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Food and Nutrition

Extracts from Nutrition for Healthy Term Infants, Statement of the Joint Working Group: Canadian Paediatric Society, Dietitians of Canada, Health Canada (2005).

Note: These guidelines are currently under review. Updated infant feeding recommendations for birth to six months of age are now available.

"Follow-up" Formulas

Like other infant formulas, follow-up formulas are regulated under the Canadian Food and Drug Regulations. Follow-up formulas are an alternative to cow's milk in the second 6 months of life when infants are already eating solid foods. Compared to cow's milk, follow-up formulas provide more appropriate quantities and forms of nutrients, including essential fatty acids, and of energy during this transition period. For example, compared to whole cow's milk, infants fed iron-fortified follow-up formula achieved better iron status (Fuchs et al., 1993). Also compared to cow's milk, follow-up formulas provide a lower renal solute load and contain fats that are better absorbed (Fuchs et al., 1992). The clinical significance of the latter has not been determined.

Although follow-up formulas have advantages compared to cow's milk, no superiority to starter formulas has been established.

References:

Fuchs, G., M. DeWier, S. Hutchinson et al. "Gastrointestinal blood loss in older infants: impact of cow milk versus formula". J. Pediatr. Gastroenterol. Nutr., 1993; 16:4-9.

Fuchs, G.J., A.S. Gastanaduy, R.M. Suskind. "Compara­tive metabolic study of older infants fed infant formula, transition formula, or whole cow's milk". Nutr. Res., 1992; 12:1467-78.

Pasteurized Cow's Milk

Due to risks of infection, non-pasteurized milk (cow's or goat's) is contraindicated. The quality and quantity of nutrients in cow's milk differ greatly from those of human milk and cow's milk does not contain many of the various growth and immunological factors found in human milk. With regard to nutrient content, cow's milk contains greater amounts of protein and minerals (calcium, phosphorus, sodium, chloride and potassium) and smaller amounts of essential fatty acids (linoleic and alpha-linolenic acid), zinc, vitamin C and niacin than human milk. The higher renal solute load of cow's milk results in a urine osmolality approximately two times higher than that observed in breastfed infants (Fuchs et al., 1992). Usually, there are no adverse clinical sequellae associated with the increased renal solute load; however, in an infant with increased water losses (e.g. diarrhea) and decreased intake (e.g. from vomiting), cow's milk may not supply enough free water (Fomon, 1993).

The use of pasteurized cow's milk is associated with occult blood loss in stool, especially in infants in the first 6 months of life. Recent studies suggest that after 6 months of age, occult blood loss in stool is unlikely to occur (Fuchs et al., 1993). Cow's milk has a low iron content and the iron is poorly absorbed. To lower the risk of iron deficiency anemia, cow's milk is not recommended before 9 to 12 months of age.

Skim Milk

Skim milk is an inappropriate milk choice during the first two years (Fomon, 1997). It provides no essential fatty acids and has a very low energy density. To meet energy needs, an infant would have to drink very large volumes of this milk. With high intakes, protein and solute intake would be significantly higher than the infant needs. Partially skimmed milk (1% or 2% fat) is also low in essential fatty acids and energy. To meet energy and essential fatty acid needs, the infant would have to eat a wide variety and adequate quantity of other foods. Approximately 15% of Canadian infants are on 2% milk around 1 year of age. Although there is no clear indication of negative consequences, there is no medical or nutritional indication to recommend the routine use of partially skimmed milk, other than convenience. There is, however, a theoretical risk of growth faltering and essential fatty acid deficiency when partially skimmed milk provides a significant component of the infants' daily intake. Therefore, while whole cow's milk (3.25% butterfat) continues to be recommended for the second year of life, 2% milk may be an acceptable alternative provided that the child is eating a variety of foods and growing at an acceptable rate.

References

Fuchs, G., M. DeWier, S. Hutchinson et al. "Gastrointestinal blood loss in older infants: impact of cow milk versus formula". J. Pediatr. Gastroenterol. Nutr., 1993; 16:4-9.

