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.

The statement promotes accurate and consistent messaging on nutrition for older infants and young children from six to 24 months of age. Guidance on nutrition from birth to six months is covered in a separate but complementary statement.

For information and ideas about how to answer the questions of parents and caregivers, see:

In Practice: Talking to families about infant nutrition.

Principles and recommendations for the nutrition of older infants (six to 12 months) and young children (12 to 24 months)

Breastfeeding - exclusively for the first six months, and continued for up to two years or longer with appropriate complementary feeding - is important for the nutrition, immunologic protection, growth, and development of infants and toddlers.

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

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

Supplemental vitamin D is recommended for infants and young children who are breastfed or receiving breastmilk

• Recommend a daily vitamin D supplement of 10 µg (400 IU) for infants and young children who are breastfed or receiving breastmilk.

Complementary feeding, along with continued breastfeeding, provides the nutrients and energy to meet the needs of the older infant.

• Recommend gradually increasing the number of times a day that complementary foods are offered while continuing to breastfeed.
• Recommend iron-rich meat, meat alternatives, and iron-fortified cereal as the first complementary foods. Encourage parents and caregivers to progress to introduce a variety of nutritious foods from the family meals.
• Ensure that lumpy textures are offered no later than nine months. Encourage progress towards a variety of textures, modified from family foods, by one year of age.

Responsive feeding promotes the development of healthy eating skills.

• Encourage responsive feeding based on the child's hunger and satiety cues.
• Promote offering finger foods to encourage self-feeding.
• 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. Ensure that foods such as meat and meat alternatives and iron-fortified cereal are offered a few times each day.
• If parents and caregivers are introducing cow milk, advise them to delay until nine to 12 months of age. Recommend limiting cow milk intake to no more than 750 mL per day.

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

• Recommend infants and young children always be supervised during feeding.
• Recommend parents and caregivers avoid offering hard, small and round, or smooth and sticky, solid foods. These may cause aspiration and choking.
• Promote safe food preparation and storage to prevent foodborne illness. Recommend avoiding products that contain raw or undercooked meat, eggs, poultry, or fish; unpasteurized milk or milk products; unpasteurized juice; and cross-contamination between cooked and uncooked foods.
• Advise parents and caregivers not to give honey to a child under one year of age. This helps to prevent infant botulism.

From one year of age, young children begin to have a regular schedule of meals and snacks, and generally follow the advice in Canada's Food Guide.

• Recommend a regular schedule of meals and snacks, offering a variety of foods from the four food groups.
• Recommend foods prepared with little or no added salt or sugar.
• Explain to parents and caregivers that nutritious, higher-fat foods are an important source of energy for young children.
• Encourage continued breastfeeding, or offering 500 mL per day of homogenized (3.25% M.F.) cow milk.
• Advise limiting fruit juice and sweetened beverages. Encourage offering water to satisfy thirst.
• Encourage parents and caregivers to be role models and instil lifelong healthy eating habits.

Recommendations on the use of breastmilk substitutes

Some infants may not be breastfed for personal, social, or rarely, medical 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, the personal, social, and economic costs of formula feeding, and the difficulty of reversing the decision not to breastfeed. Individually counsel those families who have made a fully informed choice not to breastfeed on the use of breastmilk substitutes.

Acknowledgements

The Infant Feeding Joint Working Group included members 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), Jessica DiGiovanni (PHAC), Patricia D'Onghia (HC), Erin Enros (HC), Deborah Hayward (HC), Jennifer McCrea (HC), Brenda McIntyre (HC), Julie Castleman (PHAC),  Kevin Wood (HC).

Suggested citation: Health Canada, Canadian Paediatric Society, Dietitians of Canada, & Breastfeeding Committee for Canada (2014) Nutrition for healthy term infants: Recommendations from six to 24 months.

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

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

Rationale

The World Health Organization (WHO) recommends exclusive breastfeeding from birth to six months of age and continued breastfeeding, with appropriate complementary foods, for up to two years or beyond. This public health recommendation is described in the Global Strategy for Infant and Young Child Feeding (WHO/UNICEF, 2003). Breastfeeding, with appropriate complementary feeding, is the nutrition standard for feeding the older infant, according to the Institute of Medicine's Dietary Reference Intakes (IOM, 2006). Breastfeeding and appropriate complementary feeding are among the most effective interventions to promote child health, growth and development (WHO/UNICEF, 2008).

Breastfeeding can provide all of an infant's energy needs up to six months of age (WHO, 2009; PAHO, 2003). From six to 12 months, older infants can meet their nutrition requirements with a combination of breastmilk and complementary foods (Butte et al., 2004). From six to 12 months, breastfeeding can provide one half or more of their energy needs and complementary foods can supply the remaining energy needed (Michaelsen, Weaver, Branca, & Robertson, 2003; WHO, 2009). From 12 to 24 months, an estimated one third of a young child's energy can come from breastfeeding and the remaining two thirds from complementary foods (WHO, 2009; PAHO, 2003).

Breastfeeding beyond six months has been associated with a number of positive infant and maternal health outcomes. Breastfeeding longer, in addition to a wide range of other determinants, may have a protective effect against overweight and obesity in childhood (Arenz, Rückerl, Koletzko, & von Kries, 2004; Scott, Ng, & Cobiac, 2012; von Kries et al., 1999). Limited evidence suggests breastfeeding continues to provide immune factors during the first and second years (Goldman, Goldblum, & Garza, 1983; Goldman, Garza, Nichols, & Goldblum, 1982). An observational study suggests breastfeeding to 12 months may protect against infectious illnesses, particularly gastrointestinal and respiratory infections (Fisk et al., 2011). Findings have consistently 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). Limited evidence also suggests a protective effect for the breastfeeding mother against ovarian cancer (Luan et al., 2013; Su, Pasalich, Lee, & Binns, 2013; World Cancer Research Fund & American Institute for Cancer Research, 2013). Mothers who breastfeed their older infants and young children also report experiencing an increased sensitivity and bonding with their child (Britton, Britton, & Gronwaldt, 2006; Fergusson & Woodward, 1999; Kendall-Tackett & Sugarman, 1995).

Of Canadian mothers who breastfed, 57.4% continued beyond six months (Statistics Canada, 2013). This percentage dropped to 18.9% after the first year. The most common 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 duration of breastfeeding is influenced by many cultural and social factors. One such factor is the stigma many mothers perceive around breastfeeding an older infant and young child. This can lead some mothers to conceal they are continuing to breastfeed, known as 'closet nursing' (Lawrence & Lawrence, 2005; Kendall-Tackett & Sugarman, 1995).

To help improve breastfeeding durations, it is important to promote the implementation of the WHO/UNICEF's Baby-Friendly Hospital Initiative outlined in the Ten Steps to Successful Breastfeeding. Its Canadian adaptation is Baby Friendly Initiative (BFI) Integrated 10 Steps for Hospitals and Community Health Services (WHO/UNICEF 2009; BCC, 2011). Baby-friendly initiatives are known to increase the initiation, exclusivity and duration of breastfeeding (Pound, Unger, & CPS Nutrition and Gastroenterology Committee, 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 protection, promotion and support increases the percentage of mothers who breastfeed their child beyond six months. Studies have shown that when all forms of breastfeeding support are offered at all follow-ups with the child up to nine months of age, mothers are encouraged to continue breastfeeding (Renfrew, McCormick, Wade, Quinn & Dowswell, 2012). The resource  Protecting, Promoting and Supporting Breastfeeding: A Practical Workbook for Community-Based Programs can assist in identifying specific strategies and actions to protect, promote, and support breastfeeding in a population health context.

The father or partner and the wider family are part of the mother's social environment and have a role in supporting breastfeeding, especially for longer durations (AAFP, 2008). They need information about breastfeeding, answers to their questions, and clarification about any myths or misconceptions (AAFP, 2008).

