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

Does sweetness exposure drive 'sweet tooth'?

It is widely believed that exposure to sweetened foods and beverages stimulates the liking and desire for sweetness. Here we provide an updated review of the empirical evidence from human research examining whether exposure to sweet foods or beverages influences subsequent general liking for sweetness (‘sweet tooth’), based on the conclusions of existing systematic reviews and more recent research identified from a structured search of literature. Prior reviews have concluded that the evidence for a relationship between sweet taste exposure and measures of sweet taste liking is equivocal, and more recent primary research generally does not support the view that exposure drives increased liking for sweetness, in adults or children. In intervention trials using a range of designs, acute exposure to sweetness usually has the opposite effect (reducing subsequent liking and desire for sweet taste), while sustained exposures have no significant effects or inconsistent effects. Recent longitudinal observational studies in infants and children also report no significant associations between exposures to sweet foods and beverages with measures of sweet taste preferences. Overall, while it is widely assumed that exposure to sweetness stimulates a greater liking and desire for sweetness, this is not borne out by the balance of empirical evidence. While new research may provide a more robust evidence base, there are also a number of methodological, biological and behavioural considerations that may underpin the apparent absence of a positive relationship between sweetness exposure and liking.

Development and validation of the baby eating behaviour coding system (BEBECS) to assess eating behaviour during complementary feeding

Eating behaviour in children is a matter of study for which diverse tools have been designed. Coding systems for videotaped meals allow the extraction of detailed in vivo information; however, there is no tool available for infants following a Baby-Led Weaning (BLW) method. This study aimed to create and validate a new tool to assess eating behaviour in infants during weaning, applicable regardless of the complementary feeding method. The Baby Eating Behaviour Coding System (BEBECS) was developed comprising time variables, behaviours, feeder-led actions, and other meal-related variables. Sixty videos of infants aged 6-18 months following spoon-feeding (SF) or BLW methods were coded by two trained coders. These scores were analysed together with intake and maternal ratings of liking and calmness. Additionally, combined analysis and internal comparison assessed the possible differences in BEBECS variables between SF and BLW. Inter-rater and test-retest reliability had good to excellent agreement: Cohen's Kappa >0.75, Lin's CCC >0.70, and Intraclass Correlation Coefficient >0.75, for almost all variables. Infants' liking and intake of the offered food correlated positively with meal duration and total count of mouth approaches but negatively with having leftovers and time between mouth approaches. Infants' calmness and tiredness were negatively correlated. More food than initially offered was available during the meal in BLW but not in SF. There was a tendency towards more autonomous behaviour in BLW infants regarding changes observed in the time the food was in the mouth at each stage (6, 12, and 18 months). In conclusion, BEBECS has the potential to be a valid tool for application in the research of infant eating behaviour during weaning by trained coders.

Evidence for Policies and Practices to Address Global Food Insecurity

Food insecurity affects an estimated 691-783 million people globally and is disproportionately high in Africa and Asia. It arises from poverty, armed conflict, and climate change, among other demographic and globalization forces. This review summarizes evidence for policies and practices across five elements of the agrifood system framework and identifies gaps that inform an agenda for future research. Under availability, imbalanced agriculture policies protect primarily staple food producers, and there is limited evidence on food security impacts for smallholder and women food producers. Evidence supports the use of cash transfers and food aid for affordability and school feeding for multiple benefits. Food-based dietary guidelines can improve the nutritional quality of dietary patterns, yet they may not reflect the latest evidence or food supplies. Evidence from the newer food environment elements, promotion and sustainability, while relatively minimal, provides insight into achieving long-term impacts. To eliminate hunger, our global community should embrace integrated approaches and bring evidence-based policies and practices to scale.

The Double Burden of Malnutrition is Associated with Continued Breastfeeding and Early Consumption of Ultra-Processed Drinks in Socially Vulnerable Brazilian Children

This study aimed to assess the association between the double burden of malnutrition (DBM) with continued breastfeeding and the early introduction of ultra-processed drinks in children living in situations of social vulnerability. This cross-sectional population-based study was carried out in a capital city in the Northeast of Brazil, which included 561 children. It was observed that introducing soft drinks into the child's diet during the first year of life was directly associated with DBM but indirectly with continuous breastfeeding for 12 or more months. These results indicate paths that can be followed to reverse the current scenario.

Production of freeze-dried beef powder for complementary food: Effect of temperature control in retaining protein digestibility

This study investigated the effect of temperature control during freeze-drying of beef on the in vitro protein digestibility. Frozen (at - 50 °C for 2 days)-then-aged (at 4 °C for 26 days) beef was freeze-dried at 25 °C (FD1) and 2 °C (FD2) to obtain freeze-dried beef powder. Tryptophan fluorescence intensity and total free sulfhydryl groups of beef myofibrillar proteins decreased (P < 0.05) and increased (P < 0.05) after freeze-drying, respectively. In the myosin fraction of FD2, α-helix increased and β-sheet decreased (P < 0.05) compared to raw beef. In contrast, the actin fraction of FD1 showed a decrease in α-helix and increase in β-sheet (P < 0.05) compared to raw beef. The contents of α-amino group and proteins digested to<3 kDa in the in vitro digesta of beef were retained in FD2 while the α-amino group of FD1 decreased (P < 0.05). Therefore, freeze-drying at 2 °C can efficiently retain in vitro protein digestibility of beef.

