Unhealthy diets are costly for both children and the societies in which they live. (UNICEF 2016, page 90)

The United States performed poorly on almost all indicators set by the World Breastfeeding Trends Initiative (WBTi), an international tracking, assessment and monitoring system for national implementation of the Global Strategy on Infant and Young Child Feeding.

We did, however, score 10 out of 10 on Indicator 10: Mechanisms of Monitoring and Evaluation System, because in the words of Healthy Children Project Executive Director Karin Cadwell, “We are really good at keeping track of what we aren’t doing.”

The U.S. also managed 10 out of 10 on Indicator 15: Complementary feeding — Introduction of solid, semisolid or soft foods, which measures the percentage of breastfed babies receiving complementary foods at 6 to 8 months of age. The U.S. WBTi panel reported that although more than 80 percent of U.S. babies begin to breastfeed, only 22.3 percent are exclusively breastfed at 6 months, and by eight months, almost every baby has been introduced to complementary foods.

Actually, 20 to 40 percent of babies in the U.S. are introduced to complementary foods at younger than four months. [http://jandonline.org/article/S2212-2672(17)31734-3/fulltext]  

WHO/PAHO advise complementary food be introduced to infants’ diet at 6 months of age. Human milk is meant to be the primary staple of infants’ diets, but human milk alone cannot provide everything babies need nutritionally, especially micronutrients like zinc and iron… Food before one is NOT just for fun.

“While food is certainly a fun sensory experience, it’s also really important babies between 6 and 12 months get a broad exposure to healthy foods,” Healthy Children Project’s Cindy Turner- Maffei, MA, ALC, IBCLC said during one of her presentations at the latest International Breastfeeding and MAINN Conference.

But inconsistent messaging about feeding persists, as detailed in the WBTi U.S. report.

For instance, “…the American Academy of Pediatrics has inconsistent messaging regarding when to begin complementary feeding with a breastfed baby (4 versus 6 months); FDA child care guidelines differ significantly from WIC guidelines regarding infant feeding, etc.” (p 31)

Interestingly, it was after the Clean Label Project investigated pet food that consumers expressed interest in contaminants found in infant formula and baby food, perhaps a testament to our national priorities.

What’s more, the concept of which foods offer an appropriate complement to the diet of a breastfed infant as well as the food environment, including a booming baby food industry, have changed dramatically over the past 50 years, Turner-Maffei pointed out.

The packet apocalypse, where the convenience of “ready-to-feed-super- glop” has largely replaced the art of dining and sharing meals, is upon us in the U.S. Stocked shelves offer an overwhelming array of mostly highly processed snacks and meals in a pouch that generally lack texture diversity, can lead to tooth decay, and “may be predictive of future eating habits”. (UNICEF 2016)   

In light of National Nutrition Month, let’s take a look at what appropriate complementary feeding looks like and the importance of appropriate complementary feeding for long-term health through a summary of what Turner-Maffei and colleagues found after conducting a multi-source literature search and thematic review on complementary foods/feeding and child health/outcomes.

Importance of appropriate complementary feeding (CF)

Children with inadequate or inappropriate CF are at increased risk for growth stunting, potential changes to the microbiome, being overweight, and having micronutrient deficiencies.

Stunting and chronic nutrient deficiencies have significant consequences for health, growth and cognitive development and performance.

For instance, appropriate iron levels are needed for proper brain development; deficiency is associated with thought-processing and motor development issues.

Zinc is related to immune function and optimal cell growth and repair; deficiency is associated with impaired growth, increased susceptibility to infection and an increased risk of diarrhea.  

UNICEF’s From the First Hour of Life report points out that “If appropriate complementary feeding practices were scaled up to nearly universal levels, approximately 100,000 deaths in children under five could be averted each year.” (p. 17)

Guidelines to appropriate CF

Turner-Maffei detailed that foods offered to infants must be nutrient-dense because of their small stomach size. Dietary diversity, where babies are offered a wide variety of healthy foods, help ensure nutrient needs are met. How babies are fed matters too. That is, social interaction plays an important role in appropriate feeding.

