The Healthy Feeding Guidelines for Infants and Toddlers: The "When", "What", and "How" of Infant and Toddler Feeding

Synopsis — Parents and caregivers need practical guidance about feeding their infants and toddlers, both to assure their children's normal growth and development, and to lay the foundation for life-long healthy eating habits. In order to answer the basic "when", "what", and "how" questions of complementary feeding, the Start Healthy Expert Panel — representing various areas of expertise and jointly selected by the American Dietetics Association and Gerber Products Company — developed scientifically based feeding guidelines for infants and toddlers.

The Start Healthy Feeding Guidelines are divided into five key topics: 1) nutrients and foods, 2) infant and toddler development, 3) healthy feeding relationships, 4) safe feeding, and 5) physical activity. Dividing the guidelines into these topic areas offers relevant opportunities to discuss food and feeding at every stage of infant and toddler development, as pediatric health professionals attempt to answer parents' most frequently asked questions surrounding complementary feeding.

Parents and caregivers need practical guidance about how to feed their infants and toddlers, both to assure their children's normal growth and development, and to lay the foundation for lifelong healthy eating habits. Among other benefits, establishing healthy eating habits early may help prevent obesity and other health problems during and after childhood.

The Start Healthy Feeding Guidelines for Infants and Toddlers, which provide science-based, practical information about feeding healthy infants and toddlers, is a component of the Start Healthy Initiative, a collaboration between the American Dietetic Association and Gerber Products Company. A core team, trained by the ADA on how to conduct an evidence-based analysis using the ADA approach and tools, directed and guided by an Expert Panel, conducted the bulk of the background work. The mission of the project was to develop scientifically based feeding guidelines for infants and toddlers that attempt to answer parents' most frequently asked questions surrounding complementary feeding:

"When is my baby ready for complementary foods?"
"What foods should I feed my baby?"
"How do I feed these foods?"

The Start Healthy Expert Panel confirmed that answers to questions about when infants and toddlers are ready for complementary foods are highly individual, dictated by the individual child's health, growth, and development. To determine what complementary foods are needed by infants and toddlers, the Expert Panel determined the difference between the Institute of Medicine's Dietary Reference Intakes (DRIs) of each nutrient for healthy infants and toddlers, and the amount of each nutrient in the average intake of human milk by exclusively breast-fed infants. Parents naturally look to pediatric health professionals for practical information about how to feed their infants and toddlers. Therefore, questions concerning how to feed complementary foods addressed by the Start Healthy Feeding Guidelines focus on the role of the parent and caregiver in creating a healthy feeding relationship, introducing complementary foods, handling picky eating, promoting independent feeding, and following safe feeding practices.

The Start Healthy Feeding Guidelines are divided into five key topics: 1) nutrients and foods, 2) infant and toddler development, 3) healthy feeding relationships, 4) safe feeding, and 5) physical activity. Dividing the guidelines into these topic areas offers relevant opportunities to discuss food and feeding at every stage of infant and toddler development. Including discussions of the Start Healthy Feeding Guidelines at well-child check-ups will provide families with the information they need to form healthy eating and activity habits that can last a lifetime. This article offers key insights about each of the five topics, as well as practical information that parents need for implementing the guidelines. For detailed references of the Expert Panel's conclusion statements, the reader is directed to the March 2004 issue of the Journal of the American Dietetic Association.¹

Nutrients and Foods
When determining what complementary foods infants need, the Expert Panel recognized the fact that both the volume of human milk intake and the nutrient composition of human milk are quite variable. Thus, the nutrients needed from complementary foods were calculated assuming different volumes of human milk intake (Figure 1). It is clear that the amounts of energy and other nutrients needed from complementary foods will vary throughout infancy depending on the individual child's human milk and/or formula intakes (Figure 2). Thus, it is important to routinely monitor individual infant growth and development.

By 6 months of age, the "average" breast-fed infant needs complementary foods to assure that current DRIs for a number of nutrients are met. Good sources of the limiting nutrients are shown in Table 1. Although the "average" intake of iron-fortified infant formula provides the recommended intakes of all nutrients until about 1 year of age, formula-fed infants also need complementary foods for exposure to flavors and textures and for mastering eating skills.

In addition, as explained below, special emphasis on several nutrients is warranted during the first two years of life. These include vitamin D, iron, perhaps zinc and, once breast milk or formula is replaced with whole cow's milk, essential fatty acids.