From Birth to Weaning: A Window of Opportunity for Microbiota

(1) Background: The first 1000 days of life constitute a critical window of opportunity for microbiota development. Nutrients play a crucial role in enriching and diversifying the microbiota, derived not only from solid food but also from maternal dietary patterns during gestation. (2) Methods: We conducted a comprehensive literature review using the PubMed database, covering eleven years (2013-2023). We included English-language reviews, original research papers, and meta-analyses, while excluding case reports and letters. (3) Results: Consensus in the literature emphasizes that our interaction with a multitude of microorganisms begins in the intrauterine environment and continues throughout our lives. The existing data suggest that early nutritional education programs, initiated during pregnancy and guiding infant diets during development, may influence the shaping of the gut microbiota, promoting long-term health. (4) Conclusions: Further research is necessary in the coming years to assess potential interventions and early nutritional models aimed at modulating the pediatric microbiota, especially in vulnerable populations such as premature newborns.

The Future for the Children of Tomorrow: Avoiding Salt in the First 1000 Days

It is widely known that optimal nutrition in the first 1000 days of life positively impacts the child's development throughout adulthood. In this setting, salt should not be added to complementary feeding. In developed countries, salt intake is generally higher than recommended for children. Excessive salt intake is the major determinant of hypertension and is associated with several cardiovascular outcomes. Therefore, pediatricians have a key role in raising awareness among parents to avoid salt consumption in the first 1000 days of life to ensure better health for their children. Starting from a review of the literature published in PubMed/MedLine regarding the short- and long-term consequences of salt consumption during the first 1000 days of life, our comprehensive review aims to analyze the beneficial effects of avoiding salt at such a vulnerable stage of life as the first 1000 days. Obesity, hypertension, increased salt sensitivity, high sweet drink consumption, increased mortality, and morbidity persisting in adult age represent the principal consequences of a higher salt intake during the first 1000 days of life.

Complementary Feeding Practices: Recommendations of Pediatricians for Infants with and without Allergy Risk

AIM

To investigate the routine guidance provided by pediatricians concerning the timing of complementary feeding (CF) for both healthy infants and those at a heightened risk of allergies.

METHODS

A total of 233 pediatricians participated in an anonymous online survey that included questions about demographics and recommendations for CF. Specifically, they provided guidance on the types of foods, preparation methods, supplements, time intervals for introducing new foods to infants at low and high allergy risk, and delayed food introductions for high-risk cases.

RESULTS

The respondents advised introducing certain foods at specific ages: fruits, starchy non-gluten grains, vegetables, olive oil, and meat were appropriate at 6 months; gluten-rich grains at 7 months; yogurt, hard-boiled eggs, and legumes at 8 months; fish at 8.5 months; and nuts at 9 months. Pediatricians, especially those with less than 15 years of practice, often introduced egg, seafood, gluten-rich grains, legumes, and nuts earlier for high-risk infants. Parenthood and male gender were associated with the earlier introduction of eggs and grains.

CONCLUSIONS

Greek pediatricians follow a structured food introduction schedule for CF in infants. Interestingly, they tend to delay the introduction of common food allergens and recommend longer intervals between introducing new foods, particularly for high-risk infants. Key Notes: Despite recent evidence-based indications on healthy complementary feeding strategies for infants, discrepancies persist among pediatricians regarding food choices and the order and timing of food introduction, both for healthy infants and those at risk of allergy. Guidance on complementary feeding by pediatricians is influenced by their individual characteristics. Pediatricians tend to delay the introduction of common food allergens and recommend longer intervals between introducing new foods, particularly for high-risk infants.

Identifying and understanding barriers to optimal complementary feeding in Kenya

Optimal complementary feeding between the ages of 6 and 23 months provides children with the required range of nutritious and safe foods while continuing to be breastfed to meet their needs for essential nutrients and develop their full physical and cognitive potential. The rates of exclusive breastfeeding in the first 6 months of life have increased from 32% in 2008 to 60% in 2022 in Kenya. However, the proportion of children between 6 and 23 months receiving a minimum acceptable diet remains low and has declined from 39% in 2008 to 31% in 2023. The Kenyan Ministry of Health, GAIN and UNICEF collaborated to understand the drivers of complementary feeding practices, particularly proximal determinants, which can be directly addressed and acted upon. A secondary analysis of household surveys and food composition data was conducted to outline children's dietary patterns within the different regions of Kenya and the extent to which the affordability of animal-source foods could be improved. Ethnographic data were analyzed to identify socio-cultural barriers to optimal complementary feeding. Furthermore, we outlined the critical steps for developing user-friendly and low-cost complementary feeding recipes. The results of all the analyses are presented in five of the six papers of this Special Issue with this additional paper introducing the Kenyan context and some of the critical findings. The Special Issue has highlighted multidimensional barriers surrounding the use and availability of animal-source foods. Furthermore, it emphasizes the need for a multi-sectoral approach in enacting policies and programmes that address these barriers.

