Mary Fewtrell
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110 Fewtrell
in 2001 [3] , the WHO recommended that in- fants should be exclusively breastfed for 6 months, although this contrasts with current practice in many countries, where complemen- tary foods may be introduced as early as 3–4 months of age.
Timing of Complementary Feeding
Complementary feeding recommendations and practices are generally not evidence based and vary between countries. Gastrointestinal and re- nal functions are likely to be sufficiently mature by around 4 months of age to enable infants to process some complementary foods, whereas the age at which infants attain the necessary motor skills is likely to fall within the 4- to 6-month pe- riod. There is general consensus that comple- mentary foods should not be given before 17 weeks of age as this may be associated with in- creased later fatness, respiratory symptoms and eczema. The WHO recommends that infants should be exclusively breastfed for 6 months be- fore the introduction of complementary foods [3] , based on a systematic review of the optimal duration of exclusive breastfeeding [2] compar- ing mother and infant outcomes with exclusive breastfeeding for 6 months versus 3–4 months (updated in 2012 [4] ). While there is agreement that exclusive breastfeeding for 6 months is de- sirable in situations where there is a lack of clean drinking water or of safe nutritious complemen- tary foods, there is less consensus regarding in- fants in higher-income settings. Although many countries have adopted the new WHO recom- mendation, other countries still recommend 4–6 months of breastfeeding. The ESPGHAN Com- mittee on Nutrition concluded that complemen- tary foods should not be introduced before 17 weeks of age, but that all infants should start by 26 weeks of age [1] . A review by an expert panel of the European Food Safety Authority also con- cluded that the introduction of complementary
food to healthy term infants in the EU between 4 and 6 months is safe and does not pose a risk for adverse health effects [5] .
Content of the Diet
Most current guidelines on the gradual introduc- tion of different foods during complementary feeding are based on cultural factors and food availability rather than scientific evidence. In de- veloping countries, the focus is still on providing adequate nutrients to support growth and devel- opment, whereas in more affluent environments, achieving a better balance of nutrients and avoid- ing excess may be more important. Recommen- dations are based on the concept that breast milk cannot meet the full requirements for energy, protein and micronutrients beyond about 6 months of age.
Energy
Energy requirements remain high during the first year of life. The fat content of the diet is an impor- tant determinant of its energy density and should not be less than 25% of energy intake. A higher proportion might be required if the infant’s ap- petite is poor or if the infant has recurrent infec- tions or is fed infrequently. Reduced-fat cow’s milk reduces the energy density of the diet, and consideration should be given to the rest of the infant’s diet and to its growth when deciding to introduce this. However, in countries with high rates of childhood obesity, it may be advanta- geous to accustom children to low-fat products from a fairly early age.
Iron and Zinc
More than 90% of iron requirements during the complementary feeding period of a breastfed in- fant must be provided by complementary foods.
Strategies for achieving adequate iron and zinc in- takes include the use of fortified weaning foods, iron-fortified infant formulas, foods rich in bio-
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 109–112 DOI: 10.1159/000360327
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available iron such as meat, or supplements. The most suitable strategy will vary with the circum- stances; cow’s milk is a very poor source of iron, and it is generally recommended that it should not be used as the main drink before 12 months of age.
Salt and Sugar
High intakes of salt in infancy may be associated with later higher blood pressure [6] . Further- more, infants may become accustomed to a salty taste, which could affect subsequent food prefer- ences. Hence, salt should not be added to comple- mentary foods. Sugar is associated with the devel- opment of dental caries. Its use should be restrict- ed, and good dental hygiene practices introduced early.
Gluten
In contrast to data from previous observational studies, the findings from two recent randomised trials have shown that the age at introduction of gluten does not influence the risk of developing coeliac disease. Both trials also concluded that the risk was not influenced by breastfeeding at the time of introduction of gluten [7, 8].
Vegetarian Diets
If infants receive a vegetarian diet, it is important that the diet includes a sufficient amount of milk (about 500 ml/day) and dairy products. Vegan di- ets should be discouraged in infancy, particularly because of the risk of vitamin B 12 deficiency, which can affect neurodevelopment.
Allergy
Certain foods, including egg, fish, nuts and sea- food, are potentially allergenic. However, the evi- dence that delaying the introduction of such foods reduces the risk of developing food allergy is not convincing. Allergy may be increased if sol- ids are introduced before 3–4 months of age, but also by delayed introduction of certain allergens [9] . Furthermore, the exclusion of fish and eggs
from the diet could itself have undesirable nutri- tional consequences.
Taste and Food Acceptance
Children are predisposed to like high-energy foods, to prefer sweet and salty tastes and to re- ject new foods, but these predispositions may be modified by early dietary experience and feed- ing practices. A feeding style typified by emo- tional warmth and responsiveness but high ex- pectations for children’s dietary adequacy and behaviour – accompanied by practices such as parents leading by example, making fruit and vegetables available within the home, moder- ately restricting unhealthy alternative snack foods and encouraging children to try vegeta- bles and fruits – is associated with better con- sumption in the childhood years [10] . Hence, parents play an important role in establishing good dietary habits.
