Efficacy and safety of new complementary feeding guidelines with an emphasis on red meat consumption: a randomized trial in Bogota, Colombia

Effects of New Complementary Feeding Guidelines on Eating Behaviour, Food Consumption and Growth in Colombian Children: 6-Year Follow-Up of a Randomised Controlled Trial

Complementary feeding (CF) may influence later eating behaviour and growth. Our previous Randomised Control Trial (RCT) reported that new CF guidelines (NCFGs) implemented in 6-12-month-old infants in Bogota, Colombia, had positive short-term effects on red meat, vegetable and fruit consumption. Here, we assessed the effects of the NCFGs on food consumption, eating behaviour and growth at 6 years of age. Weight and height were measured using 50 children (58.8%) from the cohort. Feeding behaviour was measured using the Child Eating Behaviour Questionnaire (CEBQ) and maternal and child food consumption was measured using a semi-quantitative food frequency questionnaire. The control group (CG) had a significantly higher weekly consumption of chocolate milk drinks (p = 0.05). The mean food responsiveness (FR) score was significantly higher in the CG (p < 0.001). Although HAZ (height for age Z-score) at 6 years of age was significantly higher in the CG (p < 0.02), there was no significant difference between groups in the change in HAZ from 6 months and 12 months to 6 years of age. BMIZ (body mass index Z-score) and % overweight (CG 18.5% versus NCFG 13%) or obese (3.7% versus 0%) were not significantly different between groups. BMIZ was positively predicted by FR (β 0.293; p = 0.014) and negatively predicted by weekly red meat consumption episodes per week at 12 months (β -0.169; p = 0.020). Although there was no direct effect of an intervention on BMIZ at 6 years of age, the results were consistent with an indirect effect via intervention effects on meat consumption at an age of 12 months and FR at 6 years of age. However, further longitudinal studies with a larger sample size are needed.

Lifestyle and dietary factors, iron status and one-carbon metabolism polymorphisms in a sample of Italian women and men attending a Transfusion Medicine Unit: a cross-sectional study

Iron (Fe) status among healthy male and female blood donors, aged 18–65 years, is estimated. General characteristics and lifestyle factors, dietary habits and major one-carbon metabolism-related polymorphisms were also investigated. An explorative cross-sectional study design was used to examine a sample of blood donors attending the Transfusion Medicine Unit of the Verona University Hospital, Italy. From April 2016 to May 2018, 499 subjects were enrolled (255 men, 244 women, 155 of whom of childbearing age). Major clinical characteristics including lifestyle, dietary habits and Fe status were analysed. The MTHFR 677C > T, cSHMT 1420C > T, DHFR 19bp ins/del and RFC1 80G > A polymorphisms were also assayed. Mean plasma concentrations of Fe and ferritin were 16·6 µmol/l (95 % CI 16·0, 17·2) and 33·8 µg/l (95 % CI 31·5, 36·2), respectively. Adequate plasma Fe concentrations (> 10·74 µmol/l) were detected in 84·3 % and adequate ferritin concentrations (20–200 µg/l) was found in 72·5 % of the whole cohort. Among the folate-related polymorphisms analysed, carriers of the DHFR 19bp del/del mutant allele showed lower ferritin concentration when compared with DHFR 19bp ins/del genotypes. In a sample of Italian healthy blood donors, adequate plasma concentrations of Fe and ferritin were reached in a large proportion of subjects. The relationship of Fe status with lifestyle factors and folate-related polymorphisms requires more investigation to clarify further gene–nutrient interactions between folate and Fe metabolism.

Quantity and Source of Protein during Complementary Feeding and Infant Growth: Evidence from a Population Facing Double Burden of Malnutrition

BACKGROUND

While high protein intake during infancy may increase obesity risk, low qualities and quantities of protein contribute to undernutrition. This study aimed to investigate the impact of the amount and source of protein on infant growth during complementary feeding (CF) in a country where under- and overnutrition co-exist as the so-called the double burden of malnutrition.

METHODS

A multicenter, prospective cohort was conducted. Healthy term infants were enrolled with dietary and anthropometric assessments at 6, 9 and 12 months (M). Blood samples were collected at 12M for IGF-1, IGFBP-3 and insulin analyses.

RESULTS

A total of 145 infants were enrolled (49.7% female). Animal source foods (ASFs) were the main protein source and showed a positive, dose-response relationship with weight-for-age, weight-for-length and BMI z-scores after adjusting for potential confounders. However, dairy protein had a greater impact on those parameters than non-dairy ASFs, while plant-based protein had no effect. These findings were supported by higher levels of IGF-1, IGFBP-3 and insulin following a higher intake of dairy protein. None of the protein sources were associated with linear growth.

CONCLUSIONS

This study showed the distinctive impact of different protein sources during CF on infant growth. A high intake of dairy protein, mainly from infant formula, had a greater impact on weight gain and growth-related hormones.