Designing intervention prototypes to improve infant and young child nutrition in Peru: a participatory design study protocol

INTRODUCTION

Nutrition during the complementary feeding period (6-23 months) is critical to ensure optimal growth and reduce the risk of diet-related disease across the life course. Strategies to reduce multiple forms of malnutrition (stunting, overweight/obesity and anaemia) in infants and young children (IYC) are a key priority in low-income and middle-income countries, including Peru. This study aims to co-design and develop prototypes for interventions to address the multiple forms of malnutrition in IYC in urban Peru, using a participatory design approach.

METHODS AND ANALYSIS

The study will be based within peri-urban communities in two areas of Peru (Lima and Huánuco city). Following the identification of key nutritional challenges for IYC aged 6-23 months through formative research (phase I), we will conduct a series of workshops bringing together healthcare professionals from government health centres and caregivers of IYC aged 6-23 months. Workshops (on idea generation; creating future scenarios; storyboarding and early implementation and feedback) will take place in parallel in the two study areas. Through these workshops, we will engage with community participants to explore, experiment, co-design and iteratively validate new design ideas to address the challenges around IYC complementary feeding from phase I. Workshop outputs and transcripts will be analysed qualitatively using affinity diagramming and thematic analyses. The intervention prototypes will be evaluated qualitatively and piloted with the participating communities.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the Ethical Review Committee of the Instituto de Investigación Nutricional (IIN) Peru (388-2019/CIEI-IIN), Loughborough University (C19-87) and confirmed by Cardiff University. Findings of the participatory design process will be disseminated through a deliberative workshop in Lima, Peru with national and regional government stakeholders, as well as participants and researchers involved in the design process. Further dissemination will take place through policy briefs, conferences and academic publications.

Benchmarking the nutrient composition and labelling practices of commercially produced ready-to-eat purées and meals for older infants and young children across seven Southeast Asian countries

Commercially produced complementary foods (CPCF), including ready-to-eat CPCF purées and meals, are gaining popularity among caregivers of older infants and young children (IYC) as a convenient alternative to home-prepared foods in low and middle-income countries. However, there is growing concern regarding the suitability of these products for older IYC, as they can contain high levels of sugar and/or sodium. Given the rapidly evolving market in Southeast Asia, it is crucial to monitor the appropriate composition and promotion of CPCF in the region. This study examined the nutrient composition and labelling practices of CPCF purées and meals sold in 2021 in the capital cities of seven Southeast Asian countries: Phnom Penh (Cambodia), Jakarta (Indonesia), Manila (Philippines), Bangkok (Thailand), Vientiane (Lao PDR), Hanoi (Viet Nam), Kuala Lumpur (Malaysia). The study adapted a nutrient profiling model from the WHO Regional Office for Europe to determine the proportion of products suitable for promotion for older IYC. The proportion of CPCF purées and meals that would require a high sugar front-of-pack warning based on the percentage energy from total sugar was also determined. Of the 459 CPCF purées/meals assessed, only 37.7% of the products met all nutrient composition requirements and none met all labelling requirements. In addition, most CPCF purées and meals were identified as having high total sugar content. To ensure that older IYC consume appropriate CPCF products, Southeast Asian countries need to implement and enforce regulations concerning the nutrient composition and labelling practices of CPCF purées and meals.

Micronutrient gaps during the complementary feeding period in seven countries in Southeast Asia: A Comprehensive Nutrient Gap Assessment

The complementary feeding period is a critical stage of child development when micronutrient needs are high and challenging to meet. Understanding if specific micronutrient gaps exist during this period is critical for effective programming. A Comprehensive Nutrient Gap Assessment (CONGA) was conducted in seven countries in Southeast Asia to estimate gaps in micronutrients commonly lacking in the diets of children aged 6-23 months and to establish the certainty of available evidence for each identified gap. Sixty-eight evidence sources were identified during this analysis, and 310 micronutrient-specific data points were identified across all seven countries. Data points varied in recency, representativeness and evidence type. The CONGA methodology enabled the estimation of a gap burden rating for each micronutrient in each country, as well as a rating of their evidence certainty. Micronutrient gaps were identified in vitamin D, zinc and iron and a potential gap was identified in calcium during the complementary feeding period in the region. Evidence relevant to intake and deficiency of folate, vitamin B12 , thiamine, niacin, vitamin C and vitamin B6 was limited across the region. Proven strategies to address these gaps include increasing the availability and consumption of nutrient-dense foods, micronutrient supplementation, large-scale fortification of staple foods and condiments and point-of-use fortification through multiple micronutrient powders and fortified speciality foods. More recent data on micronutrient availability, intake and deficiency is urgently needed in Southeast Asia.

