DRAFT - Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months

A joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada

This statement by the Infant Feeding Joint Working Group provides health professionals with evidence-informed principles and recommendations. Provinces, territories, and health organizations can use it as a basis for developing practical feeding guidelines for parents and caregivers in Canada.

This statement promotes the communication of accurate and consistent messages on infant nutrition from six to 24 months of age. Guidance on nutrition from birth to six months is covered in a separate statement.

For information and ideas about how to answer the questions of parents and caregivers, see: In Practice: Talking to families about infant and young child nutrition.

Draft principles and recommendations for the nutrition of infants and young children from six to 24 months

Breastfeeding is an important source of nutrition for older infants and young children as complementary foods are introduced.

• Support sustained breastfeeding for up to two years or beyond, as long as mother and child want to continue.

Complementary feeding begins with offering nutritious family foods.

• Recommend that parents and caregivers increase the number of times per day that they offer complementary foods, and continue breastfeeding on cue.
• Encourage offering a variety of nutritious foods from the family meals.

Responsive feeding promotes the development of healthy eating skills.

• Encourage feeding that is responsive to the child's cues.
• Promote finger foods and self-feeding from the start.
• Encourage use of an open cup, initially with help.

Iron-rich complementary foods help to prevent iron deficiency.

• Continue to recommend a variety of iron-rich foods, such as meat and meat alternatives and iron-fortified cereal.
• If parents and caregivers are introducing cow milk, advise them to delay until nine to 12 months of age. Limit cow milk to 500-750 mL (2-3 cups) per day.

Foods for infants and young children must be prepared, served and stored safely.

• Ensure infants and young children are always supervised during feeding.
• Avoid hard, small and round, or smooth and sticky solid foods. These may cause aspiration and choking.
• Promote safe food preparation and storage to prevent food poisoning. Counsel to avoid products containing raw or undercooked eggs, meat, poultry, or fish. Avoid cross-contamination between cooked and uncooked foods.
• Prevent infant botulism by not giving honey to a child under one year of age.

Young children can begin to have regular meals and snacks based on Canada's Food Guide.

• Ensure young children are offered a variety of foods from the four food groups each day.
• Recommend foods prepared with little or no added sugar or salt.
• Explain to parents and caregivers that nutritious foods that are higher in fat should not be restricted.
• Advise limiting fruit juice and sweetened beverages. Encourage offering water to satisfy thirst.
• Encourage parents and caregivers to be role models and instill lifelong healthy eating habits.

Recommendations on the use of breastmilk substitutes

Some infants may not be breastfed for personal, medical, or social reasons. Their families need support to optimize the infant's nutritional well-being.

Acknowledgements

The Infant Feeding Joint Working Group was a collaboration between Health Canada and several national organizations. Members of the working group came from:

• Canadian Paediatric Society's Nutrition and Gastroenterology Committee (CPS)
• Dietitians of Canada (DC)
• Breastfeeding Committee for Canada (BCC)
• Public Health Agency of Canada (PHAC)
• Health Canada (HC)

The working group received guidance from the Infant Feeding Expert Advisory Group and consulted broadly with stakeholders.

Members of the Infant Feeding Expert Advisory Group: Gisèle Conway, Laura Haiek, Sheila Innis, Gerry Kasten, Jack Newman, Nancy Watters

Participants on the Infant Feeding Joint Working Group: Becky Blair (DC), Genevieve Courant (BCC), Jeff Critch (CPS), Patricia D'Onghia (HC), Erin Enros (HC), Deborah Hayward (HC), Jennifer McCrea (HC), Brenda McIntyre (HC), Julie Castleman (PHAC), Kevin Wood (HC).

Breastfeeding is an important source of nutrition for older infants and young children as complementary foods are introduced.

• Support sustained breastfeeding for up to two years or beyond, as long as mother and child want to continue.

Rationale

The World Health Organization (WHO) promotes exclusive breastfeeding for the first six months and continued breastfeeding, with appropriate complementary foods, up to two years of age or longer. This is a global public health recommendation (WHO/UNICEF, 2003). Breastfeeding during the second six months is accepted as the nutrition standard for infants according to the Dietary Reference Intakes (IOM, 2006). Appropriate breastfeeding and complementary feeding are among the most effective interventions to promote child health, growth and development (WHO/UNICEF, 2008).

In the second six months, infants can meet their nutrient requirements with a combination of breastmilk and complementary foods (Butte et al., 2004). In the second year, breastfeeding continues to make an important nutritional contribution to the young child (WHO, 2009; PAHO, 2003; Michaelsen, Weaver, Branca & Robertson, 2003). Breastmilk provides about one half of an infant's energy needs up to one year of age. It provides up to one third of the infant's energy needs in the second year (WHO, 2009). Adequate complementary foods are critical because they provide additional energy and nutrients needed for proper growth and development (Michaelsen, Weaver, Branca & Robertson, 2003; UNICEF, 2003). Continued breastfeeding helps maintain the mother's breastmilk supply during complementary feeding (Michaelsen, Weaver, Branca & Robertson, 2003).

Continued breastfeeding has been associated with a number of positive infant and maternal health outcomes. Longer breastfeeding durations, in addition to a wide range of other determinants, may have a protective effect against overweight and obesity (Arenz, Rückerl, Koletzko & von Kries, 2004; Scott, Ng & Cobiac, 2012; von Kries et al., 1999). Breastfeeding provides the infant and young child with immune factors during the first and second years (Goldman, Goldblum & Garza, 1983; Goldman, Garza, Nichols & Goldblum, 1982). Longer durations of breastfeeding appear to protect against infectious illnesses, particularly gastrointestinal and respiratory infections (Fisk et al., 2011). Consistent findings have shown a decreased risk of maternal breast cancer with longer durations of breastfeeding (Collaborative Group on Hormonal Factors in Breast Cancer, 2002; Chang-Claude, Eby, Kiechle, Bastert & Becher, 2000; Brinton et al., 1995). Research also suggests that mothers who breastfeed their older infants and young children experience an increased sensitivity and bonding with their child (Britton, Britton & Gronwaldt, 2006; Fergusson & Woodward, 1999).

In 2011, 58.8% of Canadian mothers continued to breastfeed their child beyond six months of age. This percentage dropped to 19.9% after the first year (Statistics Canada, 2011). Among the reasons mothers gave for stopping were: not enough breastmilk; the infant was ready for solid food; and the infant self-weaned (Health Canada, 2012).

The decision to continue breastfeeding is a personal one. The duration of breastfeeding is influenced by many cultural and social factors. One significant example is the social stigma of breastfeeding in public. To improve breastfeeding outcomes for children and their mothers, it is important to keep implementing and promoting the Baby Friendly Initiative (BFI) Integrated 10 Steps for Hospitals and Community Health Services (WHO/UNICEF 2009). BFI implementation is known to increase the initiation, exclusivity and duration of breastfeeding (Pound et al., 2012).

The success among mothers who want to breastfeed can be improved through active support (US Dept. of Health and Human Services, 2011; AAFP, 2008). Breastfeeding support increases the percentage of mothers who breastfeed beyond six months. Studies have shown that all forms of breastfeeding support, at all follow-up time points up to nine months, can encourage mothers to continue to breastfeed (Renfrew, McCormick, Wade, Quinn & Dowswell, 2012). The resource  Practical Guide to Protect, Promote and Support Breastfeeding in Community Based Projects can assist in identifying strategies and specific actions to protect, promote and support breastfeeding in a population health context. The Institute of Medicine (IOM) has acknowledged the important role of supportive environments in encouraging breastfeeding during infancy (IOM, 2011).

The father or partner, and the family, as part of the mother's social environment, have an important role in supporting breastfeeding, in particular in supporting longer durations of breastfeeding (AAFP, 2008).

When appropriate complementary foods are being offered, there is no evidence of a risk to a child's health or nutrition with longer breastfeeding durations. Health professionals should give parents and caregivers information on appropriate complementary feeding.

References

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

American Academy of Family Physicians [AAFP] (2008).  Breastfeeding, family physicians supporting (position paper). Retrieved from: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html

Arenz, S., Rückerl, R., Koletzko, B., & von Kries, R. (2004). Breast-feeding and childhood obesity - a systematic review. International Journal of Obesity, 28:1247-1256.

Butte, N., Cobb, K., Dwyer, J., Graney, L., Heird, W., & Rickard, K. (2004). The start healthy feeding guidelines for infants and toddlers. The American Dietetic Association, 104(3): 442-454.

Britton, J.R., Britton, H.L., & Gronwaldt, V. (2006). Breastfeeding, sensitivity, and attachment. Pediatrics, 118: 1436-1443.

Brinton, L.A., Potischman, N.A., Swanson, C.A., Schoenberg, J.B., Coates, R.J., Gammon, M.D, Malone, K.E., Stanford, J.L., & Daling, J.R. (1995). Breastfeeding and breast cancer risk. Cancer Causes and Control, 6:199-208.

Chang-Claude, J., Eby, N., Kiechle, M., Bastert, G., & Becher, H. (2000). Breastfeeding and breast cancer risk by age 50 among women in Germany. Cancer Causes and Control, 11: 687-695.

Collaborative Group on Hormonal Factors in Breast Cancer (2002). Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without disease. The Lancet, 360; 187-195.

Fergusson, D.M., Woodward, L.J. (1999). Breast feeding and later psychosocial adjustment. Paediatric and Perinatal Epidemiology, 13: 144-157.

Fisk, C.M., Crozier, S.R., Inskip, H.M., Godfrey, K.M., Cooper, C., Rogers, G.C., & Robinson, S.M., Southampton Women's Survey Study Group (2011). Breastfeeding and reported morbidity during infancy: Findings from the Southampton Women's Survey. Maternal and Child Nutrition, 7(1): 61-70.

Goldman, A.S., Goldblum, R.M., & Garza, C. (1983). Immunologic components in human milk during the second year of lactation. Acta Paediatr Scand, 72:461-462.

Goldman, A.S., Garza, C., Nichols, B.L., & Goldblum, R.M. (1982). Immunologic factors in human milk during the first year of lactation. The Journal of Pediatrics, 100(4):563-567.

Health Canada (2012). Duration of exclusive breastfeeding in Canada: Key statistics and graphics (2009-2010). Retrieved from: http://www.hc-sc.gc.ca/fn-an/surveill/nutrition/commun/prenatal/exclusive-exclusif-eng.php

Institute of Medicine [IOM] (2006). Dietary Reference Intakes: The essential guide to nutrient requirements. Washington DC: National Academies Press.

Institute of Medicine [IOM] (2011). Early childhood obesity prevention policies. Washington DC: National Academies Press.

Michaelsen, K.F., Weaver, L., Branca, F., & Robertson, A. (2003).  Feeding and nutrition of infants and young children: Guidelines for the WHO European Region, with emphasis on the former Soviet countries. Retrieved from: http://www.euro.who.int/__data/assets/pdf_file/0004/98302/WS_115_2000FE.pdf

Pan American Health Organization (2003). Guiding principles for complementary feeding of the breastfed child. Washington DC: Pan American Health Organization/World Health Organization.

