Abstract
Exclusive breastfeeding is recommended by the World Health Organisation (WHO) for the first 6 months postpartum. Continued breastfeeding alongside complementary feeding, or weaning, as it is also known is also recommended up until 2 years of age for the child and beyond. The timing and types of different food and drinks introduced through complementary feeding, all play a crucial role in influencing later life food choices for the children.
The aim of this study is to critically assess the literature in the area of infant feeding practices and the potential effects they have on future dietary patterns.
This was done through collating numerous different research papers and journals on these various aspects.
It can be concluded that, various research suggests a clear connection between breastfeeding and the benefits it portrayed if done exclusively for the first 6 months of an infant’s life. Reasons why early introduction of complementary foods and their impact on feeding habits and food preferences are also well established.
However, limited research was found as to what particular factors impacted weight status in children and also what the long term effect of the delayed introduction of solid foods needs to also be determined.
(Word count: 197 words)
Key words: Breastfeeding, formula feeding, complementary feeding, weaning, infants feeding practices.
Running Headings: The effect of early life eating practices on future dietary patterns.
Introduction
The World Health Organisation (WHO) recommends exclusive breastfeeding for the first 6 months postpartum, with the continuation of breastfeeding alongside suitable complementary feeding up to two years of age and beyond (WHO, 2015).
Complementary feeding or weaning, as it is also known, is defined as the gradual process of the introduction of solid foods from breast or formula milk. This process is essential as it provides the necessary nutritional requirements for optimal growth in the first year of an infant’s life. The timing and types of different food and drinks that are introduced, all play a crucial role in influencing later life food choices for children. Many feeding habits and food preferences that children have, are influenced by the dietary patterns and feeding behaviours formed during the weaning process (Tarrent et al, 2010).
Pinpointing the factors that influence food habits and preferences is critical to the effective development of improving children’s diets. More than half of the variance that influences both the food habits and preferences is familiarity. Food neophobia or a fear or a new food usually materialises around the age of two and if often associated with a low variety and quality of diet. A Child’s experience with certain foods, also strongly impacts their food habits and preferences. Therefore a child who is exposed to a wide variety of healthy foods tends to have a healthier diet throughout their childhood and into adulthood (Cooke, 2007).
The aim of this study is to critically assess the literature in the area of infant feeding practices and the potential effects they have on future dietary patterns.
Infant feeding from birth
Exclusive breastfeeding for the first 6 months postpartum presents many advantages to the infant. Breast milk is the main source of energy and nutrients for children up to 6 months of age. It also provides more than half of the energy needs between 6 and 12 months and up to one third of the energy of children aged 12-24 months (WHO, 2015).
When breast milk is given within the first hour of a child being born, the risk of infant mortality due to acquiring infections, such as diarrhoea, is greatly reduced compared to those who are partially or non breastfed. It contains many flora-enhancing agents to promote the infants immune system and protects against many gastrointestinal infections. (WHO, 2015).
Breastfeeding is the healthiest and most natural way to feed a baby. Breast milk is a unique nutritional source that cannot be replicated by any other food product including formula milk that is produced in a laboratory. It contains all the nutrients that an infant needs in the first 6 months of life including fats, carbohydrates, proteins, vitamins, mineral and water. With that said, the nutritional benefits of breastfeeding milk are directly related to the nutrition of the mother. A healthy, stable and balanced diet is essential to ensure that the child is benefiting from the nutritional intake of the mother.
Breastfeeding promotes a healthy weight status in early childhood. A set of meta-analytic results indicated that breastfeeding was connected with lower levels of childhood obesity than formula fed infants, and also increased the likelihood of desirable weight status (Arenz et al, 2004;Moss & Yeaton, 2014).
Despite a significant amount of research that references the benefits of breastfeeding on young children’s weight status, many contemporary researchers have recently branded this association as a ‘‘myth.’’ (Casazza et al, 2013; Moss & Yeaton 2014).