Benchmarking the nutrient composition and labelling practices of dry or instant cereals for older infants and young children across seven Southeast Asian countries

In Southeast Asia, the increasing availability of commercially produced complementary foods (CPCF), including dry or instant cereals (CPCF cereals), has been noted, however, concerns exist around their nutrient profile and labelling practices. This 2021 study assessed the nutrient composition, labelling practices, and micronutrient content of CPCF cereals sold in the capital cities of seven Southeast Asian countries: Phnom Penh (Cambodia), Jakarta (Indonesia), Manila (Philippines), Bangkok (Thailand), Vientiane (Lao PDR), Hanoi (Vietnam), and Kuala Lumpur (Malaysia). The study adapted a nutrient profiling model from the WHO Regional Office for Europe to determine the proportion of products suitable for promotion for older infants and young children. Micronutrient content of fortified CPCF cereals was assessed against fortification levels specified in the Codex Alimentarius guideline for formulated complementary foods. Of the 484 products assessed, 184 (38.0%) met all nutrient composition requirements. Around one-third of CPCF cereals contained added sugars and/or sweeteners (37.2%) and high levels of sodium (28.9%). None of the CPCF cereals met all labelling requirements, primarily due to the presence of inappropriate claims on the labels. Most fortified CPCF cereals contained adequate amounts of critical micronutrients, such as calcium, iron, zinc, vitamin A, and vitamin D. However, rates of fortification varied across the seven countries, and almost a third (30.8%) of CPCF cereals were not fortified with any micronutrients. To support the appropriate promotion of CPCF in the region, Southeast Asian countries need to strengthen and enforce national binding legal measures, including national standards for the composition, labelling, and fortification of CPCF cereals.

High-pressure processing of beef increased the in vitro protein digestibility in an infant digestion model

Beef is an ideal protein source for use as a complementary food in infants. Considering the limited protein-digesting capacity of infants, it is required to enhance protein digestibility while minimizing the deterioration of beef quality. Thus, this study aimed to determine the effects of high-pressure processing (HPP) on the physicochemical properties and in vitro digestibility of beef proteins in an infant digestion model. HPP at 200 and 300 MPa decreased the tryptophan fluorescence intensity of the myosin and actin fractions relative to that at 0.1 MPa (P < 0.05). Compared to treatment at 0.1 and 100 MPa, HPP at 300 MPa decreased α-helix and β-turn contents in the myosin and actin fractions (P < 0.05), whilst increasing the β-sheet content (P < 0.05). Beef actomyosin content decreased (P < 0.05) during HPP at 200 and 300 MPa (c.f., 0.1 and 100 MPa). After in vitro digestion of beef, HPP at 200 and 300 MPa increased the α-amino group content and the abundance of proteins below 3 kDa in the digesta (P < 0.05). However, due to the considerable lipid oxidation at 300 MPa, HPP at 200 MPa is ideal for improving the protein digestibility of beef when incorporated into complementary foods for infants.

Creed‐Kanashiro H. Exploring the magnitude and drivers of the double burden of malnutrition at maternal and dyad levels in peri-urban Peru: A cross-sectional study of low-income mothers, infants and young children

Multiple forms of malnutrition coexist in Peru, especially in peri-urban areas and poor households. We investigated the magnitude of, and the contribution of, dietary and socio-demographic factors to the double burden of malnutrition (DBM) at maternal (i.e., maternal overweight/obesity with anaemia) and dyad (i.e., maternal overweight/obesity with child anaemia) levels. A cross-sectional survey was conducted among low-income mother-child (6-23 months) dyads (n = 244) from peri-urban communities in Peru. Dietary clusters and the minimum dietary diversity score (MDD) were generated for mothers and infants, respectively. A composite indicator using the maternal dietary clusters and the MDD was created to relate to dyad level DBM. Two dietary clusters were found: (i) the 'high variety (i.e., animal-source foods, fruit and vegetables), high sugary foods/beverages' (cluster 1) and (ii) the 'high potato, low fruit and vegetables, low red meat' (cluster 2). DBM prevalence among mothers and dyads was 19.9% and 36.3%, respectively. Logistic regression analyses revealed that the only socio-demographic factor positively associated with maternal DBM was maternal age (aOR/5 years: 1.35 [1.07, 1.71]). Mothers belonging to diet cluster 1 were less likely to experience the DBM (aOR = 0.52 [0.26, 1.03]), although CIs straddled the null. Socio-demographic factors positively associated with dyad level DBM included maternal age (aOR/5 years: 1.41 [1.15, 1.73]), and having ≥ two children under 5 years (aOR = 2.44 [1.23, 4.84]). Diet was not associated with dyad-level DBM. Double-duty actions that tackle the DBM are needed given that one-third of dyads and a fifth of mothers had concurrent overweight/obesity and anaemia.

Children's nutritional health and wellbeing in food insecure households in Europe: A qualitative meta-ethnography

Since the 2008 global financial crisis, there has been a rise in the number of people experiencing food insecurity. Particularly vulnerable are households with children. This systematic review and meta-ethnography of qualitative studies focuses on families' perceptions of food insecurity and how it affects children's nutritional health and wellbeing. Six electronic databases (Medline, Scopus, Web of Science, EMBASE, CINAHL and ASSIA), were searched for studies from European high-income countries between January 2008-July 2021, and supplemented by searches of grey literature databases, relevant websites, examination of reference lists and citation searches. We adhered to PRISMA and eMERGe guidelines to improve the completeness and clarity of meta-ethnographic reporting. Methodological quality of the studies were assessed using the Critical Appraisal Skills Programme qualitative checklist. We identified 11,596 records; we included 19 publications involving 813 participants in total. Data were synthesised according to Noblit & Hare's seven phases of meta-ethnography. We identified four key themes-food and eating practices, awareness, fragility, and networks of care-comprising five sub-themes. Our meta-ethnography provides a progressive 'storyline' of the children's experiences of food insecurity from both caregivers and children's perspectives. We found that children are aware of their family's limited resources and are often active in trying to help their families cope, and that food insecurity adversely impacts children's physical, psychological, and social experiences. Our analysis highlights gaps in knowledge about how food insecurity impacts children's nutritional health and wellbeing. It suggests that future research should prioritise minoritised ethnic communities, children living in temporary accommodation and caregivers of very young children.

