a nonlinear, nonhierarchical manner; 2) Projects engage interdisciplinary teams in continuous collaboration and cross talk; 3) Priorities and study designs incorporate a diverse range of contextual factors; 4) Research teams include community stakeholders from the outset through purposeful, ethical, and equitable engagement; 5) Research designs and conceptual models incorporate respectful care for the birthing parent and address implications for the lactating parent; 6) Research implications for real-world settings account for contextual factors surrounding the feeding of human milk, including exclusivity and mode of feeding. To demonstrate application of the presented translational research framework and its overarching principles, 6 case studies are included, each illustrating research gaps across all stages of the framework. Applying a translational framework approach to addressing gaps in the science of human milk feeding is an important step toward the aligned goals of optimizing infant feeding across diverse contexts as well as optimizing health for all.

Associations between early introduction to complementary foods, subsequent cereal-added bottle feeding and daily macronutrient intake among infants

Introducing complementary foods early during infancy has been associated with an increased risk of overweight later in life, but the pathway is an understudied topic. Hence the study was conducted with low-income and primarily minority mother-infant dyads to: 1) understand how the introduction of complementary foods prior to 4 months was associated with socio-demographic characteristics and food security status; 2) determine the association between early introduction to complementary foods and breastfeeding and adding cereal into the bottle in later infancy (i.e., at 6 and 9 months), and; 3) examine how adding infant cereal into the bottle was related to daily calorie and macronutrient intake in infancy. We conducted interviews with mothers (n = 201) at 4 months of age and 24-h feeding recalls at age 6 and 9 months. Results indicated that 29% of the infants were fed complementary foods before 4 months of age. Introducing complementary foods early was negatively associated with breastfeeding and positively associated with adding cereal into the bottle at 6-months. This practice was more common among those who experienced marginal to very low levels of food security. Comparing by race/ethnicity, Latinx mothers were significantly less likely to introduce solids early. After controlling for sex, infants fed cereal in the bottle were consuming significantly more calories compared to their counterparts. Specifically, adding cereal into the bottle resulted in approximately 10% additional daily calorie intake among infants. Understanding how these feeding practices affect appetite development and weight status during infancy is warranted.

Prevalence and maternal determinants of early and late introduction of complementary foods: results from the Growing Up in New Zealand cohort study

A nationally generalisable cohort (n 5770) was used to determine the prevalence of non-timely (early/late) introduction of complementary food and core food groups and associations with maternal sociodemographic and health behaviours in New Zealand (NZ). Variables describing maternal characteristics and infant food introduction were sourced, respectively, from interviews completed antenatally and during late infancy. The NZ Infant Feeding Guidelines were used to define early (≤ 4 months) and late (≥ 7 months) introduction. Associations were examined using multivariable multinomial regression, presented as adjusted relative risk ratios and 95 % confidence intervals (RRR; 95% CI). Complementary food introduction was early for 40·2 % and late for 3·2 %. The prevalence of early food group introduction were fruit/vegetables (23·8 %), breads/cereals (36·3 %), iron-rich foods (34·1 %) and of late were meat/meat alternatives (45·9 %), dairy products (46·2 %) and fruits/vegetables (9·9 %). Compared with infants with timely food introduction, risk of early food introduction was increased for infants: breastfed < 6months (2·52; 2·19-2·90), whose mothers were < 30 years old (1·69; 1·46-1·94), had a diploma/trade certificate v. tertiary education (1·39; 1·1-1·70), of Māori v. European ethnicity (1·40; 1·12-1·75) or smoked during pregnancy (1·88; 1·44-2·46). Risk of late food introduction decreased for infants breastfed < 6 months (0·47; 0.27-0·80) and increased for infants whose mothers had secondary v. tertiary education (2·04; 1·16-3·60) were of Asian v. European ethnicity (2·22; 1·35, 3·63) or did not attend childbirth preparation classes (2·23; 1·24-4·01). Non-timely food introduction, specifically early food introduction, is prevalent in NZ. Interventions to improve food introduction timeliness should be ethnic-specific and support longer breast-feeding.