Pound, S.L., Unger, S.L., Canadian Paediatric Society Nutrition and Gastroenterology Committee. (2012). The Baby-Friendly Initiative: protecting, promoting and supporting breastfeeding. Paediatr Child and Health, 17(6): 317-21.

Scott, J.A. (2012). The relationship between breastfeeding and weight status in a national sample of Australian children and adolescents. BMC Public Health, 12:107.

Statistics Canada (2011). Canadian Community Health Survey. Unpublished raw data.

UNICEF. (2003).  Nutrition - Infant and young child feeding. Retrieved from: http://www.unicef.org/nutrition/index_breastfeeding.html

U.S. Department of Health and Human Services (2011). The Surgeon General's call to action to support breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General.

von Kries, R., Koletzko, B., Sauerwald, T., von Mutius, E., Barnert, D., Grunert, V., & von Voss, H. (1999). Breast feeding and obesity: Cross sectional study. BMJ, 319:147-150.

World Health Organization and UNICEF (2003).  Global strategy for infants and young child feeding. Geneva: World Health Organization. Retrieved from: http://www.ennonline.net/pool/files/ife/global-strategy-for-iycf-who-2003(1).pdf

World Health Organization and UNICEF (2008). Strengthening action to improve feeding of infants and young children 6-23 months of age in nutrition and child health programmes: Report of proceedings. Geneva: World Health Organization. Retrieved from: http://whqlibdoc.who.int/publications/2008/9789241597890_eng.pdf

World Health Organization (2009). Infant and young child feeding (model chapter for textbooks for medical students and allied health professionals). Geneva: World Health Organization.

WHO/UNICEF (2009).  Baby-Friendly Hospital Initiative: Revised, updated and expanded for integrated care. Section 1: Background and implementation. Retrieved from: http://www.who.int/nutrition/publications/infantfeeding/9789241594950/en/index.html.

Complementary feeding begins with offering nutritious family foods.

• Recommend that parents and caregivers increase the number of times per day that they offer complementary foods, and continue breastfeeding on cue.
• Encourage offering a variety of nutritious foods from the family meals.

Rationale

In the second six months, breastfeeding alone is no longer sufficient to meet all of an infant's nutrient needs (WHO, 2003). During the initial stages of complementary feeding, the foods offered should be energy dense and rich in protein and micronutrients such as iron (WHO, 2009).

The Pan American Health Organization (PAHO) and the WHO have estimated energy requirements that for infants six to eight months of age. The energy contribution from complementary foods is approximately one fifth of the total requirement (WHO, 2009; PAHO, 2003). By nine to 11 months, complementary foods contribute just under half of the estimated total energy requirement. Breastfeeding continues to provide the main source of nutrition as other foods are introduced (WHO, 2009, Butte et al., 2004).

Frequency of complementary feeding

For infants six to eight months of age it is suggested to offer complementary foods in two to three regular meals and one to two snacks each day, depending on the child's appetite (WHO, 2009). For infants nine to 11 months of age, the frequency increases to three to four regular meals a day with one to two snacks, depending, once again, on the child's appetite. The frequency of feeding and the amount of food increases with age to accommodate higher caloric requirements and developmental growth (WHO, 1998).

As complementary foods are introduced, frequent breastfeeding continues on-cue. The WHO has noted that, “whether breastfeeds or complementary foods are given first at any meal has not shown to matter. A mother can decide according to her convenience and the child's [cues]” (WHO, 2009).

The amount of food offered to infants should be based on the principles of responsive feeding. The nutrient density and frequency of the meals should be adequate to meet the child's needs. The amount consumed at a meal will differ for each child based on:

• their breastmilk intake
• their appetite and ability to eat
• the energy density of the complementary foods

Parents and caregivers should be advised to start with small amounts of the family meal and offer more food depending on the child's appetite and hunger cues.

Family meals

From six months of age, an infant's complementary foods can be the same nutritious foods enjoyed by the family. They should be prepared and served in way that is not too spicy or salty, and is safe and easy for the infant to eat (WHO, 2009). Encourage parents and caregivers to offer an ever widening variety of flavours and foods from Canada's Food Guide during the first year. Children who have early experiences with eating healthy foods are more likely to prefer and to consume those foods and to have an eating pattern that promotes healthy growth and weight (Anzman et al., 2010; Mennella et al., 2008). These healthy eating patterns may persist into later childhood (Skinner et al., 2004). When parents and caregivers offer infants the same foods prepared for the rest of the family, it creates an opportunity to make healthy adjustments to everyone's eating habits.

The social aspect of eating is important. From this age, infants should take part in family meals. The Sample Menus are a guide on nutritious meals and snacks developed for a family with an infant at seven months and 11 months (Butte et al., 2004). The examples of foods to offer infants support the transition to meals and snacks based on Canada's Food Guide.

References

Anzman, S. L., B. Y. Rollins, and L. L. Birch. 2010. Parental influence on children's early eating environments and obesity risk: Implications for prevention. International Journal of Obesity.

Butte, N., Cobb, K., Dwyer, J., Graney L., Heird, W., & Rickard, K. (2004). The Start Healthy Feeding Guidelines for Infants and Toddlers. Journal of the American Dietetic Association, 104 (3): 442-54.

Institute of Medicine (1991). Nutrition during lactation. Washington, DC: National Academy Press.

Mennella, J. A., S. Nicklaus, A. L. Jagolino, and L. M. Yourshaw. 2008. Variety is the spice of life: Strategies for promoting fruit and vegetable acceptance during infancy. Physiology and Behavior 94(1):29-38.

Pan American Health Organization (2003).  Guiding Principles for complementary feeding of the breastfed child. Retrieved from: http://whqlibdoc.who.int/paho/2003/a85622.pdf

Skinner, J. D., W. Bounds, B. R. Carruth, M. Morris, and P. Ziegler. 2004. Predictors of children's body mass index: A longitudinal study of diet and growth in children aged 2-8y. International Journal of Obesity 28(4):476-482.

World Health Organization (2009).  Model Chapter for textbooks for medical students and allied health professionals. Retrieved from: http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf

Responsive feeding promotes the development of healthy eating skills.

• Encourage feeding that is responsive to the child's cues.
• Promote finger foods and self-feeding from the start.
• Encourage use of an open cup, initially with help.

Rationale

'Responsive feeding' means that a parent or caregiver responds in a prompt, emotionally supportive, and developmentally appropriate manner to the child's cues (DiSantis, Hodges, Johnson, & Fisher, 2011). This behaviour is not confined to one stage of infant or child development; it applies to breastfeeding on cue, introducing complementary foods, and feeding an older child.

Responsive feeding

To help avoid under or overfeeding, parents and caregivers need to be sensitive to the hunger and satiety cues of infants and young children. Responsive feeding has these characteristics (WHO, 2002; Engle & Pelto, 2011):

• It allows the child to guide feeding.
• It balances helping with encouraging self-feeding, in a way that is appropriate for the child's level of development.
• It involves eye contact and positive verbal encouragement, but not verbal or physical coercion.
• It uses eating utensils that are age-appropriate, as well as culturally appropriate.
• It responds to early hunger and satiety cues.
• It minimizes distractions during meals and feedings and takes place in a comfortable environment.
• It is sensitive to the child, including changes in the child's physical and emotional state.
• It offers different food combinations, tastes and textures.
• It uses different methods of encouragement, even if foods are initially refused.

Non-responsive feeding, on the other hand, occurs when, for example:

• the caregiver dominates the feeding
• the child controls the feeding
• the caregiver ignores the child (Black & Aboud, 2011).

Non-responsive feeding relationships may override an infant's internal hunger and satiety cues and interfere with their emerging autonomy (Black & Aboud, 2011). Pressuring infants to eat by using excessive verbal encouragement (such as "clean your plate") may also lead to negative attitudes about eating and poor eating habits (Cerro, Zeunert, Simmer & Daniels, 2002) or excessive feeding and excess weight gain (Birch, 1992; Satter, 1996; Hurley, Cross & Hughes, 2011).

Responsive feeding may influence early development of self-regulation of energy intake (DiSantis, Hodges, Johnson & Fisher, 2011).

Division of roles and responsibilities

The development of healthy eating skills is a shared responsibility (Satter, 2012; Satter, 2000). Parents and caregivers provide a selection of nutritious foods, prepared and served in a safe manner. They decide when and where food is eaten by providing regular meals and snacks in a pleasant environment. The child decides how much they want to eat and, at times, even whether they eat.

To support healthy eating skills, parents and caregivers should be encouraged to recognize and respond appropriately to their child's hunger cues, such as restlessness or irritability and to satiety cues such as turning the head away, refusing to eat, falling asleep or playing (Satter, 2000). They need to trust the child's ability to decide how much to eat and whether to eat (Satter, 2012). This kind of support promotes the development of autonomy (Satter, 1996).

Finger foods and self-feeding

Feeding skills include:

• taking food from a spoon
• chewing
• self-feeding with fingers or a spoon
• drinking from an open cup (Satter, 2000).

Finger foods add texture to the diet and encourage self-feeding. Safe finger foods include pieces of soft cooked vegetables and fruits, soft ripe fruit such as banana, cooked meat and poultry, grated cheese, bread crusts and dry toast. WHO guidelines suggest that foods offered as snacks to older infants and young children should be finger foods (WHO, 2009).

Finger foods should be integrated into an infant's diet and supplemented with foods of various textures including purees for the first few weeks (Reeves, 2008; Wright, Cameron, Tsiakas, & Parkinson, 2011; Department of Health, 2009). Introducing finger foods among the first solid foods offered encourages self-feeding from the outset (Townsend & Pitchford, 2012; Rapley, 2011). This approach is thought to take advantage of the critical period for oral and motor development, during which the infant is ready to reach out for and chew food (Rapley, 2011; Sachs, 2011).

As solid foods are introduced, infants may experience a gag reflex. This happens as they begin to learn how to move solid foods from the front to the back of the mouth (Morris & Klein, 2000). This may cause anxiety for parents and caregivers, until they are able to distinguish between gagging and actual choking (Brown & Lee, 2011). As long as the infant is sitting upright and concentrating, the risk of choking is the same as that of an adult (Rapley, 2011).

Other concerns about self-feeding include the mess created and food waste (Brown & Lee, 2011). To reduce waste, encourage parents and caregivers to offer small amounts of food and offer more based on the child's cues. Messy mealtimes are part of learning process of eating.

Open cup

As liquids other than breastmilk are introduced, they could be offered in an open cup. This practice can:

• reduce the risk of dental decay
• help to avoid night time bottles
• reduce consumption of excess calories
• promote oral and motor skill development.

The WHO recognizes the use of an open cup as the best alternative to breastfeeding (WHO/UNICEF, 2003). The Global Strategy for Infants and Young Child Feeding promotes the use of an open cup as a safe method of feeding (WHO/UNICEF, 2003). Step 9 of the Baby Friendly Initiative (BFI) supports mothers in feeding and comforting their breastfeeding infants without the use of artificial teats (BCC, 2011).