Dietary Strategies for Complementary Feeding between 6 and 24 Months of Age: The Evidence

Suboptimal complementary feeding practices remain highly prevent. This review aims to comprehensively synthesize new emerging evidence on a set of topics related to the selection and consumption of complementary foods. We synthesized evidence related to five key topics focused on nutritional interventions that target the complementary feeding period, based on four systematic reviews that include updated evidence to February 2022. While there have been many studies examining interventions during the complementary feeding period, there is an overall lack of relevant information through which to draw conclusions on the ideal feeding schedule by food type. Similarly, few studies have examined the effects of animal milk versus infant formula for non-breastfed infants (6-11 months), though those that did found a greater risk of anemia among infants who were provided cow's milk. This review highlights a number of interventions that are successful at improving micronutrient status and anthropometry during the complementary feeding period, including fortified blended foods, locally and commercially produced supplementary foods, and small-quantity lipid-based nutrient supplements. Complementary feeding education for caregivers can also be used to improve nutrition outcomes among infants in both food secure and insecure populations.

Preschoolers BMI: Associations with Patterns of Caregivers' Feeding Practices Using Structural Equation Models

Background: Childhood obesity is a major health concern. Caregivers' feeding practices are modifiable targets of obesity prevention. The study tested two hypotheses: (1) autonomy-promoting feeding practices are associated with lower BMI; and (2) diet mediates the association. We also explored examined whether feeding practices and BMI z-score (BMIz) associations are moderated by child sex, caregiver race, education, family poverty level, and food insecurity. Methods: Cross-sectional study of 437 preschoolers (44.4% girls, 38.2% Black/Other, mean age 48.1 months) and caregivers (90.2% female) from 50 child care centers. Feeding Practices were measured by Comprehensive Feeding Practices Questionnaire, child-size perception by preschooler silhouettes, temperament by the Behavior Rating Inventory of Executive Function, child diet by Young Children Food and Drink Questionnaire, and BMIz by measured weight and height. Latent profile analysis delineated feeding practice patterns. Structure equation modeling assessed the patterns in relationship to BMIz. Mediation and multiple-group analyses were used to assess mechanisms of feeding practice patterns and BMIz association. Results: From the three feeding practice patterns, Controlling, Balancing, and Regulating, Regulating was associated with lower child BMIz (b = -0.09) compared to Controlling. Higher difficult temperament (b = 0.09), higher caregiver BMIz (b = 0.26), and caregiver desire for thinner (b = 0.23) were associated with BMIz (p < 0.05). Evaluations of moderators and mediators were not significant. Conclusions: Comprehensive feeding practices support family factors related to child BMIz. Longitudinal research is needed to examine temporal associations between feeding practices and BMIz, with attention to autonomy-supporting practices, promotion of young children's self-regulation, and caregivers' perceptions of child temperament and size. Trial Registration: NCT03111264.

Eating Frequency in European Children from 1 to 96 Months of Age: Results of the Childhood Obesity Project Study

We aimed to investigate the eating frequency (EF) in children over age, and examined the influence of country, sex, feeding mode and weight status on EF. We used the dietary data of the Childhood Obesity Project, which comprised European children from five countries. Dietary data of 3-days weighed and estimated records were available monthly from 1 to 9 and at 12-, 24-, 36-, 48-, 60-, 72- and 96-months old. Generalized additive mixed effects models were used to estimate EF trajectories with EF as outcome and applying age splines. Additionally, the models were further adjusted for country, feeding mode, sex or weight status. Data from 1244 children were analysed. EF was highest at 1 month with on average 7.3 ± 1.9 feeds per day, and fell to 5.1 ± 1.1 eating occasions at the age 96 months. Night feeding was similarly often than day feeding at 1 month but declined thereafter. Significant differences in EF were observed between countries (p < 0.05), with the highest EF in Poland, and between infant feeding modes, with a higher EF in breastfed than non-breastfed infants (p < 0.05). Sex and body weight were not associated with EF. Despite the importance of EF towards total energy intake, no association with weight status was found.