Gestational weight gain and breastfeeding practices in relation to offspring body mass index among Amazonian young children

OBJECTIVE

Excessive weight gain during childhood has been considered an early life risk factor for chronic disease in the long term. We examined the role of excessive gestational weight gain (GWG) and breastfeeding (BF) practices with the offspring's body mass index-for-age z-score (zBMI) at 2 years.

METHODS

Data from 743 Amazonian young children of the MINA-Brazil population-based birth cohort study were used. Linear regression models were run to estimate the associations between excessive GWG and BF practices (exclusive breastfeeding, EBF <3 months of age and BF <1 year) with zBMI.

RESULTS

Excessive GWG and BF <1 year were associated with an adjusted 0.24 units (95% CI: 0.08, 0.41) and 0.28 units (95% CI: 0.12, 0.44) higher zBMI at age 2 years, respectively.

CONCLUSIONS

Gain excessive weight during pregnancy and shorter BF duration (<1y) were associated with a higher body mass index at 2 years of age among Brazilian Amazonian children.

Complementary and Allergenic Food Introduction in Infants: An Umbrella Review

BACKGROUND

Multiple systematic reviews examine the introduction of foods in relation to individual health outcomes, but the balance of harms and benefits has not been overviewed systematically.

OBJECTIVES

We aimed to perform an overview of systematic reviews on age of introduction of complementary and allergenic foods to the infant diet and long and short-term health outcomes.

DATA SOURCES

We searched Medline, Embase, Cochrane, and PubMed (July 25, 2022).

STUDY SELECTION

Included systematic reviews examining the introduction of complementary or allergenic foods before age 1. Outcomes included allergic, autoimmune, and inflammatory diseases, neurodevelopment, nutrition, and weight.

DATA EXTRACTION

Extraction and quality assessment were performed in duplicate (A Measurement Tool to Assess Systematic Reviews) and strength of evidence was assessed.

RESULTS

We screened 4015 articles and included 32 systematic reviews. There was moderate evidence that peanut and egg should be introduced from 4 to 11 months to prevent food allergy (6 of 10 reviews). Complementary food introduction was not associated with food allergy. Moderate certainty evidence suggested age of complementary food introduction was not associated with eczema. Age at introduction of gluten was not associated with celiac disease (high certainty evidence; 3 of 4 reviews). Low certainty evidence indicated that introducing solids before 4 months may increase the risk of childhood obesity, but not growth. There was insufficient evidence regarding an association between any food introduction and bone health, gastrointestinal diseases, autoimmune disorders, asthma, or allergic rhinitis.

LIMITATIONS

Gray literature was not included.

CONCLUSIONS

Current evidence supports introducing complementary foods around 6 months and allergenic foods before 11 months.

Dietary and Complementary Feeding Practices of US Infants, 6 to 12 Months: A Narrative Review of the Federal Nutrition Monitoring Data

Complementary foods and beverages (CFBs) are key components of an infant's diet in the second 6 months of life. This article summarizes nutrition and feeding practices examined by the 2020 Dietary Guidelines Advisory Committees during the CFB life stage. Breastfeeding initiation is high (84%), but exclusive breastfeeding at 6 months (26%) is below the Healthy People 2030 goal (42%). Most infants (51%) are introduced to CFBs sometime before 6 months. The primary mode of feeding (ie, human milk fed [HMF]; infant formula or mixed formula and human milk fed [FMF]) at the initiation of CFBs is associated with the timing of introduction and types of CFBs reported. FMF infants (42%) are more likely to be introduced to CFBs before 4 months compared with HMF infants (19%). Different dietary patterns, such as higher prevalence of consumption and mean amounts, were observed, including fruit, grains, dairy, proteins, and solid fats. Compared with HMF infants of the same age, FMF infants consume more total energy (845 vs 631 kcal) and protein (22 vs 12 g) from all sources, and more energy (345 vs 204 kcal) and protein (11 vs 6 g) from CFBs alone. HMF infants have a higher prevalence of risk of inadequate intakes of iron (77% vs 7%), zinc (54% vs <3%), and protein (27% vs <3%). FMF infants are more likely to have an early introduction (<12 months) to fruit juice (45% vs 20%) and cow's milk (36% vs 24%). Registered dietitian nutritionists and nutritional professionals should consider tailoring their advice to caregivers on dietary and complementary feeding practices, taking into account the primary mode of milk feeding during this life stage to support infants' nutrient adequacy. National studies that address the limitations of this analysis, including small sample sizes and imputed breast milk volume, could refine findings from this analysis.