Comparison of 24-Hour Recall and 3-Day Food Records during the Complementary Feeding Period in Thai Infants and Evaluation of Plasma Amino Acids as Markers of Protein Intake

Background: An accurate and reliable measurement of nutrient intake is the first and foremost step in order to optimise infant nutrition and evaluate its impact on health outcomes. However, research on the validity of dietary assessment tools used during the weaning period is limited, especially in lower-middle income countries. The primary aim of this study was to evaluate relative validity of a 24-h recall method (24-HR) using a 3-day food record (3-DFR). A secondary aim was to investigate association between protein intake from 3-DFR and plasma amino acids as a potential protein biomarker. Methods A multicentre, prospective cohort study was conducted in Chiang Mai, Thailand from June 2018 to May 2019. Food consumption data were collected in healthy infants using 24-HR and 3-DFR at 9 and 12 months of age. Blood samples were obtained at 12 months (M). Plasma amino acids were analysed using high performance liquid chromatography. Results Of 145 infants, 49% were female. At group level, paired t-tests/Wilcoxon signed rank tests did not show significant differences between average nutrient intakes from the 2 dietary assessment methods, except for vitamin A and vitamin C. Weighted kappa (Kw) was acceptable for all nutrients, except for vitamin A intake at 9 M (Kw = 0.15). The Bland–Altman analyses were unbiased for most nutrients with variable limits of agreement. At individual level, correlation coefficients (r) ranged from acceptable to excellent (r = 0.37–0.87) while cross-classifications showed acceptable outcomes, except for vitamin A. Multivariate analyses showed significant associations between protein intake at 12 M from the 3-DFR and plasma concentrations of branched-chain amino acids (BCAA) and essential amino acids (EAA), even after adjusting for gender, milk feeding type and energy intake. Conclusions For infants aged 9–12 M, a 24-HR can be used as a more practical alternative to a 3-DFR for most nutrients although caution is required for some micronutrients, especially vitamin A. A repeated interview might further improve the accuracy. Furthermore, protein intake, particularly animal-based protein, significantly predicted plasma BCAA and EAA concentrations regardless of gender, type of milk feeding and energy consumption.

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.

Translation of EU Food Law and Nutrient Reference Values Into Practice: the German Dietary Scheme for the First Year of Life

OBJECTIVES

European dietary regulations affect national dietary guidelines for child nutrition. The update of the German Dietary Scheme for the first year of life is used to examine the translation of European nutrient references into food-based guidelines while maintaining traditional habits.

METHODS

Within the Dietary Scheme, intake of energy and nutrients was calculated in the complementary feeding period for each of the 3 daily recommended complementary meals (a vegetable-potato-meat meal, a milk-cereal meal, a cereal-fruit meal) in addition to the daily liquid-milk servings (breast milk or follow-on formula). Pureed-home-made complementary meals were assumed. The adequacy of nutrient intake was evaluated by comparison with the European Food Safety Authority (EFSA) Dietary Reference Values. Macronutrient content of meals was compared to the European complementary food directive.

RESULTS

Daily intake of most nutrients following the scheme was well in line with EFSA values, whereas the commonly 'critical' nutrients iron and iodine remained far below EFSA values. Substituting breast milk or whole cow's milk with follow-on formula had only a small impact on nutrient supply. Although the different nutrient profiles of meals were not fully in line with European regulations, they add up to an overall balanced daily diet.

CONCLUSIONS

Taken together, European dietary reference values for energy and nutrients can mostly be met by the modular system of the Dietary Scheme as a total diet concept for infant nutrition in Germany. The different proposed meals generally agree with EU regulations for complementary food.

The Impact of Dietary Protein in Complementary Foods on Infant Growth and Body Composition in a Population Facing the Double Burden of Malnutrition: Protocol for a Multicenter, Prospective Cohort Study

BACKGROUND

Protein is an essential macronutrient with an important role during complementary feeding. Low protein intake contributes to undernutrition while high intake, especially from animal sources, may increase obesity risk. However, the influences of different protein sources (dairy, meat, and plants) on growth, and underlying mechanisms for these effects, are poorly understood. Animal-sourced foods provide both high-quality protein and iron and are recommended to improve iron status. However, it is unclear whether current dietary recommendations are adequate to support healthy growth and optimize iron status. These issues are of particular concern in countries facing the double burden of malnutrition, the coexistence of all forms of malnutrition. More evidence is needed to develop appropriate recommendations for these countries.

OBJECTIVE

This study will investigate associations between protein intake during complementary feeding and growth, body composition, and iron status of infants in Thailand, a country facing the double burden of malnutrition. The study will also explore how different protein sources influence growth via the growth hormone-insulin-like growth factor I (IGF-1) axis and plasma amino acids.

METHODS

A multicenter cohort study will be conducted in Chiang Mai, Thailand, in 150 healthy term infants aged 4-6 months with birth weight ≥2500 g. Demographic data, dietary intake, and anthropometry will be collected at 6, 9, and 12 months. Dietary intake will be assessed using 24-hour dietary recalls, 3-day food records, and food frequency questionnaires. Blood samples for iron status, growth hormone, IGF-1, insulin-like growth factor-binding protein III (IGFBP-3), and plasma amino acids and urine samples for body composition analysis using stable isotope dilution will be obtained at 12 months.

RESULTS

The recruitment of study participants and data collection was undertaken from June 2018 to May 2019. Data and laboratory analyses are ongoing and are expected to be completed by December 2020. A total of 150 participants were enrolled, and 146 completed the study. We hypothesized that protein intake from animal-sourced foods in recommended quantities could support normal weight and length gain and lower the risk of undernutrition associated with similar amounts of plant-based protein. However, higher protein intake, especially from milk protein, may be linked to increased body fat via plasma amino acids and the growth hormone-IGF axis.

CONCLUSIONS

The results of this study will provide data on current complementary feeding practices, focusing on protein and iron intake in Thai infants. This information, combined with data on associations with infant growth and iron status, will help inform complementary feeding recommendations for this population and may be found relevant to other settings experiencing the double burden of malnutrition.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18112.