Unhealthy Food and Beverage Consumption in Children and Risk of Overweight and Obesity: A Systematic Review and Meta-Analysis

This WHO-commissioned review contributed to the update of complementary feeding recommendations, synthesizing evidence on effects of unhealthy food and beverage consumption in children on overweight and obesity. We searched PubMed (Medline), Cochrane CENTRAL, and Embase for articles, irrespective of language or geography. Inclusion criteria were: 1) randomized controlled trials (RCTs), non-RCTs, cohort studies, and pre/post studies with control; 2) participants aged ≤10.9 y at exposure; 3) studies reporting greater consumption of unhealthy foods/beverages compared with no or low consumption; 4) studies assessing anthropometric and/or body composition; and 5) publication date ≥1971. Unhealthy foods and beverages were defined using nutrient- and food-based approaches. Risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions version I) and RoB2 [Cochrane RoB (version 2)] tools for nonrandomized and randomized studies, respectively. Narrative synthesis was complemented by meta-analyses where appropriate. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Of 26,542 identified citations, 60 studies from 71 articles were included. Most studies were observational (59/60), and no included studies were from low-income countries. The evidence base was low quality, as assessed by ROBINS-I and RoB2 tools. Evidence synthesis was limited by the different interventions and comparators across studies. Evidence indicated that consumption of sugar-sweetened beverages (SSBs) and unhealthy foods in childhood may increase BMI/BMI z-score, percentage body fat, or odds of overweight/obesity (low certainty of evidence). Artificially sweetened beverages and 100% fruit juice consumption make little/no difference to BMI, percentage body fat, or overweight/obesity outcomes (low certainty of evidence). Meta-analyses of a subset of studies indicated a positive association between SSB intake and percentage body fat, but no association with change in BMI and BMI z-score. High-quality epidemiological studies that are designed to assess the effects of unhealthy food consumption during childhood on risk of overweight/obesity are needed to contribute to a more robust evidence base upon which to design policy recommendations. This protocol was registered at https://www.crd.york.ac.uk/PROSPERO as CRD42020218109.

Moving Complementary Feeding Forward: Report on a Workshop of the Federation of International Societies for Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) and the World Health Organization Regional Office for Europe

The WHO Regional Office for Europe and the Federation of International Societies for Pediatric Gastroenterology, Hepatology, and Nutrition held a joint workshop, "Moving Complementary Feeding Forward" at the sixth World Congress Pediatric Gastroenterology, Hepatology, and Nutrition in 2021. Here we summarize workshop presentations and discussions. The workshop covered health implications of complementary feeding (CF) including allergies, challenges to meet dietary needs during the CF period, quality of commercial complementary foods (CFD) and respective marketing practices, national CF guidelines in Europe, a nutrient profiling system for CFD, and global policy perspectives on the standards and regulation of marketing for CFD. Adequate CF practices are of critical importance for short and long-term child health, prevention of nutrient deficiencies, normal growth and development, and reducing the risk of allergies. The workshop identified the need to improve feeding practices, harmonize evidence-based information and develop guidance jointly with various stakeholders, improve the composition and marketing practices of commercial CFD and their transparent labeling based on nutrient profiling. Renewed efforts for collaboration between scientists, public health experts, pediatric associations, national governments, and the WHO are necessary for advancing progress.

Retail Cost and Energy Adjusted Cost Are Associated with Dietary Diversity and Nutrient Adequacy for Diets of 6–24 Months Children

Poor nutrition during the first two years of life has long term consequences, but resource-poor households often do not have the means to access nutrient-dense and diverse diets. Pooled data of 24-h dietary recalls (n = 3336) and 2019 retail food prices were analyzed to determine associations of retail cost and energy cost (per 100 kcal) with diet quality indicators for diets of 6–24-month-old South African children who were breastfed (BF-diet) and not breastfed (NBF-diet) during the 24-h recall period. Compared to the BF-diet, retail cost for the NBF-diet was three times higher for age 6–11 months, and double for age 12–17 months. Higher retail cost and energy cost were both associated with higher mean adequacy ratios and dietary diversity scores for BF and NBF diets, except energy cost for the NBF-diet for age 6–11 months. Overall, inclusion of flesh foods, vitamin A-rich fruits and vegetables, and other fruit and vegetables increased from the lowest to the highest retail cost tertile. The higher cost of more nutritious diets highlights the importance of the affordability of diets in interventions aimed at improving diet quality. Possible strategies include: identifying the most-affordable foods within each food group, focusing on foods that provide multiple key micronutrients, and the inclusion of locally available indigenous foods.

Dietary Energy Density from Infancy to 5 Years: Results from NHANES 2009-2018

BACKGROUND

Nutrient-dense foods, which are often low in energy density (ED), are recommended for a healthy diet in infants and children. How ED changes during the transition from a complementary diet in infancy to a conventional diet is unknown.

OBJECTIVES

We aimed to describe the ED, the amount of energy (e.g., kcal) per weight (e.g., g), of food or beverage in infants and preschool-age children. It was hypothesized that ED would be higher among older children.

METHODS

The ED of food (ED-Food Only) and of food and all beverages excluding human milk and infant formula (ED-Food and Beverages) of children's (6 mo-5 y) diets were examined overall and by age subgroups using data from the NHANES (2009-2018). Survey-adjusted linear regression followed by pairwise comparisons were used to compare ED across age subgroups. The percentages of calories consumed from low-, medium-, and high-ED foods across age subgroups were also examined.

