Nutrition Publication

NNIW60 - Issues in Complementary Feeding

Editor(s): C. Agostoni, O. Brunser. vol. 60

Related Articles

Preface

Author(s): C. Agostoni, O. Brunser

Issues in complementary feeding are among the preferred topics of theNestlé Nutrition Workshops for many reasons:(1) The dietary requirements of infants in the weaning period and theeffects of the different dietary schedules later in life are still poorlyexplored on a scientific basis, and are mostly the result of family tradition,country socioeconomic background, and common beliefs.(2) In developing and, to some extent, in transition countries, malnutritionand undernutrition start immediately after the first 6 months of life, thatis after the period of exclusive breastfeeding. Therefore, plans toimprove the nutritional quality of available solid foods to be introduced,as well as to educate mothers and families to better accustom their childrento complementary feeding, have become an issue of considerableimportance in public health interventions.

Breastfeeding and Complementary Feeding of Children up to 2 Years of Age

Author(s): K.H. Brown

Appropriate breastfeeding and complementary feeding practices are fundamentalto children’s nutrition, health, and survival during the first 2 years of life. The WorldHealth Organization recommends exclusive breastfeeding until 6 months of age andcontinued breastfeeding for at least 2 years, along with the timely introduction of adequateamounts of complementary foods of suitable nutritional and microbiologicalquality. The amounts of energy and micronutrients required from complementaryfoods have been estimated as the difference between the total physiological requirementsof these food components and the amounts transferred to the child in breastmilk. Recommendations for the energy density of complementary foods and their frequencyof feeding have also been proposed. Intakes of several micronutrients, includingiron, zinc, calcium, selected B vitamins and (in some settings) vitamin A, remainproblematic because commonly available, low-cost foods contain inadequate amountsof these nutrients to provide the shortfall in breast milk. Alternative strategies to providethese nutrients include adding animal source foods to the diet, providing fortified,processed complementary foods, administering micronutrient supplements, or offeringsome combination of these approaches. Advantages, disadvantages, and possiblerisks of these different strategies are discussed.

Does Breastfeeding Protect from Growth Acceleration and Later Obesity?

Author(s): A. Singhal

Nutrition in infancy has been suggested to have a major influence or program thelong-term tendency to obesity. Breastfeeding, in particular, appears to protect againstthe development of later obesity, a conclusion supported by data from four systematicreviews and evidence that a longer duration of breastfeeding has greater protectiveeffects. The size of the effect (up to a 20% reduction in obesity risk) although modesthas important implications for public health. The mechanisms involved, althoughpoorly understood, probably include the benefits of relative undernutrition and slowergrowth associated with breast rather than formula feeding – the growth accelerationhypothesis. This hypothesis is now supported by data from animal studies and tworecent systematic reviews, which suggest an association between faster growth ininfancy and later obesity in both richer and low-income countries and for both fasterweight and length gain. The present review considers the evidence for a role of earlygrowth and breastfeeding in the programming of obesity and the underlying mechanismsinvolved.

Later Effects of Breastfeeding Practice: The Evidence

Author(s): D. Turck

Breastfeeding plays a key role in the programming process during early life but, due to confounding factors, it is difficult to draw conclusions on long-term health benefits. The magnitude of the beneficial effect of breastfeeding on blood pressure (2mmHg) and total cholesterol (0.2 mmol/l) is likely to have public health implications. However, it is unknot known whether breastfeeding reduces the risk of cardiovascular mortality. Breastfeeding may protect against the development of celiac disease. The protective role of breastfeeding against type 1 diabetes seems likely, but the mechanisms involved are still under discussion. There is no convincing evidence that breastfeeding reduces the risk of leukemia and cancer. Breastfeeding is associated with a better cognitive development (3 points) that is present as early as at 6 months of age and sustained throughout childhood and adolescence. The benefits of breast milk may be related to its high content in docosahexaenoic acid which plays an important role in brain development. Increasing the duration of breastfeeding is correlated with an increase in cognitive development.

