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2013年9月 第34期
© Copyright 2013 by Nestlé Nutrition Institute,
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© Copyright 2013 by Nestlé Nutrition Institute,
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ISSN 1270-9743
通过足量的适宜且安全
的喂养模式铸就一个健
康的开端
关于辅食添加的介绍
Raanan Shamir, Tel-Aviv (Israel)
儿童期健康饮食行为的培养
Alison K. Ventura,
Philadelphia, Pa. (USA)
喂养及其对饮食行为的影响
Lisa R. Edelson, Lausanne
(Switzerland)
the
nest
The Introduction of
Complementary Feeding
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of age [3], while in the United States,
40.4% of mothers introduced solids
Institute of Gastroenterology,
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
before this age [4].
Nutrition, and Liver Diseases
XXXXXXXXXXXXXXXXXXXXXXXXXXXX
Schneider Children’s Medical Center
Sackler Faculty of Medicine
Tel Aviv University, Tel Aviv, Israel
shamirraanan@gmail.com
Key message
Complementary feeding should be introduced to the diet no later than at 6
months of age (but not before 4
months of age) while the infant is still
being breast fed. In contrast to current
recommendations, many mothers
choose to introduce complementary
feeding before 4 months of age.
There is no food item that should
be avoided beyond 6 months of age,
including small quantities of cow’s milk
products.
Exclusive breast-feeding is recommended for the first 6 months of life [1].
Around that time, infants are introduced to solids due to nutrition as well
as developmental reasons. It has been
suggested that late (beyond 6 months
of age) or too early (before 4 months of
age) introduction of solids may have
health consequences later in life.
In this review, the term complementary feeding (CF) is used for the introduction of food other than human milk
or infant formulae as defined by the
ESPGHAN Committee on Nutrition [2].
As will be discussed later, current recommendations discourage the introduction of CF before 4 months of age
[2]. However, in a study of European
children, 32% of the participants were
introduced to solids before 4 months
Nutritional Adequacy
One of the reasons for the introduction of CF at around 6 months of age
(but not before 4 months of age) is that
the volume of human milk at this age
is insufficient to meet energy requirements, protein, iron, zinc, vitamin A
and vitamin D. Currently, there is no
evidence that earlier introduction of CF
(at 4 months) will provide an added
nutrition value. In a randomized study
conducted in a high-income setting
and assigning infants to exclusive
breast-feeding for 6 months or exclusive breast-feeding for 4 months with
the introduction of solids at 4 months,
the introduction of solids at 4 months
had a positive effect on iron stores but
not on hemoglobin levels or growth
[5]. In another study, meat intake from
4–12 and 4–16 months was positively
and significantly related to psychomotor developmental indices [6]. However, a study of Guatemalan children
aged 6–24 months has demonstrated
a deficiency of vitamin A and folate in
some children and ubiquitous deficiency in calcium, zinc and iron after CF
had been introduced [7]. Similar studies in high-income settings are lacking,
but there is still considerable concern
that, after the introduction of solids,
nutrient requirements are not fully met
not only in poor socioeconomic settings.
In addition, though beyond the
scope of this review, the introduction
2
of solid foods should include encouraging the intake of fruits and vegetables, limiting the quantity of cow’s milk
until the age of 12 months, avoiding
consumption of fruit juice and sweetened beverages, and limiting the intake of simple sugars and salts as well
as implementing safe hygiene handling of foods and avoiding the introduction of food items that can cause
choking.
Health Benefi ts
The introduction of CF has been studied for many health outcomes. The effects on allergy prevention and celiac
disease will be touched briefly:
Allergy
There is considerable evidence from
observational studies including prospective birth cohorts demonstrating
that the delayed introduction of solids
as well as the delayed introduction of
allergenic foods such as milk, eggs,
fish, nuts and soy beyond 6 months of
age does not prevent the development
of food allergy and may even increase
the risk of allergy (table 1).
Thus, the recommendations of the
ESPGHAN Committee on Nutrition
from 2008 [2] that CF should not be
introduced before 4 months of age
(stated as 17 weeks) and not after 6
months of age (26 weeks) are in line
with current scientific evidence.