Education of family members to support weaning to solids and nutrition in later infancy in term-born infants

BACKGROUND

Education of family members about infant weaning practices could affect nutrition, growth, and development of children in different settings across the world.

OBJECTIVES

To compare effects of family nutrition educational interventions for infant weaning with conventional management on growth and neurodevelopment in childhood.

SEARCH METHODS

We used the standard strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5), MEDLINE via PubMed (1966 to 26 June 2018), Embase (1980 to 26 June 2018), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 26 June 2018). We searched clinical trials databases, conference proceedings, and references of retrieved articles. We ran an updated search from 1 January 2018 to 12 December 2019 in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost.

SELECTION CRITERIA

We included randomised controlled trials that examined effects of nutrition education for weaning practices delivered to families of infants born at term compared to conventional management (standard care in the population) up to one year of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified eligible trial reports from the literature search and performed data extraction and quality assessments for each included trial. We synthesised effect estimates using risk ratios (RRs), risk differences (RDs), and mean differences (MDs), with 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 21 trials, recruiting 14,241 infants. Five of the trials were conducted in high-income countries and the remaining 16 were conducted in middle- and low-income countries. Meta-analysis showed that nutrition education targeted at improving weaning-related feeding practices probably increases both weight-for-age z scores (WAZ) (MD 0.15 standard deviations, 95% CI 0.07 to 0.22; 6 studies; 2551 infants; I² = 32%; moderate-certainty evidence) and height-for-age z scores (0.12 standard deviations, 95% CI 0.05 to 0.19; 7 studies; 3620 infants; I² = 49%; moderate-certainty evidence) by 12 months of age. Meta-analysis of outcomes at 18 months of age was heterogeneous and inconsistent in the magnitude of effects of nutrition education on WAZ and weight-for-height z score across studies. One trial that assessed effects of nutrition education on growth at six years reported an uncertain effect on change in height and body mass index z score. Two studies investigated effects of nutrition education on neurodevelopment at 12 to 24 months of age with conflicting results. No trials assessed effects of nutrition education on long-term neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

Nutrition education for families of infants may reduce the risk of undernutrition in term-born infants (evidence of low to moderate certainty due to limitations in study design and substantial heterogeneity of included studies). Modest effects on growth during infancy may not be of clinical significance. However, it is unclear whether these small improvements in growth parameters in the first two years of life affect long-term childhood growth and development. Further studies are needed to resolve this question.

Impact of Infant and Young Child Feeding (IYCF) Nutrition Interventions on Breastfeeding Practices, Growth and Mortality in Low- and Middle-Income Countries: Systematic Review

Undernutrition is associated with 45% of total infant deaths, totalling 2.7 million globally per year. The vast majority of the burden is felt in low- and middle-income countries (LMICs). This review aims to assess the effectiveness of infant and young child feeding (IYCF) interventions. We searched multiple databases including Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE. Title/abstract screening and full-text screening and data extraction filtered 77 studies for inclusion. Breastfeeding education interventions (n = 38) showed 20% increase in rates of early initiation of breastfeeding, 102% increase in exclusive breastfeeding (EBF) at 3 months and 53% increase in EBF at 6 months and 24% decreases in diarrheal diseases. Complementary feeding education intervention (n=12) showed a 0.41 standard deviation (SD) increase in WAZ, and 0.25 SD in HAZ in food secure setting. Complementary food provision with or without education (n=17) showed a 0.14 SD increase in HAZ and 36% decrease in stunting. Supplementary food interventions (n=12) showed a significant 0.15 SD increase in WHZ. Subgroup analyses showed healthcare professional led interventions were largely more effective, especially on breastfeeding outcomes. We believe this is a comprehensive review of the existing literature on IYCF studies in LMICs. Though breastfeeding education is well supported in its effectiveness on breastfeeding practices, limited evidence exists for growth outcomes. Supplementation interventions seem to have better effects at improving growth. However, more research is required to reach more substantial conclusions.

Complementary feeding and micronutrient status: a systematic review

BACKGROUND

Proper nutrition during early life is critical for growth and development.

OBJECTIVES

The aim was to describe systematic reviews conducted by the Nutrition Evidence Systematic Review team for the USDA and the Department of Health and Human Services Pregnancy and Birth to 24 Months Project to answer the following: What is the relation between 1) timing of introduction of complementary foods and beverages (CFBs) or 2) types and/or amounts of CFBs consumed and micronutrient status (iron, zinc, vitamin D, vitamin B-12, folate, and fatty acid status)?

METHODS

A literature search identified articles from developed countries published from January 1980 to July 2016 that met the inclusion criteria. Data were extracted and risk of bias assessed. Evidence was qualitatively synthesized to develop a conclusion statement, and the strength of the evidence was graded.

RESULTS

Nine articles addressed the timing of CFB introduction and 31 addressed types or amounts or both of CFBs. Moderate evidence suggests that introducing CFBs at age 4 mo instead of 6 mo offers no advantages or disadvantages in iron status among healthy full-term infants. Evidence is insufficient on the timing of CFB introduction and other micronutrient status outcomes. Strong evidence suggests that CFBs containing iron (e.g., meat, fortified cereal) help maintain adequate iron status or prevent deficiency in the first year among infants at risk of insufficient iron stores or low intake. Benefits for infants with sufficient iron stores (e.g., infant formula consumers) are less clear. Moderate evidence suggests that CFBs containing zinc (e.g., meat, fortified cereal) support zinc status in the first year and CFB fatty acid composition influences fatty acid status. Evidence is insufficient with regard to types and amounts of CFBs and vitamin D, vitamin B-12, and folate status, or the relation between lower-iron-containing CFBs and micronutrient status.