Health professionals help to create supportive environments for breastfeeding when they continue to promote this practice as the normal way of feeding, along with appropriate complementary foods, for older infants and young children. Discuss with parents their views, concerns and questions. Explore topics such as returning to work or school, breastfeeding and child care, possible concerns about the social stigma of breastfeeding an older infant and young child, and peer and professional breastfeeding resources in the community.

References

American Academy of Family Physicians. (2008).  Breastfeeding, family physicians supporting (position paper).

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.

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).

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).

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

Kendall-Tackett, K.A., & Sugarman, M. (1995). The social consequences of long-term breastfeeding. J Hum Lact, 11(3):179-183.

Lawrence, R.A., & Lawrence, R.M. (2005). Breastfeeding: A guide for the medical professional, 5^th edition.Rochester NY: Elsevier Mosby. Pp. 22.

Luan, N., Wu, Q., Gong, T., Vogtmann, E., Wang, Y., & Liun, B. (2013). Breastfeeding and ovarian cancer risk: A meta-analysis of epidemiologic studies. Am J Clin Nutr,98:1020-1031.

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.

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.

Renfrew. M.J., McCormick, F.M., Wade, A., Quinn, B., & Dowswell, T. (2012). Support for healthy breastfeeding mothers with healthy term babies (Review). The Cochrane Collaboration, 5:1-169.

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

Statistics Canada. (2013). Canadian Community Health Survey - Annual component: 24-month shared file, 2011-2012. Maternal experiences - Breastfeeding. Unpublished raw data.

Su, D., Pasalich, M., Lee, A.H., & Binns, C.W. (2013). Ovarian cancer risk is reduced by prolonged lactation : A case-control study in Southern China. Am J Clin Nutr, 97:354-359.

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 Cancer Research Fund and American Institute for Cancer Research. (2013). Public health goals and personal recommendations. Second Expert Report, Chapter 12.

World Health Organization and UNICEF. (2003).  Global strategy for infants and young child feeding. Geneva: World Health Organization.

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.

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

World Health organization and UNICEF. (2009). Baby-Friendly Hospital Initiative: Revised, updated and expanded for integrated care. Section 1: Background and implementation.

Supplemental vitamin D is recommended for infants and young children who are breastfed or receiving breastmilk

• Recommend a daily vitamin D supplement of 10 µg (400 IU) for infants and young children who are breastfed or receiving breastmilk.

Rationale

Vitamin D is an essential nutrient. It helps the body use calcium and phosphorous to build and maintain strong bones and teeth (IOM, 2011). Although sunlight stimulates the formation of vitamin D in the skin, current practice advises that infants and young children avoid direct sunlight due to the risk of skin cancer (Health Canada, 2012). A daily vitamin D supplement is recommended from birth for all breastfed infants. This is an effective preventative measure against vitamin D-deficiency rickets (Lerch & Meissner, 2007).

For advice about vitamin D for infants and young children who are not breastfed or receiving breastmilk see In Practice: Talking with families about nutrition for older infants and young children.

Six to 12 months of age

Limited data are available on supplementation practices between six and 12 months of age. Nationally, available data suggests that 79.6% of infants are given a vitamin D supplement when they are breastfed or receiving breastmilk (Statistics Canada, 2013). Of these infants, 88.2% were given the supplement "every day" or "almost every day" (Statistics Canada, 2013). It is important to keep recommending a vitamin D supplement of 10 µg (400 IU) for older infants while they are breastfed or receiving breastmilk.

12 to 24 months of age

Young children who are breastfed or receiving breastmilk should continue to receive a daily vitamin D supplement of 10 µg (400 IU). Advising the continuation of this supplement is a conservative approach to achieving adequate vitamin D intakes. It also provides a consistent and straight forward public health message. In individual practice, the decision to discontinue the supplement beyond 12 months of age can be informed by a dietary assessment of other contributors of vitamin D, such as cow milk.

There is no national survey data, but smaller studies suggest that young children may be at increased risk of vitamin D deficiency if they are breastfed without vitamin D supplementation or with only occasional supplementation (Gesser, Plotnik & Muth, 2003; Gordon et al., 2008). Continuing the supplement while a young child is breastfed or receiving breastmilk will minimize that risk.

Excessive intake is not a concern for children who continue to receive a vitamin D supplement, regardless of the child's intake of cow milk and other food sources. Total intake is unlikely to approach the Tolerable Upper Intake Level of 2500 IU per day.

After two years of age, a vitamin D supplement is no longer recommended. It is recommended that children's eating patterns follow Canada's Food Guide.

References

Gessner, B.D., Plotnik, J., & Muth, P.T. (2003). 25-hydroxyvitamin D levels among healthy children in Alaska. J Pediatr. 143:434-7.

Gordon, C.M., Feldman, H.A., Sinclair, L., Williams, A.L., Kleinman, P.K., Perez-Rossello, J., & Cox, J.E. (2008). Prevalence of vitamin D deficiency among healthy infants and toddlers. Arch Pediatr Adolesc Med. 162:505-12.

Health Canada. (2012). Sun safety tips for parents.

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

Lerch, C., & Meissner, T. (2007). Interventions for the prevention of nutritional rickets in term born children. Cochrane Database of Systematic Reviews. Issue 4, Article No.: CD006164.

Statistics Canada. (2013). Canadian community health survey - Annual component: 24-month shared file, 2011-2012. Maternal experiences - Breastfeeding. Unpublished raw data

Complementary feeding, along with continued breastfeeding, provides the nutrients and energy to meet the needs of the older infant.

• Recommend gradually increasing the number of times a day that complementary foods are offered while continuing to breastfeed.
• Recommend iron-rich meat, meat alternatives, and iron-fortified cereal as the first complementary foods. Encourage parents and caregivers to progress to introduce a variety of nutritious foods from the family meals.
• Ensure that lumpy textures are offered no later than nine months. Encourage progress towards a variety of textures, modified from family foods, by one year of age.

Rationale

At about six months of age, breastfeeding should still be the main source of nutrition. However, it is no longer sufficient to meet all of the older infant's nutrient needs (WHO, 2009; Butte et al., 2004; PAHO, 2003). During the initial stages of complementary feeding, the foods offered as a 'complement' to breastfeeding should be energy-dense and rich in nutrients such as iron (WHO, 2009).

The Pan American Health Organization (PAHO) and the WHO have estimated energy requirements for older infants six to eight months of age. The energy contribution from complementary feedings is approximately one fifth of the total requirement (WHO, 2009; PAHO, 2003). By nine to 11 months, complementary feedings contribute just under half of the estimated total energy requirement.

When complementary feeding begins, breastfeeding continues on-cue. The WHO has noted that, "whether breastfeeds or complementary foods are given first at any meal has not been shown to matter. A mother can decide according to her convenience and the child's [cues]" (WHO, 2009), which will change with the child's advancing age and feeding pattern.

For advice on complementary feeding from 12 to 24 months see From one year of age, young children can begin to have regular meals and snacks, and generally follow the advice in Canada's Food Guide

Frequency of complementary feeding

From six to eight months, parents and caregivers should work towards offering complementary foods in two to three feedings, and one to two snacks each day, depending on the older infant's appetite (WHO, 2009). During this initial stage, it is important that parents and caregivers be responsive to hunger cues.

The amount of food offered should also be based on the principles of responsive feeding. The amount consumed at a feeding will differ based on factors such as:

• how they are feeling
• the presence of distractions
• the time of day
• their breastmilk intake
• their appetite and ability to eat
• the energy density of the complementary foods.

The nutrient density and frequency of the feedings should be adequate to meet the older infant's needs (PAHO, 2003). Parents and caregivers should be encouraged to start by offering small amounts of foods from the family meals, modified to an appropriate texture and size for their age and development. They should offer more food depending on their appetite and hunger cues.