Fuchs, G.J., A.S. Gastanaduy, R.M. Suskind. "Compara­tive metabolic study of older infants fed infant formula, transition formula, or whole cow's milk". Nutr. Res., 1992; 12:1467-78.

Fomon, S.J. "Nutrition of Normal Infants". Mosby, St. Louis, 1993.

Fomon, S.J., L.T. Filer et al. "Skim milk in infants feeding". Acta Pediatrica Scand., 1997; 66:17-30.

"Other" Milks

Goat's milk

For the same reasons as cow's milk, pasteurized goat's milk  is not an appropriate milk choice for infants before 9 to 12 months of age (Taitz and Armitage, 1984). Unlike cow's milk, goat's milk may or may not be fortified with vitamin D (fortification will be indicated on the label). Because of cross-reactivity, infants who are allergic to cow's milk protein are also likely to have an allergic reaction to goat's milk (Fomon, 1993; Jeness et al., 1967; Saperstein, 1960). After 9 months of age, full-fat goat's milk may be used as an alternative to cow's milk (Razafindrakoto et al., 1994). If partly skimmed or skimmed goat's milk is ever used, a product with added vitamin A as well as vitamin D should be chosen.

Soy, rice and other vegetarian beverages

Soy, rice and other vegetarian beverages, whether or not they are "fortified," are not appropriate alternatives to breast milk or infant formula or to pasteurized whole milk in the first two years. "Fortified" vegetarian beverages will be fortified with vitamins A, D and B12, riboflavin, calcium and zinc, and may contain other vitamins and minerals. However, there are no minimum requirements for total fat or protein. Rice and vegetarian beverages other than soy contain virtually no protein and if used as a whole or major source of nutrition, may result in marasmus and failure-to-thrive (Muir and Kalnins, 1987).

References:

Fomon, S.J. "Nutrition of Normal Infants". Mosby, St. Louis, 1993.

Jeness, R., N. Phillip, E.B. Kalan. "Immunological comparison of beta-lactoglobulins". Fed. Proc., 1967; 26:340

Muir, A., D. Kalnins. "False advertising resulting in infant malnutrition". CMAJ, 1987; 136:1274-5.

Razafindrakoto, O., N. Ravelomana, A. Rasolofo et al. "Goat's milk as a substitute for cow's milk in under­nourished children: a randomized double-blind trial". Pediatrics, 1994; 94:65-9.

Saperstein, S. "Antigenicity of the whey proteins in evaporated cow's milk and goat's milk". Ann. Allergy, 1960; 18:765-73.

Taitz, L.S., B.L. Armitage. "Goat's milk for infants and children". ".Br. Med. J., 1984; 288:428-9.

Fruit Juices

Fruit juices provide a source of vitamin C, energy and some variety in infants' diet. If fruit juices are given to infants, the volume should be limited to avoid interfering with the intake of breast milk or infant formula.

Although a limited intake of fruit juices is a common and acceptable practice in Canada, excessive consumption may indirectly contribute to inadequate intakes of needed nutrients and energy (Smith and Lifshitz, 1994). Because of the sorbitol and fructose content of fruit juices, excessive intake may lead to diarrhea, poor weight gain and failure to thrive (Smith and Lifshitz, 1994). Certain types of juice are likely to increase the risk of diarrhea (Hockstra et al., 1995). A randomized, double-blind, cross-over study showed less carbohydrate malabsorption with sorbitol-free white grape juice compared to clear apple juice (Smith et al., 1995). Excessive fruit juice intake may also be associated with dental caries and nursing bottle syndrome (Navia, 1994).

References:

Hockstra, J.H., J.H.L. van den Aker, Y.F. Ghoos et al. "Fluid intake and industrial processing in apple juice-induced chronic non-specific diarrhea". Arch. Dis. Child, 1995; 73:126-30.