CONCLUSIONS

Several conclusions on CFBs and micronutrient status were drawn from these systematic reviews, but more research that addresses specific gaps and limitations is needed.

Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: a systematic review

BACKGROUND

Systematic reviews (SRs) were conducted by the Nutrition Evidence Systematic Review (NESR) team for the USDA's and the Department of Health and Human Services' Pregnancy and Birth to 24 Months Project.

OBJECTIVES

The aim was to describe the SRs examining the relationship between types and amounts of complementary foods and beverages (CFBs) and growth, size, and body-composition outcomes.

METHODS

The NESR team collaborated with subject matter experts to conduct this SR. The literature was searched and screened using predetermined criteria. For each included study, data were extracted and risk of bias was assessed. The evidence was qualitatively synthesized to develop a conclusion statement, and the strength of evidence was graded.

RESULTS

This SR includes 49 articles that examined type, amount, or both of CFBs consumed and growth, size, and body-composition outcomes. Moderate evidence suggests that consuming either different amounts of meat, meat instead of iron-fortified cereal, or types of CFBs with different fats or fatty acids does not favorably or unfavorably influence growth, size, or body composition. In relation to overweight/obesity, insufficient evidence is available with regard to the intake of meat or CFBs with different fats or fatty acids. Limited evidence suggests that type and amount of fortified infant cereal does not favorably or unfavorably influence growth, size, body composition, or overweight/obesity. Limited evidence suggests that sugar-sweetened beverage consumption during the complementary feeding period is associated with increased obesity risk in childhood but is not associated with other measures of growth, size, or body composition. Limited evidence showed a positive association between juice intake and infant weight-for-length and child body mass index z scores. Insufficient evidence is available on other CFBs or dietary patterns in relation to outcomes.

CONCLUSIONS

Although several conclusions were drawn, additional research is needed that includes randomized controlled trials, examines a wider range of CFBs, considers issues of reverse causality, and adjusts for potential confounders to address gaps and limitations in the evidence.

Impact of a modified version of baby-led weaning on iron intake and status: a randomised controlled trial

OBJECTIVE

To determine the iron intake and status of infants following a version of baby-led weaning (BLW) modified to prevent iron deficiency (Baby-Led Introduction to SolidS; BLISS) compared with those of infants following traditional spoon-feeding.

DESIGN, PARTICIPANTS AND INTERVENTION

This randomised controlled trial included 206 participants assigned to control (n=101) or BLISS (n=105) groups. Both groups received standard midwifery and 'Well Child' care. BLISS participants received eight additional visits (from before birth to 9 months) providing education and support on the BLISS approach to complementary feeding (ie, BLW modified to increase iron intake). The primary outcome of the BLISS study (growth) has been previously reported. This paper reports the key prespecified secondary outcomes, iron intake and iron status.

OUTCOME MEASURES

Intake of iron and key absorption modifiers were assessed using weighed 3-day diet records at 7 and 12 months. A venipuncture blood sample was collected at 12 months to determine plasma ferritin, haemoglobin, soluble transferrin receptor, C-reactive protein and α1-acid glycoprotein concentrations; and body iron was calculated.

RESULTS

Differences in median dietary iron intakes between the control and BLISS groups were not significant at 7 (difference 0.6 mg/day; 95% CI -1.0 to 2.3) or 12 (-0.1 mg/day; -1.6 to 1.4) months of age. Similarly, there were no significant differences in plasma ferritin concentration (difference -2.6 µg/L; 95% CI -10.9 to 5.8), body iron (0.04 mg/kg; -1.1 to 1.2) or the prevalence of depleted iron stores, early functional iron deficiency or iron deficiency anaemia (all p≥0.65) at 12 months of age.

CONCLUSIONS

A baby-led approach to complementary feeding does not appear to increase the risk of iron deficiency in infants when their parents are given advice to offer 'high-iron' foods with each meal.

TRIAL REGISTRATION NUMBER

ACTRN12612001133820; Pre-results.

Educational interventions for improving primary caregiver complementary feeding practices for children aged 24 months and under

BACKGROUND

Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants.

OBJECTIVES

To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants.

SEARCH METHODS

In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status.

SELECTION CRITERIA

Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically-developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta-analysis using a random-effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We included 23 studies (from 35 reports) with a total of 11,170 caregiver-infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community-based studies while four were facility-based studies. In addition, 13 of the included studies were cluster-randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding.Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate-quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate-quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low-quality evidence). There was limited (low to very low-quality) evidence of an effect for all growth outcomes.Quality of evidenceThere is moderate to very low-quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes.

AUTHORS' CONCLUSIONS

Overall, we found evidence that education improves complementary feeding practices.

Complementary feeding patterns among ethnic groups in rural western China

OBJECTIVE

This study investigated complementary feeding practices among four ethnic groups (Han, Uygur, Tibetan, and Zhuang) based on a cross-sectional survey in rural western China.