Older infants nine to 11 months of age can be offered up to three feedings a day with one to two snacks, depending, once again, on their appetite. The frequency of feedings and the amount of food increases with age to accommodate higher energy requirements for development and growth (WHO, 1998). At about 12 months, parents and caregivers can begin to establish a schedule of regular of meals and snacks (Satter, 2000).

The Sample Menus provide examples of nutritious complementary feeding for older infants at seven and 11 months of age. Sample menus for a young child at 17 months are also available.

Foods from the family meals

From six months of age, an older infant's complementary foods can be many of the same nutritious foods enjoyed by the family. They should be prepared and served with little or no added salt or sugar (WHO, 2009). Commercial infant foods are not needed and can be high in added sugar (Garcia, Raza, Parrett, &Wright, 2013).

Advise parents and caregivers to first introduce iron-rich meat and meat alternatives, and iron-fortified cereals. Aside from iron-rich foods being the first foods introduced, there is no particular order for the introduction of other foods or food groups (except fluid cow milk). Vegetables, fruit, and milk products such as cheese and yoghurt can be introduced, between 6 to 9 months, along with a variety of iron-rich foods.

Encourage parents and caregivers to progress to offering new foods. This ensures a variety of flavours and foods from Canada's Food Guide are being consumed by 12 months. For advice about introducing new foods if parents or caregivers have concerns about food allergies see In Practice: Talking with families about nutrition for older infants and young children.

Children who have early experiences with eating nutritious foods are more likely to prefer and to consume those foods and to have an eating pattern that promotes healthy growth (Ahern, 2013; Anzman, Rollins & Birch, 2010; Mennella, Nicklaus, Jagolino, & Yourshaw, 2008). These healthy eating patterns may continue into later childhood (Skinner, Bounds, Carruth, Morris, & Ziegler, 2004).

The social aspect of eating is another important reason that older infants should take part in family meals. Encourage parents and caregivers to include infants and young children, even if their feeding times do not always align. Family meals should be eaten at the table to ensure older infants and young children are safe and supervised.

During family meals, an older infant may not consume a significant amount of food. However, meal times provide exposure to tastes, colours, and textures. Encourage relaxed, pleasant, and positive meals times without distractions such as television (PAHO, 2003; Satter, 2000). Family meals create an opportunity for modelling healthy eating habits.

Texture of complementary foods

As an older infant's neuromuscular system matures, the types and textures of complementary foods they are able to consume will grow (WHO, 1998). Infants process foods using four age-related methods: suckling, sucking, munching, and chewing. An infant from birth to six months will have the oral motor skills to suckle, suck, and swallow (WHO, 1998).

During the initial stages of complementary feeding, the older infant develops up and down mandibular movements which allow them to 'munch'. These movements permit consumption of some solid foods, such as crackers, toast, and ready-to-eat breakfast cereals, regardless of whether teeth have appeared (Morris & Klein, 2000; WHO, 1998). It is important that parents and caregivers provide a variety of soft textures (such as lumpy, and tender-cooked and finely minced, pureed, mashed or ground) and finger foods from six months of age. Safe finger foods include: pieces of soft-cooked vegetables and fruits; soft, ripe fruit such as banana; finely minced, ground or mashed cooked meat, deboned fish, and poultry; grated cheese; and bread crusts or toasts. For safety reasons, there are some food shapes and textures that should not be offered to children younger than four years.

Although an older infant is capable of consuming more solid foods, the time required to complete a feeding may take longer than with foods that are pureed (WHO, 1998). An older infant's efficiency in consuming purees will peak at about 10 months, but their ability to consume other solid food textures will continue to improve until about 24 months of age (WHO, 1998). Gagging is a natural reflex that older infants may experience and should be discussed with parents and caregivers.

Between about eight and 12 months, the older infant develops lateral movements of the tongue. These allow the older infant to move food to the teeth. This movement enables biting and chewing of chopped foods and a greater variety of finger foods (WHO, 1998).

It is important for parents and caregivers to progress quickly to foods with a lumpy texture. Delaying the introduction of lumpy textures beyond the age of nine months is associated with feeding difficulties in older children and a lower intake of nutritious foods such as vegetables and fruit (Coulthard, Harris & Emmett, 2009).

By 12 months of age, young children should be offered a variety of family foods with modified textures, such as ground, mashed, or chopped foods, with a tender consistency (Morris & Klein, 2000). Between 12 and 18 months, young children will acquire full chewing movements (WHO, 1998).

References

Ahern, S.M., Caton, S.J., Bouhlal, S., Hausner, H., Olsen, A., Nicklaus, S., Moller, P., & Hetherington, M.M. (2013). Eating a rainbow. Introducing vegetables in the first years of life in 3 European countries. Appetite, 7:48-56.

Anzman, S. L., B. Y. Rollins, & Birch, L.L. (2010). Parental influence on children's early eating environments and obesity risk: Implications for prevention. International Journal of Obesity. 34: 1116-1124.

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.

Coulthard, H., Harris, G., & Emmett, P. (2009). Delayed introduction of lumpy foods to children during the complementary feeding period affects child's food acceptance and feeding at 7 years of age. Maternal and child nutrition, 5: 75-85.

Garcia, A.L., Raza S., Parrett A., & Wright, C. M. (2013). Nutritional content of infant commercial weaning foods in the UK. Arch Dis Child, 98: 793-797.

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

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

Pan American Health Organization. (2003).  Guiding principles for complementary feeding of the breastfed child.

Satter, E. (2000). Child of mine: Feeding with love and good sense. Boulder, Colorado: Bull Publishing Company.

Skinner, J. D., W. Bounds, B. R. Carruth, M. Morris, & Ziegler, P. (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.

World Health Organization. (1998).  Complementary feeding of young children in developing countries: A review of current scientific knowledge.

Responsive feeding promotes the development of healthy eating skills.

• Encourage responsive feeding based on the child's hunger and satiety cues.
• Promote offering finger foods to encourage self-feeding.
• 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 hunger and satiety 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 avoid under- or overfeeding, parents and caregivers need to be sensitive to the hunger and satiety cues of infants and young children. Responsive feeding (PAHO, 2003; Engle & Pelto, 2011):

• Allows the child to guide feeding
• Balances helping with encouraging self-feeding, in a way that is appropriate for the child's level of development
• Involves eye contact and positive verbal encouragement, but not verbal or physical coercion
• Uses eating utensils that are age-appropriate, as well as culturally appropriate
• Responds to early hunger and satiety cues
• Minimizes distractions during meals and feedings
• Takes place in a comfortable and safe environment
• Is sensitive to the child, including changes in the child's physical and emotional state
• Offers different food combinations, tastes, and textures

Responsive feeding may influence a child's early development in self-regulating energy intake (DiSantis, Hodges, Johnson & Fisher, 2011; IOM, 2011; Townsend & Pitchford, 2012). Non-responsive feeding relationships may override an infant's internal hunger and satiety cues and interfere with their emerging autonomy (Black & Aboud, 2011; IOM, 2011). Pressuring infants to eat by using excessive verbal encouragement (such as "clean your plate") may lead to negative attitudes about eating and poor eating habits (Cerro, Zeunert, Simmer, & Daniels, 2002) as well as excessive feeding and excess weight gain (Birch, 1992; Satter, 1996; Hurley, Cross, & Hughes, 2011). On the other hand, parents and caregivers who restrict higher-fat, energy-dense foods due to concern about overeating may adversely affect self-regulation and actually increase the child's intake of the foods when they are offered (IOM, 2011).

Roles and responsibilities of parent and child during feeding

The development of healthy eating skills is a shared responsibility (Satter, 2012; Satter, 2000). For young infants, parents are responsible for what milk source is offered, and the child, with infant-led or on-cue feeding, is responsible for everything else (that is, when, where, and how much).