Complementary feeding
The current recommendations set by the WHO (2001) state that solid foods should only be introduced to an infant’s diet no earlier than 6 months postpartum. . However, despite the fact that these recommendations are set at an international level in many countries including the UK, many studies suggest that a large proportion of infants are prematurely introduced to complementary feeding before 4 months postpartum. An example of this is a study by Tarrent et al, that found 22.6% of infants had been totally weaned by 12 weeks. However, this study cannot be deemed representative of the total population of Ireland, as it was only carried out at a single centre, in a deprived area of Dublin.
Research indicates that infants who are formula fed or used a combination of breastfeeding and formula feeding, were introduced to complementary feeding before 4 months of age (Doub et al,2015). Research also suggests that factors such as a high pre-pregnancy BMI, young maternal age and fewer years in education, low socioeconomic status, maternal smoking and a lack of information provided from healthcare professionals are all contributing elements to early introduction of complementary feeding (Doub et al, 2015; Gibbs & Forste, 2014; Wijndaele et al, 2009).
Consequently, early introduction of complementary feeding can lead to under-nutrition for infants as the nutrient dense milk is being replaced with potentially less nutritional meals (Amezdroz et al, 2015). Many of the benefits that were provided by breastfeeding to the infants, may be altered as a result of early introduction of complementary feeding (Klag et al, 2015). However, both these studies recognised the need for further studies in order to examine the possible protective effect of breast milk feeding on weight gain when solids are introduced early.
Infant’s are also at greater risk of developing many allergies, particularly when foods are introduced to the infant’s diet that is not recommended. For example, gluten products, eggs and shellfish. (WHO, 2009). Yet, this is a fairly controversial debate so further research is definitely recommended in this area.
It is important to note that the current recommendations take into consideration the development and physiological maturation of gastrointestinal and renal function of the infant. Foods that are introduced too early that contain a high solute load, may result in the need for the infants kidneys to work to a capacity that exceeds this (Foote1 KD & Marriott DL, 2003).
Early introduction of complementary foods (<17 weeks) can result in the consumption of more energy-dense foods, which may encourage extreme calorie consumption. This is influenced by the maternal diet, therefore if the mother’s diet is rich in energy-dense foods, the infant’s diet will mirror it. This may lead to excessive weight gain, which can be a contributing factor to infant and childhood obesity (Doub et al, 2015). However, the time in which the introduction of complementary foods takes place has been found to have no clear association with childhood obesity. Nevertheless very early introduction of solid foods, (before 4 months postpartum) was found to increase BMI in young children. (Pearce et al, 2013).
A study by Huh et al 2011, discovered formula fed infants introduced to solid foods before 4 moths were more prone an overweight status at 3 years of age than those introduced to solids between 4-5 months. However the results are considered not significant due to the relatively small sample size. In contrast, there was no consistent relationship between the timing of the introduction of complementary foods and an unhealthy weight status found in the majority of studies in a systematic review by Moorcraft et al (Moss & Yeaton, 2014).
Delayed introduction of complementary feeding beyond the recommended timeframe (>6 months), may have a detrimental effect on the feeding behaviour of the infant. Negative feeding behaviours can include picky eating, food neophobia and food rejection. This is due to the limited dietary variety, especially in micronutrient dense foods, such including fruit and vegetables. (Shim et al, 2011).
Delayed introduction of complementary feeding can also cause insufficient nutrition status in the infant, particularly in iron status due to the depletion of iron stores around 6 months postpartum. This is because breast milk and/or formaula milk alone no longer provides the adequate nutrition to infants greater than 6 months postpartum. All these factors coupled together, can lead to a failure to thrive and a falter in growth (Tarrent et al, 2010; Amezdroz et al, 2015).
Although there is evidence to support the short term impact of the introduction of complementary foods, the long term impact is still uncertain, therefore more research needs to be carried out in this particular area. A suggestion was to pay specific attention to the hematological results in order to achieve a definitive conclusion on this critical issue. (Qasem et al, 2015).
Infant feeding practices
Many of the feeding practices that an infant will acquire in the first few years will be strongly influenced by the infant’s mother. According to the Social Cognitive Theory, infant feeding practices can be generally categorised into two main groups; internal personal factors and socio-environmental factors (Williams et al, 1999; Bandura 1986).