METHODS

In 2005, a stratified multistage cluster random sampling method was used to recruit 9712 children (7411 Han, 1032 Uygur, 678 Tibetan, and 591 Zhuang) between 6 and 35 months of age and their mothers from 45 counties in 10 provinces (autonomous regions, municipalities) in western China.

RESULTS

The rates of early introduction (before 6 months) of complementary foods in four ethnic groups (Han, Uygur, Tibetan, and Zhuang) were 71.30%, 95.95%, 82.40%, and 72.30%, respectively. The Infant and Child Feeding Index (ICFI) for Uygur and Tibetan children was lower than that for Han children at all age groups. Uygur children were more likely to have unqualified ICFI compared with Han children in a multivariate logistic regression (odds ratio (OR)=5.138, 95% confidence interval (CI): 4.340-6.084). A higher level of maternal education, greater family wealth, and the availability of complementary feeding educational materials decreased the likelihood of an unqualified ICFI. The nutritional status of children (Han, Tibetan, and Zhuang) with qualified ICFI was better than that for children with unqualified ICFI.

CONCLUSIONS

Appropriate interventions are required to improve complementary feeding practices in rural western China.

Adaptation of New Colombian Food-based Complementary Feeding Recommendations Using Linear Programming

OBJECTIVE

The aim of the study was to use linear programming (LP) analyses to adapt New Complementary Feeding Guidelines (NCFg) designed for infants aged 6 to 12 months living in poor socioeconomic circumstances in Bogota to ensure dietary adequacy for young children aged 12 to 23 months.

DESIGN

A secondary data analysis was performed using dietary and anthropometric data collected from 12-month-old infants (n = 72) participating in a randomized controlled trial. LP analyses were performed to identify nutrients whose requirements were difficult to achieve using local foods as consumed; and to test and compare the NCFg and alternative food-based recommendations (FBRs) on the basis of dietary adequacy, for 11 micronutrients, at the population level.

RESULTS

Thiamine recommended nutrient intakes for these young children could not be achieved given local foods as consumed. NCFg focusing only on meat, fruits, vegetables, and breast milk ensured dietary adequacy at the population level for only 4 micronutrients, increasing to 8 of 11 modelled micronutrients when the FBRs promoted legumes, dairy, vitamin A-rich vegetables, and chicken giblets. None of the FBRs tested ensured population-level dietary adequacy for thiamine, niacin, and iron unless a fortified infant food was recommended.

CONCLUSIONS

The present study demonstrated the value of using LP to adapt NCFg for a different age group than the one for which they were designed. Our analyses suggest that to ensure dietary adequacy for 12- to 23-month olds these adaptations should include legumes, dairy products, vitamin A-rich vegetables, organ meat, and a fortified food.

Complementary Feeding Interventions Have a Small but Significant Impact on Linear and Ponderal Growth of Children in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Background: World Health Assembly member states have committed to ambitious global targets for reductions in stunting and wasting by 2025. Improving complementary diets of children aged 6-23 mo is a recommended approach for reducing stunting in children <5 y old. Less is known about the potential of these interventions to prevent wasting.Objective: The aim of this article was to review and synthesize the current literature for the impact of complementary feeding interventions on linear [length-for-age z score (LAZ)] and ponderal [weight-for-length z score (WLZ)] growth of children aged 6-23 mo, with the specific goal of updating intervention-outcome linkages in the Lives Saved Tool (LiST).Methods: We started our review with studies included in the previous LiST review and searched for articles published since January 2012. We identified longitudinal trials that compared children aged 6-23 mo who received 1 of 2 types of complementary feeding interventions (nutrition education or counseling alone or complementary food supplementation with or without nutrition education or counseling) with a no-intervention control. We assessed study quality and generated pooled estimates of LAZ and WLZ change, as well as length and weight gain, for each category of intervention.Results: Interventions that provided nutrition education or counseling had a small but significant impact on linear growth in food-secure populations [LAZ standardized mean difference (SMD): 0.11; 95% CI: 0.01, 0.22] but not on ponderal growth. Complementary food supplementation interventions with or without nutrition education also had a small, significant effect in food-insecure settings on both LAZ (SMD: 0.08; 95% CI: 0.04, 0.13) and WLZ (SMD: 0.05; 95% CI: 0.01, 0.08).Conclusions: Nutrition education and complementary feeding interventions both had a small but significant impact on linear growth, and complementary feeding interventions also had an impact on ponderal growth of children aged 6-23 mo in low- and middle-income countries. The updated LiST model will support nutrition program planning and evaluation efforts by allowing users to model changes in intervention coverage on both stunting and wasting.

Trends in Iron, Zinc, and Vitamin A Status Biomarkers Among Colombian Children: Results From 2 Nationally Representative Surveys

BACKGROUND

Micronutrient deficiencies are still highly prevalent in countries undergoing the nutrition transition, but nationally representative data documenting their burden in children are exceedingly rare.

OBJECTIVE

To examine the distribution and recent trends in micronutrient status biomarkers of Colombian children.

METHODS

We compared the distributions of plasma ferritin, serum zinc, and vitamin A in Colombian children between 2005 and 2010 using 2 cross-sectional, nationally representative surveys overall and by categories of sociodemographic variables. Analysis for ferritin included boys and nonpregnant girls aged 1 to 17 years. Analyses for zinc and vitamin A included children aged 1 to 4 years.