Traditional Foods vs. Manufactured Baby Foods

Author(s): E.L. Ferguson, N. Darmon

The provision of nutrient-dense complementary foods is essential to ensure aninfant’s nutrient requirements are met. Yet often, relative to recommendations, traditionalcomplementary foods have low levels of nutrients, suggesting a role, for fortifiedmanufactured baby foods, in ensuring dietary adequacy. In this review, the potentialbenefits and safety of using fortified manufactured baby foods versus traditional foodsalone are evaluated based on evidence from food composition data, diet modeling andintervention studies. Results from the food composition data and diet modeling suggestthat ensuring a nutritionally adequate complementary feeding diet based on traditionalfoods alone is difficult. Conversely, except for biochemical iron status,intervention trials do not show consistent benefits, for growth or biochemical zinc orriboflavin status, with the use of fortified manufactured baby foods versus traditionalfoods alone. The safety of manufactured baby foods will depend on food preparationpractices and the presence of effective governmental regulatory infrastructures.Hence, in environments where fortified manufactured baby foods are expensive,unavailable or where there is an absence of effective governmental regulatory infrastructures,the use of traditional foods is advised. Conversely, where affordable manufacturedbaby foods are available, marketed safely and fortified appropriately, theiruse is likely to result in improved nutrient intakes and infant biochemical iron status.In all environments, the promotion of breastfeeding, active feeding and high levels ofhygiene is essential to ensure optimal nutritional status.

Potential Contaminants in the Food Chain: Identification, Prevention and Issue Management

Author(s): F.P. Scanlan

Contaminants are a vast subject area of food safety and quality. They are generallydivided into chemical, microbiological and physical classes and are present in our foodchain from raw materials to finished products. They are the subject of international andnational legislation that has widened to cover more and more contaminant classes andfood categories. In addition, consumers have become increasingly aware of and alarmedby their risks, whether rightly or not. What is the food industry doing to ensure the safetyand quality of the products we feed our children? This is a valid question which this articleattempts to address from an industrial viewpoint. Chemical food safety is considereda complex field where the risk perception of consumers is often the highest. The effectsof chronic or acute exposure to chemical carcinogens may cause disease conditions longafter exposure that can be permanently debilitating or even fatal. It is also a moving target,as knowledge about the toxicity and occurrence data of new chemical contaminantscontinues to be generated. Their identification, prevention and management are challengesto the food industry as a whole. A reminder of the known chemical hazards in thefood chain will be presented with an emphasis on the use of early warning to identifypotential new contaminants. Early warning is also a means of prevention, anticipatingfood safety concerns before they become issues to manage. Current best managementpractices including Hazard Analysis and Critical Control Points relating to the supplychain of baby foods and infant formulae will be developed. Finally, key lessons from acase study on recent contamination issues in baby food products will be presented.

The Microbiological Risk

Author(s): L. Morelli

Microbiological risk in the first part of life is endowed with peculiar features whencompared to the same risk in adulthood. The purpose of this review is to highlightthese age-related traits. While pathogens harmful for neonates and infants have beenreviewed, less attention has been paid to the role played by the infant gut as battlefield between pathogens and protecting bacteria or between pathogens and theimmune system. Immediately after birth a race for colonizing the gut begins; the maintool for neonates to select good bacteria is represented by mother’s milk. Quite surprisingly,this milk carries potentially harmful bacteria, but antibodies, oligosaccharidesand the whole breast milk composition provide a powerful selective tool.Nevertheless this selective action is deeply influenced by the type and/or time (i.e.premature) of delivery or in premature subjects; recent data also show that breastmilk could have a different potential in selecting bacterial species. The hygienic conditionsof parents and, more generally, of the surrounding environment play a role inthe selection of the intestinal biota of infants. It is then possible to group neonatesaccording to the composition of the microbiota. Results of ecological studies suggestthat neonates with a different microbiota could have a different microbiological risk.