Navia, J.M. "Caries prevention in infants and young children: which etiologic factors should we address?" J. Public Health Dent., 1994; 54:195-6.

Smith M.M., Davis. F.I. Chasalow et al. "Carbohydrate absorption from fruit juice in young children". Pediatr., 1995; 95:340-4.

Smith, M.M., F. Lifshitz. "Excess fruit juice consumption as a contributing factor in nonorganic failure to thrive". Pediatrics, 1994; 93:438-43.

"Other" Beverages

Beverages containing caffeine and theobromine, a caffeine-related substance, are not recommended for infants. Caffeine and theobromine act as stimulant drugs in the body. Coffee, tea, some carbonated beverages such as colas, and hot chocolate contain these substances.

Sodas, fruit drinks, punches and sport drinks are not recommended for infants because of their high sugar content and lack of nutrients other than carbohydrates. As with fruit juice, intake of these foods may increase the risk of dental caries and nursing bottle syndrome.

Beverages containing artificial sweeteners such as aspartame are not recommended for infants or young children. Infants are growing rapidly and require energy for growth; these products may interfere with the intake of energy-dense foods.

Herbal Teas

A recent trend toward the use of "natural" substances and alternative medicine has increased interest in herbs and the sale of herbal teas. Because of their small size and rapid growth rate, infants are potentially more vulnerable than adults to the pharmacological activity of some of the flavouring and chemical substances occurring in herbal teas. Toxic effects of herbal teas have been reported in an infant fed herbal tea (Sperl et al., 1995), as well as two breastfed newborns whose mothers were drinking large amounts of herbal tea mixtures (Rosti et al., 1994). In Canada, at present, there is no requirement to label herbal teas regarding their suitability for use by infants. At this time, there is not enough scientific information on the safety of various herbs and herbal preparations to recommend their general use during pregnancy, lactation and for infants.

References:

Sperl, W., H. Stuppner, I. Gassner et al. "Reversible hepatic veno-occlusive disease in an infant after consumption of pyrrolizidine-containing herbal tea". Eur. J. Pediatr., 1995; 154:112-6.

Rosti, L., A. Nardine, M.E. Bettinelli et al. "Toxic effects of a herbal tea mixture in two newborns". Acta Paediatr. Scand., 1994; 83:683.

Solid Foods

The transition to other solid foods, such as more textured purées, finger foods and table foods eaten by the rest of the family, takes place in the latter part of the second 6 months of life because infants are ready to chew and need more texture in their foods. Some infants go from semi-liquid cereals and puréed baby foods to finger foods and table foods in just a few months. Safe finger foods include bread crusts, dry toast, pieces of soft cooked vegetables and fruits, soft ripe fruit such as banana, cooked meat and poultry, and cheese cubes. At this time, most infants are developmentally ready to feed themselves and should be encouraged to do so (Hahn, 1993; Satter, 1990; Illingworth and Lister, 1964). Important feeding behaviours at this time include taking food from a spoon, chewing, self-feeding with fingers or a spoon, and independent drinking from a cup or bottle (Pridham, 1990; Satter, 1990). By 1 year of age, the ingestion of a variety of foods from the different food groups of Canada's Food Guide to Healthy Eating is desirable.

Home-prepared foods. Parents and caregivers may prepare their infant's solid foods by puréeing cooked fresh or frozen foods. In the past, it was recommended that home-prepared carrots, spinach, turnip and beets, which could contain nitrates, not be fed to infants under 6 months of age because of the danger of methaemoglobinaemia. Very young infants may be particularly susceptible to nitrites because fetal haemoglobin is more readily oxidized to methaemoglobin than haemoglobin (Bruning-Fann and Kaneene, 1993). Current infant feeding practices (later introduction of solid foods) are not likely to result in an infant consuming sufficient plant nitrate to cause methaemoglobinaemia even in susceptible infants (AAP, 1970).