Infant age at egg introduction and malnutrition‐related child growth in the United States

To evaluate the relationship between infant age of egg introduction and malnutrition‐related growth outcomes in the United States, we analysed secondary data of 1716 mother–child dyads in the Infant Feeding Practices Study II and its Year 6 Follow‐Up Study. Malnutrition‐related growth outcomes included body mass index z‐score (BMIZ), obesity (weight‐for‐height z‐score [WHZ] ≥3 or BMIZ ≥ 2), WHZ, wasting (WHZ < −2), height‐for‐age z‐score (HAZ), and stunting (HAZ < –2). Infant age at egg introduction was analysed as a continuous variable. We used generalised estimating equations to estimate the mean difference in continuous outcomes and relative risk [RR]) for binary outcomes, adjusting for related maternal and child confounders. We also explored interactions with child sex, maternal race/ethnicity, maternal educational level, ever breastfeeding, and formula feeding. In the total sample, a later infant age at egg introduction was associated with a lower mean difference in HAZ (confounder‐adjusted mean difference = −0.08, 95% confidence interval [CI]: −0.12 to −0.03 per month) and a higher risk of stunting (confounder‐adjusted RR = 1.17, 95% CI: 1.03–1.33 per month) at 6 years. The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Among females but not among males, later introduction of eggs was associated with a lower mean WHZ (−0.06 [−0.12 to 0.00] per month) at 12 months. Later egg introduction during infancy was associated with a lower mean HAZ and a higher risk of stunting in 6‐year‐old children. Besides this, it was associated with a lower WHZ among females at 12 months.

This secondary data analysis evaluated the relationship between infant age at egg introduction and malnutrition‐related growth outcomes among young US children within the Infant Feeding Practices Study II and its Year 6 Follow‐up Study.

In the total sample, a later infant age at egg introduction was associated with a lower mean 6‐year height‐for‐age z‐score and a higher risk of stunting at 6 years.

The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Later introduction of eggs was associated with a lower mean weight‐for‐height z‐score among females. However, this association was not observed among males.

Improving Nutrition in the First 1000 Days in the United States: A Federal Perspective

The first 1000 days begins with pregnancy and ends at the child's second birthday. Nutrition throughout the life course, and especially during the first 1000 days, supports maternal health and optimal growth and development for children. We give a high-level summary of the state of nutrition in the first 1000 days in the United States. We provide examples where continued efforts are needed. We then discuss select opportunities to strengthen federal research and surveillance, programs, and communication and dissemination efforts aimed at improving nutrition and positively, and equitably, influencing the health and well-being of mothers and children. (Am J Public Health. 2022;112(S8):S817-S825. https://doi.org/10.2105/AJPH.2022.307028).

Obesity in children and adolescents: epidemiology, causes, assessment, and management

This Review describes current knowledge on the epidemiology and causes of child and adolescent obesity, considerations for assessment, and current management approaches. Before the COVID-19 pandemic, obesity prevalence in children and adolescents had plateaued in many high-income countries despite levels of severe obesity having increased. However, in low-income and middle-income countries, obesity prevalence had risen. During the pandemic, weight gain among children and adolescents has increased in several jurisdictions. Obesity is associated with cardiometabolic and psychosocial comorbidity as well as premature adult mortality. The development and perpetuation of obesity is largely explained by a bio-socioecological framework, whereby biological predisposition, socioeconomic, and environmental factors interact together to promote deposition and proliferation of adipose tissue. First-line treatment approaches include family-based behavioural obesity interventions addressing diet, physical activity, sedentary behaviours, and sleep quality, underpinned by behaviour change strategies. Evidence for intensive dietary approaches, pharmacotherapy, and metabolic and bariatric surgery as supplemental therapies are emerging; however, access to these therapies is scarce in most jurisdictions. Research is still needed to inform the personalisation of treatment approaches of obesity in children and adolescents and their translation to clinical practice.