Celiac Disease
Celiac disease occurs in genetically
susceptible individuals. However, environmental factors including breast-
feeding may be involved in the pathogenesis of the disease. A study of a
prospective cohort from Denver has
shown that the risk of developing celiac disease is increased when gluten
is introduced into the diet before 3
months of age and after 7 months of
age [8]. Evidence for the age of introduction, quantity of gluten and the importance of breast-feeding while being introduced to gluten comes from
the observations during the celiac disease epidemic in Sweden. A metaanalysis including the observations
from Sweden has shown that the risk
to develop celiac disease is reduced
when gluten is introduced to the diet
while the infant is still breast fed [9]. A
prospective cohort, funded by the European Union (PREVENTCD, FP6), recruited newborns with a genetic risk
for developing celiac disease and examined the effect of breast-feeding
and introduction of gluten at 4 months
of age compared to 6 months of age
on the development of celiac disease
at the age of 3 years [10]. By the second part of 2013, all children in this
cohort will be at least 3 years of age,
enabling to shed more light on the relationship between the age of gluten
introduction and the development of
celiac disease.
Based on the available literature,
current recommendations suggest
that both the early (below 4 months)
and late (7 or more months) introduction of gluten should be avoided and
that the introduction of gluten to the
diet should be done when the infant is
still being breast fed [1].
Table 1. Prospective birth cohorts evaluating the effect of the introduction of
solids on the development of allergic diseases
Study
Number of
children
Country
Evidence
GINI study
[11]
4,753
Germany
No evidence that delayed introduction of
solids beyond 4 months or delayed
introduction of most allergenic foods
beyond 6 months prevents the
development of eczema
Lisa study [3]
2,073
Germany
No evidence that delayed introduction of
solids beyond 4 or 6 months prevents
allergies at the age of 6 years; for eczema,
a protective effect of delayed introduction
could not be excluded
KOALA
study [12]
2,558
The Netherlands
Delayed introduction of cow’s milk products
was associated with higher risk for eczema;
delayed introduction of other foods was
associated with an increased risk for atopy
at 2 years of age
Generation R
study [13]
6,905
The Netherlands
No evidence for eczema and wheezing
prevention of delayed introduction of
allergenic foods after 6 months of age
In summary, current knowledge
about the nutritional needs, developmental requirements and the effect of
CF introduction on later health outcomes suggests that CF should be
introduced to the diet no later than at
6 months of age (but not before 4
months of age) while the infant is still
being breast fed, and that there is no
food item that should be avoided beyond 6 months of age, including small
quantities of cow’s milk products.
References
1. ESPGHAN Committee on Nutrition, Agostoni
C, Braegger C, Decsi T, et al: Breast-feeding.
A commentary by the ESPGHAN Committee
on Nutrition. J Pediatr Gastroenterol Nutr
2009;49:112–125.
2. Agostoni C, Decsi T, Fewtrell M, et al,
ESPGHAN Committee on Nutrition:
Complementary feeding: a commentary by
the ESPGHAN Committee on Nutrition. J
Pediatr Gastroenterol Nutr 2008;46:99 –110.
3. Zutavern A, Brockow I, Schaaf B, et al:
Timing of solid food introduction in relation to
eczema, asthma, allergic rhinitis, and food
and inhalant sensitization at the age of 6
years: results from the prospective birth
cohort LISA. Pediatrics 2008;121:e44–e52.
4. Clayton HB, Li R, Perrine CG, et al:
Prevalence and reasons for introducing
infants early to solid foods: variations by
milk feeding type. Pediatrics 2013;131:
e1108–e1114.
5. Jonsdottir OH, Thorsdottir I, Hibberd PL, et
al: Timing of the introduction of complementary foods in infancy: a randomized controlled
trial. Pediatrics 2012;130:1038–1045.
3
6. Morgan J, Taylor A, Fewtrell M: Meat
consumption is positively associated with
psychomotor outcome in children up to 24
months of age. J Pediatr Gastroenterol Nutr
2004;39:493–498.
7. Vossenaar M, Solomons NW: The concept of
‘critical nutrient density’ in complementary
feeding: the demands on the ‘family foods’
for the nutrient adequacy of young Guatemalan children with continued breastfeeding.
Am J Clin Nutr 2012;95:859 –866.