What Do Parents Need to Know?
According to NHANES III, 9% of children less than 3 years of age in 1989-1994 were iron deficient and one-third of these were also anemic.³ Because iron deficiency can result in cognitive and other deficits, some of which may not be reversible, prevention of iron deficiency is extraordinarily important.⁴ By about 6 months of age, the "average" breastfed term infant requires an additional source of dietary iron or an iron supplement to assure the iron requirement is met. Complementary foods such as meats and iron-fortified cereals contribute significant amounts of iron and are helpful in preventing deficiency. An ounce (30 g) of infant cereal provides most of the daily iron requirement, particularly if fed with vitamin C-rich foods (such as strained fruits), which enhance iron absorption from the cereal. Formula-fed infants should receive only iron-fortified formula, and these formulas also should be used for supplementing breastfed infants if required.

Because rickets due to vitamin D deficiency has been observed recently in dark-skinned breastfed infants and other infants without adequate sun exposure, the AAP recommends 200 IU vitamin D as a supplement for breastfed infants and infants receiving less than 500 mL formula per day. The Start Healthy Feeding Guidelines echo this recommendation.

Low intake of the essential fatty acids, linoleic, and a-linolenic acid, may be associated with poor growth, scaly skin lesions, impaired wound healing, impaired visual acuity and other problems. Although both human milk and currently available formulas provide generous amounts of these fatty acids, cow's milk, especially skim and lower-fat milks, have very low levels of these fatty acids and have been associated with biochemical evidence of deficiency.⁶ To help assure adequate intakes of these fatty acids, the Start Healthy Feeding Guidelines state that cow's milk should not be introduced until after a year of age, and then only whole milk should be offered.

If whole cow's milk intake is limited to two cups per day, an additional tablespoon of oil in food preparation or added to already prepared foods is needed to provide adequate intake of linoleic and a-linolenic acid. Most vegetable oils provide the necessary amount of linoleic acid, but only soybean oil provides adequate linoleic and a-linolenic acid. Canola oil, a good source of a-linolenic acid, has less linoleic acid than other vegetable oils. Thus, if soybean oil is not advisable, a mixture of 50% canola oil and 50% safflower or corn oil will provide the necessary amounts of both essential fatty acids.

Currently, there is concern that infants, even if receiving adequate amounts of linoleic and a-linolenic acids, may also need a dietary source of the long-chain polyunsaturated products of these fatty acids, e.g., arachidonic and docosahexaenoic acids, particularly the latter. Because human milk contains these fatty acids and formulas supplemented with them are available, intakes by breastfed and formula-fed infants are adequate. Whether a dietary source of these long-chain fatty acids is needed after introduction of complementary foods is not clear.

Fiber-rich foods such as whole grains, fruits, and vegetables should be encouraged, but it is difficult to achieve the AI of fiber (19 g) for 1- to 3-year-old children. This may reflect the fact that the AI for fiber for young children is based on limited data.

Development
The normal, healthy infant's gastrointestinal tract is mature enough to digest complementary foods by 3-4 months of age. By the time most nutrients in the baby's diet come from table foods, the physiological capabilities of the infant digestive tract are near adult proficiency. Despite some renal immaturity, most babies have no problem maintaining water balance even if feedings provide a relatively high potential renal solute load (above 33mOsm/L). However, during acute illness, when fluid intake may be limited and water losses considerable, diets with a higher solute load may lead more rapidly to dehydration.

Developmental readiness for complementary foods varies considerably among infants. In most babies, the developmental skills needed to eat complementary foods appear between 4 and 6 months of age. For most infants, breast milk and/or iron-fortified infant formulas provide all required nutrients for about the first 6 months after birth and significant but varying amounts thereafter. Readiness for and acceptance of different food textures appears to depend on the child's developmental stage and prior experience with a particular texture. Infants will learn to eat foods of varying textures if they are exposed to them at appropriate developmental stages. A gradual exposure to solid textures during the sensitive period for learning-to-chew (from the time complementary foods are introduced through 10 months of age) may decrease the risk of later rejection of certain textures, refusing to chew, or vomiting.

What Do Parents Need to Know?
The introduction of a variety of flavors and foods during the first 2 years of life may enhance acceptance of a wider variety of flavors and foods in later childhood and increase the likelihood that a child will be willing to try new foods. Exclusively breastfed infants are exposed to a variety of flavors through their mother's breast milk, suggesting the importance of dietary variety not just for babies, but for their mothers as well.