Offering infants an open cup decreases the exposure of the teeth to liquids containing sugar including milk, fruit juices, and fruit drinks. This exposure may increase the risk of dental decay (ADA, 2004).

Use of an open cup has been shown to be a safe and easily learned in infancy (Howard et al., 2003; Lang, Lawrence, & Orme, 1994). Infants can pace their own intake, which makes it easier for them to control their breathing and swallow when they are ready (Lang, Lawrence, & Orme, 1994). The use of an open cup also fosters positive body and eye contact, because it initially requires help from the caregiver (Ministry of Health of New Zealand, 2008).

Findings from longitudinal studies suggest that bottle-feeding, irrespective of the type of milk used, may be an independent factor associated with infant weight gain (Li, Magadia, Fein, & Grummer-Strawn, 2012). Prolonged bottle-feeding, later than 12 to 14 months, of age has been associated with the consumption of excess calories and an increased risk of obesity in childhood (Gooze, Anderson, & Whitaker, 2011).

It is common for training cups such as sippy cups to have no-spill valves. An infant gets liquids out of these training cups by sucking (ADA, 2004; Morris & Klein, 2000). These cups therefore do not support the development of mature drinking skills (Morris & Klein, 2000). To encourage oral and motor skill development, it is also important to avoid using a cup with a lid and valve. An open cup is the most appropriate choice as a training cup for the older infant (ADA, 2004).

For more information on reducing the risk of early childhood caries or dental decay see In Practice: Talking to families about infant and young child nutrition.

References

American Dental Association (2004). From baby bottle to cup: Choose training cups carefully, use them temporarily. Journal of the American Dental Association, 135: 387.

Black, M.M. & Aboud, F.E. (2011). Responsive feeding is embedded in a theoretical framework of responsive parenting. The Journal of Nutrition, 141: 490-494.

Breastfeeding Committee for Canada (2011).  Breastfeeding Committee for Canada Baby-Friendly Initiative Integrated 10 Steps & WHO Code Practice Outcome Indicators for Hospitals and Community Health Services: Summary (the interpretation for Canadian practice). Retrieved from: http://www.breastfeedingcanada.ca/documents/2012-05-14_BCC_BFI_Ten_Steps_Integrated_Indicators_Summary.pdf

Brown A. & Lee M. (2010) A descriptive study investigating the use and nature of baby led weaning in a UK sample of mothers. Maternal & Child Nutrition, 7(1): 34-47.

Cerro N, Zeunert S, Simmer KN, & Daniels LA. (2002). Eating behaviour of children 1.5-3.5 years born preterm: Parent's perceptions. J Pediatr Health Care, 38(1):72-8.

DiSantis, K.I., Hodges, E.A., Johnson, S.L., & Fisher, J.O. (2011). The role of responsive feeding in overweight during infancy and toddlerhood: A systematic review. International Journal of Obesity, 35: 480-492.

Engle, P.L. & Pelto, G.H. (2011). Responsive feeding: Implications for policy and program implementation. The Journal of Nutrition, 141: 508-511.

Flint, A., New, K., & Davies, M.W. (2007). Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD005092. DOI: 10.1002/14651858.CD005092.pub2.

Gooze, R.A., Anderson, S. E., & Whitaker, R.C. (2011). Prolonged bottle use and obesity at 5.5 years of age in US children. The Journal of Pediatrics , 159(3): 431-436 .

Howard, C.R., Howard, F.M., Lanphear, B., Eberly, S., deBlieck, E.A., Oakes, D., & Lawrence, R.A. (2003). Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics, 111(3): 511-518.

Hurley, K.M., Cross, M.B., & Hughes, S.O. (2011). A systematic review of responsive feeding and child obesity in high-income countries. The Journal of Nutrition, 141: 495-501.

Kagihara, L., Niederhauser, V.P., & Stark, M. (2009). Assessment, management, and prevention of early childhood caries. Journal of the American Academy of Nurse Practitioners, 21:1-10.

Lang, S., Lawrence, C.J., & Orme, R., L. (1994). Cup feeding: An alternative method of infant feeding. Archives of Disease in Childhood, 71:365-369.

Li, R., Magadia, J., Fein, S.B., & Grummer-Strawn, L.M. (2012). Risk of bottle-feeding for rapid weight gain during the first year of life. Arch Pediatr Adolesc Med, 166(5): 431-436.

Ministry of Health of New Zealand (2008).  Food and nutrition guidelines for healthy infants and toddlers (aged 0-2): A background paper. Retrieved from: http://www.health.govt.nz/publication/food-and-nutrition-guidelines-healthy-infants-and-toddlers-aged-0-2-background-paper

Morris, S.E., Klein, M.D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development 2nd edition. Tuscon, AZ: Therapy Skill Builders.

Rapley, G. (2011). Baby-led weaning: Transitioning to solid foods at the baby's own pace. Community Practitioner, 84(6):20-23.

Reeves, S. (2008). Baby-led weaning. British Nutrition Foundation Nutrition Bulletin, 33: 108-110.

Sachs, M. (2011). Baby-led weaning and current UK recommendations - are they compatible? Maternal and Child Nutrition. 7:1-2.

Satter, E. (1996). Internal regulation and the evolution of normal growth as the basis for prevention of obesity in childhood. Journal of the American Dietetic Association, 9: 860-864.

Satter, E. (2012).  Ellyn Satter's division of responsibility in feeding. Retrieved from http://www.ellynsatter.com/ellyn-satters-division-of-responsibility-in-feeding-i-80.html.

Satter, E. (2000). Child of Mine: Feeding with Love and Good Sense. Boulder, Colorado: Bull Publishing Company.

Schwartz, S.S., Rosivack, R.G., Michelotti, P. (1993). A child's sleep habit as a cause of nursing caries. J Dent Child, 22-5.

Townsend, E., Pitchford, N.J. (2012). Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case-controlled sample. BMJ Open, 2: e000298.

World Health Organization (2002).  Complementary feeding: Report of the global consultation summary of guiding principles. Retrieved from http://www.who.int/nutrition/publications/infantfeeding/924154614X/en/index.html

World Health Organization and UNICEF (2003).  Global Strategy for Infants and Young Child Feeding. Geneva: World Health Organization. Retrieved from: http://www.ennonline.net/pool/files/ife/global-strategy-for-iycf-who-2003(1).pdf

Wright, C.M., Cameron, K., Tsiaka, M., & Parkinson, K.N. (2011). Is baby-led weaning feasible? When do babies first reach out for and eat finger foods? Maternal and Child Nutrition, 7(1):27-33.

Iron-rich complementary foods help to prevent iron deficiency.

• Continue to recommend a variety of iron-rich foods, such as meat and meat alternatives and iron-fortified cereal.
• If parents and caregivers are introducing cow milk, advise them to delay until nine to 12 months of age. Limit cow milk to 500-750 mL (2-3 cups) per day.

Rationale

After six months, an infant's iron stores are depleted. Iron-rich, complementary foods should be introduced to reduce the risk of iron deficiency (Butte et al., 2002; Dewey & Chaparro, 2007; Meinzen-Derr et al., 2006). The risk of iron deficiency increases during the second six months and the second year. This is because rapid growth during this time dictates higher iron needs (IOM, 2001). Moreover, studies suggest that the nutritional quality of children's diets and their consumption of key micronutrients, including iron, tend to decline during the second year (Picciano et al., 2000).

In Canada, the prevalence of iron deficiency anemia is estimated at 4% - 5% for infants and young children (Christofides, Schauer & Zlotkin, 2005). To generate a true, population-based assessment of iron deficiency and iron deficiency anemia, surveillance of iron status within groups or communities is required.

The major risk factors for iron deficiency anemia among healthy term infants are:

• race and ethnicity
• socio-economic status
• early introduction of cow milk
• excessive milk intake,
• prolonged exclusive breastfeeding
• prolonged bottle feeding (CPSP, 2011).

Emphasize prevention of anemia over treatment. There is an association between iron deficiency anemia and irreversible developmental delays in cognitive function (CPSP, 2011).

Iron-rich foods

The risk of iron deficiency can be reduced by the timely introduction and continued consumption of complementary foods high in bioavailable iron (Fomon, Nelson, Serfass & Zeigler, 2005). Between six and 12 months, infants should be offered iron-rich foods two or more times a day. During the second year, iron-rich foods should be offered at each meal, at least three or more times per day.

Grain products and cereals for infants and young children should be iron-fortified.The bioavailability of iron in meat is substantially higher than it is in non-heme iron sources such as cereals. Even small servings of meat, poultry, or fish contribute substantially to iron intake, because much of the iron in these foods is in heme form. Meat not only contains more absorbable iron, but it has also been shown to enhance absorption of non-heme iron by 150%. This occurs when meat and plant-based foods are eaten together (Engelmann et al, 1998a).

Daily consumption of foods rich in vitamin C, such as fruits and vegetables, can help to enhance iron absorption of non-heme iron. It is especially effective as a complement to iron-fortified cereals.

For children one year of age and older, iron-containing foods, such as meat and meat alternatives, and iron-fortified grain products provide iron in sufficient amounts. Supplemental iron is not generally required for young children unless the diet is lacking in these foods.

Cow milk introduction

Early introduction of cow milk has been negatively correlated with iron status in infants and young children. This is because milk is low in iron, displaces iron-rich foods, and inhibits iron absorption. It can also cause gastrointestinal bleeding and increased occult blood loss in stool (Fleischer Michaelsen, 2000; Fomon, Nelson, Serfass & Zeigler, 2005; Bondi & Lieuw, 2009; Ziegler et al., 1999; Jiang, Jeter, Nelson & Ziegler, 2000; Leung & Sauve, 2003; Rodrigues, Fernandes, Batista de Morais & Amancio, 2008).

To lower the risk of iron deficiency anemia, do not recommend cow milk before nine to 12 months of age. After nine months, when an infant is eating a wider variety of foods, including iron-rich meat and alternatives, and cereals, introducing cow milk is not associated with iron deficiency (Yeung & Zlotkin, 2000).

The amount of milk consumed by some young children may also increase their risk of iron deficiency (Maguire et al., 2013). Excessive consumption of cow milk has been identified as the most common risk factor for severe anemia in young children (Sandoval, Berger, Ozkaynak, Tugal & Jayabose, 2002; Bondi & Lieuw, 2009).

An excessive amount of cow milk for most young children is more than 750 mL per day (Kazal, 2002; CDC, 1998). At this volume, cow milk can displace other foods that are sources of nutrients not found in milk. In addition, fibre intake can be affected which could lead to constipation (CPS, 2011). If cow milk is introduced, it should be limited to no more than 750 mL per day for children younger than two years. Offering cow milk in an open cup can help avoid excess consumption (Maguire et al, 2013).

Goat milk has a similar composition to cow milk and poses the same risks for the development of iron deficiency in infants when consumed in excessive amounts by young children (CDC, 1998).