8. Norris JM, Barriga K, Hoffenberg EJ, et al:
Risk of celiac disease autoimmunity and
timing of gluten introduction in the diet of
infants at increased risk of disease. JAMA
2005;293:2343–2351.
9. Akobeng AK, Ramanan AV, Buchan I, Heller
RF: Effect of breast feeding on risk of coeliac
disease: a systematic review and meta-analysis of observational studies. Arch Dis Child
2006;91:39 –43.
10. Troncone R, Ivarsson A, Szajewska H, Mearin
ML; Members of European Multistakeholder
Platform on CD (CDEUSSA): Review article:
future research on coeliac disease – a
position report from the European multistakeholder platform on coeliac disease
(CDEUSSA). Aliment Pharmacol Ther
2008;27:1030 –1043.
11. Filipiak B, Zutavern A, Koletzko S, et al: Solid
food introduction in relation to eczema:
results from a four-year prospective birth
cohort study. J Pediatr 2007;151:352–358.
12. Snijders BE, Thijs C, van Ree R, van den
Brandt PA: Age at fi rst introduction of cow
milk products and other food products in
relation to infant atopic manifestations in the
fi rst 2 years of life: the KOALA Birth Cohort
Study. Pediatrics 2008;122:e115–122.
13. Tromp II, Kiefte-de Jong JC, Lebon A,
et al: The introduction of allergenic foods and
the development of reported wheezing and
eczema in childhood: the Generation R study.
Arch Pediatr Adolesc Med 2011;165:
933–938.
the
nest
Alison K. Ventura
Department of Nutrition Sciences
College of Nursing and Health Professions
Drexel University, Philadelphia, Pa., USA
akventura@drexel.edu
Key message
Preferences are a strong driver of children’s dietary intake.
Young children show innate preferences for sweet, salty, and savory
tastes and aversion to bitter tastes, but
also a strong propensity to learn from
experience.
Healthy eating behaviors can be
promoted by repeatedly exposing children to healthy foods, pairing novel
healthy foods with familiar, preferred
foods, and introducing new foods in a
positive social context.
Preferences are a strong driver of children’s dietary intake [1]; thus, an understanding of the factors that influence food preferences is an essential
basis for understanding how preferences can be molded to promote healthful eating behaviors. The abilities that
underlie food preferences and eating
behaviors – taste, smell, and oral motor
skills – develop long before an infant’s
first direct experience with solid foods.
The development of taste and smell
systems begins in utero, and both
senses are functionally mature by the
third trimester [2, 3]. Additionally, the
fetus begins to swallow significant
amounts of amniotic fluid by late ges-
Fostering the Development
of Healthy Eating Behaviors during Childhood
Table 1. Selected neurodevelopmental milestones related to feeding
Milestone
Age, months
Function
Loss of extrusion
reflex
2–4
Allows for acceptance of
nonliquid food without choking
or gagging
Sits with support
3–4
Allows for head and neck control
needed for swallowing solids
Increased chewing
efficiency
6–10
Enables transition from pureed
to solid textures
Pincer grasp
10–12
Increased ability to pick up small
objects during self-feeding
Precise up and
down tongue
movements
18–24
Improved ability to chew solid
textures
Circulatory jaw
rotation
24–26
Improved ability to chew solid
textures
References
Fig. 1. Typical schedule for introducing new foods across the first year of life.
Note: Choking hazards should be avoided until after the first year (or longer). Examples
include raw carrots, nuts, seeds, raisins, grapes, popcorn and pieces of hot dogs.
Table 2. Specific strategies to promote
healthy eating behaviors during early
childhood
tation [4]. Prenatal functioning of these
abilities prepare the fetus for later
feeding behaviors and acceptance of
the postnatal diet.
Neonates exhibit both unlearned
and learned behaviors that guide feeding and shape food acceptance patterns. Unlearned behaviors include
preferences for sweet [5] and savory
tastes [6] as well as aversion to bitter
tastes [5]. A preference for salty tastes
emerges at 4 months of age [7]. Several innate reflexes that support feeding abilities, such as rooting and sucking, are also present at birth. Learned
responses include preferences for
stimuli experienced in utero, such as
taste and odors from the mothers’ diet
4
that are transmitted through the amniotic fluid [8].