Commercial baby foods. In response to consumer demands, the major infant food manufacturers have recently reformulated a large number of their products to remove added sugar and modified starches. Modified food starches are sometimes used in commercial infant food products. They provide a means of controlling viscosity, prevent solids from separating from liquids and impart what is considered to be a desirable "mouth feel" to these products. There is no toxicological basis for excluding these starches from infant foods. They provide a source of carbohydrate and energy in infant diets, although they may dilute other nutrients in the product.

References:

American Academy of Pediatrics. "Infant methaemoglobinaemia, the role of dietary nitrate". Pediatrics, 1970; 46:475-7.

Bruning-Fann, C., J. Kaneene. "The effects of nitrate, nitrite and n-nitroso compounds on human health: a review". Vet. Human Toxicol., 1993; 35:521.

Hahn, N.I. "Why children and parents must play while they eat: an interview with T. Berry Brazelton, MD." J. Am. Diet. Assoc., 1993; 93:1385-7.

Illingsworth, R.S., J. Lister. "The critical or sensitive period, with special reference to certain feeding problems in infants and children". J. Pediatr., 1964; 65:839-48

Pridham, K.F. "Feeding behavior of 6- to 12-month-old infants: assessment and sources of parental information". J. Pediatr., 1990; 117:S174-80.

Satter, E. "The feeding relationship: problems and interventions." J Pediatr., 1991; 118:71-74

Safety and Supervision

The risk of choking can be lowered when caregivers are aware of their toddlers' chewing and swallowing abilities, supervise infants while eating, avoid offering foods with the potential to cause choking, and know how to handle choking if it occurs.

(a) Supervision. The use of a "propped bottle" to feed an unattended infant is not recommended because of the danger of choking or aspirating as the flow of milk into the mouth may be too rapid. Supervision includes the infant sitting upright while eating, and not lying down, walking, running or being distracted from the task of safe eating. Eating in the car is considered unsafe since if choking should occur, it is difficult to pull over to the side of the road safely (Pipes and Trahms, 1993). In addition, there is the increased risk of choking if the car stops suddenly.

Unsafe foods. Hard, small and round, smooth and sticky solid foods can block a young child's airway. The following foods are not safe for infants and children under 4 years of age: popcorn, hard candies, gum, cough drops, raisins, peanuts or other nuts, sunflower seeds, fish with bones, and snacks using toothpicks or skewers (Harris et al., 1984). The following foods are safer for infants and young children when they are prepared as described: wieners diced or cut lengthwise, grated raw carrots or hard fruit 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 leading to asphyxia.

References:

Harris, C.S., S.P. Baker, G.A. Smith et al. "Childhood asphyxiation by food: a national analysis and overview". JAMA, 1984; 251:2231-5.

Pipes, P.L., C.M. Trahms. "Nutrition in Infancy and Childhood" (5th ed). Mosby, St. Louis, 1993, pp 102, 133.

Nutrition in the Second Year

The development of healthy eating skills is a shared responsibility: parents and caregivers provide a selection of nutritious, age-appropriate foods, and decide when and where food is eaten; toddlers decide how much they want to eat and, at times, even whether they eat (Satter, 1987). To encourage healthy eating skills, parents and caregivers have an obligation to recognize and respond appropriately to their toddler's individual verbal and non-verbal hunger cues (e.g. restlessness or irritability) and to satiety cues such as turning the head away, refusing to eat, falling asleep or playing (Satter, 1990). Infants can be encouraged to feed themselves at the beginning of a meal when they are hungry, but may need help if they tire later in the meal. Pressuring infants to eat by using excessive verbal encouragement (e.g. "empty your bottle [or cup]" or "clean your plate") may lead to negative attitudes about eating, poor eating habits or excessive feeding that may foster excess weight gain (Campbell, 1994; Birch, 1992).