Internal personal factors that affect the infant feeding practices, includes the cognitive and affective capacity of the mother. For example, if a mother has more knowledge and appreciates the importance of recommendations, generally the guidelines will be adhered to. The expected outcome, (believing it is best for the infant) having confidence (being comfortable in making decisions), previous experience and biological factors such as age all play a crucial role in internal personal factors which affect the infant feeding practices (Williams et al, 1999).
Socio-environmental factors can also have an impact on infant feeding practices. These include institutional bodies, (healthcare professionals or policies put in place) social such as family support dynamics, socio-demographic, (education, income, ethnicity) physical factors, for example fatigue or nipple pain and finally cost and availability to particular foods all contribute to infant feeding practices (Williams et al, 1999).
In order to have a positive effect on an infants feeding practices, offering a wide range of nutritionally balanced and varied foods in the early years of a child’s life, particularly between 6 and 12 months, has been shown to influence the encouragement of future healthy eating dietary patterns (Amezdroz et al, 2015).
Nicklaus et al 2009, suggests a child’s early experience with certain foods has been shown to impact the variety of the child’s diet in later years. A nutritionally adequate diet is of particular importance, especially to young children; therefore it is of particular importance to establish positive infant feeding practices (Martins 2006).
Research suggests that frequent exposure to a wide range of foods in the first two years of life results in a wider variety of foods consumed. (Skinner et al, 2002).
In order to increase a child’s acceptance of healthy foods and establish a positive relationship with different types of foods, there is a need for the use of effective strategies such as exposure to different types of foods, modeling and the use of rewards. This is extremely important when foods are initially rejected, as this is crucial point when acceptance can be increased, resulting in the consumption and acceptance of originally rejected foods (Birch et al. 1998; Sullivan and Birch 1994; Martins 2006). Providing the food does not have a negative gastro-intestinal effect on the body, repeated ingestion also leads to increased acceptance (Cooke, 2007).
Up to 50% of children between 4 and 24 months are considered picky or fussy eaters by their parents. Although picky or fussy eating behaviour appears to be relatively common in infants and young children, there seem to be significant variations in the severity and determinants. Nonetheless, picky or fussy eating behavior is a concern no matter what end of the spectrum due to possible malnutrition and increased dietary inadequacy, even though it is unclear whether this concerns malnutrition of certain nutrients leading to the possible risk of children being underweight. Thus, research is conflicting to whether picky or fussy eating is related to malnutrition and underweight (Werthmann et al, 2015).
Contradictory to this infant feeding practices may have a substantial influence on the prevalence of childhood obesity, which was 16.9% in 2009-2010 in the US (Klag et al, 2015). Obesity is the result of continuous positive energy imbalance resulting in constant weight gain. Many parents are unaware that their children are in fact classified as overweight or obese. Guidelines stipulate that children up to 4 years of age, on or above the 98th centile on the UK BMI 1990 growth charts are classified as obese, and those on or above the 91st centile (Cole et al, 1995) on BMI growth charts are considered overweight. (Stewart, 2012).
Parents of overweight or obese children are being encouraged by health professionals that the number of meals and portion sizes containing foods high in sugar and saturated fat need to be reduced. These need to be replaced with foods lower in energy to avoid excess caloric consumption. They also need to be aware of age-appropriate portions and appreciate different portion sizes for different ages. This should potentially reduce the risk of increased over eating and energy over-consumption. If this issue is not addressed in early life and children are not made aware of the importance of how portion size effects from an early age, this can lead to bad habits relating to portion size in later life (Stewart, 2012).
Results by Johnson et al 2014 support this statement as they found a strong connection between portions offered by parents or caregivers, and the amounts children consume at a meal. It suggest that factors unrelated to the child, for example the amount being served to himself or herself, are important prognosticators of a child’s food consumption.
In conclusion, the guidelines and benefits of breastfeeding exclusively for the first 6 months of an infant’s life are well established. Early implications of complementary foods and the reasons as to why any feeding habits and food preferences that children have, influence dietary patterns and feeding behaviours formed during the weaning process is also well researched. However, more research needs to be done to establish whether or not breastfeeding as well as the early introduction of complementary foods has an impact weight status. The long term effect of the delayed introduction of solid foods needs to also be determined.
(Total word count: 2000)
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