Iron deficiency

The terms 'iron deficiency', 'iron deficiency anemia' and 'anemia' are often used interchangeably. Technically, they are identified by different hematological indices. Iron deficiency occurs on a continuum and clinical symptoms may not be apparent until a deficiency is severe. Iron deficiency is far more common than iron deficiency anemia.

In the initial phase, iron depletion, iron stores (measured as serum ferritin) are reduced but functional iron is not affected. If iron depletion continues and stores continue to decline, transport iron is affected. This compromises the iron available to other tissues. In this stage, bone marrow iron is absent and serum ferritin is low.

As iron deficiency progresses, iron deficiency anemia develops. This is a more severe stage, in which the shortage of iron results in biochemical changes. Numerous hematological changes include reduced production of iron-containing compounds such as red blood cells. In this phase, there are also more observable symptoms in infants, such as pallor, poor appetite, irritability, and slowed growth and development.

Brief questions can help identify infants at risk of dietary deficiency (Williams & Innis, 2005). Before conducting a more invasive investigation of iron deficiency, consider developing questions from the following factors:

• The infant's iron endowment at birth
• Infant's growth rate
• History of feeding breastmilk or commercial infant formula
• Age of introduction to cow milk, and frequency and amount consumed
• Age of introduction to solid foods
• Age of introduction of heme-containing meat, fish, and poultry, and frequency of consumption (Williams & Innis, 2005)

If an infant is identified as at risk they may benefit from medicinal iron drops from six months of age. Alternatively, these infants can be screened for iron deficiency anemia between six and twelve months of age (Rourke, Rourke & Leduc, 2011).

Iron deficiency is not the only cause of anemia. For this reason, measurement of hemoglobin alone lacks specificity and sensitivity as a measure of iron status (IOM, 2001). No one biochemical measurement is available to identify either iron deficiency or iron deficiency anemia. Ideally, hemoglobin measurement should be combined with other measures of iron status such as:

• serum ferritin
• transferrin saturation
• zinc protoporphyrin
• serum transferrin receptor 1 concentration (TfR1)
• reticulocyte hemoglobin concentration (CHr)
• mean corpuscular volume (Baker, Greer & AAP Committee on Nutrition, 2010).

Currently, hemoglobin and serum transferrin are the most widely used indicators of iron status (Domellof, 2007).

References

Baker, R., Greer, F. & the Committee on Nutrition (2010). Clinical report - Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics, 126(5), 1040-1050. doi:10.1542/peds.2010-2576

Bondi, S. & Lieuw, K. (2009). Excessive cow's milk consumption and iron deficiency in toddlers: Two unusual presentations and review. Infant, Child and Adolescent Nutrition, 1(3), 133-139.

Butte, N., Lopez-Alarcon, M., & Garza, C. (2002).  Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva: World Health Organization. Retrieved from WHO website: http://whqlibdoc.who.int/publications/9241562110.pdf

Canadian Paediatric Surveillance Program [CPSP] (2011).  Iron-deficiency anemia in children. Retrieved from: http://www.cpsp.cps.ca/uploads/publications/RA-iron-deficiency-anemia.pdf

Centers for Disease Control and Prevention (CDC) (2002). Iron deficiency in the United States, 1999-2000. MMWR, 51(40, 897-899. Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/mmwr/PDF/wk/mm5140.pdf

Centers for Disease Control and Prevention (CDC) (1998).  Recommendations to prevent and control iron deficiency in the United States. MMWR, 47(RR-3), 1-36). Retrieved from Centers for Disease Control and Prevention website: www.cdc.gov/mmwr/preview/mmwrhtml/00051880.htm

Christofides, A., Schauer, C., & Zlotkin, S.H. (2005). Iron deficiency anemia among children: Addressing a global public health problem within a Canadian context. Paediatrics and Child Health, 10, 597-601.

Coleman, B. (2006). Early introduction of non-formula cow's milk to southern Ontario infants. Canadian Journal of Public Health, 97(3), 187-190.

Canadian Paediatrics Society Community Paediatrics Committee (CPS). (2011). Managing functional constipation in children. Paediatr Child Health, 16(10): 661-665.

Dewey, K. & Chaparro, C. (2007). Symposium on ‘Nutrition in early life: New horizons in a new century.' Session 4: Mineral metabolism and body composition. Iron status of breast-fed infants. Proceedings of the Nutrition Society, 66, 412-422.

Domellof, M. (2007). Iron requirements, absorption and metabolism in infancy and childhood. Current Opinion in Clinical Nutrition & Metabolic Care, 10(3), 329-335.

Engelmann, M, Davidsson, L, Sandstrom, B, Walczyk, T, Hurrell, R, & Michaelsen, K. (1998). The influence of meat on nonheme iron absorption in infants. Pediatric Research, 43(6), 768-773.

Fleischer Michaelsen, K. (2000). Cow's milk in complementary feeding. Pediatrics, 106(5), 1302-1303.

Fomon, S., Nelson, S., Serfass, R., & Zeigler, E.E. (2005). Absorption and loss of iron in toddlers are highly correlated. Journal of Nutrition, 135, 771-777.

Hurrell, R & Egli, I. (2010). Iron bioavailability and dietary reference values. American Journal of Clinical Nutrition, 91, 1461S-1467S.

Institute of Medicine (2001). Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc. Washington: National Academy Press.

Jiang, T., Jeter, J., Nelson, S., & Ziegler, E. (2000). Intestinal blood loss during cow milk feeding in older infants. Archives of pediatrics and adolescent medicine, 154, 673-678.

Kazal, L.A. (2002). Prevention of iron deficiency in infants and toddlers. Am Fam Physician. 66(7):1217-1225.

Leung, A. & Sauve, R. (2003). Whole cow's milk in infancy. Paediatrics and Child Health, 8(7), 419-421.

Maguire, J., Lebovic, G., Kandasamy, S., Khovratovich, M., Mamdani, M., Birken, C., & Parkin, P. (2013). The relationship between cow's milk and stores of vitamin D and iron in early childhood. Pediatrics, 131:e144 - e151.

Meinzen-Derr, M., Guerrero, L., Altaye, M., Ortega-Gallegos, H., Ruiz-Palacios, G., & Morrow, A. (2006). Risk of infant anemia is associated with exclusive breast-feeding and maternal anemia in a Mexican cohort. Journal of Nutrition, 136, 452-458.

Picciano, M., Smiciklas-Wright, H., Birch, L., Mitchell, D., Murray-Kolb, L., & McConahy, K. (2000). Nutritional guidance is needed during dietary transition in early childhood. Pediatrics, 106, 109-114. doi: 10.152/peds.106.1.109

Rourke, L., Rourke, J., & Leduc, D. (2011). Rourke baby record: Evidence-based infant/child health maintenance. Retrieved from: http://rourkebabyrecord.ca/pdf/RBR2011Nat_Eng.pdf

Rodrigues Fernandes, S., Battista de Morais, M., & Amancio, O. (2008). Intestinal blood loss as an aggravating factor of iron deficiency in infants aged 9 to 12 months fed whole cow's milk. Journal of Clinical Gastroenterology, 42(2), 152-156.

Sandoval, C., Berger, E., Ozkaynak, M.F., Tugal, O., & Jayabose, S. (2002). Severe iron deficiency anemia in 42 pediatric patients. Pediatric Hematology and Oncology, 19, 157-161.

Williams, P.L., Innis, S.M. (2005). Food Frequency Questionnaire for assessing infant iron nutrition. Canadian Journal of Dietetic Practice and Research, 66(3): 176-182.

Yeung, G., & Zlotkin, S. (2000). Efficacy of meat and iron-fortified commercial cereal to prevent iron-depletion in cow milk-fed infants 6 to 12 months of age: A randomized controlled trial. Canadian Journal of Public Health, 91(4), 263-267.

Ziegler, E., Jiang, T., Romero, E., Vinco, A., Frantz, J. & Nelson, S. (1999). Cow's milk and intestinal blood loss in late infancy. Journal of Pediatrics, 135, 720-726.

Foods offered to infants and young children must be prepared, served and stored safely.

• Ensure infants and young children are always supervised during feeding.
• Avoid hard, small and round, or smooth and sticky solid foods. These may cause aspiration and choking.
• Promote safe food preparation and storage to prevent food poisoning. Counsel to avoid products containing raw or undercooked eggs, meat, poultry, or fish. Avoid cross-contamination between cooked and uncooked foods.
• Prevent infant botulism by not giving honey to a child under one year of age.

Rationale

Foods provided to infants must be free of pathogens, appropriate in size and texture, and fed safely.

Supervision

Parents and caregivers should supervise infants and young children when eating. They should ensure they are sitting upright. They should not be lying down, walking, running or distracted from the task of safe eating. To help ensure proper supervision while eating, include infants and young children in family meal times.

The most common injuries associated with bottles, pacifiers, and sippy cups, among young children occur when they fall while using these products. The most common injuries are lacerations to the mouth (AAP, 2012). Young children who are just learning to walk and run are at highest risk of these injuries. Health care practitioners should promote the proper use of these products. At the same time, they should increase awareness of the recommendation to transition to an open cup, with the child remaining seated while drinking (AAP, 2012).

Eating in a moving vehicle is considered unsafe. If choking should occur, it is difficult to attend to the child while driving or pull over to the side of the road safely (Pipes & Trahms, 1993). There are safety risks if the driver has to cross lanes to reach the side of the road, get out of the car in moving traffic, or perform emergency care on a busy road. There is also an increased risk of choking if the car stops suddenly.

Choking and aspiration

Parents and caregivers can reduce the risk of choking if they:

• are aware of their young child's chewing and swallowing abilities
• supervise them while eating
• avoid offering foods with the potential to cause choking
• know how to handle choking if it occurs.

Hard, small and round, smooth and sticky solid foods can block a young child's airway (CPS, 2012; Rourke, Rourke &Leduc, 2011). The following foods are not safe for children under four years of age: popcorn, hard candies or cough drops, gum, marshmallows, raisins, peanuts or other nuts, seeds, fish with bones, and snacks using toothpicks or skewers (CPS, 2012; AAP, 2010). The following foods are safer for infants and young children when they are prepared as described: sausages and hot dogs diced or cut lengthwise, grated raw carrots or hard fruit (e.g. apple) pieces, fruits with pits removed, chopped grapes, and peanut butter spread thinly on crackers or bread. Peanut butter served alone, or on a spoon, is potentially unsafe because it can stick in the palate or posterior pharynx and form a seal that is difficult to dislodge, leading to asphyxia (AAP, 2010).

It is not possible to prevent all choking incidents. Encourage parents and caregivers to get training in choking first aid and cardiopulmonary resuscitation (AAP, 2010).

Safe preparation and storage

Infants and young children are vulnerable to food-borne illness. Safe food preparation and storage is very important to reduce the risk. Refer to Health Canada's Food Safety Information for Children Ages 5 & Under.