For the older infant and young child, parents and caregivers provide a selection of nutritious foods, prepared and served in a safe manner, in addition to the child's milk source. By one year of age, parents and caregivers take responsibility for when and where food is eaten by providing regular meals and snacks. At every age the child decides how much they want to eat and whether they want to eat at all (Satter, 2000).

To support healthy eating skills, encourage parents and caregivers to recognize and respond appropriately to their 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

Offering finger foods among the first complementary foods 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 older infant is ready to reach out for and 'munch' the food (Rapley, 2011; Sachs, 2011, WHO, 1998; Wright, Cameron, Tsiakas, & Parkinson, 2011).

Reassure parents and caregivers that self-feeding is a developmental and experimental process for the older infant and young child. They may not actually consume a significant amount of the finger foods. For older infants, it is important that finger foods are part of a diet that provides a variety of textures (Wright, Cameron, Tsiakas, & Parkinson, 2011; WHO, 1998).

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

Open cup

As fluids other than breastmilk are introduced, they can be offered in an open cup. Use of an open cup has been shown to be a safe and easily learned skill in infancy (Howard et al., 2003; Lang, Lawrence, & Orme, 1994).

Older infants can be offered water from an open cup along with complementary feedings. At first, they will need help with the cup from the parent or caregiver. Advise parents and caregivers to assist by holding the cup against the mouth. Initially, when the cup is presented, the older infant will use the familiar suckling pattern (Morris & Klein, 2000). The older infant will develop a coordinated sucking action and will begin to hold the jaw in a stable open position as the cup approaches (Morris & Klein, 2000). Older 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).

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). An open cup is the most appropriate choice to encourage skill development (ADA, 2004).

Encouraging use of an open cup for older infants can help avoid prolonged bottle-feeding. Use of bottles among young children has been associated with the consumption of excess calories and may contribute to the risk of obesity in childhood (Gooze, Anderson, & Whitaker, 2011).

Offering older infants an open cup can help to decrease constant consumption and over exposure of the teeth to sugar-containing liquids. Decreasing this exposure may help reduce the risk of dental decay (ADA, 2004). For more information on reducing the risk of early childhood caries, see In Practice: Talking with families about nutrition for older infants and young children.

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.

Birch, L.L. (1992). Children's preferences for high-fat foods. Nutr Rev, 50:249-255.

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.

Brown, A., & Lee, M. (2011). 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, K.N., & Daniels, L.A. (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.

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.

Institute of Medicine. (2011). Early Childhood Obesity Prevention Policies. 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.

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.

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

Pan American Health Organization. (2003).  Guiding principles for complementary feeding of the breastfed child.

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

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

Satter, E. (2012).  Ellyn Satter's division of responsibility in feeding.

Satter, E. (2000). Child of mine: Feeding with love and good sense. Boulder, Colorado: Bull Publishing Company.

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.

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. (1998).  Complementary feeding of young children in developing countries: A review of current scientific knowledge.

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. Ensure that foods such as meat and meat alternatives and iron-fortified cereal are offered a few times each day.
• If parents and caregivers are introducing cow milk, advise them to delay until nine to 12 months of age. Recommend limiting cow milk intake to no more than 750 mL per day.

Rationale

At about six months, an older infant's iron stores are depleted (IOM, 2001; Butte, Lopez-Alarcon, & Garza, 2002; Dewey & Chaparro, 2007).  The risk of iron deficiency increases from six to 12 months of age. This is because rapid growth during this time dictates higher iron needs (IOM, 2001). The risk is still present from 12 to 24 months as studies suggest that the nutritional quality of a young child's diet and their consumption of key micronutrients, including iron, tend to decline (Picciano et al., 2000).

Iron deficiency occurs on a continuum and symptoms such as pallor, poor appetite, irritability, and slowed growth and development may not be apparent until a deficiency is severe (IOM, 2006; CPSP, 2011). Iron deficiency can lead to iron deficiency anemia, which is associated with irreversible developmental delays in cognitive function (CPSP, 2011).

The following factors help identify older infants at risk of iron deficiency (Williams & Innis, 2005):

• The infant's iron endowment at birth
• Infant's growth rate
• Duration of exclusive breastfeeding
• Age of introduction to cow milk, and frequency and amount consumed
• Age of introduction to solid foods
• Age of introduction of heme-containing foods such as meat, fish, and poultry, and frequency of consumption

If an older infant is identified as being at risk, parents and caregivers should be given dietary advice to increase their child's iron intake by offering iron-rich foods and avoiding early introduction and excessive consumption of cow milk. Older infants can also be screened for iron deficiency anemia between six and twelve months of age (Rourke, Rourke & Leduc, 2011). Alternatively, they may benefit from medicinal iron drops from six months of age. If at anytime from six to 24 months, an older infant or young child is determined to have risk factors for iron deficiency then consideration for screening is advised.

Iron-rich foods

The risk of iron deficiency can be reduced by the timely introduction and regular consumption of iron-rich complementary foods such as meat and meat alternatives and iron-fortified cereal (Butte et al., 2002; Dewey & Chaparro, 2007; Meinzen-Derr et al., 2006). Between six and 12 months, infants should be offered iron-rich foods two or more times a day. From 12 to 24 months of age, iron-rich foods should be offered at each meal.

The bioavailability of the heme form of iron is substantially higher in meat than it is in non-heme iron sources such as cereals, legumes, eggs and tofu. Even small servings of meat, poultry, or fish contribute to iron intake, because much of the iron in these foods is in the heme form (Hambidge et al., 2011; Krebs et al., 2013).

Meat not only contains a more absorbable form of 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., 1998). Daily consumption of foods rich in vitamin C, such as fruits and vegetables, can also help to enhance absorption of iron from non-heme sources.

Encourage parents and caregivers to offer older infants meat, fish, poultry, or meat alternatives each day. But note Canada's Food Guide advice to limit luncheon meats, sausages, or pre-packaged meats higher in salt and fat. Certain types of fish should also be avoided because of concerns about their mercury content.

Iron-fortified grain products such as iron-fortified infant cereal and ready-to-eat breakfast cereals should be offered to older infants and young children, especially in the absence of a heme iron source in their meals. Unenriched rice and imported, white flour-based grain products, such as some types of pasta, are lower in iron.

Cow milk introduction

To reduce the risk of iron deficiency cow milk is not recommended for older infants before nine to 12 months of age. Cow milk is low in iron, can displace iron-rich foods, and can inhibit iron absorption. Use of cow milk as a main milk source for infants younger than six months of age can cause gastrointestinal bleeding and increased occult blood loss in stool (Michaelsen, 2000; Fomon, Nelson, Serfass, & Zeigler, 2005; Bondi & Lieuw, 2009; Ziegler et al., 1999; Jiang, Jeter, Nelson, & Ziegler, 2000; Leung, & Sauve, 2003; Fernandes, de Morais, & Amancio, 2008).

Once an older infant is regularly eating a wide variety of iron-rich foods such as meat, meat alternatives, and iron fortified cereals, the introduction of cow milk is not associated with iron deficiency (Yeung, & Zlotkin, 2000; Agostoni, & Turck, 2011).

It is not just the early introduction of cow milk, but also the volume of cow milk consumed that is a risk factor for iron deficiency (Maguire et al., 2013; Agostini, & Turck, 2011). 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).

For young children, cow milk intake should not exceed 750 mL per day (Kazal, 2002; CDC, 1998). At volumes in excess of 750 mL, cow milk can displace other foods that are sources of nutrients not found in milk. In addition to iron, fibre intake may be adversely affected, which could lead to constipation (CPS, 2011). Offering milk in an open cup may help to avoid excess consumption (Maguire et al., 2013).

Goat milk poses the same risks for the development of iron deficiency as cow milk when consumed in excessive amounts by young children (CDC, 1998).

References

Agostoni, C., & Turck, D. (2011). Is cow's milk harmful to a child's health? JPGN, 53: 594-600.

