The Start Healthy Infant and Toddler Feeding Guidelines*

How

Research Question:
a) How can parents establish a healthy feeding relationship?

Conclusion:
The healthy feeding relationship is a division of responsibility between the parent and the child. The parent sets an appropriate and nurturing feeding environment and provides appropriate healthy foods. The child decides whether and how much to eat.

Responsive parenting appears to be at the core of a healthy feeding relationship. This involves:

•   Recognizing the child's developmental abilities with respect to feeding
• Balancing the child's need for assistance with encouragement of self-feeding.
• Allowing the child to initiate and guide feeding interactions.
• Responding early and appropriately to hunger and satiety cues.

Research Question:
b) How do infants and toddlers communicate hunger and fullness? How should caregivers respond?

Conclusion:
For infants, hunger cues may include: crying, excited arm and leg movements, smiling, cooing, and/or gazing at the caregiver during feeding indicating desire to continue, opening mouth and moving forward as spoon approaches, swiping food toward the mouth, moving head forward to reach spoon.

Hungry toddlers may point at foods or beverages, ask for foods or beverages, and or reach for foods.

Infant's satiety cues may include: falling asleep, becoming fussy during feeding, slowing the pace of eating, stopping sucking, spitting out or refusing nipple, refusing spoon, batting the spoon away, closing mouth as spoon approaches.

Toddlers may slow the pace of eating, become distracted or notice surroundings more, play with food, throw food, want to leave the table or chair, and/or doesn't eat everything on the plate. To help avoid under-feeding or over-feeding, parents and caregivers must be sensitive to the hunger and satiety cues of the healthy infant and young child. Crying is often, but not always a sign of hunger, so parents should check if the infant is hungry or experiencing some discomfort (e.g. wet diapers, cold temperature, or pain from air bubbles in their stomach).

Research Question
c) How should parents or caregivers introduce complementary foods for the first time?

Conclusion:
No controlled studies have addressed the practical aspects of introducing complementary foods for the first time. Mixing cereal with breast milk enhances acceptance of cereal by breast fed infants. Repeated exposure to foods enhances acceptance of new foods by both breast fed and formula fed infants. As with all feeding interactions, caregivers should observe the infant's intake and non-verbal cues and respond appropriately.

Research Question:
d) How quickly and in what order should complementary foods be introduced?

Conclusion:
There is no evidence for a benefit to introducing complementary foods in any specific sequence or at any specific rate. However, it is generally recommended that first solid foods be single ingredient foods and that they be started one at a time at 2 to 7 day intervals. The order of introduction of complementary foods is not critical, except for providing nutrients required from complementary foods. Meat and fortified infant cereals provide many of these nutrients. Combination foods (instead of single-ingredient foods) may be given to older infants after tolerance for the individual components has been established.

Research Question:
e) How much food provides a portion or serving for infants and toddlers?

Conclusion:
Children often eat s mall frequent meals and snacks throughout the day – customarily 3 regular meals and 2-3 appropriate, healthy snacks. Portions should provide essential nutrients but not exceed energy requirements for the child.

Research Question:
f) How are picky eating and food jags described?

Conclusion:
There is no scientific definition of picky eating. Rather, picky eating is defined by the caregivers' perception. Parents perceive a toddler to be a picky eater when he or she accepts only a few foods, refuses to try new foods, totally avoids some food groups, and exhibits strong food preferences, including presentation and preparation methods. Studies show that occasional picky eating is not associated with changes in nutrient intake or height and weight. Consuming a single food or foods for extended periods of time is commonly called a food jag. The health consequences of persistent picky eating or food jags on nutritional status or growth are not known.

Research Question:
g) How can parents and caregivers help children accept a wider variety of foods?

Conclusion:
While no specific strategies to address picky eating have been shown to be effective, some general feeding guidelines apply:

•   Be patient; occasional picky eating can be a normal stage of development.

• Provide multiple and varied options of new and familiar foods and allow the toddler to choose.

• Offer foods again and again to enhance acceptance.

• If a particular food is rejected, move on and try it again later; avoid forcing toddlers to eat or finish foods.

• The parent's role is to provide a variety of foods and allow the toddler to choose how much, if any, she will eat.

• Since picky eating or food jags may result in inadequate growth or nutrient inadequacy, growth or nutrient status should be monitored.

• Growth also should be monitored more frequently if a “food jag” persists.

Research Question:
h) How can caregivers help the child develop independence in feeding?

Conclusion:
To help children develop independence in feeding, parents and caregivers may need to demonstrate feeding skills rather than rely on verbal prompts alone. Awareness of developmental feeding skills is needed so that the tasks presented are appropriate. Cultural differences in mothers' expectations and encouragement of self-feeding should be recognized and respected, but if inappropriate, these should not be encouraged.

Research Question:
i) How can parents and caregivers feed safely?

Conclusion:
Keep all foods safe to eat and appropriate for baby's development. Providing guidance to parents and caregivers about safe feeding may increase their awareness and understanding, thereby helping to reduce the risks of foodborne illness, choking, lead poisoning and non-food eating and high intakes of nitrates, nitrites and methylmercury.

• For infant formula, closely follow manufacturer's use and storage instructions on the label.

• In handling expressed breastmilk, keep it clean and avoid contamination when it is collected and stored.

• Bottle-fed infants are at higher risk of exposure to foodborne bacteria, particularly if the bottles are left at room temperature for several hours. 

• Make sure the baby's bottle is cleaned and disinfected after each use.

• To help ensure that homemade or commercially prepared baby food is safe, follow general food safety guidelines and/or the manufacturer's package directions.

• Since infants and toddlers can be at risk for choking, knowledge of choking hazards can lessen the chances of it occurring.