RESULTS

Mean ED-Food Only was 1.21 kcal/g (95% CI: 1.13, 1.29 kcal/g) among 6- to 11-mo-olds and 1.62 kcal/g (95% CI: 1.54, 1.69 kcal/g) among 12- to 17-mo-olds (P < 0.05). ED-Food and Beverages was higher across consecutive age subgroups from 0.99 kcal/g (95% CI: 0.96, 1.02 kcal/g) in 12-17 mo through 3 y (1.22 kcal/g; 95% CI: 1.19, 1.26 kcal/g; P < 0.05). Mean percentage of calories consumed from low-ED food (≤1.0 kcal/g) became lower with age from 6- to 11-mo-olds (47.3%; 95% CI: 44.3%, 50.4%) through 18- to 23-mo-olds (16.2%; 95% CI: 14.5%, 17.9%; P < 0.05). A greater percentage of calories was consumed from high-ED food (≥3.0 kcal/g) among 18- to 23-mo-olds (39.0%; 95% CI: 37.1%, 40.9%) than among 12- to 17-mo-olds (34.0%; 95% CI: 32.0%, 35.9%; P < 0.05).

CONCLUSIONS

ED increased across age subgroups, driven by a decrease in the percentage of calories consumed from low-ED food and an increase in the percentage of calories consumed from high-ED food.

Child feeding practices in rural Ethiopia show increasing consumption of unhealthy foods

The quality of complementary feeding can have both short- and long-term health impacts by delaying or promoting child growth and establishing taste preferences and feeding behaviours. We aimed to assess the healthy and unhealthy feeding practices of infants and young children in rural Ethiopia. We conducted two rounds of surveys in December 2017/18 in Habru district, North Wello, rural Ethiopia among caregivers of infants and young children (N = 574). We characterised the consumption of infants and young children using non-quantitative 24 h recall and the World Health Organization infant and young child feeding indicators. Sociodemographic characteristics, anthropometry and haemoglobin concentrations were assessed. Breastfeeding was a norm as 82% and 67% were breastfed in the first and second rounds. Between the two rounds, dietary diversity increased from 5% to 17% (p < 0.05), but more pronounced increases were observed in the consumption of ultra-processed food (UPFs). Up to one-in-five (22%) of the children consumed UFPs. With an average of only three food groups consumed, the consumption of nutrient-dense foods like animal source foods, fruits and vegetables was very low particularly among younger children. UPFs are an additional risk factor that contributes to poor quality diets. Behavioural Change Communication interventions, including those in rural areas, should explicitly discourage the consumption of UPFs. Future studies should aim to quantify the amount of UPFs consumed and evaluate how this is associated with diet adequacy and nutritional outcomes.

Diet and food insecurity among mothers, infants, and young children in Peru before and during COVID‐19: A panel survey

The COVID‐19 pandemic may impact diet and nutrition through increased household food insecurity, lack of access to health services, and poorer quality diets. The primary aim of this study is to assess the impact of the pandemic on dietary outcomes of mothers and their infants and young children (IYC) in low‐income urban areas of Peru. We conducted a panel study, with one survey prepandemic (n = 244) and one survey 9 months after the onset of COVID‐19 (n = 254). We assessed breastfeeding and complementary feeding indicators and maternal dietary diversity in both surveys. During COVID‐19, we assessed household food insecurity experience and economic impacts of the pandemic on livelihoods; receipt of financial or food assistance, and uptake of health services. Almost all respondents (98.0%) reported adverse economic impacts due to the pandemic and 46.9% of households were at risk of moderate or severe household food insecurity. The proportion of households receiving government food assistance nearly doubled between the two surveys (36.5%–59.5%). Dietary indicators, however, did not worsen in mothers or IYC. Positive changes included an increase in exclusive breastfeeding <6 months (24.2%–39.0%, p < 0.008) and a decrease in sweet food consumption by IYC (33.1%–18.1%, p = 0.001) and mothers (34.0%–14.6%, p < 0.001). The prevalence of sugar‐sweetened beverage consumption remained high in both mothers (97%) and IYC (78%). In sum, we found dietary indicators had not significantly worsened 9 months into the COVID‐19 pandemic. However, several indicators remain suboptimal and should be targeted in future interventions.

Almost all respondents (98.0%) reported negative economic impacts on their households from the pandemic.

During the pandemic, almost half of households (46.9%) were at risk of moderate or severe household food insecurity.

During the pandemic, 66.9% of households received cash transfers, and 59.4% received food assistance from the government.

Nine months into the pandemic, positive changes included an increased prevalence of exclusive breastfeeding <6 months, a decreased proportion of mothers and infants and young children (IYC) consuming sweet foods, and stable dietary indicators for IYC and women.

Consumption of sugar‐sweetened beverages and unhealthy foods remained high across the two time periods for mothers and IYC and should be targeted in future interventions.