Bacteria such as E. coli, Salmonella and Listeria monocytogenes can be destroyed when foods are heated to a safe internal cooking temperature. Raw or undercooked meat, poultry, or fish should never be offered to infants and young children.

Avoid raw or lightly cooked eggs and foods containing raw or lightly cooked eggs, such as homemade mayonnaise, sauces and dressings, homemade ice cream and mousses to prevent salmonellosis (Health Canada, 2006). Also, cracks in egg shells can allow the transfer of Salmonella from the shell surface to the egg contents. Eggs contaminated with Salmonella bacteria may cause salmonellosis.

Infant botulism

Infant botulism is a rare disease that can affect otherwise healthy children under one year of age. It is caused by a bacterium called Clostridium botulinum. When swallowed, spores of this bacterium can grow and produce poison in an infant's intestines. Symptoms include constipation, general weakness, a weak cry, a poor sucking reflex, irritability, lack of facial expression, and loss of head control. In some cases, an infant may have trouble breathing due to paralysis of the diaphragm.

In Canada, honey is the only food that has been directly implicated in infant botulism (Health Canada, 2009). Less than 5% of the honey produced in Canada contains Clostridium botulinum spores, and usually the number of spores is low (Health Canada, 2009). However, even a small number of spores can cause infant botulism. There may be no visible signs or smell. The risk is present in both pasteurized and non-pasteurized honey because the process of pasteurizing honey does not use temperatures high enough to kill the spores. There is also technically a risk with products that contain honey such as baked goods as the cooking process is not sufficient to destroy the bacterium. In Canada, there were only 42 reported cases of infant botulism between 1979 and the end of 2006, however, only three cases have been linked to the consumption of honey. Corn syrup has never been directly implicated in a case of infant botulism.

Parents and caregivers should not give honey to a child less than one year old. They should not add honey to infant food, or use honey on a pacifier or soother.

References

American Academy of Pediatrics (2012). Injuries associated with bottles, pacifiers, and sippy cups in the United States, 1991-2010. Pediatrics, 129(6): 104-110.

American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention (2010). Policy statement - Prevention of choking among children. Pediatrics, 125 (3): 601-607.

Canadian Paediatric Society, Injury Prevention Committee. (2012). Position statement - Preventing choking and suffocation in children. Paediatr Child Health, 17(2): 1-6.

Health Canada (2009). Infant botulism - It's your health. Retrieved from: http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/diseases-maladies/botu-eng.php

Health Canada (2006). It's your health - Salmonella prevention. Retrieved from: http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/food-aliment/salmonella-eng.php

Rourke, L., Rourke, J., & Leduc, D. (2011).  Rourke baby record: Evidence-based infant/child health maintenance. Retrieved from: http://rourkebabyrecord.ca/pdf/RBR2011Nat_Eng.pdf

Young children can begin to have regular meals and snacks based on Canada's Food Guide.

• Ensure young children are offered a variety of foods from the four food groups each day.
• Recommend foods prepared with little or no added sugar or salt.
• Explain to parents and caregivers that nutritious foods that are higher in fat should not be restricted.
• Advise limiting fruit juice and sweetened beverages. Encourage offering water to satisfy thirst.
• Encourage parents and caregivers to be role models and instill lifelong healthy eating habits.

Rationale

By one year of age, young children should be consuming a variety of foods from the different food groups of Canada's Food Guide. When possible, children should share mealtimes and snack times with other members of the family.

Variety

To prevent nutrient deficiencies, parents and caregivers should offer a variety of foods daily from the four food groups in Canada's Food Guide. Most young children, if offered a varied diet from each of the food groups, will consume adequate amounts of nutrients and energy (Steyn, Nel, Nantel, Kennedy, & Labadarios, 2006). If they are not offered foods from all food groups on a regular basis, it is not possible for young children to self-select a nutritionally adequate diet. No single food, even if it is perceived as healthy and nutritious, should be consumed to excess (Bondi & Lieuw, 2009; Skinner, Ziegler, & Ponza, 2004).

Based on the estimated average breastmilk intake in the second year (WHO, 1998), nearly two thirds of a young child's energy requirements are provided by complementary foods (WHO, 2009; PAHO, 2003). Frequent, nutrient-dense meals and snacks are important to meet a young child's nutrient and energy needs. Encourage parents and caregivers to offer young children two to four meals per day and one to two small snacks (WHO, 2007).

Over the course of the second year, parents and caregivers should work up to offering the amounts and types of foods recommended at two years of age in Canada's Food Guide. This entails:

• 4 servings of vegetables and fruit
• 3 servings of grain products
• 2 servings of milk and alternatives
• 1 serving of meat and alternatives.

View a Sample Menu developed for a family with a 17 month old with examples of nutritious meals and snacks for children at this age (WHO, 2009; PAHO, 2003; IOM, 2001).

Limiting added sugar and salt

Added sugar and salt should be avoided when preparing food for infants and young children. Plain foods, prepared simply, allow young children to experience food's natural flavours.

Health Canada's Food and Drug Regulations have strict limits on sodium, food additives, and the addition of vitamins and minerals to certain infant foods intended for those under 12 months of age. However there are no regulations on sugars in foods intended for infants.

When choosing prepackaged and prepared foods, encourage parents and caregivers to read and compare the Nutrition Facts table on food labels and choose foods lower in salt (sodium). The ingredient list on food labels can use different words for added sugars, salt or seasoning. Encourage parents and caregivers to review the ingredient list on prepackaged products to help identify and limit these foods.

Dietary fat

Dietary fat restriction during the first two years is not recommended. This is because it may compromise a child's intake of energy and essential fatty acids (omega-3 and omega-6 fats). This can adversely affect growth and development (Butte et al., 2004). There is no evidence that such restrictions provide any benefits during childhood. Nutritious foods that contain fat, such as breastmilk, whole cow milk, cheese, avocado and nut butters, provide a concentrated energy source for young children during a life stage when their requirements are particularly high.

Fish, and breastmilk, depending on the mother's dietary intake, are sources of the omega-3 fats EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) (Butte et al., 2004). These are produced by the body only in small amounts from other dietary fats. The optimal amount of EPA and DHA for infants and young children has not been determined.

Advise, however, that certain types of fish should be avoided because of the risk of overexposure to mercury. These fish include fresh tuna and canned white tuna, shark, and swordfish. Learn more from the advisory from Health Canada.

Fruit juices and sweetened beverages

Children aged one to three years form the highest percentage of fruit juice consumers (Garriguet, 2008). About 60% of them reported drinking fruit juice. However, the consumption of sweetened beverages was relatively lower. Less than 30% of young children reported drinking fruit drinks and less than 10% reported drinking soft drinks.

One survey indicated that the percentage of children who consumed fruit juice more than doubled between six months of age and one year (from 33% to 77%) (Grummer-Strawn, Scanlon & Fein, 2008). In the same age groups, the increase in the percentage of children who consumed sweetened beverages, such as soft drinks and fruit drinks, was larger (from 3% to 15%).

Fruits and vegetables should be emphasised instead of juice as recommended in Canada's Food Guide. Fruit juice lacks the fiber of whole fruit. Because of the fructose and sorbitol content of fruit juices, excessive intake may lead to diarrhea (AAP, 2001). In addition, fruit juice intake can displace intake of breastmilk and it may contribute to inadequate intakes of needed nutrients (Skinner, Ziegler & Ponza, 2004).

Parents and caregivers should delay offering juice until an infant is able to drink from an open cup. Only 100% fruit or vegetable juice should be offered. If offered, intake should be limited to no more than one or two offerings per day. Based on infants energy needs, approximate daily amount could be 125-175 ml/d (AAP, 2001). Recommend water to satisfy thirst, or anticipated thirst. Sweetened beverages, such as fruit drinks and punches, should be avoided for this age group.

Being a role model

Parents, caregivers, and peers influence a child's food preferences and eating habits (CPS, 2012). The early childhood years are a time to discover new foods and to develop an appreciation for healthy eating. Parents and caregivers play a role in a child's acceptance of a wider variety of foods (CPS, 2012; Addessi, Galloway, Visalberghi, & Birch, 2005).

Eating with the family is important to help young children develop healthy eating patterns and learn skills through imitation (CPS, 2012). Young children will be more likely to enjoy a variety of foods and try new foods they eat along with the rest of the family.

Young children can also be involved from an early age in preparing foods. They can, for example, pick or wash vegetables or stir a mix (Chu et al., 2012). This builds on their curiosity and eagerness to learn and helps to create positive eating environments and attitudes.

References

Addessi, E, Galloway, A.T., Visalberghi, E., & Birch, L.L. (2005). Specific social influences on the acceptance of novel foods in 2-5-year-old children. Appetite, 24(3): 264-271.

American Academy of Pediatrics (AAP) Committee on Nutrition (2001). The use and misuse of fruit juice in pediatrics. Pediatrics, 107(5), 1210-1213.

Bondi, S. & Lieuw, K. (2009). Excessive cow's milk consumption and iron deficiency in toddlers: Two unusual presentations and review. Infant, Child and Adolescent Nutrition, 1(3), 133-139.

Butte, N., Cobb, K., Dwyer, J., Graney, L., Heird, W., & Rickard, K. (2004). The start healthy feeding guidelines for infants and toddlers. The American Dietetic Association, 104(3): 442-454.

Canadian Paediatric Society, Nutrition and Gastroenterology Committee (2012). The 'picky eater': The toddler or preschooler who does not eat. Paediatr Child Health, 17(8). 455-457.

Chu, Y.L., Farmer, A., Fung, C., Kuhle, S., Storey, K.E, Veugelers, P.J. (2012). Involvement in home meal preparation is associated with food preference and self-efficacy among Canadian children. Public Health Nutrition, 16(1): 108-112.

Guarriguet, D. (2008)  Beverage consumption of children and teens. Health Reports, 19(4). Retrieved from: http://www.statcan.gc.ca/pub/82-003-x/2008004/article/6500228-eng.htm

Grummer-Strawn, L., Scanlon, K., & Fein, S. (2008). Infant feed and feeding transitions during the first year of life. Pediatrics, 122, S36-S42.

Health Canada (2007). Eating well with Canada's Food Guide - A resource for educators and communicators. Ottawa: Minister of Health Canada.

Institute of Medicine (1991). Nutrition during lactation. Washington, DC: National Academy Press.

Pan American Health Organization (2003).  Guiding Principles for complementary feeding of the breastfed child. Retrieved from: http://whqlibdoc.who.int/paho/2003/a85622.pdf

Skinner, J., Ziegler, P., & Ponza, M. (2004). Transition in infants' and toddlers' beverage patterns. Journal of the American Dietetic Association, 104, S45-S50.

Steyn, N.P., Nel, J.H., Nantel, G., Kennedy, G., & Labadarios, D. (2006). Food variety and dietary diversity scores in children: Are they good indicators of dietary adequacy? Public Health Nutrition, 9(5): 644-650.