Timing and pattern of growth faltering in children up-to 18 months of age and the associated feeding practices in an urban setting of Sri Lanka

BACKGROUND

Growth faltering is commonly encountered in breastfed infants during 4-6 months of age in low socioeconomic communities. The objective of this study was to describe the changes of growth indices with age, timing of growth faltering and its association with the feeding practices in children up-to 18 months of age.

METHODS

A cross sectional descriptive study was conducted in 254 children aged 12 and 18 months attending an immunization clinic. Data on growth were extracted from the Child Health Development Record. Weight and length were measured using standard methods. Feeding practices were assessed using interviewer-administered questionnaire. A drop of > 0.25 in weight-for-age Standard Deviation Score (SDS) from birth SDS was defined as weight faltering.

RESULTS

Weight faltering occurred at some point in 64.2% (n = 163) during first 18 months of life, and 78.5% of whom, had the onset ≤ 4 months of age. Majority (76.6%, n = 98) with weight for age faltering by 4 months remained so at 12 months (p = 0.497), while 29.7% (n = 38) had a weight-for-length below-2SD (p < 0.001). Prevalence of weight faltering was 50.4%, 46.1%, 48.4% and 48% at 4, 6, 9 and 12 months respectively. Exclusive breastfeeding was given at least until 4 months in 88% (n = 223) and up to 6 months in 60% (n = 153) while 92.9% (n = 236) were breastfed at 12 months, with 38.2% (n = 97) were breastfed on demand after six months. Complementary feeding (CF) was started before 6 months in 40.6% (n = 52) with early weight faltering, but only 20.3% received it with proper consistency. Breastfeeding throughout the night was significantly associated with current weight-for-length being < -1SD (OR = 1.89, CI, 1.04-3.45; p = 0.037).

CONCLUSIONS

Early growth faltering was found in this population with high exclusive breastfeeding rates and persisting growth faltering was associated with poor feeding practices. Therefore, timely individualized interventions need to be taken to improve long term growth.

Real-World LEAP Implementation

Purpose of Review

In 2015, findings from the Learning Early About Peanut allergy (LEAP) trial provided the first convincing evidence that peanut allergy may be preventable through early peanut introduction into the infant diet. Here we discuss implementation of the LEAP study findings around the world and emerging evidence of the impacts on infant feeding and food allergy.

Recent Findings

The LEAP findings led to rapid changes in allergy prevention guidelines internationally to recommend early peanut introduction. There is now emerging evidence that this has been followed by a substantial increase in early peanut introduction to infants. Studies investigating the impact of these changes in infant feeding practices on the prevalence of peanut allergy are underway.

Summary

The LEAP trial represented a significant step forwards in food allergy prevention and new research over the past 5 years has provided insights into how best to implement this intervention in the real world.

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.

Timing and types of fluids and foods first introduced in a representative sample of toddlers attending day care programs across Lebanon: Are parents following international recommendations?

BACKGROUND

Current WHO's recommendation for optimal infant feeding advises exclusive breastfeeding for 6 months. After this initial period, infants should receive nutritionally adequate and safe complementary food starting from the age of 6 months with continued breastfeeding up to 2 years of age or beyond.

PURPOSE

This study examined the timing and types of fluids and foods first introduced in a representative sample of toddlers (n = 1051) from 79 daycares across Lebanon. Questionnaires were self-administered to parents of toddlers (12-36 months) with a participation rate of 67%.

RESULTS

Results showed that more than half of toddlers (55.7%) were introduced to infant formula within their first month of life. Around two-thirds received water as the first type of additional fluid (62.5%) with a mean age of 3.86 ± 2.15 months and fruits or cooked vegetables (69.7%) as the first types of food introduced with a mean age of 5.73 ± 1.56 months. Unfortunately, two-third (67.3%) were not breastfed after solid food introduction.

PRACTICE IMPLICATIONS

Our data on current suboptimal feeding practices in Lebanon shows the need to reinforce BF and CF practices recommendations and guidelines at the community, social and health system levels.