Small, frequent feedings

Small and frequent, nutritious, energy-dense feedings are important for meeting the nutrient and energy requirements of infants during the second year. The term "feedings" is used, rather than "meals and snacks," because it better reflects toddlers' need for food when they are hungry or willing to eat rather than at conventional meal and snack times (Heird, 1994). Older infants need four to six small feedings a day in addition to their milk source (Hendricks and Badruddin, 1992). Their appetites vary, not only according to growth and activity, but also according to factors like fatigue, frustration, minor illnesses and social context. Therefore, older infants should be given small servings, along with the opportunity to ask for more if they are still hungry.

Variety

Ingestion of a variety of foods daily from the food groups in Canada's Food Guide to Healthy Eating (Health and Welfare Canada, 1992) is recommended to prevent nutrient deficiencies (Hendricks and Badruddin, 1992). Seventy years ago, Davis (1928) and, more recently, Birch and co-workers (1991) demonstrated that most young children, if provided access to a varied diet of foods from each of the food groups, will consume adequate amounts of nutrients and energy. However, if they do not have access to foods from all food groups on a regular basis, self-selection of a nutritionally adequate diet is not possible (Heird, 1994). No single food, even if it is perceived as nutritious and healthful, should be consumed in excess (Smith and Lifshitz, 1994). As with all foods, moderation in fluid intake is recommended

Dietary fat

The optimal amount of fat in the diet is related to the infant's stage of develop­ment and requirement for energy. Energy and nutrient requirements are particularly high in the first 2 years of life. Thus, dietary fat restriction would potentially compromise both energy and essential fatty acid intake and is not advised. There is no evidence that restricting fat intake in children reduces illness in later life or provides benefit to children during childhood (Health Canada and CPS, 1993; Health and Welfare Canada, 1990a).

References:

Birch, L.L. "Children's preferences for high-fat foods". Nutr. Rev., 1992; 50:249-55.

Birch, L.L, S.L. Johnson, G. Andresen et al. "The variability of young children's energy intake". N. Eng. J. Med., 1991; 324:232-5

Campbell, M.L. "Influencing healthy eating in preschool children". O.N.E. Bulletin, 1994; 13(3):3-4. Davis, C.M. "Self selection of diet by newly weaned infants: an experimental study". Am. J. Dis. Child, 1928; 36:651-79.

Health and Welfare Canada. "Canada's Food Guide to Healthy Eating". Canada Communications Group, Ottawa, 1992.

Health and Welfare Canada. "Nutrition Recommendations: The Report of the Scientific Review Committee". Minister of Supply and Services Canada, Ottawa, 1990a.

Health Canada, Canadian Paediatric Society. "Nutrition Recommendations Update ... Dietary Fat and Children". Minister of Supply and Services Canada, Ottawa, 1993.

Heird, W.C. "Nutritional requirements during infancy and childhood". In: Modern Nutrition in Health and Disease, M.E. Shils, J.A. Olson and M. Shike (eds). Lea & Febiger, Philadelphia, 1994, pp 740-49. Hendricks, K.M., S.H. Badruddin." Weaning recom­mendations: the scientific basis". Nutr. Rev., 1992; 50:125-33.

Satter, E. "How to get your kid to eat ... But not too much". Bull Publishing Company, Palo Alto, Calif., 1987.

Satter, E. "The feeding relationship: problems and interventions." J Pediatr., 1991; 118:71-74Smith, M.M., F. Lifshitz. "Excess fruit juice consumption as a contributing factor in nonorganic failure to thrive". Pediatrics, 1994; 93:438-43.

Iron Deficiency Anemia

Iron deficiency is most common among infants between the ages of 6 and 24 months. The major risk factors for iron deficiency anemia in infants relate to socioeconomic status, the early discontinuation of breastfeeding and include the early consumption of cow's milk, and inadequate funds for appropriate foods (Canadian Paediatric Society, 1991; Gray-Donald et al., 1990). Other high-risk groups include low birth weight and premature infants (Friel et al., 1990; Shannon, 1990), and older infants who drink large amounts of milk or juice, and eat little solid food (Feightner, 1994). The importance of preventing rather than treating anemia has been emphasized by findings that iron deficiency anemia is a risk factor for what may be irreversible developmental delays in cognitive function (Lozoff et al., 1991, 1996; Walter et al., 1989).