World Health Organization (2009).  Model chapter for textbooks for medical students and allied health professionals. Retrieved from: http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf

WHO/UNICEF (1998).  Complementary feeding of young children in developing countries: A review of current scientific knowledge. WHO/NUT 98.1, Retrieved from: http://whqlibdoc.who.int/hq/1998/WHO_NUT_98.1.pdf

Recommendations on the use of breastmilk substitutes

Some infants may not be breastfed for personal, medical, or social reasons. Their families need support to optimize the infant's nutritional well-being. The International Code of Marketing of Breast-milk Substitutes (WHO, 1981) advises health professionals to inform parents about the importance of breastfeeding, and the personal, social and economic costs of formula feeding. Individually counsel those families who have made a fully informed choice not to breastfeed on the use of breastmilk substitutes.

For an infant who is not breastfed or receiving breastmilk:

• Recommend commercial infant formula until nine to 12 months of age.
• Advise pasteurized whole cow milk can be introduced at nine to 12 months of age. Skim milk is inappropriate in the first two years.
• Advise that, for most healthy children, there is no indication for the use of commercial formulas beyond one year of age.
• Advise that soy, rice, or other vegetarian beverages, whether or not they are fortified, are inappropriate alternatives to cow milk in the first two years.
• Avoid prolonged bottle feeding. Advise against giving bottles at night.

Rationale

Infant formula until nine to 12 months of age

For an infant who is not breastfeeding or receiving breastmilk, recommend commercial infant formula until nine to twelve months of age. Other beverages are not appropriate as an infant's main milk source before nine months of age. Such beverages include cow and goat milk. Once an infant is regularly consuming a variety of iron-rich foods, commercial infant formula can be replaced with pasteurized, whole cow milk.

Follow-up formulas are breastmilk substitutes designed for infants six to 12 months of age, when an infant is eating solid foods. Follow-up formulas have advantages when compared to cow milk. They supply more appropriate quantities of energy and nutrients, including essential fatty acids and iron. However, no superiority has been established when they are compared to the ‘starter' commercial infant formulas that the infant has been consuming in the first six months.

Formula after one year of age

For most healthy infants there is no indication for the use of commercial infant formula beyond one year of age (CPS, 2012). Weaning from the bottle should occur at the beginning of the second year (AAP, 2009).

By 12 months of age cow milk, along with nutritious family foods, will provide sufficient amounts of nutrients (Butte et al., 2004). In the second year it is estimated that about one third of a child's caloric intake comes from their milk source and the remaining two thirds from complementary foods (WHO, 2009; PAHO, 2003; IOM, 2001). View a Sample Menu developed for a family with a 17 month old with examples of nutritious meals and snacks for children at this age (WHO, 2009; PAHO, 2003; IOM, 2001). For a child who is not breastfed, 500 mL (2 cups) of cow milk should be offered daily as part of meals and snacks.

For a child who has been fed soy-based infant formula because they cannot be given cow milk-based formula for cultural, religious or health reasons such as galactosemia, they should continue to be fed soy-based commercial infant formula for the first two years. This is also the case for a vegan child under two years of age who is no longer breastfed.

Vegetarian beverages

Soy, rice, nut, or other vegetarian beverages, whether or not they are fortified, are inappropriate as the main milk source for non-breastfed children younger than two years of age. They are low in energy, fat, and often protein (Mangels & Messina, 2001; Cockell, Bonacci & Belonje, 2004; Imataka, Mikami, Yamanouchi, Kano, & Eguchi, 2004; Moilanen, 2004; Dunham & Kollar, 2006). These products do not contain adequate amounts of several vitamins and minerals (Mangels & Messina, 2001; Cockell, Bonacci, & Belonje, 2004; Imataka, Mikami, Yamanouchi, Kano, & Eguchi, 2004; Moilanen, 2004).

Rice or almond-based beverages are particularly low in protein. This is a concern for infants, since they typically obtain most of their protein from their milk source (Liu & Frieden, 2002; Venter, 2009). Rice milk has been linked to malnutrition or kwashiorkor when given to infants and young children (Keller, Shuker, Heimall, & Cianferoni, 2012). In addition, rice milk has been found to contain low levels of arsenic, leading to advice against its use for young children (Food Standard Agency, 2009; Venter, 2009).

Data suggests that the consumption of vegetarian beverages by infants and young children under two years of age is currently minimal (Siega-Riz, Kinlaw, Deming & Reidy, 2010).

Avoid prolonged bottle feeding

When introducing new liquids, other than formula, after six months of age, it is ideal to offer them in an open cup. Formula can continue to be offered in a bottle, as initially at this age, some infants may have difficulty consuming the same volumes with an open cup. The transition from bottle feeding to open cup feeding should occur no later than 18 months of age (IOM, 2011). This promotes mature oral and motor skill development (Morris & Klein, 2000). It can also help reduce the risks associated with long-term use of bottles such as the displacement of nutrient rich solid foods (Maguire, 2013).

References

American Academy of Pediatrics (2009). Pediatric Nutrition Handbook. 6th Edition. ed. Kleinman RE.

Butte, N., Cobb, K., Dwyer, J., Graney, L., Heird, W., & Rickard, K. (2004). The start healthy feeding guidelines for infants and toddlers. The American Dietetic Association, 104(3): 442-454.

Canadian Paediatric Society, Nutrition and Gastroenterology Committee (2012). The ‘picky eater': The toddler or preschooler who does not eat. Paediatr Child Health, 17(8). 455-457.

Cockell, K.A., Bonacci, G., & Belonje, B. (2004). Manganese content of soy or rice beverages is high in comparison to infant formulas. Journal of the American College of Nutrition, 23(2): 124-130.

Dunham, L., Kollar, L.M. (2006). Vegetarian eating for children and adolescents. Journal of Pediatric Health Care, 20(1):27-34.

Food Standards Agency (2009).  Survey of total and inorganic arsenic in rice drinks. Retrieved from: http://www.food.gov.uk/science/research/surveillance/fsisbranch2009/survey0209

Fox, MK, Pac, S, Devameu N, & Jankowski, L. (2004). Feeding Infants and Toddler Study: What foods are infants and toddlers eating? J.Am. Diet. Assoc., 104:S22-S30.

Institute of Medicine (IOM) (2011). Early Childhood Obesity

Prevention Policies. Washington, DC: The National Academies Press.

Imataka, G., Mikami, T., Yamanouchi, H., Kano, K., & Eguchi, M. (2004). Vitamin D deficiency rickets due to soybean milk. Journal of Pediatric and Child Health, 40(3): 154-155.

Keller, M.D., Shuker, M., Heimall, J., & Cianferoni, A. (2012). Severe malnutrition resulting from use of rice milk in food elimination diets for atopic dermatitis. Israel Medical Association Journal, 14(1): 40-42.

Liu, T. & Frieden, I.J. (2002). Rice dream nondairy beverages [1]. Archives of Dermatology, 138(6): 838.

Maguire, J., Lebovic, G., Kandasamy, S., Khovratovich, M., Mamdani, M., Birken, C., & Parkin, P. (2013). The relationship between cow's milk and stores of vitamin D and iron in early childhood. Pediatrics, 131:e144 - e151.

Mangels, A.R., Messina, V.(2001). Considerations in planning vegan diets: Infants.  Journal of the American Dietetic Association,  101(6): 670-677.

Moilanen, B.C. (2004) Vegan diets in infants, children and adolescents. Pediatrics in Review, 25 (5): 174 -176.

Morris, S.E., Klein, M.D. (2000). Pre-feeding skills: A comprehensive resource for mealtime development. 2nd ed. Tuscon, AZ: Therapy Skill Builders.

Siega-Riz,A.M., Kinlaw, A., Deming, D.M., & Reidy, K.C. (2010). Food consumption patterns of infants and toddlers: Where are we now? J Am Diet Assoc., 110(suppl 3):S38-S51.

Venter, C. (2009). Cow's milk protein allergy and other food hypersensitivities in infants. Journal of Family Health Care, 19(4): 128-134.

In practice: Talking to families about infant and young child nutrition

• What supports are important for women to continue breastfeeding after returning to the workplace or school?
• How can women be supported to feel comfortable breastfeeding in public places?
• At what age can children transition from whole milk to low fat milk (such as skim, 1% or 2% cow milk)?
• How can parents be assured that their child is eating well?
• What advice can be given to parents on introducing new foods if they have concerns about food allergies?
• What guidance can be given for feeding a 'picky eater'?
• Is there advice for Aboriginal populations on food safety when offering infants traditional foods?
• Do healthy young children need nutritional supplements?
• What is the advice on vitamin D for children 1 year and older?
• Are there children who should continue with a vitamin D supplement after the first year?
• Is there any need for 'transition' or 'toddler' milks?
• Do vegetarian or vegan infants need supplements?
• How can parents and caregivers reduce the risk of early childhood carries?
• At what age should parents and caregivers offer other liquids to a breastfed child?
• References

What supports are important for women to continue breastfeeding after returning to the workplace or school?

A mother's return to full-time employment or school is strongly, negatively associated with breastfeeding duration (Hawkins et al., 2007). In Canada, parental benefits were extended in 2000 to allow about one year of job-protected, paid leave. However, women who are self-employed, work part-time, or who have not worked long enough, may not qualify for this extended leave (Heymann & Kramer, 2009). Some may not be able to afford the reduced rate of pay while on leave, and others choose to return to work for a variety of reasons before their child is one year old.

When mothers stop breastfeeding upon return to work or school, some believe that:

• they will be unable to maintain a milk supply
• breastfeeding will take too much time
• they will have discomfort when they are away from their infant (Johnston & Esposito 2007).

Studies also suggest that some mothers may stop breastfeeding because of unsupportive or hostile workplaces (Johnston & Esposito, 2009; Heymann & Kramer, 2009).

Mothers can successfully maintain breastfeeding with support from the workplace or school environment and appropriate child care arrangements (Johnston & Esposito, 2007; Hawkins, Griffiths, Dezateux, Law, & the Millennium Cohort Study Child Health Group, 2007; Heymann & Kramer, 2009). Factors which may support women and increase the duration of breastfeeding include:

• the availability of nearby child care
• the use of breast pumps to express milk
• flexible work and class schedules
• supportive family, friends, supervisors, and colleagues
• workplaces and schools that provide a comfortable and private place to express milk and a refrigerator for storage (Johnston & Esposito, 2007; Heymann & Kramer, 2009).

How can women be supported to feel comfortable breastfeeding in public places?

Health professionals can help to create supportive environments for breastfeeding by continuing to promote this practice as the normal way of feeding infants and young children. At the child's regular medical appointments, the health professional can affirm the choice to breastfeed beyond infancy and into early childhood.

The right of women to breastfeed anytime and anywhere is protected under the law. Early weaning is a common practice in North American cultures; only a minority of people accept long-term breastfeeding. 'Closet nursing' describes a practice that has evolved in response to criticism of breastfeeding older infants and children (Riordan, 2010).

At what age can children transition from whole milk to low fat milk (such as skim, 1% or 2% cow milk)?