Taste and smell preferences, as
well as neuromuscular skills necessary
for solid food consumption, continue
to develop postnatally. Tastes and
odors from the mothers’ diet are also
transmitted through the breast milk,
and infants learn to prefer these flavors [9]. Similarly, formula-fed infants
show preference for the specific flavors of the formula they are given [10].
Table 1 outlines several cognitive and
motor milestones that prepare the infant for the eventual transition from a
milk- to a table food-based diet.
Figure 1 illustrates a typical schedule for introducing new foods. This
1.
Breast-feeding exclusively for the first
6 months of life.
2.
Eat a healthful and varied diet during
pregnancy and lactation to ensure the
infant is exposed to and learns to
prefer the flavors of healthy foods.
3.
Provide repeated exposure to novel
foods (especially typically rejected
foods such as vegetables) to promote
acceptance of those foods.
4.
Introduce novel foods within a positive
social environment that includes
encouragement and responsive
feeding practices. Avoid pressuring or
coercing children to eat.
5.
Pair novel foods with familiar or
energy-dense foods. For example, add
breast milk or formula to novel
vegetable purees when introducing
new foods to infants or serve
vegetables with a small side of full-fat
dressing when introducing new foods
to toddlers.
6.
Use your own behaviors and attitudes
to model healthful dietary patterns.
transition can be difficult for caregivers attempting to instill healthy eating
behaviors as young children (especially 2- to 5-year-olds) exhibit heightened
levels of neophobia, defined as fear of
new foods. Additionally, the unlearned
preferences mentioned above mean
that young children will readily accept
energy-dense and nutrient-sparse ‘kid’
foods, such as pizza and ice cream,
and may reject healthier foods, such
as green vegetables. Fortunately,
young children also show considerable
plasticity in preferences and can be
guided toward healthier foods through
repeated exposure [11], associative
conditioning [12], and positive social
contexts [13]. Table 2 outlines specific
suggestions for how caregivers can
use these strategies to promote
healthy eating behaviors during early
childhood.
5
1. Birch LL: Dimensions of preschool children’s
food preferences. J Nutr Educ 1979;11:77–80.
2. Bradley RM: Development of the taste bud
and gustatory papillae in human fetuses;
in Bosma JF (ed): Oral Sensation and
Perception. Springfi eld, Charles C Thomas,
1972, pp 137–162.
3. Schaeffer JP: The lateral wall of the cavum
nasi in man, with especial reference to the
various developmental stages. J Morphol
1910;21:613–707.
4. Pritchard JA: Deglutition by normal and
anencephalic fetuses. Obstet Gynecol
1965;25:289 –297.
5. Ganchrow JR, Steiner JE, Daher M: Neonatal
facial expressions in response to different
qualities and intensities of gustatory stimuli.
Infant Behav Dev 1983;6:473–484.
6. Steiner JE: What the human neonate can tell
us about umami; in Kawamura Y, Kare MR
(eds): Umami: A Basic Taste. New York,
Marcel Dekker, 1987, pp 97–123.
7. Beauchamp GK, Cowart BJ, Moran M:
Developmental changes in salt acceptability
in human infants. Dev Psychobiol
1986;19:17–25.
8. Schaal B, Marlier L, Soussignan R: Human
foetuses learn odours from their pregnant
mother’s diet. Chem Senses 2000;25:729 –
737.
9. Mennella JA, Jagnow CP, Beauchamp GK:
Prenatal and postnatal fl avor learning by
human infants. Pediatrics 2001;107:E88–E93.
10. Mennella JA, Forestell CA, Morgan LK,
Beauchamp GK: Early milk feeding infl uences
taste acceptance and liking during infancy.
Am J Clin Nutr 2009;90:780S–788S.
11. Birch LL, McPhee L, Shoba BC, Pirok E,
Steinberg L: What kind of exposure reduces
children’s food neophobia? Looking vs.
tasting. Appetite 1987;9:171–178.
12. Anzman-Frasca S, Savage JS, Marini ME,
Fisher JO, Birch LL: Repeated exposure
and associative conditioning promote
preschool children’s liking of vegetables.
Appetite 2012;58:543–553.
