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Feeding
John Paul L. Oliveros, MD, DPPS, DPSPGHAN
Pediatric Gastroenterology
The First 1000 days of life
2016 Nutrition Month Talking Points: First 1000 days ni baby pahalagan para sa malusog na kinabukasan.
National Nutrition Council
The First two Years of Life
W. H . O. TRADITIONAL
COMPLEMENTARY
FOOD
SOLID FOODS
Solid foods
Infant formula
MILK
BREASTMILK Breastmilk
Infant formula
Why?
Importance of Complementary Feeding
• Fill the nutrient gap of breastmilk at 6mos
• Train infant on appropriate feeding skills necessary for healthy eating
habits later in life
Navarro, et. al., Fundamentals of Pediatrics: Competency-Based
2. MAINTENANCE OF BREASTFEEDING
3. RESPONSIVE FEEDING
6. FOOD CONSISTENCY
2. MAINTENANCE OF BREASTFEEDING
• Continue frequent, on-demand breastfeeding until 2 years of age
or beyond
Timing of complementary feeding
• Vary between countries and influenced by social and cultural factors
• Factors:
• Developmental readiness
• GI and renal functions: 4mos
• Neurodevelopmental skills: 4-6mos
• Nutritional requirements
• No apparent growth with EBF for 6months (Kramer)
• Iron deficiency anemia not significantly increased at 6mos EBF
• Health effects
• AGE lower in EBF for 6mos
• Increased risk of allergy if solids introduced before 3-4mos
• Increased risk of obesity if solids introduced before 3-4mos
Increase the number of times the child is fed complementary foods as he/she
gets older
The number of meals that an infant or young child needs in a day depends on:
• how much energy the child needs to cover the energy gap
• the amount that a child can eat at one meal
• Stomach capacity: 30 ml/kg body weight
• the energy density of the food offered
• More than breastmilk: > 0.8 kcal/g
What
AGE ENERGY NEEDED PER AMOUNT TEXTURE FREQUENCY
DAY IN ADDITION TO
BREAST MILK
6-8 months 200 kcal/day Start with 2-3 tbsp. Start with thick 2-3 meals per day
per feed, increasing porridge, well mashed
gradually to ½ of a foods Depending on child’s
250 ml cup appetite, 1-2 snacks
Continue with mashed may be offered
family foods
9-11 months 300 kcal/day ½ of a 250 ml cup Finely chopped or 3-4 meals per day
mashed foods, and
foods that baby can Depending on child’s
pick up appetite, 1-2 snacks
may be offered
12-23 ¾ to full 250 ml cup 550 kcal/day Family foods, chopped 3-4 meals per day
months or mashed if needed
Depending on child’s
appetite, 1-2 snacks
What
Frequency (F) Frequent feeding, from six months of age and while breastfeeding continues
Amount (A) Adequate amounts of food, sufficient to meet growing needs of the child, and
increasing with age
Texture (T) Appropriate consistency, energy dense, micronutrient rich
Variety (V) A variety of different foods
Active (A) Responsively fed
Hygiene (H) Hygienically prepared, fed with clean feeding implements-not using a bottle
Issues on Complementary Feeding
• CF and allergy
• CF and type 1 diabetes mellitus, obesity and cardiovascular
diseases
• Baby-Led Weaning
Complementary Feeding and Allergies
• Increasing rates of allergic diseases
• despite advice to restrict or delay introduction of
potentially allergenic solid foods (e.g. Cow milk, fish, egg,
gluten, peanut)
? Immune tolerance
? certain factors (e.g. breastfeeding)
Complementary Feeding and Allergies
• “Critical window” : between 4-6 months
• Some evidence of increased allergy risk when solids introduced EARLY,
before 3-4 months but evidence for delaying beyond 6 months is
weak
• Some evidence that DELAYED introduction of allergenic foods may
increase allergy risk
• Excessive protein intake (milk, meat, cheese) >15% total calories during
CF correlates with risk of overweight/obesity in later age, in parallel with
a decrease in fat intake
AAP 2014
CF and Risk for type 1 DM, Obesity and
Cardiovascular Diseases
• It is inappropriate, during the first year of age, to add salt to food, due
to a possible increase in risk of hypertension in later age
Strazzullo P, et al. Nutr Metab
Cardiovasc Dis 2012;22
• Baby-Led Weaning
• Method for introducing CF to infants whereby infants feed themselves with hand-
held foods instead of being spoon-fed with purees by parents
• Auto-weaning
• offering chopped and minced family meals to the infants
In both methods:
• infants should be milk-fed, ideally exclusively breastfed on demand
• should be offered complementary foods from 6 months of age
Alternative Complementary Feeding Methods
• Advantages:
• improves relationships during shared family meals
• promotes infant’s autonomy
• saves time and money
• encourages healthier dietary intakes for parent
Alternative Complementary Feeding Methods
Concerns:
• Risk of inadequate iron intake
• generally offered steamed vegetables which are not good sources of absorbable iron
Carter RC, et al. Pediatrics 2010;126
• Risk of choking
• oral motor function not yet well developed to safely ingest whole foods In 199 BLW infants, 30% had at least one
episode of choking with solid food ingestion (apple)
Townsend E,
Pitchford NJ. BMJ Open 2012;2
What is the best method?
• No “De Cahon”
• Know the advantages and disadvantages of each method
• Factors to consider:
• Infection risk
• Allergy risk
• Neurodevelopmental capacity
• Availability of food and resources
Optimizing complementary feeding
Not before 4 months but by 6 months
When Continue breastfeeding up to 2 years or more
Adequate sources of energy, macro- and micronutrients
What Appropriate proportion of nutrients
Appropriate frequency of feeding and texture of food
Repeated exposures to facilitate acceptance
How Responsive feeding
Make and Keep food safe to eat
Toddler Feeding
AGE ENERGY NEEDED AMOUNT TEXTURE FREQUENCY
PER DAY IN
ADDITION TO
BREAST MILK
6-8 months 200 kcal/day Start with 2-3 tbsp. Start with thick 2-3 meals per day
per feed, increasing porridge, well
gradually to ½ of a mashed foods Depending on
250 ml cup child’s appetite, 1-2
Continue with snacks may be
mashed family offered
foods
9-11 months 300 kcal/day ½ of a 250 ml cup Finely chopped or 3-4 meals per day
mashed foods, and
foods that baby can Depending on
pick up child’s appetite, 1-2
snacks may be
offered
12-23 months ¾ to full 250 ml cup 550 kcal/day Family foods, 3-4 meals per day
chopped or mashed
if needed Depending on
child’s appetite, 1-2