Infants weaned from breastfeeding before 9 months of age should receive iron-fortified formula. Non-fortified formula and cow's milk are unsuitable alternatives as they contain very little natural iron which is poorly absorbed. When milk is combined with other dietary sources of iron, such as iron-fortified infant cereals, puréed liver, meat, fish, legumes and egg yolk, it may be possible to avoid iron deficiency and anemia. However, there are limited data to support or refute this estimation. After 9 months of age, when a wider variety of foods is being ingested, the introduction of cow's milk is not associated with any risk of iron deficiency. Despite recommendations to the contrary, many Canadian infants receive cow's milk or evaporated milk in the second 6 months of life because of convenience and relatively low cost. For infants of informed parents who choose not to adhere to these guidelines, one may either provide medicinal iron drops starting at 6 months of age, or screen for anemia around 6 to 8 months of age.

For children more than 1 year of age, iron-containing foods, such as those listed above, provide iron in sufficient amounts. Supplemental iron is not required unless the diet is lacking in these foods.

References:

Canadian Paediatric Society, Nutrition Committee. "Meeting the iron needs of infants and young children: an update". Can. Med. Assoc. J., 1991; 144:1451-4.

Feightner, J.W. "Prevention of iron deficiency anemia in infants". In: The Canadian Guide to Clinical Preventa­tive Health Care. Canadian Task Force on the Periodic Health Examination. 1994. Health Canada. pp 232-42.

Friel, J.K., W.L. Andrews, J.D. Mathew et al. "Iron status of very low birthweight infants during the first 15 months of infancy". Can. Med. Assoc. J., 1990; 143:733-7.

Gray-Donald, K., S. Di-Tommaso, F. Leamann et al. "The prevalence of iron deficiency anemia in low income Montreal infants aged 10-14 months" [abstr]. J. Can. Diet. Assoc., 1990; 51:424.

Lozoff, B., E. Jimeniz, A. Wolf. "Long-term develop­mental outcome of infants with iron deficiency". N. Eng. J. Med., 1991; 325:687-94.

Lozoff, B., A.W. Wolf, E. Jimenez. "Iron-deficiency anemia and infant development: effects of extended oral iron therapy". J. Pediatr., 1996; 129:382-9.

Shannon, K.M. "Anemia of prematurity: progress and prospects". Am. J. Pediatr. Hematol. Oncol., 1990; 12(1):14-20.

Walter, T., I. De Andraca, P. Chadud et al. "Iron deficiency anemia: advese effects on infant phychomotor development". Pediatrics, 1989; 84:7-17.

Vegetarian Diets

With careful planning, vegetarian diets for infants and children can be nutritionally adequate (Sanders, 1995; Sanders and Reddy, 1994). For vegan infants who are not breastfed, commercially prepared soy-based infant formula is recommended during the first 2 years of life to provide adequate nutrients and energy for growth and development. For older infants, a carefully selected vegetarian diet can meet all the requirements of a growing child; however, deficiencies of iron, vitamin B12, vitamin D and energy have been reported in vegetarian

children (Sanders, 1995; Jacobs and Dwyer, 1988). Parents who feed their infant vegan diets in the first 2 years of life may benefit from consultation with a dietitian or nutritionist to ensure the adequacy of their infant's food (nutrient) intake, and to assess the need for nutrient supplements.

References:

Jacobs, C., J.T. Dwyer. "Vegetarian children: appropriate and inappropriate diets". Am. J. Clin. Nutr., 1988; 48:811-8.

Sanders, T.A.B. "Vegetarian diets and children". Pediatr. Clinics of North America, 1995; 42:955-65.

Sanders, T.A.B., S. Reddy. "Vegetarian diets and children". Am. J. Clin. Nutr., 1994; 59(suppl):S1176-81.