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.

Canadian Paediatric Surveillance Program. (2011).  Iron-deficiency anemia in children.

Centers for Disease Control and Prevention. (1998).  Recommendations to prevent and control iron deficiency in the United States. MMWR, 47(RR-3), 1-36).

Canadian Paediatrics Society Community Paediatrics Committee. (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.

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.

Fernandes, S.M, de Morais, B.M., & Amancio, O.M. (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.

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.

Hambidge, K.M., Sheng, X., Mazariegos, M., Jiang, T., Garces, A., Li, D., Westcott, J., Tshefu, A., Sami, N., Pasha, O., Chomba, E., Lokangaka, A., Goco, N., Manasyan, A., Wright, L.L., Koso-Thomas, M., Bose, C., Goldenberg, R.L., Carlo, W.A., McClure, E.M., & Krebs N.F. (2011). Evaluation of meat as a first complementary food for breastfed infants: impact on iron intake. Nutrition Reviews. 69(Suppl.1): S57-S63.

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.

Institute of Medicine (2006). Dietary reference intakes - The essential guide to nutrient requirements. Washington DC: National Academies 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.

Krebs, N.F., Sherlock, L.G., Westcott, J., Culbertson, D., Hambidge, K.M., Feazel, L.M., Robertson, C. E., & Frank, D.N. (2013). Effects of different complementary feeding regimens on iron status and enteric microbiota in breastfed infants. J Pediatr. 163: 416-423.

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.

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

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

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

• Recommend infants and young children always be supervised during feeding.
• Recommend parents and caregivers avoid offering hard, small and round, or smooth and sticky, solid foods. These may cause aspiration and choking.
• Promote safe food preparation and storage to prevent foodborne illness. Recommend avoiding products that contain raw or undercooked meat, eggs, poultry, or fish; unpasteurized milk or milk products; unpasteurized juice; and cross-contamination between cooked and uncooked foods.
• Advise parents and caregivers not to give honey to a child under one year of age. This helps to prevent infant botulism.

Rationale

Supervision

Parents and caregivers should supervise and actively engage infants and young children when eating. The child should be sitting upright, not be lying down, walking, running or distracted from the task of safe eating. A good way to ensure proper supervision is to include infants and young children in family meals.

Injuries can occur with bottles, pacifiers, and 'sippy' cups when young children fall while using these products. The most common type of injury is lacerations to the mouth (AAP, 2012). Young children who are just learning to walk and run are at highest risk of these injuries (AAP, 2012). Advise parents and caregivers of these dangers. In addition, promote the transition to an open cup.

Eating in a moving vehicle is considered unsafe. If choking should occur, it is difficult to attend to the young 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 foods, small and round foods, and 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 younger than four years: hard candies or cough drops, gum, popcorn, marshmallows, peanuts or other nuts, seeds, fish with bones; snacks using toothpicks or skewers (CPS, 2012; AAP, 2010). The food that has been most commonly associated with fatal choking among children is a hot dog (AAP, 2010). Hot dogs and sausages are a safer shape for children when they are diced or cut lengthwise. The following foods are safer when prepared as follows:

• Grate raw carrots and hard fruits such as apples
• Remove the pits from fruits
• Chop grapes
• Thinly spread peanut butter on crackers or toast. 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).
• Finely chop foods of fibrous or stringy textures such as celery or pineapple.

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, 2012). 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.

Unpasteurized milk and milk products, as well as unpasteurized juices, should not be offered to infants and young children because of the risk of foodborne illness.

Infant botulism

Infant botulism is a rare disease that can affect otherwise healthy infants. 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, 2011). Less than 5% of the honey produced in Canada contains Clostridium botulinum spores, and usually the number of spores is low (Health Canada, 2011). 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.

Since the first reported case in 1979, there have been 42 reported cases of infant botulism in Canada (Health Canada, 2013). Only three cases have been linked to 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 (2011). Infant botulism.

Health Canada (2012). Salmonella and Salmonellosis.

Health Canada. (2013). Infant botulism.

Pipes, P.L., & Trahms, C.M. (1993). Nutrition in infancy and childhood (5^th ed). Mosby, St. Louis.

Rourke, L., Rourke, J., & Leduc, D. (2011).  Rourke baby record: Evidence-based infant/child health maintenance.

From one year of age, young children begin to have a regular schedule of meals and snacks, and generally follow the advice in Canada's Food Guide.

• Recommend a regular schedule of meals and snacks, offering a variety of foods from the four food groups.
• Recommend foods prepared with little or no added salt or sugar.
• Explain to parents and caregivers that nutritious, higher-fat foods are an important source of energy for young children.
• Encourage continued breastfeeding, or offering 500 mL per day of homogenized (3.25% M.F.) cow milk.
• Advise limiting fruit juice and sweetened beverages. Encourage offering water to satisfy thirst.
• Encourage parents and caregivers to be role models and instil lifelong healthy eating habits.

Rationale

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

Meals and snacks from 12- 24 months

A regular schedule of meals and snacks will help young children to develop healthy eating habits (Satter, 2000).  For young children, complementary foods provide nearly two thirds of their energy needs based on the estimated average breastmilk intake (WHO, 1998; WHO, 2009; PAHO, 2003). Frequent, nutrient-dense meals and snacks are important to meet a young child's needs for energy and nutrients. Parents and caregivers should aim to offer young children three meals per day and two to three snacks (WHO, 2009).

To prevent nutrient deficiencies, parents and caregivers should offer a variety of foods daily from the four food groups in Canada's Food Guide. Young children will get adequate nutrients and energy when offered a varied diet (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).

From 12 to 24 months, parents and caregivers should work up to offering the amounts and types of foods recommended for a child two to three years of age in Canada's Food Guide. Portion sizes for young children are roughly one quarter to one half of an adult portion. Explain to parents and caregivers that it is not necessary to offer one whole serving at one time. Two sets of Sample Menus for a family with a 17 month old give examples of nutritious meals and snacks for young children at this age.

While the parent or caregiver is responsible for setting the frequency and timing of meals and snacks and ensuring that they contain a variety of nutritious foods, the child should decide how much, or whether, they eat (Satter, 2000). Children will compensate for eating less on some days or at a particular meal by eating more at other meals.

Salt and sugar

Advise parents and caregivers to limit or avoid adding salt and sugar when preparing food for young children (Michaelsen, Weaver, Branca, & Robertson, 2003). This allows 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 foods for infants less than 12 months of age. However, there are no regulations on sugars.

If 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 sodium (salt). The ingredient list on food labels can use different words for added sugars or salt. Encourage parents and caregivers to review the ingredient list carefully.

Dietary fat

Dietary fat restriction is not recommended for children younger than two years (Picciano et al., 2000). This is because it may compromise a young child's intake of energy and essential 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, homogenized (3.25% M.F.) cow milk, cheese, avocado and nut butters provide a concentrated energy source during a life stage when requirements are particularly high. Similar to the advice in Canada's Food Guide, there is no need to restrict unsaturated fats such as vegetable oils, salad dressings, margarine and mayonnaise during meal preparation for young children.

Fish, particularly fatty 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. While the optimal amount of EPA and DHA for infants and young children has not been determined, parents and caregivers are encouraged to offer fish, as a good food source, and work up to two servings per week as a general guideline by 24 months of age. Advise, however, that certain types of fish should be avoided, or at least limited to no more than 75 grams per month, because of the risk of overexposure to mercury. These fish include fresh or frozen tuna, shark, swordfish, marlin, orange roughy and escolar. Learn more from the advisory from Health Canada.Consult local, provincial, or territorial governments for information about eating locally caught fish.