PAHO/WHO set forth Guiding Principles for Complementary Feeding of the Breastfed Infant (2003) which states:

1. Practice exclusive breastfeeding from birth to 6 months, and introduce complementary food at 6 months of age (180) days while continuing to breastfeed.
2. Continue frequent, on-demand breastfeeding until 2 years of age or beyond.
3. Practice responsive feeding, applying the principles of psychosocial care.
4. Practice good hygiene and proper food handling.
5. Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding.
6. Gradually increase food consistency and variety as the infant grows older, adapting to the infant’s requirements and abilities.
7. Increase the number of times that the child is fed complementary foods as the child gets older.
8. Feed a variety of nutrient-rich foods to ensure all nutrient needs are met.
9. Use fortified complementary foods or vitamin-mineral supplements for the infant, as needed.
10. Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, favorite foods. After illness, give food more often than usual and encourage child to eat more.

Another important document, Indicators for assessing infant and young child feeding practices (WHO 2008), provides core indicators for infant and young child feeding.

It sets a minimum meal frequency guideline:

• 2 meals for BF infants 6-8 months
• 3 meals for BF infants 9-23 months
• 4 meals for non-BF infants 6-23 months.

Children aged 6 to 23 months should consume from at least 4 of 7 food groups which are:

1. Grains, roots, and tubers
2. Legumes and nuts
3. Dairy products (milk, yogurt, cheese)
4. Flesh foods (meat, fish, poultry)
5. Eggs
6. Vitamin-A rich fruits and vegetables
7. Other fruit and vegetables

Iron-rich or iron-fortified food should be consumed daily. In fact, “Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used.” (PAHO/WHO, 2003, p. 37)

What can we do?

Three themes that arose from Turner-Maffei and colleagues’ study help direct our efforts to encourage ongoing healthy eating habits.

Theme one, the flavor bridge, refers to the flavors babies are exposed to through amniotic fluid and breastmilk. This exposure is linked to later acceptance of aromatic foods.

“A wide variety of flavors either ingested (e.g., fruit, vegetables, spices) or inhaled (e.g., tobacco, perfumes) by the mother are transmitted to her amniotic fluid and/or milk, significantly increasing in intensity in milk within hours after consumption. Infants’ experience with these volatiles and tastes modifies their acceptance in mother’s milk, formula, and solid foods.” (Mennella, 2014, p 706s)

Mennella makes clear, “breastfeeding confers greater acceptance of healthy foods…only if they are part of the mothers’ diet…” (2014)

The second theme Turner-Maffei, et al explored was dietary diversity. Part of the Global Exploration of Human Milk Study (GEHM) shows that the dietary diversity of an urban U.S. city falls significantly below that of the diversity achieved by the Shanghai site. (Woo, et al 2015)

The authors write: “Of particular concern is that only 28% of the highly breastfed Cincinnati infants between 6 and 12 months of age achieved adequate complementary diet diversity. This prevalence is consistent with infants in several developing nations, where obtaining adequate nutrition is a concern. Thus, the likelihood of achieving adequate nutrition may be lower in this group, even when concerns about food scarcity in the US are minimal.” (p. 5)

Increasing awareness of the “biologically-driven dependence of breastfed infants on high-quality, nutrient-dense complementary foods” could help shift this phenomenon.

With the prevalence of iron in U.S. diets, Turner-Maffei notes that iron absorption differs from non-heme elemental sources (like fortified cereals) and heme sources (meat). Unabsorbed iron can encourage the growth of unwanted microbes like Enterobacter, Salmonella, and Listeria.

Parental feeding styles make up theme three.  

Savage, Fisher and Birch define an ideal feeding style as responsive, supportive, non-manipulative, and authoritative.

Townsend and Pitchford found that Baby-Led Weaning (BLW) had a positive impact on the liking of foods that make up healthy nutrition.

Turner-Maffei, along with all of us at HCP, encourage you to help shift awareness that Food Before One is NOT Just for Fun!