CONCLUSIONS

In the absence of specific recommendations and with the poor involvement of the various stakeholders, it was noted that more than half of the parents were not following the WHO recommendation concerning unnecessary fluid supplementation of infants and were introducing food before the recommended age of 6 months; moreover, only a minority of mothers continued breastfeeding after introducing food to their infants.

Complementary Feeding and Iron Status: "The Unbearable Lightness of Being" Infants

The complementary feeding (CF) period that takes place between 6 and 24 months of age is of key importance for nutritional and developmental reasons during the transition from exclusively feeding on milk to family meals. In 2021, a multidisciplinary panel of experts from four Italian scientific pediatric societies elaborated a consensus document on CF, focusing in particular on healthy term infants. The aim was to provide healthcare providers with useful guidelines for clinical practice. Complementary feeding is also the time window when iron deficiency (ID) and iron deficiency anemia (IDA) are most prevalent. Thus, it is appropriate to address the problem of iron deficiency through nutritional interventions. Adequate iron intake during the first two years is critical since rapid growth in that period increases iron requirements per kilogram more than at any other developmental stage. Complementary foods should be introduced at around six months of age, taking into account infant iron status.

Dietary intake and nutritional status of Korean children and adolescents: a review of national survey data

In Korea, several national cross-sectional surveys monitor the diet, nutritional status, and health status of children. This continual dedicated national surveillance system contributes to the identification of nutritional and health issues, establishment of public health policies, and development of nutrition recommendations. This paper provides recent information about the Korea National Health and Nutrition Examination Survey and the Korean Youth Risk Behavior Web-based Survey and describes key nationwide survey findings published in the last 5 years on infant feeding practices and the dietary intake and nutritional status of Korean infants, children, and adolescents. There have been increasing trends in children, and teenagers who skip breakfast, eat fast food, consume sugary drinks, have vitamin D deficiency, and are obese. This review will inform pediatricians, nutritionists, and other health care practitioners who track children's growth and development. It may also help researchers and policymakers identify diet-related policies and strategies for chronic disease prevention in Korean infants, children, and adolescents.

An index measuring adherence to New Zealand Infant Feeding Guidelines has convergent validity with maternal socio-demographic and health behaviours and with children's body size

Using data from a nationally generalisable birth cohort, we aimed to: (i) describe the cohort’s adherence to national evidence-based dietary guidelines using an Infant Feeding Index (IFI) and (ii) assess the IFI’s convergent construct validity, by exploring associations with antenatal maternal socio-demographic and health behaviours and with child overweight/obesity and central adiposity at age 54 months. Data were from the Growing Up in New Zealand cohort (n 6343). The IFI scores ranged from zero to twelve points, with twelve representing full adherence to the guidelines. Overweight/obesity was defined by BMI-for-age (based on the WHO Growth Standards). Central adiposity was defined as waist-to-height ratio > 90th percentile. Associations were tested using multiple linear regression and Poisson regression with robust variance (risk ratios, 95 % CI). Mean IFI score was 8·2 (sd 2·1). Maternal characteristics explained 29·1 % of variation in the IFI score. Maternal age, education and smoking had the strongest independent relationships with IFI scores. Compared with children in the highest IFI tertile, girls in the lowest and middle tertiles were more likely to be overweight/obese (1·46, 1·03, 2·06 and 1·56, 1·09, 2·23, respectively) and boys in the lowest tertile were more likely to have central adiposity (1·53, 1·02, 2·30) at age 54 months. Most infants fell short of meeting national Infant Feeding Guidelines. The associations between IFI score and maternal characteristics, and children’s overweight/obesity/central adiposity, were in the expected directions and confirm the IFI’s convergent construct validity.