RESULTS

The mean 2010 to 2005 differences in ferritin, zinc, and vitamin A were 2.5 µg/L (95% confidence interval [CI]: 1.3 to 3.7), -34.9 µg/dL (95% CI: -39.6 to -30.2), and -11.5 µg/dL (95% CI: -12.3 to -10.7), respectively, after adjusting for sociodemographic characteristics. These differences varied significantly by region of residence. In 2010, region of residence was a significant correlate for all 3 micronutrients. Other important correlates included age and maternal education for ferritin and body mass index-for-age Z score, maternal education, wealth index, food insecurity, and urbanicity for vitamin A.

CONCLUSIONS

Plasma ferritin was slightly higher in 2010 than in 2005, whereas serum zinc and vitamin A were substantially lower in 2010. In the absence of obvious causal explanations, it is uncertain whether this decline represents a worsening of micronutrient status in Colombian children or an artifact due to systematic laboratory or data management errors incurred in the surveys.

Iron Status at Age 6 Months in Colombian Infants Exclusively Breast-fed for 4 to 5 Versus 6 Months

OBJECTIVES

The optimal age for introducing complementary feeding to breast-fed infants may differ depending on the setting. Prolonged exclusive breast-feeding (EBF) protects against infection but may increase the risk of iron deficiency (ID)/anaemia (IDA) in vulnerable infants. The aim of the present study was to compare haemoglobin (Hb), serum ferritin (SF), anaemia (Hb < 11 g/L), ID (SF < 12 μg/L) and IDA (Hb < 10.5 g/dL + Hct < 33% + ID) using observational analyses in 6-month old infants from Bogota, Colombia who were EBF for 4 to 5 versus 6 months or older, and examine predictors.

METHODS

Infant feeding was recorded, anthropometry performed, and blood obtained for Hb and SF at 6 months in healthy term infants (birth weight > 2500 g), all EBF for ≥4 months.

RESULTS

One hundred eight infants (54% boys) were recruited; 46% EBF for 4 to 5 months, 54% EBF at 6 months. Prevalence of anaemia, ID, and IDA was 20%, 10%, and 5%, with no significant difference between EBF4-5 and EBF6 groups. In multivariate models, anaemia/ID were predicted by greater weight gain from 0 to 6 months, and anaemia also by caesarean delivery; Hb was lower in infants with higher intake of cows' milk; SF was lower in boys and those with greater weight gain. EBF4-5 versus EBF6 was not a significant predictor of any outcome.

CONCLUSIONS

Anaemia and ID were common at 6 months but were not affected by EBF for 4 to 5 versus 6 months, suggesting 6 months EBF is safe in this population. Further research is, however, required to examine effects on later iron status. The findings highlight the need to emphasise avoidance of cow's milk before 12 months.

Early deterioration of iron status among a cohort of Bolivian infants

Iron deficiency (ID) and iron deficiency anemia (IDA) are major contributors to infant and maternal morbidity worldwide. There is limited longitudinal data on iron status in young infants and on methods to adjust iron biomarkers for inflammation. We aimed to quantify the prevalence of inflammation-adjusted ID, anemia, and IDA over the first year in a cohort of Bolivian infants and their mothers. Healthy mother-infant dyads were recruited from two peri-urban hospitals. Infants provided three blood draws (2, 6-8, and 12-18 months; N = 160); mothers provided two blood draws (1 and 6-8 months postpartum [plus third anemia measurement at 12-18 months]; N = 250). Blood was analyzed for hemoglobin, ferritin, soluble transferrin receptor, C-reactive protein (CRP), and alpha(1)-acid glycoprotein (AGP). Iron biomarkers were adjusted for inflammation using CRP and AGP; hemoglobin cutoffs were adjusted for altitude. Inflammation (elevated CRP or AGP) was 17% among toddlers 12-18 months of age. ID (inflammation-adjusted ferritin) increased with age (<1%, 56%, and 79% at each blood draw), as did anemia and IDA (anemia: 70%, 76%, and 81%; IDA: <1%, 46%, and 68%). Maternal ID declined from the first to second assessment (39% vs. 27%). Inflammation-adjusted ID prevalence was up to 15 percentage points higher than unadjusted estimates. The high prevalence of ID, anemia, and IDA in this cohort of Bolivian infants beginning at 6-8 months of age suggests that early interventions may be necessary in vulnerable populations.

Why is multiple micronutrient powder ineffective at reducing anaemia among 12-24 month olds in Colombia? Evidence from a randomised controlled trial

In Colombia's bottom socio-economic strata, 46.6% of children under two are anaemic. A prevalence of above 20% falls within the WHO guidelines for daily supplementation with multiple micronutrient powder (MNP). To evaluate the effect of daily MNP supplementation on anaemia amongst Colombian children aged 12-24 months we ran a cluster RCT (n=1440). In previous work, we found the intervention had no impact on haemoglobin or anaemia in this population. In this current paper, we investigate this null result and find it cannot be explained by an underpowered study design, inaccurate measurements, low adoption of and compliance with the intervention, or crowding out through dietary substitution. We conclude that our intervention was ineffective at reducing rates of childhood anaemia because MNP itself was inefficacious in our population, rather than poor implementation of or adherence to the planned intervention. Further analysis of our data and secondary data suggests that the evolution with age of childhood anaemia in Colombia, and its causes, appear different from those in settings where MNP has been effective. Firstly, rates of anaemia peak at much earlier ages and then fall rapidly. Secondly, anaemia that remains after the first year of life is relatively, and increasingly as children get older, unrelated to iron deficiency. We suggest that factors during gestation, birth, breastfeeding and early weaning may be important in explaining very high rates of anaemia in early infancy. However, the adverse effects of these factors appear to be largely mitigated by the introduction of solid foods that often include meat. This renders population wide MNP supplementation, provided after a diet of solid foods has become established, an ineffective instrument with which to target Colombia's childhood anaemia problem.