In general, continued breastfeeding or whole cow milk, which has 3.25% milk fat, is recommended for young children throughout the second year. However, partly skimmed, 2% milk is acceptable provided that the child is growing well and eating a wide variety and an adequate quantity of foods.

Convenience is the main rationale for offering partly skimmed milk at this age, since others in the household are drinking it. It is lower in essential fatty acids and energy compared to whole cow milk. There is a theoretical risk of growth faltering and essential fatty acid deficiency, particularly for children under one year, if such milk becomes a significant component of their daily intake. Skim milk, however, is an inappropriate choice for children less than two years. It provides no essential fatty acids and has a very low energy density.

Some households use evaporated whole or 2% milk, or powdered whole or partly skim milk. These are suitable milk alternatives, provided the products are properly diluted or reconstituted.

It is suitable to offer full-fat, fortified soy-based beverage at one year of age, as long as the child is growing normally and consuming a variety of foods, including breastmilk or cow milk (Dunham & Kollar, 2006). However, non-fat varieties should be avoided along with flavoured soy-based beverages (such as chocolate and vanilla), which contain added sugar.

How can parents be assured that their child is eating well?

Ensure that parents and caregivers are providing a variety of foods so their child can self-select a balanced diet to meet their energy and nutrient needs. If a breastfed infant doesn't seem to be getting enough breastmilk in the second six months, encourage mothers to take steps to increase breastfeeding with professional guidance. More solid foods can also be offered.

Discuss growth monitoring with parents and caregivers. This provides a tool for evaluating the health of infants and young children (Collaborative Statement, 2010). Reassure parents that each child has his or her own pattern of growth (Haskey, 2010). Regular measurements of the child's growth over time will indicate whether they are consuming adequate amounts of food.

What advice can be given to parents on introducing new foods if they have concerns about food allergies?

There is no evidence that the order in which solid foods are introduced to infants affects their risk of developing a food allergy, including for infants at risk of atopy (Boyce, 2010; AAP, 2008). Common food allergens, such as fish, wheat, dairy products and whole eggs, can be introduced from about six months of age. Ensure that any food offered to infants is an appropriate texture for their developmental age.

Suggest parents introduce new foods one at time. If an infant were to have an allergic reaction, it will be easier to identify, which food that may have caused the reaction. Every couple of days, an infant can be introduced to a new food.

What guidance can be given for feeding a 'picky eater'?

Young children's appetites vary, not only according to growth and activity, but also according to factors like fatigue, frustration, minor illnesses and social environment. Young children should be given small servings, along with the opportunity to ask for more (CPS, 2012).

It is quite common to have to offer a new food more than ten times before a child accepts it. Advise parents to keep offering these foods and wait for the child to try it on their own (Sullivan & Birch, 1994). Reassure parents that this behaviour is a normal, experimental phase of complementary feeding.

Encourage parents and caregivers to continue to offer a variety of nutritious foods at each meal, trying different food combinations, tastes and textures. Encourage them to create a positive mealtime environment using the principles of responsive feeding.

Is there advice for Aboriginal populations on food safety when offering infants traditional foods?

In these guidelines, it is recommended that parents and caregivers "Do not offer products containing raw or undercooked eggs, meat, poultry or fish." In some Aboriginal cultures in Canada, in particular Inuit culture, traditional or 'country' foods are consumed raw or frozen. Traditional foods have significant nutritional, social, cultural and spiritual values, and the socio-cultural aspects of traditional food harvesting, processing, sharing and consumption are an important part of individual and community health and well-being. Encourage families to seek advice from knowledgeable elders and follow traditional practices to help reduce the risk of food borne illness.

Do healthy young children need nutritional supplements?

For most healthy young children nutritional supplements are not required. The Food and Drug Regulations (Part B, Section B.01.001) define a nutritional supplement as 'a food sold or represented as a supplement to a diet that may be inadequate in energy and essential nutrients.' Nutritional supplements are available for young children aged 1 year and above. When a child's diet may be inadequate in energy or essential nutrients, the child should be referred to a clinician. This might be appropriate, for instance, if the child is a picky eater (CPS, 2012a) or if a young child is falling off the growth chart (CPS, 2012b). Multivitamin and mineral supplements, aside from sometimes vitamin D and iron, are also generally not needed for healthy young children.

What is the advice on vitamin D for children 1 year and older?

Ensure young children are offered vitamin D-rich foods each day. Vitamin D is an essential nutrient. It helps the body use calcium and phosphorous to build and maintain strong bones and teeth (IOM, 2011). It is important that the diets of older infants and young children include vitamin D rich foods to ensure adequate dietary intake of this nutrient and to minimize risks to bone health such as rickets.

A daily vitamin D supplement is currently recommended from birth to one year for all breastfed infants. Infants who are not breastfed do not require a vitamin D supplement because commercial infant formula and cow milk have vitamin D added during manufacturing.

For young children, 12 months of age and older, encourage parents and caregivers to offer children vitamin D-rich foods, including cow milk, each day. In addition, young children should frequently be offered food sources of vitamin D, such as fish, egg yolks, soft margarine, bread made with vitamin D-enhanced yeast, and yogurt or cheese made from fortified milk. When choosing prepackaged and prepared foods, encourage parents and caregivers to read and compare the Nutrition Facts table on food labels and choose foods higher in vitamin D.

Because there are very few naturally-occurring food sources of vitamin D, the major contributors to dietary intake are fortified foods. To help address the current issue of limited vitamin D in the food supply, an evaluation is being conducted by Health Canada to determine if changes are needed to the current fortification policy.

There are no national estimates on the vitamin D blood status of infants or children under three years of age. However, available data on serum 25-hydroxyvitamin D (25OHD) levels for young children three to five years of age suggest that rates of vitamin D deficiency are low (Statistics Canada, 2012). National Canadian survey data (excluding those living on-reserve and in the Territories), based on a one-day diet recall, indicated that 87% of boys and 88% of girls aged one to three years regularly consumed an average of 500 mL of cow milk per day (Garriguet, 2008).

If parents and caregivers offer young children 500 mL of cow milk per day, it will contribute to adequate dietary vitamin D intake. This advice is in line with usual consumption patterns for this age group and will also contribute to adequate intakes of calcium. While 500 mL of cow milk a day is important for vitamin D intake, any amount in excess of 750 mL per day may pose a risk to iron status (Maguire et al., 2013).

Are there children who should continue with a vitamin D supplement after the first year?

Young children who do not consume cow milk may benefit from continuing to receive a daily vitamin D supplement of 400 IU (10 µg) until their daily diet regularly includes vitamin D from other dietary sources. Excessive intake is not a concern for children who continue to take a vitamin D supplements. Total intake for this nutrient is unlikely to approach the Tolerable Upper Intake Level of 2500 IU per day (IOM, 2011).

Is there any need for 'transition' or 'toddler' milks?

In general, no 'Growing-up milks' or 'toddler milks' are marketed as an alternative or complement to cow milk for children older than 12 months of age (Crowley & Westland, 2011). They claim advantages over cow milk (Bohles et al., 2011). These milks are based on cow milk ingredients, and include other, non-milk ingredients. Currently, there are no regulations governing the nutrient content of 'toddler' or 'growing up' milks. Various countries are working to develop such regulations (Codex Alimenatarius Commission, 2011). If parents and caregivers nonetheless offer these milks instead of cow milk, they should check that the nutritional composition is similar to that of cow milk and that they contain key nutrients, including calcium and vitamin D, in comparable amounts to cow milk (Bohles et al., 2011).

Do vegetarian or vegan infants need supplements?

For vegetarian diets that are limited in variety and nutritional quality, professional advice regarding supplements is appropriate. After dietary assessment, nutrient supplements should be recommended for vegetarian diets which are found to be nutritionally incomplete.

With careful planning by knowledgeable parents and caregivers, vegetarian diets can meet all the nutritional requirements of a growing child, provided they include milk products and eggs (Van Winckel, Vande Velde, De Bruyne, & Van Biervliet, 2011; ESPGHAN, 2008). However, there is an increased risk of nutrient deficiencies for young children with more restricted diets (Van Winckel, Vande Velde, De Bruyne, & Van Biervliet, 2011). Special attention should be given to vegetarian children's intake of calcium, zinc, iron, vitamin D, and vitamin B12.

An infant or young child who is fed a vegan diet, which excludes any animal-based foods, may benefit from consultation with a dietitian.

How can parents and caregivers reduce the risk of early childhood caries?

Early childhood caries is the most common infectious disease in children. It tends to develop well in advance of a child's first dental visit. It can lead to infection, eating difficulties, and numerous other dental and social problems (Anderson, Cooney, & Quinonez, 2008).

Prevalence of dental caries is lower where infants and children have access to fluoridated water. Fluoridation of the water supply is the most effective, cost efficient means of preventing dental caries. Recommend fluoride supplements in areas with low fluoride levels in the water source.

Parents and caregivers can also reduce the risk of early childhood caries by avoiding night time and long-term use of baby bottles containing any liquids other than water (ADA, 2004). Children who fall asleep with a bottle in their mouth are at significantly greater risk of caries than infants who discard the bottle before falling asleep (Schwartz, Rosivack, & Michelotti, 1993). When an infant is asleep, liquid can pool in the mouth, and salivary flow and oral cleaning are diminished (Kagihara, Niederhauser, & Stark, 2009).

Drinking juice has been associated with dental decay in young children (AAP, 2001). Encourage parents and caregivers to limit juices and sweetened beverages. If they are offered, it should be at mealtime and in an open cup. Allowing children to carry a bottle or juice box around throughout the day encourages constant consumption and over exposure of the teeth to sugar-containing liquids (AAP, 2001). If a child is thirsty between meals, it is best to offer water (ADA, 2004).

At what age should parents and caregivers offer other liquids to a breastfed child?

From about six months of age, infants can be offered water from an open cup along with complementary feedings. At first, they will need help with the cup. Parents and caregivers can offer small amounts of 100% fruit juice during the second six months, but it is better to offer pieces of whole fruit and vegetables instead. Cow milk can be offered from nine to 12 months.

Any beverages, such as sodas, fruit drinks, punches, and sport drinks are not recommended for infants and young children, because of their high sugar content and lack of micronutrients. Like fruit juice, these drinks increase the risk of early childhood caries.

Infants and young children should not have beverages containing caffeine and caffeine-related substances. Caffeine acts as a stimulant drug in the body. Coffee, tea, some carbonated beverages such as colas, and hot chocolate contain these substances.

Infants and young children should not have beverages containing artificial sweeteners such as aspartame. These sweeteners may interfere with intake of the nutritious, energy-dense foods they need because of their rapid growth.

References

American Academy of Pediatrics Committee on Nutrition (2001). The use and misuse of fruit juice in pediatrics. Pediatrics, 107(5): 1210-1213.

American Academy of Pediatrics (2008). Effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics, 121; 183-191.

American Dental Association [ADA] (2004). From baby bottle to cup: Choose training cups carefully, use them temporarily. Journal of the American Dental Association, 135: 387.