Cereal Fortification Programs in Developing Countries

Author(s): S. Bulusu, L. Laviolette, V. Mannar, V. Reddy

Malnutrition is a major problem among children especially in the developing world. Inmost developing countries children show growth faltering between 6 and 24 months ofage due to inadequate complementary feeding. Complementary foods are transitionalfoods given in addition to breast milk, following exclusive breastfeeding during the first 6months, to meet the full nutritional requirements of the infant. Strategies to improve theavailability of and accessibility to low cost complementary foods can play an importantrole in improving the nutritional status of infants and young children. Cereals constitutethe most suitable vehicle for delivering micronutrients to an at-risk population becauseof their widespread consumption, stability and versatility. To reduce the vulnerability tothe health impacts of micronutrient deficiencies, several developed and developingcountries have adopted various innovative, cost-effective strategies to fortify cerealbasedcomplementary foods and to reach children through public programs. This articlereviews cereal fortification programs in developing countries, with special reference tolow cost fortified complementary foods, and emphasizes the need for public-private-civicsector initiatives to improve the health and wellbeing of people around the world.

Processed Infant Cereals as Vehicles of Functional Components

Author(s): M. Domellöf, C. West

Cereals are the most common complementary foods all over the world and there isnow a novel possibility to add functional components to target health problems thatare not caused by a simple nutritional deficiency. So far there have been very few publishedtrials on the addition of functional components to infant cereals. A single trialhas suggested that infant cereals containing a combination of probiotics, prebioticsand zinc are an effective adjunct to oral rehydration solution in the treatment of acutegastroenteritis. Up to now there has been no evidence that infant cereals supplementedwith probiotics or prebiotics have a preventive effect on diarrhea but a recentstudy has suggested that a milk fat globule membrane (MFGM) protein fraction addedto an infant cereal reduces the risk of diarrhea in a developing country. There aresome promising results suggesting that infant cereals supplemented with probiotics orprebiotics may prevent atopic eczema. The addition of prebiotic oligosaccharides toinfant cereals may lead to softer stools, likely to benefit those infants who are sufferingfrom constipation. More studies are needed to verify these results and to assessthe effects of other functional components – especially probiotics, prebiotics,nucleotides, novel protein fractions and recombinant human milk proteins – added toinfant cereals.Copyright

Functional Ingredients in the Complementary Feeding Period and Long-Term Effects

Author(s): C. Agostoni, E. Riva, M. Giovannini

The complementary feeding period is a critical stage for growth and development.Infants in developing countries and selected individuals in developed countries maybenefit from micronutrient supplementation, but long-term effects are still poorlyexplored. We have some evidence, coming from observational studies, of the role ofiron in the second semester of life for optimal brain development and functioningthrough early adulthood, but the advantage seems to be restricted to those infantswho are effectively iron-deficient. For long-chain polyunsaturated fatty acids we havelimited observations from randomized trials that they could promote the maturation ofvisual acuity in the short-term, without direct evidence linking supplementation duringthe complementary feeding period to later functional measurements. Probioticsand prebiotics, as well as other micronutrients, such as zinc, represent new promisingareas of investigating effects on the immune system. The medium- and long-termeffects need to be extensively explored, and any type of association recorded to checkthe safety of dietary supplements, considering their overconsumption, starting atearly ages, in western countries.

The Influence of Gluten: Weaning Recommendations for Healthy Children and Children at Risk for Celiac Disease

Author(s): S. Guandalini

In most developed countries, gluten is currently most commonly introducedbetween 4 and 6 months of age, in spite of little evidence to support this practice. Asfor infants at risk of developing food allergies, there is clear evidence that introducingsolid foods before the end of the 3rd month is detrimental and should be avoided. Arecent growing body of evidence however challenges the notion that solids (andamong them, gluten-containing foods) should be introduced beyond the 6th month oflife. Another important aspect of gluten introduction into the diet has to do with itspossible role in causing type-1 diabetes (IDDM). Recently, a large epidemiologicalinvestigation in a cohort of children at risk for IDDM found that exposure to cereals(rice, wheat, oats, barley, rye) that occurred early (3 months) as well as late (7months) resulted in a significantly higher risk of the appearance of islet cell autoimmunitycompared to the introduction between 4 and 6 months. As for celiac disease,the protective role of breastfeeding can be considered ascertained, especially the protectionoffered by having gluten introduced while breastfeeding is continued.Evidence is emerging that early (3 months) and perhaps even late (7 months orafter) first exposure to gluten may favor the onset of celiac disease in predisposedindividuals. Additionally, large amounts of gluten at weaning are associated with anincreased risk of developing celiac disease, as documented in studies from Scandinaviancountries. In celiac children observed in our center, we could show that breastfeedingat the time of gluten introduction delays the appearance of celiac disease and makes itless likely that its presentation is predominantly gastrointestinal. Based on currentevidence, it appears reasonable to recommend that gluten be introduced in smallamounts in the diet between 4 and 6 months, while the infant is breastfed, and thatbreastfeeding is continued for at least a f