Predictive Utility of Composite Child Feeding Indices (CCFIs) for Child Nutritional Status: Comparative Analyses for the Most Suitable Formula for Constructing an Optimum CCFI

Composite child feeding indices (CCFIs) developed from various relevant measures of dietary intake by infants and young children have several potential applications in nutritional epidemiological studies for the development and deployment of precise public health nutrition interventions against child undernutrition. The predictive utility of some CCFIs (computed from varying formulation components) for child nutritional status (stunting, wasting, and underweight) were compared. The purpose of the study was to identify the most suitable among them for possible standardization, validation, and adoption by nutritional health researchers. Using cluster sampling, data from 581 mother–child pairs were collected. Multivariable regression analyses were applied to the data obtained through a community-based analytical cross-sectional survey design. Three of the CCFIs were found to be significantly associated with only wasting (WHZ) from the linear regression models after adjusting for potential confounders and/or correlates. None of the CCFIs (whether in the continuous nor categorical form) was consistently predictive of all three measures of child nutritional status, after controlling for potential confounders and/or correlates, irrespective of the choice of regression method. CCFI 5 was constructed using a dimension reduction technique—namely principal component analysis (PCA)—as the most optimal summary index in terms of predictiveness for child wasting status, validity, and reliability (Cronbach’s α = 0.80) that captured relevant dimensions of optimal child food intake. The dimension reduction approach that was used in constructing CCFI 5 is recommended for standardization, validation, and possible adoption for wider applicability across heterogeneous population settings as an optimum CCFI usable for nutritional epidemiological studies among children under five years.

Complementary feeding and food-group level inequality among Ethiopian children 6-23 months of age (2011-2019)

Ensuring diet quality in the first 2 years of life is critical to preventing malnutrition and instilling healthy food preferences. Children's diet quality has changed little over time and inequalities by socioeconomic status, rural-urban residence, but also by food group may exist. Using data from the 2011, 2016 and 2019 demographic and health surveys (DHS), we estimated the prevalence and inequalities in the minimum diet diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD). We further assessed food group-level inequities. In 2019, only 13.5% of children 6-23 months of age met the MDD, 55% met the MMF and only 11% met the MAD indicator. Absolute and relative measures of inequality were calculated. Modest increases in MDD, MMF and MAD were observed over the past decade (2011-2019). These modest improvements were concentrated in limited geographical areas, among children in wealthier households, and urban residents. Unhealthy practices such as bottle-feeding and zero fruit and vegetables have been increasing; whereas, inequities in the consumption of nutrient-dense foods have widened. Nevertheless, children from the wealthiest quintile also failed to meet the MDD. Multisectoral efforts that span from diversifying the food supply, regulating the marketing of unhealthy foods, and promoting minimal processing of perishables (i.e., to extend shelf-life) are needed. Context-adapted behavioural change communication along with nutrition-sensitive social protection schemes are also needed to equitably improve the diet quality of children in Ethiopia.

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.

Observation of Traditional Caregiver-Infant Feeding Behaviours and Porridge and Energy Intakes during One Meal to Define Key Messages for Promoting Responsive Feeding in the Amparafaravola District, Rural Madagascar

Undernutrition is highly prevalent in young children in Madagascar and insufficient intake per meal could be one of the main causes. A cross-sectional survey of infant feeding practices including video-recorded meal observations was carried out with 101 caregiver-infant pairs in the Amparafaravola district, Northeast Madagascar. The objective was to quantify the porridge/energy intake of 9-11-month-old children and assess its association with the caregiver-infant feeding behaviours. Then, key messages for promoting responsive feeding (RF) were developed and tested through focus group discussions. The mean porridge intake was 12.8 ± 7.5 g/kg body weight (BW)/meal, corresponding to hardly one-third of the 300 kcal recommended from complementary foods for 9-11-month-old children. Analysis of meal videos suggested that mothers practiced the five positive feeding behaviours (self-feeding, responsive, active, social, and distraction), and rarely the negative ones. Only 6.9% of mothers used positive RF "very frequently", although it was associated with higher intakes (p < 0.05), with mean intake reaching 21 g/kg BW. In focus groups, caregivers approved the six RF messages and related counselling cards. They suggested some modifications to improve their understanding, and counselling cards were revised accordingly. The long-term impact of RF-promoting card use on the meal intakes and the nutritional status of young children must now be assessed.

Understanding delays in the introduction of complementary foods in rural Ethiopia

Age-appropriate breastfeeding and introduction to complementary foods can shape child feeding practices, ensure adequate energy and nutrient intake and prevent linear growth faltering. This study aimed to assess mothers' and health workers' knowledge of timely introduction to complementary foods and evaluate the relationship between delays in complementary feeding and subsequent linear growth. We conducted two rounds of surveys (March/August 2017) among 249 health workers (n = 249) and caregivers (n = 2635) of children 6-23 months of age. We collected information about socio-demographic characteristics, knowledge and practice related to timely introduction to complementary foods. The study was conducted in households from the Productive Safety Net Programme (PSNP) districts, in four highland regions of Ethiopia. Delays in the introduction to complementary feeding were widespread with 53% of children 6-8 months of age not consuming solid, semisolid or soft foods in the past 24 h. After controlling for child, caregiver and household characteristics, children not introduced to complementary foods by 6-8 months had a 0.48 SD lower length-for-age z-score at 12-15 months. Caregivers' knowledge was strongly and inversely correlated with untimely introduction of complementary foods in logistic regressions (OR = 0.55, p < 0.01). In turn, local health extension worker's knowledge was strongly correlated with caregiver's knowledge. Consequently, frequent and timely visits by health extension workers emphasising not only on what to feed but also when and how to feed a child are needed. Innovative ways of increasing reach, intensity and frequency of nutrition messaging by using the PSNP interactions as an additional point of contact would need to be explored further.