Anderson, R.D., Cooney, P., & Quinonez, C.R. (2008). Your health care team, early childhood caries, and dental care policy. Oral Health, 18-20.

Boyce, J.A., Assa'ad, A., Burks, A.W., Jones, S.M., Sampson, H.A., Wood, R.A., Plaut, M., Cooper, S.F., Fenton, M.J., Arshad, S.H., Bahna, S.L., Beck, L.A., Byrd-Bredbenner, C., Camargo, C.A., Eichenfield, L., Furuta, G.T., Hanifen, J.M., Jones, C., Kraft, M., Levy, B.D., Lieberman, P., Luccioli, S., McCall, K.M., Schneider, L.C., Simon, R.A., Simons, F.E., Teach, S.J., Yawn, B.P., & Schwaninger, J.M. (2012) Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAIDSponsored Expert Panel. The Journal of Allergy and Clinical Immunology. 126(6):S1- S58.  Böhles, H.J.,  Fusch, C.,  Genzel-Boroviczény, O.,  Jochum, F.,  Kauth, T.,  Kersting, M.,  Koletzko, B.,  Lentze, M.J.,  Mihatsch, W.A.,  Przyrembel, H., &  Wabitsch, M. (2011). Composition and use of milk products for young children: Updated recommendations of the Nutrition Committee of the German Society of Pediatric and Adolescent Medicine (DGKJ). Monatsschrift fur Kinderheilkunde, 159(10): 981-984.

Canadian Paediatric Society, Nutrition Committee (2012a). The 'picky eater': The toddler or preschooler who does not eat. Paediatr. Child Health, 17(8):455-57.

Canadian Paediatric Society (2012b). Position Statement: The toddler who is falling off the growth chart. Paediatr. Child Health, 17(8):447-454

Codex Alimentarius Commission (2011). Proposal to review the Codex Standard for follow-up formula (Codex Stan 156-1987).

Crowley, H., Westland, S. (2011). Infant milks available in the UK. Abbots Langley, Hertfordshire: The Caroline Walker Trust.

Dietitians of Canada, Canadian Paediatrics Society, The College of Family Physicians of Canada, & Community Health Nurses of Canada (2010). Collaborative statement.  Promoting optimal monitoring of child growth in Canada: Using the new WHO growth charts. Retrieved from: http://www.cps.ca/tools/growth-charts-statement-FULL.pdf

Dunham, L. & Kollar, L. M. (2006). Vegetarian eating for children and adolescents. Journal of Pediatric Health Care, 20(1): 27-34.

European Society of Pediatric Gastroenterology, Hepatology and Nutrition, Committee on Nutrition (2008). Complementary feeding: A commentary by the ESPGHAN. Journal of Pediatric Gastroenterology and Nutrition, 46:99-110.

Fomon, S.J. (1993). Nutrition of normal infants. St. Louis, MO: Mosby-Year Book Inc.

Guarriguet, D. (2008)  Beverage consumption of children and teens. Health Reports, 19(4). Retrieved from: http://www.statcan.gc.ca/pub/82-003-x/2008004/article/6500228-eng.htm

Haskey, N. (2010).  Is my child growing well? Questions and answers for parents. Retrieved from: http://www.cps.ca/tools/Growth-Parents.pdf

Hawkins, S.S., Griffiths, L.J., Dezateux, C., Law, C., & the Millennium Cohort Study Child Health Group. (2007). The impact of maternal employment on breast-feeding duration in the UK Millennium Cohort Study. Public Health Nutrition, 10(9): 891-896.

Heymann, J., Kramer, M.S. (2009). Public policy and breast-feeding: A straightforward and significant solution. Can J Public Health, 100(5):381-383.

Institute of Medicine (2011). Dietary reference intakes for calcium and vitamin D. Washington DC: The National Academies Press.

Kagihara, L., Niederhauser, V.P., & Stark, M. (2009). Assessment, management, and prevention of early childhood caries. Journal of the American Academy of Nurse Practitioners, 21:1-10.

Johnston, M., Esposito, N. (2007). Barriers and facilitators for breastfeeding among working women in the United States. JOGNN, 2007. 36: 9-20

Maguire, J., Lebovic, G., Kandasamy, S., Khovratovich, M., Mamdani, M., Birken, C., & Parkin, P. (2013). The relationship between cow's milk and stores of vitamin D and iron in early childhood. Pediatrics, 131 :e144 - e151.

Mangels, A.R., Messina, V.(2001). Considerations in planning vegan diets: Infants.  Journal of the American Dietetic Association,  101(6): 670-677.

Moilanen, B.C. (2004) Vegan diets in infants, children and adolescents. Pediatrics in Review, 25 (5): 174 -176

Riordan, J., Wambach, K. (2010). Breastfeeding and human lactation. Sudbury MA.: Jones and Bartlett Publishers, Inc.

Schwartz, S.S., Rosivack, R.G., & Michelotti, P. (1993). A child's sleep habit as a cause of nursing caries. J Dent Child, 22-5.

Statistics Canada (2012).  Canadian health measures survey: Cycle 2 data tables distribution of vitamin D [(25-OH)] measured in plasma for the household population, by age and sex, Canada, 2009 to 2011. Retrieved from: http://www.statcan.gc.ca/pub/82-626-x/2012002/t058-eng.htm

Van Winckel, M., Vande Velde, S., De Bruyne, R., & Van Biervliet, S. (2011). Vegetarian infant and child nutrition. Eur J Pediatr, 170: 1489-1494.

What you can offer: Sample menus for families with older infants and young children

Important tips for families:

• These menus are only a guide. Follow your infant's hunger cues to decide when to feed him or her.
• Eat together as a family as often as you can. Offer infants and young children foods from the family meal.
• Keep breastfeeding on-cue, not just at mealtimes.
• Let infants decide how much they want to eat from the foods offered.
• When you start offering complementary foods, at six months, the amount an infant eats will be very small. For example, it may be a total of 30 - 45 mL or 2 to 3 tablespoons a day. Gradually increase the amount of food you offer. Pay attention to your child's appetite.
• Portion sizes for older infants and young children are roughly one quarter to one half on an adult portion. Examples include: 30 - 45 mL cooked vegetables, grains, meats or meat alternatives; 45 -75 mL soft fruit,  ½  medium egg; 60 - 125 mL prepared hot or cold cereal; 30 mL shredded cheese or yogurt; 125 mL milk; and ¼  to ½ toasts, muffin or pita.

Sample menu: What you can offer a seven-month old infant

Time of day	What you can offer
Early morning	Breastfeeding
Breakfast	Breastfeeding Iron-fortified infant cereal Mashed strawberries or other soft fruit
Snack	Breastfeeding Whole grain dry toast, cut into small pieces or strips
Lunch	Breastfeeding Ground or finely minced plain, dark chicken or other meat Cooked and mashed broccoli or other vegetable
Snack	Breastfeeding Unsweetened stewed (dried, then cooked) prunes
Supper	Breastfeeding Iron-fortified infant cereal Hard-boiled egg, mashed or finely minced or grated Cooked and mashed sweet potato or other vegetable
Snack	Breastfeeding

Sample menus: What you can offer an 11-month old infant

Time of day	What you can offer
Early morning	Breastfeeding	Breastfeeding	Breastfeeding
Breakfasts	Breastfeeding Iron-fortified infant cereal Cantaloupe, chopped	Breastfeeding Iron-fortified infant cereal Strawberries, chopped	Breastfeeding Iron-fortified infant cereal Kiwi, chopped
Snacks	Breastfeeding Whole grain bread, cut into strips Unsweetened stewed prunes	Breastfeeding Unsweetened o-shaped oat cereal Wild blueberries thawed from frozen	Breastfeeding Whole grain and fruit muffin Carrot, shredded
Lunches	Breastfeeding Chicken, chopped Steamed brown rice Cooked carrots and broccoli chopped	Breastfeeding Boneless salmon mashed Sweet potato mashed Green peas, cooked soft	Breastfeeding Roast turkey leg, chopped Whole grain bread, cut into strips Squash, mashed Canned peaches chopped
Snacks	Breastfeeding Cheddar cheese, shredded Whole wheat pita, cut into small strips	Breastfeeding Egg, hard-boiled egg, chopped Whole grain bread, cut into strips	Breastfeeding Soft tofu , chopped Blueberries, sliced in half Unsalted crackers
Suppers	Breastfeeding Lean pork roast, chopped Whole wheat pasta Cooked legumes, chopped Banana and strawberries, chopped	Breastfeeding Mixed dish: ground beef with tomatoes diced, and macaroni Unsweetened, stewed prunes	Breastfeeding Halibut, boned and flaked Steamed brown rice Cooked green peppers chopped Canned peaches chopped
Snacks	Breastfeeding	Breastfeeding	Breastfeeding

Sample menus: What you can offer a 17-month old child

Time of day	What you can offer
Early mornings	Continue to offer breastfeeding	Continue to offer breastfeeding	Continue to offer breastfeeding
Breakfasts	Unsweetened o-shaped oat cereal Whole grain toast Strawberries sliced or thawed from frozen Breastfeeding or homogenized milk from a cup or in cereal	Cooked oatmeal Blueberries cut in halves or wild blueberries thawed Egg, scrambled Breastfeeding or homogenized milk from a cup or in cereal	Whole grain toast Smooth peanut butter thinly spread on toast Banana, sliced Breastfeeding or homogenized milk from a cup
Snacks	Whole wheat English muffin Banana, sliced Water from a cup	Unsweetened o-shaped oat cereal Fruit cocktail Water from a cup	Whole grain tortilla Cheese, shredded Mango, chopped Water from a cup
Lunches	Whole wheat roll Salmon, boneless with mayonnaise Romaine lettuce Legumes chopped Unsweetened applesauce Breastfeeding or homogenized milk from a cup	Baked beans Whole wheat crackers Red and green peppers, cut in strips Cantaloupe or honeydew melon Breastfeeding or homogenized milk from a cup	Cooked quinoa Chopped chicken Carrot and cucumber, cut in thin strips Soft pear sliced Breastfeeding or homogenized milk from a cup
Snacks	Berries Plain rye crackers Water from a cup	Whole wheat pita, cut into strips Hummus Water from a cup	Unsweetened o-shaped oat cereal Plum, sliced Water from a cup
Suppers	Stewed beef, chopped Steamed brown rice Carrots, cooked, cut in strips Steamed broccoli chopped Canned peaches Breastfeeding or homogenized milk from a cup	Mixed dish: Macaroni with ground turkey and tomato, diced Green beans sliced Sweet potato mashed Breastfeeding or homogenized milk from a cup	Halibut, poached, boneless Roasted potato, chopped Steamed broccoli and cauliflower chopped Fruit cocktail in juice Breastfeeding or homogenized milk from a cup
Snacks	Whole grain muffin Mango or soft fruit, chopped Breastfeeding or homogenized milk from a cup	Plain yogurt Grapes, cut in halves Breastfeeding or homogenized milk from a cup	Whole wheat bread with soft margarine Strawberries sliced Breastfeeding or homogenized milk from a cup