Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: a systematic review.

BACKGROUND: Systematic reviews (SRs) were conducted by the Nutrition Evidence Systematic Review (NESR) team for the USDA's and the Department of Health and Human Services' Pregnancy and Birth to 24 Months Project. OBJECTIVES: The aim was to describe the SRs examining the relationship between types and amounts of complementary foods and beverages (CFBs) and growth, size, and body-composition outcomes. METHODS: The NESR team collaborated with subject matter experts to conduct this SR. The literature was searched and screened using predetermined criteria. For each included study, data were extracted and risk of bias was assessed. The evidence was qualitatively synthesized to develop a conclusion statement, and the strength of evidence was graded. RESULTS: This SR includes 49 articles that examined type, amount, or both of CFBs consumed and growth, size, and body-composition outcomes. Moderate evidence suggests that consuming either different amounts of meat, meat instead of iron-fortified cereal, or types of CFBs with different fats or fatty acids does not favorably or unfavorably influence growth, size, or body composition. In relation to overweight/obesity, insufficient evidence is available with regard to the intake of meat or CFBs with different fats or fatty acids. Limited evidence suggests that type and amount of fortified infant cereal does not favorably or unfavorably influence growth, size, body composition, or overweight/obesity. Limited evidence suggests that sugar-sweetened beverage consumption during the complementary feeding period is associated with increased obesity risk in childhood but is not associated with other measures of growth, size, or body composition. Limited evidence showed a positive association between juice intake and infant weight-for-length and child body mass index z scores. Insufficient evidence is available on other CFBs or dietary patterns in relation to outcomes. CONCLUSIONS: Although several conclusions were drawn, additional research is needed that includes randomized controlled trials, examines a wider range of CFBs, considers issues of reverse causality, and adjusts for potential confounders to address gaps and limitations in the evidence.

Complementary feeding and micronutrient status: a systematic review.

BACKGROUND: Proper nutrition during early life is critical for growth and development. OBJECTIVES: The aim was to describe systematic reviews conducted by the Nutrition Evidence Systematic Review team for the USDA and the Department of Health and Human Services Pregnancy and Birth to 24 Months Project to answer the following: What is the relation between 1) timing of introduction of complementary foods and beverages (CFBs) or 2) types and/or amounts of CFBs consumed and micronutrient status (iron, zinc, vitamin D, vitamin B-12, folate, and fatty acid status)? METHODS: A literature search identified articles from developed countries published from January 1980 to July 2016 that met the inclusion criteria. Data were extracted and risk of bias assessed. Evidence was qualitatively synthesized to develop a conclusion statement, and the strength of the evidence was graded. RESULTS: Nine articles addressed the timing of CFB introduction and 31 addressed types or amounts or both of CFBs. Moderate evidence suggests that introducing CFBs at age 4 mo instead of 6 mo offers no advantages or disadvantages in iron status among healthy full-term infants. Evidence is insufficient on the timing of CFB introduction and other micronutrient status outcomes. Strong evidence suggests that CFBs containing iron (e.g., meat, fortified cereal) help maintain adequate iron status or prevent deficiency in the first year among infants at risk of insufficient iron stores or low intake. Benefits for infants with sufficient iron stores (e.g., infant formula consumers) are less clear. Moderate evidence suggests that CFBs containing zinc (e.g., meat, fortified cereal) support zinc status in the first year and CFB fatty acid composition influences fatty acid status. Evidence is insufficient with regard to types and amounts of CFBs and vitamin D, vitamin B-12, and folate status, or the relation between lower-iron-containing CFBs and micronutrient status. CONCLUSIONS: Several conclusions on CFBs and micronutrient status were drawn from these systematic reviews, but more research that addresses specific gaps and limitations is needed.

Nutrient intakes of US infants, toddlers, and preschoolers meet or exceed dietary reference intakes.

OBJECTIVES: To assess the usual nutrient intakes of 3,273 US infants, toddlers, and preschoolers, aged 0 to 47 months, surveyed in the Feeding Infants and Toddlers Study (FITS) 2008; and to compare data on the usual nutrient intakes for the two waves of FITS conducted in 2002 and 2008. DESIGN: The FITS 2008 is a cross-sectional survey of a national random sample of US children from birth through age 47 months. Usual nutrient intakes derived from foods, beverages, and supplements were ascertained using a telephone-administered, multiple-pass 24-hour dietary recall. SUBJECTS: Infants aged birth to 5 months (n=382) and 6 to 11 months (n=505), toddlers aged 12 to 23 months (n=925), and preschoolers aged 24 to 47 months (n=1,461) were surveyed. METHODS: All primary caregivers completed one 24-hour dietary recall and a random subsample (n=701) completed a second 24-hour dietary recall. The personal computer version of the Software for Intake Distribution Estimation was used to estimate the 10th, 25th, 50th, 75th, and 90th percentiles, as well as the proportions below and above cutoff values defined by the Dietary Reference Intakes or the 2005 Dietary Guidelines for Americans. RESULTS: Usual nutrient intakes met or exceeded energy and protein requirements with minimal risk of vitamin and mineral deficiencies. The usual intakes of antioxidants, B vitamins, bone-related nutrients, and other micronutrients were adequate relative to the Adequate Intakes or Estimated Average Requirements, except for iron and zinc in a small subset of older infants, and vitamin E and potassium in toddlers and preschoolers. Intakes of synthetic folate, preformed vitamin A, zinc, and sodium exceeded Tolerable Upper Intake Level in a significant proportion of toddlers and preschoolers. Macronutrient distributions were within acceptable macronutrient distribution ranges, except for dietary fat, in some toddlers and preschoolers. Dietary fiber was low in the vast majority of toddlers and preschoolers, and saturated fat intakes exceeded recommendations for the majority of preschoolers. The prevalence of inadequate intakes, excessive intake, and intakes outside the acceptable macronutrient distribution range was similar in FITS 2002 and FITS 2008. CONCLUSIONS: In FITS 2008, usual nutrient intakes were adequate for the majority of US infants, toddlers, and preschoolers, except for a small but important number of infants at risk for inadequate iron and zinc intakes. Diet quality should be improved in the transition from infancy to early childhood, particularly with respect to healthier fats and fiber in the diets of toddlers and preschoolers.