[Guidelines for complementary feeding in healthy infants]

A proper nutrition during the first two years of life is critical to reach the full potential of every human being; now, this period is recognized as a critical window for promoting optimal growth, development, and good health. Therefore, adequate feeding at this stage of life has an impact on health, nutritional status, growth and development of children; not only in the short term, but in the medium and long term. This paper provides recommendations on complementary feeding (CF) presented as questions or statements that are important for those who take care for children during this stage of life. For example: When to start complementary feedings: 4 or 6 months of age?; Exposure to potentially allergenic foods; Introduction of sweetened beverages; Use of artificial sweeteners and light products; Food introduction sequence; Food consistency changes according to neurological maturation; Number of days to test acceptance and tolerance to new foods; Amounts for each meal; Inadequate complementary feeding practices; Myths and realities of complementary feeding; Developmental milestones; Practice of "Baby Led Weaning" and practice of vegetarianism.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Health organisations recommend exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries. Recently, research has suggested that introducing solid food at around four months of age while the baby continues to breastfeed is more protective against developing food allergies compared to exclusive breastfeeding for six months. Other studies have shown that the risks associated with non-exclusive breastfeeding are dependent on the type of additional food or fluid given. Given this background we felt it was important to update the previous version of this review to incorporate the latest findings from studies examining exclusive compared to non-exclusive breastfeeding.

OBJECTIVES

To assess the benefits and harms of additional food or fluid for full-term healthy breastfeeding infants and to examine the timing and type of additional food or fluid.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2016) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 11 trials (2542 randomised infants/mothers). Nine trials (2226 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one primary (breastfeeding duration) and one secondary (weight change) outcome. None of the trials reported on physiological jaundice. Infant mortality was only reported in one trial.For the majority of older trials, the description of study methods was inadequate to assess the risk of bias. Most studies that we could assess showed a high risk of other biases and over half were at high risk of selection bias.Providing breastfeeding infants with artifical milk, compared to exclusive breastfeeding, did not affect rates of breastfeeding at hospital discharge (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.97 to 1.08; one trial, 100 infants; low-quality evidence). At three months, breastfeeding infants who were provided with artificial milk had higher rates of any breastfeeding compared to exclusively breastfeeding infants (RR 1.21, 95% CI 1.05 to 1.41; two trials, 137 infants; low-quality evidence). Infants who were given artifical milk in the first few days after birth before breastfeeding, had less "obvious or probable symptoms" of allergy compared to exclusively breastfeeding infants (RR 0.56, 95% CI 0.35 to 0.91; one trial, 207 infants; very low-quality evidence). No difference was found in maternal confidence when comparing non-exclusive breastfeeding infants who were provided with artificial milk with exclusive breastfeeding infants (mean difference (MD) 0.10, 95% CI -0.34 to 0.54; one study, 39 infants; low-quality evidence). Rates of breastfeeding were lower in the non-exclusive breastfeeding group compared to the exclusive breastfeeding group at four, eight, 12 (RR 0.68, 95% CI 0.53 to 0.87; one trial, 170 infants; low-quality evidence), 16 and 20 weeks.The addition of glucose water resulted in fewer episodes of hypoglycaemia (below 2.2 mmol/L) compared to the exclusive breastfeeding group, reported at 12 hours (RR 0.07, 95% CI 0.00 to 1.20; one trial, 170 infants; very low-quality evidence), but no significant difference at 24 hours (RR 1.57, 95% CI 0.27 to 9.17; one trial, 170 infants; very low-quality evidence). Weight loss was lower for infants who received additional glucose water (one trial, 170 infants) at six, 12, 24 and 48 hours of life (MD -32.50 g, 95% CI -52.09 to -12.91; low-quality evidence) compared to the exclusively breastfeeding infants but no difference between groups was observed at 72 hours of life (MD 3.00 g, 95% CI -20.83 to 26.83; very low-quality evidence). In another trial with the water and glucose water arms combined (one trial, 47 infants), we found no significant difference in weight loss between the additional fluid group and the exclusively breastfeeding group on either day three or day five (MD -1.03%, 95% CI -2.24 to 0.18; very low-quality evidence) and (MD -0.20%, 95% CI -0.86 to 0.46; very low-quality evidence).Infant mortality was reported in one trial with no deaths occurring in either group (1162 infants). The early introduction of potentially allergenic foods, compared to exclusively breastfeeding, did not reduce the risk of "food allergy" to one or more of these foods between one to three years of age (RR 0.80, 95% CI 0.51 to 1.25; 1162 children), visible eczema at 12 months stratified by visible eczema at enrolment (RR 0.86, 95% CI 0.51 to 1.44; 284 children), or food protein-induced enterocolitis syndrome reactions (RR 2.00, 95% CI 0.18 to 22.04; 1303 children) (all moderate-quality evidence). Breastfeeding infants receiving additional foods from four months showed no difference in infant weight gain (g) from 16 to 26 weeks compared to exclusive breastfeeding to six months (MD -39.48, 95% CI -128.43 to 49.48; two trials, 260 children; low-quality evidence) or weight z-scores (MD -0.01, 95% CI -0.15 to 0.13; one trial, 100 children; moderate-quality evidence).