Conclusions
• Complementary foods should not be intro- duced before 17 weeks of age, but all infants should start complementary foods by 26 weeks of age
• It is important to ensure that complementary foods provide adequate energy density (mini- mum 25% fat), and that the diet includes good sources of protein, iron and zinc. Strategies used to achieve this will vary with the environ- ment
• The complementary feeding period is impor- tant for establishing good eating habits and food preferences. Sugar and salt should not be added to complementary foods
112 Fewtrell 8 Lionetti E, Castellaneta S, Francavilla R, et al: Introduction of gluten, HLA status, and the risk of celiac disease in children.
N Engl J Med 2014;371:1295–1303.
9 Prescott SL, Smith P, Tang M, Palmer DJ, Huntley SJ, Cormack B, Heine RG, Gibson RA, Makrides M: The impor- tance of early complementary feeding in the development of oral tolerance: con- cerns and controversies. Pediatr Allerg Immunol 2008; 19: 375–380.
10 Blissett J: Relationships between parent- ing style, feeding style and feeding prac- tices and fruit and vegetable consump- tion in early childhood. Appetite 2011;
57: 826–831.
References
1 Agostoni C, Decsi T, Fewtrell MS, et al;
ESPGHAN Committee on Nutrition:
Complementary feeding: a commentary by the ESPGHAN Committee on Nutri- tion. J Pediatr Gastroenterol Nutr 2008;
46: 99–110.
2 Kramer MS, Kakuma R: Optimal dura- tion of exclusive breastfeeding. Coch- rane Database Syst Rev 2002; 1:
CD003517.
3 WHO: The optimal duration of exclusive breastfeeding. Report of an Expert Con- sultation. Geneva, WHO, 2001.
4 Kramer MS, Kakuma R: Optimal dura- tion of exclusive breastfeeding. Coch-
rane Database of Syst Rev 2012; 8:
CD003517.
5 EFSA Panel on Dietetic Products, Nutri- tion and Allergies (NDA): Scientific opinion on the appropriate age for in- troduction of complementary feeding of infants. EFSA J 2009; 7: 1423. http://
www.efsa.europa.eu/de/efsajournal/
doc/1423.pdf.
6 Geleijnse JM, Hofman A, Witteman JC, Hazebroek AA, Vankenburg HA, Grob- bee DE: Long-term effects of neonatal sodium restriction on blood pressure.
Hypertension 1997; 29: 913–917.
7 Vriezinga SL, Auricchio R, Bravi E, et al:
Randomized feeding intervention in infants at high risk for celiac disease.
N Engl J Med 2014;371:1304–1315.
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 109–112 DOI: 10.1159/000360327
2 Nutrition of Healthy Infants, Children and Adolescents
Key Words
Tolerance induction ã Sensitization ã Allergen avoidance ã Breastfeeding ã Atopic dermatitis
Key Messages
• Allergen contact during the first months of life modulates the induction of tolerance and sensitiza- tion to food antigens
• Nutritional intervention can reduce the risk of aller- gic manifestations, particularly of atopic dermatitis and cow’s milk protein allergy, during the first year of life in children with a positive family history of allergy • Exclusive breastfeeding for the first 4 months of life, with gradual introduction of solid foods with a high diversity during continuous breastfeeding from the 5th month onward, is strongly recommended for all healthy infants, regardless of allergy risk
• Maternal exclusion diets during pregnancy and/or lactation do not reduce allergy risks for the off- spring and are not recommended. Fish in the ma- ternal diet seems to reduce the risk of allergic dis- eases in the offspring
• Delaying the introduction of certain allergens be- yond the 7th month of life has no preventive effect and is not recommended. Fish should be intro- duced during the second half-year of life
• There is some evidence that certain probiotics giv- en to the mother and/or infant and some prebiotic mixtures as supplements to infant formulae may re- duce the risk of allergy, and particularly of eczema,
in children. Due to the heterogeneity of products, study designs, target groups, applications and the timing and duration of supplementation, no gen- eral recommendations can be made
© 2015 S. Karger AG, Basel
Introduction
Contact with food allergens in early infancy mod- ulates the development of tolerance to food aller- gens, but also of sensitization and allergic mani- festations. Nutritional intervention aiming at a reduction in allergy risk should be started early in infancy, and potentially even with the maternal diet during the last weeks of pregnancy. Data on alimentary allergy prevention were obtained in observational cohort studies, which describe as- sociations and can generate hypotheses, and in controlled intervention studies, which can dem- onstrate causal relationships. The available data do not support the conclusion that maternal elimination diets during pregnancy and lactation provide a benefit for allergy risk reduction in the infant. Data on breastfeeding effects on allergy point to a beneficial impact of exclusive breast- feeding during the first 4 months of life, with con- tinued breastfeeding while solid foods are being
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 113–117 DOI: 10.1159/000360328