Evidence regarding the order of complementary food introduction is limited. Historically, a general progression beginning with rice cereal mixed with breast milk or formula, gradually followed by strained fruits and/or vegetables has been recommended. However, this common advice does not appear to be based on scientific evidence for any benefit to the infants. The Start Healthy Feeding Guidelines, therefore, state that the order of complementary food introduction is not critical, except with respect to providing the nutrients needed from complementary foods as described above. Meat and fortified infant cereals provide many of these nutrients as first foods for the breastfed infant.

For all infants, initial solid foods should be single-ingredient foods and introduced one at a time. Studies documenting an optimal time before the introduction of the next new food were not found. Recommendations range from 2- to 7-day intervals.⁷ One new food every 2 to 4 days (e.g., 2 - 3 per week) seems reasonable. Combination foods may be given after tolerance for the individual components has been established.

The evidence-based review of how to introduce complementary foods identified only one controlled study addressing this issue. This study showed that mixing cereal with human milk enhances acceptance of cereal by breastfed infants.¹³ Other studies suggest that repeated exposure to different flavors (i.e., foods) enhances acceptance of new foods by both breast-fed and formula-fed infants.¹⁴ Repeated exposures to a particular food are usually necessary. Studies show that up to 10 to 15 exposures may be necessary before an unfamiliar food is accepted.^15,16

Healthy Feeding Relationship
The healthy feeding relationship is a division of responsibility between the parent and the child. The parent sets an appropriate safe and nurturing feeding environment and provides appropriate, healthy foods. The child decides whether and how much to eat.¹⁷ Responsive parenting appears to be at the core of a healthy feeding relationship. This involves:

• Recognizing the child's developmental abilities and feeding skills
• Balancing the child's need for assistance with encouragement of self feeding,
• Allowing the child to initiate and guide feeding interactions, and
• Responding early and appropriately to hunger and satiety cues.

For infants, hunger cues may include crying, excited arm and leg movements, opening mouth and moving forward as the spoon approaches, and swiping food toward the mouth. Smiling, cooing, and/or gazing at the caregiver during feeding may indicate the desire to continue. Hungry toddlers may point at foods or beverages, ask for foods or beverages, or reach for foods.

Infant's satiety cues may include falling asleep, becoming fussy during feeding, slowing the pace
of eating, stopping sucking, spitting out or refusing nipple, batting away or refusing the spoon, and closing the mouth as the spoon approaches. Toddlers may slow the pace of eating, become distracted or notice surroundings more, play with food, throw food, want to leave the table or chair, or not eat everything on the plate. To help avoid underfeeding or overfeeding, parents and caregivers must be sensitive to the hunger and satiety cues of the healthy infant and young child. Crying is often, but not always, a sign of hunger. Parents will need to determine if the infant is hungry or experiencing discomfort.

Parents should be aware of and respond to their infant's or toddler's developmental skills and appetite cues so that they can provide appropriate foods in a positive, safe, and healthy feeding environment. The Feeding Plan featured in the center spread of this issue of Pediatric Basics summarizes the physical milestones during the first 2 years of life, as well as the eating skills, appetite cues, and appropriate food textures associated with each. Professionals are encouraged to use this guide to help parents and caregivers understand the developmental progression of feeding skills during the first 2 years of life. Cultural differences in mothers' expectations and encouragement of self-feeding must be recognized and respected;¹⁸ however, guidance should be provided if these practices seem inappropriate.

What Do Parents Need to Know?
Infants and toddlers have small stomachs and need small, frequent healthy meals and snacks. Usually this translates into three meals with two to three snacks a day. Parents and caregivers need to recognize their child's day-to-day appetite variability and adjust portion sizes accordingly. Portion sizes need to provide essential nutrients and not exceed energy requirements. Encourage parents and caregivers to begin with a teaspoon of food at a time whether it's meat, fortified cereal, vegetable or fruit, gradually increasing the amount of food as the infant/toddler accepts it.

To help children develop independence in feeding, parents and caregivers may need to demonstrate feeding skills rather than rely on verbal prompts alone.¹⁹ Watching a caregiver slowly scoop up food with a spoon and bring it to his or her own mouth may help a child to better understand the mechanics of self-feeding. Awareness of the child's developmental feeding skills is needed so that the tasks presented are appropriate. For example, a child must be able to stabilize her head and balance her trunk before she is ready to begin attempts at self-feeding.