13. Addessi E, Galloway AT, Visalberghi E, Birch
LL: Specifi c social infl uences on the
acceptance of novel foods in 2-5-year-old
children. Appetite 2005;45:264–271.
the
nest
Feeding Practices and
Their Influence on Eating Behavior
Lisa R. Edelson
Nestlé Research Center, Lausanne, Switzerland
LisaRobin.Edelson@rdls.nestle.com
Key message
The techniques parents use to feed
their children can influence later eating
behavior and food preferences.
Foods should not be used to a reward good behavior or eating other
foods. Serving small portions to children allows them to eat until they are
full and reduces plate waste.
Parents play an important role in the
development of children’s eating habits through selecting which foods to
offer as well as how these foods are
presented to the child. By introducing
(and reintroducing) foods in the right
way, parents can help their children to
enjoy healthy foods and to eat appropriate portions of food.
Some common feeding practices
have short-term benefits but may be
harmful in the long term. For example,
by using one food (e.g., ice cream) as
a reward for eating another (peas), parents may convince children to eat the
healthy food at that particular meal
250
Familiar (liked) food
Intake (gm)
200
150
100
50
Initially rejected food
0
1
2
3
Means; n=40
4
5
6
7
8
9
10 11 12 13 14 15 16
Days
Fig. 1. Changes in intake of a familiar and initially rejected puree in
5- to 8-month-old infants. After 78 exposures, the children consumed as much of the initially
disliked food as of the familiar, liked food [7].
6
and consider this to be a success.
However, this usage of rewards communicates to children a relative ‘value’
of the two foods: namely, that ice
cream is desirable and that peas are
not. Over time, this can increase the
liking of the reward food and decrease
the liking of the target food [1], such
that when the children are able to select their own foods, they will not
serve themselves peas. Recent studies suggest that using non-food rewards (e.g., stickers) or praise can be
effective alternatives [2].
Another common practice is to
ask children to ‘clean their plates’. Although this practice discourages
wastefulness, it can lead to overeating.
When children are trained to pay attention to their internal fullness cues,
rather than external indicators like the
amount of food on the plate, they are
better able to adjust their intake to the
caloric content of the food [3]. It has
also been established that when children are served larger portions, they
consume more food [4]; thus, it is important that parents serve foods in appropriate quantities. A solution to both
problems is to use child-sized plates
and serve small portions (or even let
the children serve themselves) and al-
Helene Souza/pixelio.de
low the children to take more if they
are still hungry: there will be less
waste and the amount consumed will
be based on the child’s hunger, rather
than an arbitrary portion.
Young children are often neophobic,
i.e., afraid of trying new foods. One
effective way to introduce a new food
is through ‘modeling’: eating the food
with positive affect. If children see a
parent or sibling enjoying a food, they
will be more interested in trying it
themselves [5]. Remind parents not to
give up if a child refuses a food: it may
take 7–10 tastes before he/she likes it
(figure 1) [6, 7], although many parents
give up after only 3 refusals.
References
1. Birch LL: Development of food acceptance
patterns in the fi rst years of life.
Proc Nutr Soc 1998;57:617– 624.
2. Cooke LJ, Chambers LC, Añez EV, Wardle J:
Facilitating or undermining? The effect of
reward on food acceptance. A narrative
review. Appetite 2011;57:493–497.
3. Birch LL, McPhee L, Shoba BC, Steinberg L,
Krehbiel R: ‘Clean up your plate’: effects of
child feeding practices on the conditioning of
meal size. Learn Motiv 1987;18:301–317.
4. Orlet Fisher J, Rolls BJ, Birch LL: Children’s
bite size and intake of an entrée are greater
with large portions than with age-appropriate
or self-selected portions. Am J Clin Nutr
2003;77:1164–1170.
7
5. Addessi E, Galloway AT, Visalberghi E, Birch
LL: Specifi c social infl uences on the
acceptance of novel foods in 2-5-year-old
children. Appetite 2005;45:264–271.
6. Birch LL, Marlin DW: I don’t like it; I never
tried it: effects of exposure on two-year-old
children’s food preferences. Appetite
1982;3:353–360.
7. Maier A, Chabanet C, Schaal B, Issanchou S,
Leathwood P: Effects of repeated exposure
on acceptance of initially disliked vegetables
in 7-month old infants. Food Qual Prefer
2007;18:1023–1032.