Infant Feeding and Ethnic Differences in Body Mass Index during Childhood: A Prospective Study

This study investigated ethnic differences in childhood body mass index (BMI) in children from Dutch and Turkish descent and the role of infant feeding factors (breastfeeding duration, milk feeding frequency, as well as the timing, frequency and variety of complementary feeding (CF)). We used data from 244 children (116 Dutch and 128 Turkish) participating in a prospective study in the Netherlands. BMI was measured at 2, 3 and 5 years and standard deviation scores (sds) were derived using WHO references. Using linear mixed regression analyses, we examined ethnic differences in BMI-sds between 2 and 5 years, and the role of infant feeding in separate models including milk or CF factors, or both (full model). Relative to Dutch children, Turkish children had higher BMI-sds at age 3 (mean difference: 0.26; 95%CI: 0.04, 0.48) and 5 (0.63; 0.39, 0.88), but not at 2 years (0.08; -0.16, 0.31). Ethnic differences in BMI-sds were somewhat attenuated by CF factors at age 3 (0.16; -0.07, 0.40) and 5 years (0.50; 0.24, 0.77), whereas milk feeding had a minor impact. Of all factors, only CF variety was associated with BMI-sds in the full model. CF factors, particularly CF variety, explain a small fraction of the BMI-sds differences between Dutch and Turkish children. The role of CF variety on childhood BMI requires further investigation.

Complementary feeding of infants and young children 6 to 23 months of age

Complementary feeding, when foods are introduced to complement a milk-based diet, generally occurs between 6 and 23 months of age. It is a critical period for both physical and cognitive development. During this period, the growth rate of the brain is one of the fastest during the life span and, consequently, the timing, dose, and duration of exposure to specific nutrients can result in both positive and negative effects. Complementary feeding is more than ensuring an adequate intake of nutrients; it also is about avoiding excess intakes of calories, salt, sugars, and unhealthy fats. Meals are cultural and social events where young children observe, imitate, learn about foods to like or dislike, and form lifelong eating habits and practices. Meals are also when a child learns to touch foods and connect food tastes to how foods look and feel. Ideally, complementary feeding is responsive and promotes child autonomy, but it can also be used to manage behavior problems or overly indulge a child, resulting in long-term consequences for nutrition and health. Therefore, in addition to what a child is fed, attention to how a child is fed is also important. In this review, 12 topics relevant for updating global guidance on complementary feeding were identified: age of introduction of complementary foods; continued breastfeeding; responsive feeding; safe preparation and storage of complementary foods; food textures, flavors, and acceptance; energy and meal and snack frequency; fats, protein, and carbohydrates; dietary diversity; milks other than breast milk; fluid needs; unhealthy foods and beverages; and use of vitamin and mineral supplements or supplementary foods.

Nutrition beyond the first 1000 days: diet quality and 7-year change in BMI and overweight in 3-year old children from the Dutch GECKO Drenthe birth cohort

The identification of early-life determinants of overweight is crucial to start early prevention. As weight gain accelerates between 2 and 6 years, we studied the association between diet quality in children aged 3 years and the change in BMI and overweight incidence in the following 7 years. From the Dutch GECKO Drenthe birth cohort, 1001 children born in 2006 or 2007 with complete data on diet (food frequency questionnaire at the age of 3 years) and growth at the age of 3 and 10 years were included. Diet quality was estimated with the evidence-based Lifelines Diet Score (LLDS). Measured height and weight at the age of 3 and 10 years were used to calculate BMI z-scores standardized for age and sex. The associations of the LLDS (in quintiles) with BMI-z change and overweight incidence were studied with linear and logistic regression analyses. Overweight prevalence in the total study population increased from 8.3% at the age of 3 years to 16.7% at the age of 10 years. The increase in overweight prevalence ranged from 14.7% in Q1 to 3.5% in Q5. Children with a better diet quality (higher quintiles of LLDS) increased significantly less in BMI-z (confounder adjusted βLLDS = -0.064 (-0.101; -0.026)). Children with a poor diet quality at the age of 3 years had a considerably higher risk for overweight at the age of 10 years (confounder adjusted OR for Q1 vs. Q5 was 2.86 (95% CI 1.34-6.13). These results show the importance of diet in healthy development in the early life following the first 1000 days when new habits for a mature diet composed of food groups with lifelong importance are developed, providing a relevant window for overweight prevention early in life.