Allergic Infants: Growth and Implications while on Exclusion Diets

Author(s): K. Laitinen, E. Isolauri

The complex nature of allergic disease exposes infants to an increased risk of nutritionalinadequacies. Allergic inflammation requiring extensive dietary regimens mayunderlie the poor growth frequently reported. Nutritional management is directedtowards the prevention of explicitly diet-related deficiencies, the mainstay of treatmentof food allergy being strict avoidance of offending antigens in the diet. The advantage ofelimination diets lies in silencing the specific allergic inflammation induced by the foodresponsible, the effect thus being antigen-specific. Concomitantly, food may also containimmunomodulatory factors, and indeed research into the management of allergic diseaseis evolving from passive allergen avoidance to the invention of novel dietary compoundswith specific effects in alleviating the immunoinflammatory reaction andstabilizing the gut mucosal barrier. Active schemes include supplementation of nutrients,particularly fatty acids and antioxidant vitamins, and probiotics with propertiesinfluencing immunoregulatory pathways. However, the conceivable joint effects of arange of nutrients and other potentially active components in the subject’s habitual dietcannot be ruled out. Prior to implementation of these concepts in management regimesor products for infants, further exploration of their effects and mechanisms, includingboth short- and long-term safety evaluation, is called for.

Weaning Infants with Malnutrition, Including HIV

Author(s): N.W. Solomons

A normal pregnancy and adequate lactation performance should produce at 6 monthsof life a healthy baby, who has a weight and height within the limits of internationalgrowth norms. When that does not happen and the child is either too small (or toobig), i.e. ‘malnourished’, strong determinants will have been maternal health, combinedwith environmental stress to the baby. In discussing differential strategies forweaning and complementary feeding, the distinction must first be made between trueclinical malnutrition and simply deviant growth. The former needs rehabilitationtherapy, which is beyond the scope of this discussion. For deviant poor growth, onemust devise a regimen that removes an infant from any low-weight danger zone forincreased early mortality risk. Thereafter, one can address the emerging scientific evidencethat rapid accelerated catch-up growth has implications for increased metabolicderangement and chronic disease risk in childhood and beyond. Human immunodeficiencyvirus (HIV), infecting either mother or mother and offspring, is one of theemerging situations that will produce malnutrition before a child is due to be weaned.It will also often induce early weaning. Attention to specific micronutrient supplementationis recommended in HIV-seropositive and malarial infants.

Adverse Effects of Cow’s Milk in Infants

Author(s): E.E. Ziegler

The feeding of cow’s milk has adverse effects on iron nutrition in infants and youngchildren. Several different mechanisms have been identified that may act synergistically.Probably most important is the low iron content of cow’s milk. It makes it difficultfor the infant to obtain the amounts of iron needed for growth. A second mechanism isthe occult intestinal blood loss, which occurs in about 40% of normal infants duringfeeding of cow’s milk. Loss of iron in the form of blood diminishes with age and ceasesafter 1 year of age. A third factor is calcium and casein provided by cow’s milk in highamounts. Calcium and casein both inhibit the absorption of dietary nonheme iron.Infants fed cow’s milk receive much more protein and minerals than they need. Theexcess has to be excreted in the urine. The high renal solute load leads to higher urineconcentration during the feeding of cow’s milk than during the feeding of breast milkor formula. When fluid intakes are low and/or when extrarenal water losses are high,the renal concentrating ability of infants may be insufficient for maintaining water balancein the face of high water use for excretion of the high renal solute. The resultingnegative water balance, if prolonged, can lead to serious dehydration. There is strongepidemiological evidence that the feeding of cow’s milk or formulas with similarly highpotential renal solute load places infants at an increased risk of serious dehydration.The feeding of cow’s milk to infants is undesirable because of cow’s milk’s propensityto lead to iron deficiency and because it unduly increases the risk of severe dehydration.