Milk source

Encourage continued breastfeeding for the older infant and young child. If an older infant is no longer breastfed, pasteurized, homogenized (3.25% M.F.) cow milk is recommended as the main milk source, and can be introduced from nine to 12 months. Breastmilk or homogenized (3.25% M.F.) cow milk provides about one third of a young child's energy requirements from 12 months of age (WHO, 1998; WHO, 2009; PAHO, 2003). A young child's milk source also provides protein and vitamins and minerals important for strong bones and teeth.

Before two years of age, partly skimmed, 2% or 1% milk is not routinely recommended as a young child's main milk source. Skim milk is an inappropriate choice for children younger than two years.

Some households may use evaporated or powdered milk. These are suitable milk alternatives, provided the products are properly diluted or reconstituted. Advise parents and caregivers to choose a full-fat (not a low fat or fat-free) evaporated or powdered milk if it is used as the main milk source for a young child.

Pasteurized, full-fat goat milk may be used as an alternative to cow milk. If goat milk is used parents and caregivers should choose goat milk with added folic acid and vitamin D. Due to the similarity in the sequences of the milk proteins, there are frequent cross-reactions between milk proteins from different animal species (goat, sheep, and cow milk) (Restani et al., 1999; Bernard, Creminon, Negroni, Peltre, & Wal, 1999; Järvineni & Chatchatee, 2009). Older infants and young children who have a food allergy to cow milk protein are likely to have an allergic reaction to goat or sheep milk.

Fortified soy beverages are not suitable as a main milk source for children younger than two years. For the older infant and young child who is no longer breastfed and is not being introduced to cow milk, soy-based commercial infant formula is recommended until two years of age.

If fortified soy beverage is being offered occasionally as a complementary food, in addition to breastmilk or cow milk as the main milk source, it should be an unflavoured, full-fat, fortified soy beverage (Dunham & Kollar, 2006).

Other plant-based beverages, such as almond, rice, and coconut 'milks', are not nutritionally comparable to homogenized (3.25% M.F.) cow milk. They have a very different macronutrient composition, and are not suitable milk alternatives.

Fruit juices and sweetened beverages

Children aged one to three form the highest percentage of fruit juice consumers (Garriguet, 2008). Drinking juice has been associated with dental decay in young children (AAP, 2001). Fruit juice intake can displace intake of breastmilk and may contribute to inadequate intakes of nutrients from solid foods (Skinner, Ziegler, & Ponza, 2004). Remind parents and caregivers that young children have small stomachs and fill up quickly on beverages. Because of the fructose and sorbitol content of fruit juices, excessive intake may also lead to diarrhea (AAP, 2001).

Fruit juice lacks the fibre of whole fruit.  Fruits and vegetables should be emphasised instead of juice as recommended in Canada's Food Guide. Only 100% fruit or vegetable juice should be offered.

Recommend offering water frequently (ADA, 2004). Juice should be offered much less frequently if at all.  Allowing children to carry a bottle, 'sippy' cup, or juice box around throughout the day encourages constant consumption and over exposure of the teeth to sugar (ADA, 2004; AAP, 2001). Offerings should be limited to no more than one or two times per day. Approximate daily amount could be 125-175 mL/day (CPS, 2013; AAP, 2001).

Sweetened beverages, such as pop, fruit drinks, punches and sports drinks have a high sugar content and lack vitamins and minerals. Like fruit juice, they can also increase the risk of early childhood caries, and should be limited. Unsweetened homogenized (3.25% M.F.) milk is recommended over sweetened milk, such as chocolate milk, or flavoured soy-based beverages, such as chocolate and vanilla, which contain added sugar.

Beverages containing caffeine or artificial sweeteners should not be offered to young children. Coffee, tea, some carbonated beverages, and hot chocolate may also contain caffeine or caffeine-related substances. Caffeine is a drug that acts as a stimulant. Other beverages such as diet pop or fruit drinks contain artificial sweeteners. These may interfere with a young child's intake of nutritious, energy-dense foods needed for their rapid growth.

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 helps young children develop healthy eating patterns and learn skills through imitation (CPS, 2012). Young children are more likely to try and enjoy a variety of foods when they are offered the same foods the rest of the family are eating (Skafida, 2013; Ahern, et al., 2013).

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

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.

Ahern, S.M., Caton, S.J., Bouhlal, S., Hausner, H., Olsen, A., Nicklaus, S., Moller, P., Hetherington, M.M. (2013). Eating a rainbow. Introducing vegetables in the first years of life in 3 European countries. Appetite, 7:48-56.

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

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

Bernard, H., Creminon, C., Negroni, L., Peltre, G., & Wal, J.M. (1999). IgE cross reactivity of caseins from different species in allergic humans to cow's milk proteins. Food Agric Immuno, 11: 101-111.

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. (2013).  Feeding your baby in the first year. Retrieved from: http://www.caringforkids.cps.ca/handouts/feeding_your_baby_in_the_first_year

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.

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

Garriguet, D. (2008).  Beverage consumption of children and teens. Health Reports, 19(4).

Järvinen, K., & Chatchatee, P. (2009). Mammalian milk allergy: Clinical suspicion, cross-reactivities and diagnosis. Current Opinion in Allergy and Clinical Immunology, 9(3):251-258.

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.

Pan American Health Organization. (2003).  Guiding Principles for complementary feeding of the breastfed child.

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

Restani, P, Gaiaschi, A, Plebani A, Beretta, B, Cavagni, G, Fiocchi, A, Poiesi, C, Velona, T, Ugazio, A.G., & Galli, C.L. (1999). Cross-reactivity between milk proteins from different animal species. Clin Exp Allergy,29: 997-1004.

Satter, E. (2000). Child of mine: Feeding with love and good sense. Boulder, Colorado: Bull Publishing Company.

Skafida, V. (2013). The family meal panacea: Exploring how different aspects of family meal occurrence, meal habits and meal enjoyment relate to young children's diets. Sociology of Health & Illness, 35(6): 906-923.

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.

World Health Organization. (1998).  Complementary feeding of young children in developing countries: A review of current scientific knowledge. WHO/NUT 98.1.

Recommendations on the use of breastmilk substitutes

Some infants may not be breastfed for personal, social, or rarely, medical reasons. Their families need support to optimize the infant's nutritional well-being. The International Code of Marketing of Breast-milk Substitutes, and subsequent World Health Assembly resolutions on nutrition for infants and young children, 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. If commercial infant formula is used as a breastmilk substitute, it should be prepared and stored safely, according to manufacturer's directions, to reduce the risk of illness from bacterial growth.

For an older infant or young child who is not breastfed or receiving breastmilk:

• Recommend commercial infant formula until nine to 12 months of age.
• Advise pasteurized homogenized (3.25% M.F.)cow milk be introduced at nine to 12 months of age. Skim milk is not appropriate in the first two years.
• Advise that, for most healthy young children, there is no indication for the use of commercial formulas beyond one year of age.
• Advise that soy, rice, or other plant-based beverages, whether or not they are fortified, are inappropriate alternatives to cow milk in the first two years.
• Recommend avoiding prolonged bottle feeding and giving bottles at night.

Rationale

Commercial infant formula until nine to 12 months of age

For an older infant who is not breastfed or receiving breastmilk, recommend commercial infant formula until nine to 12 months. Once an older infant is regularly consuming a variety of iron-rich foods, commercial infant formula can be replaced with pasteurized, homogenized (3.25% M.F.) cow milk. Partly skimmed 2% or 1% M.F. milk is not routinely recommended. Skim milk is inappropriate to offer children younger than two years. Partly skimmed or skim milk do not provide sufficient essential fatty acids and have a lower energy density. If iron-rich foods are not yet regularly consumed at nine months, it may be beneficial to postpone the transition to homogenized (3.25% M.F.) cow milk until the older infant is closer to 12 months.

Follow-up commercial infant formulas may be used as breastmilk substitutes for infants older than six months.  These commercial infant formulas generally contain more iron and calcium than 'starter' formulas. However, no superiority has been established.