Timing of Introduction of Complementary Foods - United States, 2016-2018

The American Academy of Pediatrics (AAP) recommends introducing complementary foods (i.e., any solid or liquid other than breast milk or infant formula) to infants at approximately age 6 months (1). Although a consensus on ideal timing is lacking, most experts agree that introduction of complementary foods before age 4 months is too early because of infant gastrointestinal and motor immaturity (1,2). In addition, early introduction prevents exclusively breastfed infants from reaching the recommended 6 months of exclusive breastfeeding (1) and might be associated with increased risk for overweight and obesity (3). Nationally representative data on complementary feeding are limited; state-level estimates have been previously unavailable. CDC analyzed 2016-2018 data from the National Survey of Children's Health (NSCH) (N = 23,927) to describe timing of complementary feeding introduction and prevalence of early introduction of complementary foods before age 4 months (early introduction) among children aged 1-5 years. Prevalence of early introduction was 31.9% nationally and varied geographically and across sociodemographic and infant feeding characteristics. These estimates suggest that many infants are introduced to complementary foods before they are developmentally ready. Efforts by health care providers and others who might influence infant feeding practices could help decrease the number of infants who are introduced to complementary foods too early.

Complementary feeding practices and their association with adiposity indicators at 12 months of age

Nutrition during the first 1000 days of life represents a window of opportunity to reduce the risk of metabolic dysfunctions later in life. Exclusive breastfeeding (EBF) and adequate introduction of solid foods are essential to promote metabolic and nutritional benefits. We evaluated the association of infant feeding practices from birth to 6 months (M) with adiposity indicators at 12 M. We performed a secondary analysis of 106 healthy term infants born from a cohort of healthy pregnant women. Type of breastfeeding (exclusive or nonexclusive), the start of complementary feeding (CF) (before (<4 M) or after (≥4 M)), and adiposity (body mass index - BMI, body mass index-for-age - BMI/A, waist circumference - WC, and waist circumference-length ratio - WLR) were evaluated at 12 M using descriptive statistics, mean differences, X2, and linear regression models. During the first 6 M, 28.3% (n = 30) of the infants received EBF. Early CF (<4 M) was present in 26.4% (n = 28) of the infants. Children who started CF < 4 M were less breastfed, received added sugars as the most frequently introduced food category, and showed higher BMI, BMI/A, WC, and WLR; those who consumed added sugars early (<4 M) had a higher WC. Starting CF < 4 M was the main factor associated with a higher WC at 12 M. Unhealthy infant feeding practices, such as lack of EBF, early CF, and early introduction of sugars, may be associated with higher adiposity at 12 M.

Complementary Feeding: Pitfalls for Health Outcomes

The term complementary feeding is defined as the period in which a progressive reduction of breastfeeding or infant-formula feeding takes place, while the infant is gradually introduced to solid foods. It is a crucial time in the infant's life, not only because of the rapid changes in nutritional requirements and the consequent impact on infant growth and development, but also for a generation of lifelong flavor preferences and dietary habits that will influence mid and long-term health. There is an increasing body of evidence addressing the pivotal role of nutrition, especially during the early stages of life, and its link to the onset of chronic non-communicable diseases, such as obesity, hypertension, diabetes, and allergic diseases. It is clear that the way in which a child is introduced to complementary foods may have effects on the individual's entire life. The aim of this review is to discuss the effects of complementary feeding timing, composition, and mode on mid and long-term health outcomes, in the light of the current evidence. Furthermore, we suggest practical tips for a healthy approach to complementary feeding, aiming at a healthy future, and highlight gaps to be filled.

Nutrition in developmental age: few rules to stay healthy

The first 1000 days of life represent a critical window for infants' and children's development. Overweight and insulin resistance, at the basis of non-communicable diseases (NCDs), are linked to various risk factors that begin in childhood, including children's diet. Italian data on infants' and children's dietary habits show higher intake of proteins, simple sugars, unhealthy fats and salt than recommended, while the iron intake is below requirement. We reviewed current literature analyzing observational studies, meta-analysis, systematic review and randomized clinical trials of the last 10 years (from 2009) on nutrition in developmental age, providing some few rules to abide by. Exclusive breastfeeding is recommended by World Health Organization for the first 6 months of life and it should be continued alongside the complementary feeding period until 12 months, or even afterward. Complementary feeding should not be started before the 17th week of age with energetically adequate foods, paying attention to limit protein intake and favoring iron-rich foods. Intake of simple sugars should be limited or avoided at all; it has been demonstrated that substituting sugar-sweetened beverages with water decreases body fatness development in adolescence. Quality of the ingested fats is more important than their quantity: polyunsaturated fatty acids should be preferred. Sodium intake should be limited in the first 24 months of life, as first prevention measure of arterial hypertension later in adulthood. Healthy eating habits are the first important step toward the prevention of NCDs.