Whole Cow’s Milk: Why, What and When?

Author(s): K. Fleischer Michaelsen, C. Hoppe, L. Lauritzen, C. Mølgaard

There are differences between at what age industrialized countries recommendthat cow’s milk can be introduced to infants. Most countries recommend waiting until12 months of age, but according to recommendations from some countries (e.g.Canada, Sweden and Denmark) cow’s milk can be introduced from 9 or 10 months.The main reason for delaying introduction is to prevent iron deficiency as cow’s milk isa poor iron source. In one study mainly milk intake above 500 ml/day caused iron deficiency.Cow’s milk has a very low content of linoleic acid (LA), but a more favorableLA/-linolenic ratio, which is likely to be the reason why red blood cell docosahexaenoicacid (DHA) levels seem to be more favorable in infants drinking cow’s milkcompared to infants drinking infant formula that is not supplemented with DHA. It hasbeen suggested that cow’s milk intake can affect the later risk of obesity, blood pressureand linear growth, but the evidence is not convincing. There are also considerabledifferences in recommendations on at what age cow’s milk with reduced fatintake can be introduced. The main consideration is that low-fat milk might limitenergy intake and thereby growth, but the potential effects on development of earlyobesity should also be considered. Recommendations about the age for introduction ofcow’s milk should take into consideration traditions and feeding patterns in the population,especially the intake of iron and long-chain polyunsaturated fatty acids andshould also give recommendations on the volume of milk.

Meat as an Early Complementary Food for Infants: Implications for Macro- and Micronutrient Intakes

Author(s): N.F. Krebs

Optimal complementary feeding is recognized to be critical for prevention of infectiousmorbidity and mortality and for optimal growth and development. The nutrientswhich become limiting in human milk after approximately 6 months of exclusivebreastfeeding are predictable based on the dynamic composition of human milk andthe physiology of infant nutritional requirements. Iron and zinc are two micronutrientsfor which the concentrations in human milk are relatively independent of maternalintake, and for which the older infant is most dependent on complementary foods tomeet requirements. Traditional feeding practices, including reliance on cereals andplant-based diets, do not complement these recognized gaps in human milk. Meats orcellular animal proteins are richer sources of these critical minerals as well as otheressential nutrients. Yet, cellular animal proteins are often introduced only late ininfancy in developed countries, and may be only rarely consumed by young children indeveloping countries. Plant-based diets result in a predominance of energy from carbohydrates,often including highly refined carbohydrates that are also likely to have ahigh glycemic index. This pattern of macronutrient intake is contrary to that of theperiod when the human genome evolved, and may influence the metabolic profile inyoung children, especially under conditions of nutritional abundance.

Functional Fermented Milk Products

Author(s): O. Brunser, M. Gotteland, S. Cruchet

Fermented foods have been used since prehistoric times. Their number, varietyand geographic origin are considerable, and different substrates and agents includingbacteria, yeasts and moulds have been used in their preparation. In the last few decadesthe scientific approach to the study of the participating microorganisms and theresulting products have provided a better understanding of their biological importance.Among the many health-related properties of fermented foods, effects on bloodpressure have been described after casein hydrolysis by lactic acid bacteria. Peptideswith antimicrobial activity, mainly against Gram-negative bacteria, and derived fromcasein have also been identified. This could explain, at least in part, the antidiarrhealeffects of fermented products including those on traveler’s diarrhea and against colonizationby Helicobacter pylori. One of the best known advantages of fermented milkproducts is their capacity to improve lactose tolerance in hypolactasic subjects. Withthe growing prevalence of allergies and inflammatory bowel diseases, considerableinterest has been focused on the effects of lactic acid bacteria in these conditions;there is evidence that these agents are associated with improvements in allergy; nosuch evidence exists for Crohn’s disease or ulcerative colitis. A cholesterol-loweringcapacity has also been described for some microorganisms. Not all the fermentingmicroorganisms have probiotic capacities as the latter are strain-specific.