After one year of age

By 12 months of age homogenized (3.25% M.F.) cow milk, along with nutritious family foods, can provide sufficient energy and nutrients (Butte et al., 2004). From 12 to 24 months, an estimated one third of a young child's energy can come from their milk source and the remaining two thirds from complementary foods (WHO, 2009; PAHO, 2003). The Sample Menus give examples of nutritious meals and snacks for young children at this age. For a young child who is not breastfed, 500 mL (2 cups) of homogenized (3.25% M.F.) cow milk should be offered each day as part of meals and snacks.

Some young children have been fed soy-based commercial 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 until two years of age. This is also the case for a vegan younger than two years who is no longer breastfed.

Plant-based beverages

Soy, rice, almond, or other plant-based beverages such as coconut 'milk', whether or not they are fortified, are not appropriate as the main milk source for a child younger than two years. Most 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). Some of these products may not contain adequate amounts of several vitamins and minerals (Mangels & Messina, 2001; Cockell, Bonacci, & Belonje, 2004; Imataka, Mikami, Yamanouchi, Kano, & Eguchi, 2004; Moilanen, 2004; Dunham & Kollar, 2006).

Rice and almond-based beverages are particularly low in protein (Liu & Frieden, 2002; Venter, 2009). This is a concern for infants, since they obtain most of their protein from their milk source. Rice milk has been linked to severe malnutrition when given to infants and young children (Keller, Shuker, Heimall, & Cianferoni, 2012). Coconut 'milk' is very high in calories, with most of the calories coming from fat, and very low in calcium.

Avoid prolonged bottle feeding

When introducing new fluids, other than commercial infant formula, after six months of age, it is best to offer them in an open cup. Parents and caregivers can keep offering commercial infant formula in a bottle, because some older infants may at first have difficulty consuming the same volumes with an open cup.

The transition from bottle feeding to an open cup should take place by about 12 months (IOM, 2011; AAP, 2009). This transition should be complete for all fluids no later than 18 months of age (IOM, 2011). Use of an open cup promotes the development of mature drinking skills (Morris & Klein, 2000). Encouraging the use of an open cup can help reduce nighttime and long-term use of bottles, particularly when they contain fluids other than water, which can decrease the risk of early childhood caries (ADA, 2004). It can also help reduce the other risks associated with long-term use of bottles such as the displacement of nutrient rich solid foods (Maguire et al., 2013).

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.

American Academy of Pediatrics. Committee on Nutrition (2009). Pediatric Nutrition Handbook, 6th Edition, Amercian Academy of Pediatrics. Elk Grove Village, IL.

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.

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.

Institute of Medicine. (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. 2^nd ed. Tuscon, AZ: Therapy Skill Builders.

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

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

World Health Organization. (2009).  Model Chapter for textbooks for medical students and allied health professionals.

In practice: Talking with families about nutrition for older infants and young children

• What supports help mothers to keep breastfeeding after returning to work or school?
• How can mothers be supported to feel comfortable breastfeeding an older infant or young child?
• What advice can be given to parents and caregivers on introducing new foods if they have concerns about food allergies?
• How can I reassure parents and caregivers that gagging is natural?
• What guidance can be given for feeding a 'picky eater'?
• Is there advice for Aboriginal people on food safety when offering infants traditional foods?
• Do older infants and young children who are not breastfed, or receiving breastmilk, need a vitamin D supplement?
• At what age can children transition from homogenized (3.25% M.F.) milk to low fat milk (such as partly skimmed 1% or 2%)?
• Is there any need for 'growing-up milk' or 'toddler milk'?
• Do vegetarian or vegan infants need supplements?
• What dietary advice helps reduce the risk of early childhood caries?
• What dietary advice helps to manage mild to moderate constipation in a young child?

What supports help mothers to keep breastfeeding after returning to work or school?

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). Even among those who qualify, 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.

Mothers who stop breastfeeding upon return to work or school may do so because they believe that they will be unable to maintain a milk supply, that breastfeeding will take too much time, or that 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 workplaces (Johnston & Esposito, 2007; Heymann & Kramer, 2009). Restrictions on breastfeeding by employers or governments may be grounds for complaints on the basis of gender or sex discrimination under the Canadian Charter of Rights and Freedoms or provincial, territorial or federal human rights legislation.

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). Public health nurses and International Board-certified lactation consultants can provide guidance and support to breastfeeding mothers returning to work or school. Other factors that may increase the duration of breastfeeding include (Johnston & Esposito, 2007; Heymann & Kramer, 2009):

• 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 clean and comfortable place to express milk and a refrigerator for storage.

How can mothers be supported to feel comfortable breastfeeding an older infant or young child?

Health professionals can support breastfeeding of the older infant and young child by continuing to promote this practice as the normal way of feeding.

Early weaning is a common practice in North American cultures. However, in some countries, mainly developing countries, it is more common for breastfeeding to continue up to and past two years (WHO, 2013). In more traditional societies and earlier in human evolution, breastfeeding between two and four years of age was a common practice (Riordan & Wambach, 2010; Dettwyler, 1995).

Some mothers may be reluctant to admit they are still breastfeeding an older infant or young child due to their perception that it is not well accepted (Lawrence & Lawrence, 2005). This response is referred to as 'closet nursing' (Riordan & Wambach, 2010).

Health professionals should treat breastfeeding mothers non-judgementally, accepting the diversity of their views, and supporting them to breastfeed as long as mother and child desire. Community health centres and support groups can help women who are facing difficulties or have no experience of long-term breastfeeding among their family and friends. At the child's regular medical appointments, the health professional can affirm the choice to breastfeed beyond infancy and into early childhood. The office environment of a health professional can support long-term breastfeeding by displaying  breastfeeding-friendly pictures or posters in a waiting room.

What advice can be given to parents and caregivers 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 older infants affects their risk of developing a food allergy. This includes infants at risk of atopy (Chan & Cummings, CPS Community Paediatrics Committee, 2013; Boyce et al., 2010; AAP, 2008). Common food allergens, such as peanut, fish, wheat (including iron-fortified infant cereals with wheat), milk products, soy and whole eggs, can be introduced from about six months of age (Chan, Cummings & CPS Community Paediatrics Committee, 2013). Several of these foods, such as iron-fortified infant cereals with wheat, fish and whole eggs, should be among the first solid foods offered because they are also a source of iron. At this age, these and other iron-rich foods, such as meat and meat alternatives and iron-fortified cereals are important to help meet the nutrient needs of the rapidly growing older infant (Dewey & Chaparro, 2007; Meinzen-Derr et al., 2006).

When introducing a food that is among the list of common food allergens, suggest that parents and caregivers avoid offering more than one of these per day and wait two days before they introduce another of the common food allergens. This makes it easier to identify a food that may have caused a reaction.

When any new food is introduced, it is important that parents and caregivers watch for signs of an allergic reaction.  To reduce the risk of choking, also ensure that the foods offered are an appropriate texture and size for the child's age and development.

Once a potential food allergen has been introduced successfully, advise parents and caregivers to continue to offer the food regularly in order to maintain the child's tolerance (Chan, Cummings, & CPS Community Paediatrics Committee, 2013).  Parents and caregivers should continue to introduce new foods to help ensure exposure to a wide variety of family foods by one year of age.

For infants and young children with a family history of food allergy, health care providers should approach each case on an individual basis.

How can I reassure parents and caregivers that gagging is natural?

Gagging is a natural reflex that helps older infants avoid choking (Rapley, 2011). As complementary foods are introduced, gagging may occur when the infant is not yet able to collect the food bolus and move it backwards with efficiency (Morris & Klein, 2000). Occasionally, food sticks to the back of the tongue or falls over the back before the swallow is triggered, resulting in the protective action of a gag or cough (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 an older infant is attentive, sitting upright, and is free from distractions, the risk of choking is the same as for an adult (Rapley, 2011). There are however, some food shapes and textures that are choking hazards and should not be offered to children younger than four years.