A parent's approach to child feeding is central to the child's early feeding experience. The evidence reviewed describes this relationship as a division of responsibility between parent and child.²⁰ Health care professionals should recognize the potential barriers (e.g., inadequate time or resources) to establishing such a healthy feeding relationship.^21-23

Picky eating is a common complaint of parents of toddlers.²⁴ Our evidence-based review did not reveal an agreed-upon, validated, objective definition of picky eating. Rather, picky eating is a subjective term defined by the caregivers' perception: a toddler who limits the number of foods accepted, refuses to try new foods, totally avoids some food or food groups, and/or exhibits strong food preferences, including those for food presentation and preparation. Consuming a single food or only a few foods for an extended period is commonly called a food jag. Occasional picky eating is to be expected and usually is not associated with major changes in nutrient intake or rates of growth. The health consequences of persistent picky eating or food jags are not known. But since picky eating or food jags may result in inadequate growth or nutrient inadequacy, growth and nutrient status should be monitored.

Parents and caregivers have a formative role as models for their child's healthy eating. They need to be aware of and respond to their infant's or toddler's developmental skills and appetite cues so that they can provide appropriate foods, in appropriate amounts, in a positive, safe, and healthy feeding environment. The Panel agrees with Ellyn Satter's practical suggestions for feeding complementary foods. (See "How to Spoon Feed")

Safe Feeding
Consistent with the Dietary Guidelines for Americans, the Start Healthy Feeding Guidelines recognize safe feeding as an important issue for parents and caregivers of infants and toddlers, and focus on food safety areas unique to infants and toddlers. These include how to store expressed human milk, formula and baby foods safely and what foods to avoid to prevent choking. Providing guidance to parents and caregivers about safe feeding can help increase their awareness and understanding, thereby reducing infants' and toddlers' risks of foodborne illness, choking, and other safety concerns.

What Do Parents Need to Know?
The foods offered to infants and young children need to be safe to eat and appropriate for the child's development. The following list, which provides parents and caregivers with guidance about safe feeding, may increase their awareness and understanding and thereby may reduce the risk of foodborne illness, choking, lead poisoning, nonfood eating, and high intake of nitrates, nitrites, and methylmercury.

• In handling expressed breast milk, keep it clean and avoid contamination when it is collected and stored.
• For infant formula, closely follow manufacturer's use and storage instructions on the label.
• Bottle-fed infants are at higher risk of exposure to foodborne bacteria, particularly if the bottles are left at room temperature for several hours.
• Make sure the baby's bottle is cleaned and disinfected after each use.
• To help ensure that homemade or commercially prepared baby food is safe, follow general food safety guidelines and the manufacturer's package directions.

Since infants and toddlers can be at risk for choking, knowledge of choking hazards can lessen the chances of it occurring.

For infants with a strong family history of food allergy, the introduction of major food allergens such as eggs, milk, wheat, soy, peanuts, tree nuts, fish and shellfish should be delayed. Introduction of foods associated with "lifelong" sensitization (peanuts, tree nuts, fish, and shellfish) should be delayed beyond the child's first birthday.²⁵ Nursing mothers of at-risk infants may need to limit their own intake of particularly allergenic foods.^26,27 Use of hypoallergenic formula may be suggested, but decisions about such formulas and other dietary restrictions should be reached in consultation with the health care provider. There is no evidence that these precautions are of any benefit to the infant who is not at risk for allergy. Caregivers of all infants are advised, however, to introduce new foods one at a time and to watch for adverse reactions.

Physical Activity
Finally, nutritional guidelines should address not only energy intake but also energy output, the major component of which is dependent on physical activity. An appropriate level of activity allows a level of food intake that ensures nutrient adequacy without excessive weight gain. Infant and toddler's enjoyment of movement and activity needs to be encouraged and nurtured to provide appropriate motor skill development and learning. Although there is no objective evidence that activity during early childhood is related to activity, fitness, health, or body weight later in life, there are recommendations in this area. The guidelines concerning activity are based primarily on the recommendations from Active Start (National Association for Sport and Physical Education)²⁸ and AAP's position that television is inappropriate for children under 2 years because of its potentially negative effects on development and physical activity. Instead, AAP encourages more interactive activities that will promote brain development such as talking, playing, singing and reading.²⁹