AUTHORS' CONCLUSIONS

We found no evidence of benefit to newborn infants on the duration of breastfeeding from the brief use of additional water or glucose water. The quality of the evidence on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. The majority of studies showed high risk of other bias and most outcomes were based on low-quality evidence which meant that we were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence to disagree with the current international recommendation that healthy infants exclusively breastfeed for the first six months.

Major dietary patterns and risk of acute myocardial infarction in young, urban Pakistani population

Objective:

To investigate the role of dietary intake in the development of premature acute myocardial infarction (AMI) in a hospital-based Pakistani population in Karachi.

Methods:

In a case control study, 203 consecutive patients (146 males and 57 females) with their first AMI and age below 45 years were enrolled with informed consent. Similarly, 205 gender and age matched (within 3 years) healthy adults were also included as controls. Dietary intake of both cases and controls was assessed by using a simple 14-item food frequency questionnaire. Using factor analysis, 3 major dietary patterns- prudent dietary pattern, combination dietary pattern and western dietary pattern were identified. Fasting plasma/serum of both cases and controls were analyzed for homocysteine, folate, vitamin B₁₂, blood Pb, ferritin, cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides. ANOVA and conditional logistic regression were used to predict the association of dietary patterns with AMI.

Results:

Consumption of prudent diet, characterized by high consumption of legumes, vegetables, wheat, chicken and fruits, is protective against the risk of premature AMI. Moderate to high consumption of combination diet, characterized by high intake of eggs, fish, fruits, juices and coffee was associated with decreased risk of AMI. No association was observed between western diet, characterized by high intake of meat, fish and tea with milk and risk of AMI.

Conclusions:

Consumption of a prudent dietary pattern and a combination dietary pattern is protective against the risk of AMI in a Pakistani population.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2014) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted data and assessed risk of bias.

MAIN RESULTS

We included eight trials (984 randomised infants/mothers). Six trials (n = 613 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one secondary outcome (weight change). The trials that provided outcome data compared exclusively breastfed infants with breastfed infants who were allowed additional nutrients in the form of artificial milk, glucose, water or solid foods.In relation to the majority of the older trials, the description of study methods was inadequate to assess the risk of bias. The two more recent trials, were found to be at low risk of bias for selection and detection bias. The overall quality of the evidence for the main comparison was low.In one trial (170 infants) comparing exclusively breastfeeding infants with infants who were allowed additional glucose water, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), with more infants in the exclusive breastfed group still exclusively breastfeeding. Conversely in one small trial (39 infants) comparing exclusive breastfed infants with non-exclusive breastfed infants who were provided with artificial milk, fewer infants in the exclusive breastfed group were exclusively breastfeeding at one week (RR 0.58, 95% CI 0.37 to 0.92) and at three months (RR 0.44, 95% CI 0.26 to 0.76) and there was no significant difference in the proportion of infants continuing any breastfeeding at three months between groups (RR 0.76, 95% CI 0.56 to 1.03).For infant morbidity (six trials), one newborn trial (170 infants) found a statistically, but not clinically, significant difference in temperature at 72 hours (mean difference (MD) 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24 mmol/L, 95% CI -0.51 to 0.03). Weight loss was also higher (grams) in infants at six, 12, 24 and 48 hours of life in the exclusively breastfed infants compared to those who received additional glucose water (MD 7.00 g, 95% CI 0.76 to 13.24; MD 11.50 g, 95% CI 1.71 to 21.29; MD 13.40 g, 95% CI 0.43 to 26.37; MD 32.50 g, 95% CI 12.91 to 52.09), but no difference between groups was observed at 72 hours of life. In another trial (47 infants analysed), we found no significant difference in weight loss between the exclusively breastfeeding group and the group allowed either water or glucose water on either day three or day five (MD 1.03%, 95% CI -0.18 to 2.24) and (MD 0.20%, 95% CI -1.18 to 1.58).Three trials with four- to six-month-old infants provided no evidence to support any benefit from the addition of complementary foods at four months versus exclusive breastfeeding to six months nor any risks related either morbidity or weight change (or both).None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence of benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water, and the quality of the evidence from a small pilot study on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer-term effects on infants and mothers, though randomising infants to receive supplements without medical need may be problematic.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.

Meeting iron needs for infants and children

PURPOSE OF REVIEW

Iron deficiency early in life is associated with impaired neurological development. This study reviews the latest research on how to best meet iron requirements in infants and children.

RECENT FINDINGS

There is concurrent evidence that delayed cord clamping is well tolerated and improves infant iron stores. Iron supplements or enriched complementary foods starting before 6 months of life do not reduce iron deficiency prevalence in low-risk populations. However, for low birth weight infants, iron supplements before 6 months of life have long-term benefits. Iron deficiency anaemia (IDA) during the second half year of life is rare in countries with high compliance to iron-rich complementary foods, but remains a major problem globally. In high-risk populations, iron supplementation reduces IDA and possibly improves growth. However, increased risk of infections is a concern and optimal preventive strategies have not yet been determined. Finally, there is concurrent evidence that iron supplementation of anaemic school-aged children reduces IDA and possibly improves neuropsychological outcomes.

SUMMARY

Interventions for prevention of iron deficiency should be prioritized in risk groups. However, the unclear long-term benefits and possible risk of adverse effects, particularly increased infections in developing countries, prompt further large-scale, double-blinded trials.