Associations of Less Healthy Snack Food Consumption with Infant Weight-for-Length Z-Score Trajectories: Findings from the Nurture Cohort Study

Little is known about the impact of less healthy snack foods on weight trajectories during infancy. This secondary analysis of data from the Nurture cohort explored prospective associations of less healthy snack foods with infant weight trajectories. Pregnant women were recruited and, upon delivery of a single live infant, 666 mothers agreed to participate. Mothers completed sociodemographic and infant feeding questionnaires, and infant anthropometrics were collected during home visits at 3, 6, 9, and 12 months. Less healthy snack food consumption was assessed by asking how frequently baby snacks and sweets were consumed each day during the previous three months. Multilevel growth curve models explored associations of baby snacks and sweets with infant weight-for-length (WFL) z-scores. On average, mothers were 27 years old, 71.5% were non-Hispanic Black, and 55.4% had household incomes of ≤$20,000/year. Consumption of less healthy snack foods increased during infancy with a median intake of 3.0 baby snacks/day and 0.7 sweets/day between 10 and 12 months. Growth curve models showed that infants who consumed sweets >2 times/day had significantly higher WFL z-scores during the second half of infancy compared to infants who never consumed sweets. Less healthy snacks may contribute to the risk of obesity during infancy and promoting healthy snack food choices during this critical time is important.

Appropriate age range for introduction of complementary feeding into an infant's diet

Following a request from the European Commission, the Panel on Nutrition, Novel Foods and Food Allergens (NDA) revised its 2009 Opinion on the appropriate age for introduction of complementary feeding of infants. This age has been evaluated considering the effects on health outcomes, nutritional aspects and infant development, and depends on the individual's characteristics and development. As long as foods have an age-appropriate texture, are nutritionally appropriate and prepared following good hygiene practices, there is no convincing evidence that at any age investigated in the included studies (< 1 to < 6 months), the introduction of complementary foods (CFs) is associated with adverse health effects or benefits (except for infants at risk of iron depletion). For nutritional reasons, the majority of infants need CFs from around 6 months of age. Infants at risk of iron depletion (exclusively breastfed infants born to mothers with low iron status, or with early umbilical cord clamping (< 1 min after birth), or born preterm, or born small-for-gestational age or with high growth velocity) may benefit from earlier introduction of CFs that are a source of iron. The earliest developmental skills relevant for consuming pureed CFs can be observed between 3 and 4 months of age. Skills for consuming finger foods can be observed in some infants at 4 months, but more commonly at 5-7 months. The fact that an infant may be ready from a neurodevelopmental perspective to progress to a more diversified diet before 6 months of age does not imply that there is a need to introduce CFs. There is no reason to postpone the introduction of potentially allergenic foods (egg, cereals, fish and peanut) to a later age than that of other CFs as far as the risk of developing atopic diseases is concerned. Regarding the risk of coeliac disease, gluten can be introduced with other CFs.

Systematic review methods for the Pregnancy and Birth to 24 Months Project

The USDA's Nutrition Evidence Systematic Review (NESR) team specializes in conducting systematic reviews (SRs) to inform federal nutrition policy and programs. The NESR's dedicated staff collaborate with leading scientists to answer important food- and nutrition-related public health questions by objectively reviewing, evaluating, and synthesizing research using state-of-the-art methodology. NESR uses a rigorous, protocol-driven methodology that is designed to minimize bias; to ensure availability of SRs that are relevant, timely, and high quality; and to ensure transparency and reproducibility of findings. This article describes the methods used by NESR to conduct a series of SRs on diet and health in infants, toddlers, and women who are pregnant as part of the Pregnancy and Birth to 24 Months Project.