What Do Parents Need to Know?
All infants and toddlers need to engage in daily age-appropriate activity that promotes physical development and the enjoyment of movement. Motor skills like cognitive skills flourish when infants and toddlers are exposed to safe stimulating environments. Nurturing motor skill development and physical activity in early childhood is fundamental to later motor development and motor coordination. According to Active Start, toddlers should participate daily in at least 30 minutes of structured, 60 minutes of unstructured physical activity and should not be sedentary for more than 60 minutes at a time, except when sleeping. The important message for parents and caregivers is to make a conscious effort to include movement and physical activity in a child's day, to provide structured and unstructured play environments that encourage exploration and active play and to limit excessive use of infant restraints, such as car seats, strollers or bouncy chairs. Health professionals should encourage positive parental role modeling and parent-child interaction in a safe, supervised play environment.

Conclusions
Updating current dietary guidelines with an evidence-based approach confirmed that current recommendations by AAP, ADA and CDC are supported by the scientific literature. Advice for several key details, however, warrant updating. These include:

• Meat and iron fortified infant cereals are good sources of iron for the breastfed infant and should be first foods.
• The order of introduction of fruits and vegetables does not matter, but parents need to encourage dietary variety.
• Toddlers may need dietary sources of essential fatty acids.
• Basing nutrient needs on the new DRIs, as described above, provides updated information concerning energy needs, menus, portion sizes and foods to emphasize.

The Start Healthy Feeding Guidelines for Infants and Toddlers can be used by dietetics and pediatric professionals as a foundation for communicating dietary and feeding advice for infants and toddlers. In formulating these Guidelines, nutrients needed from complementary foods were identified as differences between DRIs and average intakes of each nutrient from human milk. The nutrient needs from complementary foods estimated in this way can be used to develop appropriate menus. They also provide the basis for development of a much-needed food guide for infants and toddlers. Most important, perhaps, the Start Healthy Feeding Guidelines are a scientifically sound reference for providing quick, straightforward answers to questions asked over and over by parents of young children: "When is my child ready for complementary foods?", "What foods are needed?", and "How should these foods be fed?"

Dr. Nancy Butte is a Professor of Pediatrics at the Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas. She is a member of several professional organizations, including the American Society of Nutritional Sciences, American Society of Clinical Nutrition, American Dietetic Association, International Society for Research on Human Milk and Lactation, and Society for International Nutrition Research. Her current research efforts focus on the environmental and genetic determinants of childhood obesity in Hispanic children.

Ms. Kathleen Cobb is currently an expert consultant with the national 5 A Day Program, where she is responsible for strategic visioning and planning for the 5 A Day coordinators across the country. As a leader in her professional organization, the American Dietetic Association, she has served on their Board and leadership for the House of Delegates and helped design both Childhood and Adolescent and Adult Weight Management Certificate programs.

Ms. Laura Graney is a registered dietitian, and has a Master of Science degree in Dietetics from Mount Mary College in Milwaukee, WI. She has been employed in the field of public health nutrition for the past 24 years. She is currently the WIC Project Nutritionist for Sheboygan County (WI) where she tries to empower pregnant, breastfeeding and post-partum women and parents/caretakers of young children (Birth to 5 Years) with the nutrition "know-how" to adopt healthy lifestyle behaviors.

Dr. William Heird is Professor of Pediatrics at Baylor College of Medicine in Houston, Texas. He is involved in both clinical and basic research concerning fatty acid metabolism during infancy. His more than 150 publications cover many areas of pediatric nutrition with focus on parenteral nutrition in pediatric patients, protein and energy needs of low birth weight infants and metabolism of essential fatty acids.

Dr. Karyl Rickard is Professor of Nutrition and Dietetics, Indiana University School of Health and Rehabilitation Sciences, Indianapolis. For over 25 years at James Whitcomb Riley Hospital for Children, she provided leadership in pediatric nutrition, and, advanced nutritional care of infants and children, the role of the dietitian in pediatrics and the science of clinical nutrition. She, in collaboration with subspecialty pediatricians and pediatric dietitians at Riley, developed model systems for nutritional care of newborns in the intensive care unit and children with other chronic illnesses.

We wish to acknowledge Mary Sue Brady, DMSc, RD, FADA for graciously lending her expertise to the preparation of this manuscript.