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. They should be offered small portions of foods initially, along with the opportunity to ask for more (CPS, 2012).

It is quite common to offer a new food more than ten times before a child will accept it (Sullivan & Birch, 1994). Advise parents to keep offering these foods and wait for the child to try it on their own. Reassure parents and caregivers 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. Offering a variety of vegetables to older infants has been shown to contribute to an increased acceptance and intake of these foods later on in life (Ahern, et al., 2013). Encourage them to create a positive mealtime environment using the principles of responsive feeding.

If a young child generally seems happy and healthy and their growth is normal, picky eating behaviours and temporary changes in appetite should not cause concern (CPS, 2012). Discuss normal growth and development with parents and caregivers. Reassure them that each child has his or her own pattern of growth (Haskey, 2010). Regular measurements of the child's growth over time will help show whether they are consuming adequate amounts of food (Dietitians of Canada, Canadian Paediatrics Society, The College of Family Physicians of Canada, & Community Health Nurses of Canada, 2010).

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

These guidelines recommend that parents and caregivers "not offer products containing raw or undercooked eggs, meat, poultry or fish."  However, an allowance under this recommendation can be made for traditional or 'country' foods that are consumed raw or frozen, as is the case for some Aboriginal cultures in Canada, in particular, Inuit. To safely store and prepare these foods, it is very important to follow the traditional ways and listen to knowledgeable elders. Hunters keep country food safe by:

• hunting animals that are healthy and show no sign of sickness
• drying extra meat in the early spring and fall
• freezing extra meat in the winter.

Following these practices reduces or eliminates the infant's risk from pathogens and parasites in food.

Do infants and young children who are not breastfed or receiving breastmilk need a vitamin D supplement?

Infants who are not breastfed or receiving breastmilk do not require a vitamin D supplement. Commercial infant formula, recommended as a breastmilk substitute for this age group, has vitamin D added during manufacturing. After nine to 12 months, parents and caregivers are advised to transition from commercial infant formula to homogenized (3.25% M.F.) cow milk. Because cow milk is fortified with vitamin D, these older infants and young children also do not require a vitamin D supplement.

Vitamin D blood status reflects vitamin D from all sources including the vitamin D synthesised in the body as well as intakes from food and supplements (IOM, 2011). Children three to eight years of age have very low rates of vitamin D deficiency, and appear to have the lowest prevalence of inadequate blood status when compared to any other age group (Statistics Canada, 2012). This suggests that at current vitamin D intake levels the blood status is generally adequate.

It is recommended to continue to emphasize offering vitamin D-rich foods, including 500 mL of homogenized (3.25% M.F.) cow milk. The vitamin D provided in 500 mL of cow milk per day has been shown to be sufficient in maintaining adequate bone health in most children two to five years of age (Maguire et al., 2013). Cow milk contributes more than three quarters of the vitamin D in the diets of young children. Other food contributors of vitamin D are margarine, fish and eggs (Statistics Canada, 2013). 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).

Young children who do not consume cow milk should receive a daily vitamin D supplement of 400 IU (10 µg).

At what age can children transition from homogenized (3.25% M.F.)milk to low fat milk (such as partly skimmed 1% or 2%)?

Homogenized (3.25% M.F.) milk is recommended as a young child's main milk source until two years of age for those who are no longer breastfed.  After 2 years of age, children can switch to the family milk according to the advice in Canada's Food Guide. Skim (non-fat) milk is an inappropriate choice for children less than two years of age. It provides no essential fatty acids and has a very low energy density.

Partly skimmed (2% or 1% M.F.) milk is low in essential fatty acids and lower in energy than homogenized (3.25% M.F.) milk. There is no clear indication of negative consequences from the use of partly skimmed milk (Wosje, Specker, & Giddens, 2001; Simell et al., 2000). However, there is a theoretical risk of growth faltering and essential fatty acid deficiency, particularly in infants, if the milk becomes a significant component of their daily intake. Growth monitoring can help assess the impact of dietary changes.

Convenience may be one reason for parents and caregivers to offer partly skimmed (2% or 1% M.F.) milk since others in the household are drinking it. If it is offered before two years, it is important to ensure that the child is growing well and eating a wide variety and an adequate quantity of nutritious foods. Check that parents and caregivers are providing other sources of fat such as soft margarine, nut or seed butters, vegetable oil, fatty fish and avocado. Explain that nutritious foods that are higher in fat are an important source of energy for young children.

Is there any need for 'growing-up milk' or 'toddler milk'?

After nine to 12 months, an older infant or young child can transition directly to homogenized (3.25% M.F.) milk. 'Growing-up milk' or 'toddler milk' is marketed as an alternative or complement to cow milk for children older than 12 months of age (Crowley & Westland, 2011). These products are based on cow milk ingredients and include other non-milk ingredients. Various countries are working to develop international standards for them (Codex Alimenatarius Commission, 2011). If parents and caregivers offer 'growing-up milk' or 'toddler milk' instead of cow milk, advise them to check that the product contains key nutrients, such as calcium, vitamin D, vitamin A, protein, and fat, 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, recommend nutrient supplements if the infant's diet is 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). Special attention should be given to vegetarian children's intake of calcium, zinc, iron, vitamin D, and vitamin B12. There is risk of nutrient deficiencies for young children with more restricted diets (Van Winckel, Vande Velde, De Bruyne, & Van Biervliet, 2011). An infant or young child who is fed a vegan diet, which excludes any animal-based foods, may benefit from consultation with a dietitian.

What dietary advice helps reduce the risk of early childhood caries

Early childhood caries is a common and preventable infectious disease in children (CIHI, 2013; Anderson, Cooney, & Quinonez, 2008). It can lead to serious infection, eating difficulties, and other dental and social problems (Anderson, Cooney, & Quinonez, 2008).

Fluoridation of the water supply is the most effective, cost efficient means of preventing dental caries (CDA, 2012). Dental caries are less prevalent where infants and children have access to fluoridated water (CDC, 1999).

Parents and caregivers can also reduce the risk of early childhood caries by avoiding night-time and long-term use of bottles containing any liquid other than water (AAP, 2001). 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 also been associated with dental decay in young children (AAP, 2001). Advise parents and caregivers to limit fruit juice and sweetened beverages. Emphasise oral hygiene as part of a daily routine.

What dietary advice helps to manage mild to moderate constipation in a young child?

Reassure parents and caregivers that constipation is a common problem in childhood and there can be many different causes (Rowan-Legg & CPS, 2011). However, constipation can lead to stomach pain and infrequent, hard, dry, or large stools with blood on their surface. These can be difficult and painful to pass (CPS, 2013). Abdominal distension requires further investigation and intervention by a health professional.

Young children should be offered water and a variety of foods high in fibre each day. These foods include whole grain breads and cereals, vegetables and fruit, and meat alternatives such as beans and lentils. A young child's cow milk intake should not exceed 750 mL per day. Also, ensure that young children are not filling up on juice or other beverages. Too much milk or juice can displace foods that are sources of fibre in the diet.

If a child's constipation is persistent, parents and caregivers should see their health care provider.

References

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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 older infant's hunger cues to decide when to feed him or her. At about 12 months of age, you can begin to establish a schedule of regular meals and snacks every two-and-a-half to three hours.
• Eat together as a family as often as you can. Offer older infants and young children foods from the family meal.
• Keep breastfeeding, initially on-cue. Continue to breastfeed for as long as both you and your child want to.
• Let older infants and young children decide how much they want to eat from the foods offered.
• When you first introduce complementary foods, the amount an older infant eats may 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 of an adult portion. Examples of an initial offering could 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 ½ of a piece of toast or muffin, or ¼ of a pita or other flatbread.
• If an older infant or young child seems thirsty, offer water.