Sources of energy and nutrients in the diets of infants and toddlers.

OBJECTIVE: To identify major sources of energy and 24 nutrients and dietary constituents in the diets of US infants and toddlers and to describe shifts in major nutrient sources as children age. DESIGN: Data from 24-hour recalls collected in the 2002 Feeding Infants and Toddlers Study were analyzed to determine the percentage contribution of foods and supplements to total intakes of energy, nutrients, and other dietary constituents. A total of 3,586 unique foods and dietary supplements were reported. Reported foods and supplements were classified into 71 groups based on similarities in nutrient content and use. Nine-hundred seventy-nine food mixtures were disaggregated into their ingredients and ingredients were classified into one of the 71 groups using the same decision rules that guided classification of foods analyzed at the whole food level. SUBJECTS/SETTING: A national random sample of 3,022 US infants and toddlers 4 to 24 months of age. STATISTICAL ANALYSES PERFORMED: The population proportion formula was used to determine the percentage contribution of each of the 71 groups to total intakes. This was done by summing the weighted amount of a given nutrient provided by a given group for all individuals in the sample and dividing by the total weighted amount of that nutrient consumed by all individuals from all foods and supplements. Groups that provided at least 1% of the nutrient in question were rank-ordered. Separate tabulations were prepared for three age groups (4-5 months, 6-11 months, and 12-24 months). RESULTS: Infant formula, breast milk, and milk are major contributors of energy and most nutrients in the diets of infants and toddlers. Among toddlers, juices and fruit-flavored drinks are the second and third most important sources of energy. Fortified foods make substantial contributions to intakes of many essential nutrients, and these contributions increase as children age. For example, among toddlers, fortified grain-based foods make substantial contributions to intakes of vitamin A, iron, and folate, relative to foods that are naturally rich in these nutrients. Supplements also make substantial contributions to intakes of vitamins and selected minerals, particularly among toddlers. CONCLUSIONS: In assessing dietary intakes of infants and toddlers, dietetics professionals need to carefully consider contributions of fortified foods and supplements. Dietetics professionals should educate caregivers of infants and toddlers about the importance of foods (rather than just nutrients) in promoting health and about the importance of early feeding practices in the development of lifelong eating habits. Caregivers should be encouraged to avoid relying on fortified foods and supplements to meet nutrient needs and educated about the potential risk of excessive intakes. Caregivers of toddlers and infants over 4 to 6 months of age who are consuming solid foods should be encouraged to feed a wide variety of fruits, vegetables, and whole grains, as well as foods naturally rich in iron.

Feeding Infants and Toddlers Study: do vitamin and mineral supplements contribute to nutrient adequacy or excess among US infants and toddlers?

OBJECTIVE: To report the prevalence of dietary supplement use in a random sample of US infants 4 to 24 months of age, and to compare demographic characteristics, usual nutrient intakes, and food patterns of supplement users and nonusers. DESIGN: Data from 24-hour recalls collected for the 2002 Feeding Infants and Toddlers Study were analyzed. Recalls included nutrient contributions from dietary supplements as well as all foods and beverages. We estimated usual energy and nutrient intakes of supplement users and nonusers, as well as the prevalence of nutrient adequacy and excess in the two groups. We also compared demographic characteristics and food patterns of supplement users and nonusers and, for supplement users, estimated the proportion of total intake provided by foods and the proportion provided by supplements. SUBJECTS: A national random sample of 3,022 infants and toddlers age 4 to 24 months, including 430 vitamin and/or mineral supplement users and 2,592 nonusers. STATISTICAL ANALYSIS: We compared means, percentile distributions, and proportions by age and supplement subgroup, and applied the Dietary Reference Intakes to assess usual nutrient intakes. We conducted regression analysis to determine which population characteristics predict the use of dietary supplements in this population. RESULTS: Overall, 8% of infants age 4 to 5 months received some type of dietary supplement. The prevalence of supplement use increased with age, to 19% among infants 6 to 11 months and 31% among toddlers 12 to 24 months. The vast majority of supplement users (97%) received only one type of supplement, most commonly a multivitamin and/or mineral supplement. Vitamin/mineral supplement use among infants and toddlers was associated with being a first-born child and being reported by the primary caretaker as being a picky eater. Characteristics that were independent predictors of supplement use were living in the Northeast, being male, and living in a household with fewer children. We found no significant differences between supplement users and nonusers in mean daily intakes of nutrients or nutrient density from foods alone, and few differences in food consumption. Overall, the prevalence of inadequate intakes was low (<1% to 2%). However, 65% of supplement nonusers and 9% of supplement users had vitamin E intakes less than the Estimated Average Requirement. Excessive intakes (ie, intakes above the Tolerable Upper Intake Level) were noted for both supplement users and nonusers for vitamin A (97% and 15% of toddlers) and zinc (60% and 59% of older infants and 68% and 38% of toddlers) as well as for folate among supplement users (18% of toddlers). CONCLUSIONS: Generally, healthy infants and toddlers can achieve recommended levels of intake from food alone. Dietetics professionals should encourage caregivers to use foods rather than supplements as the primary source of nutrients in children's diets. Vitamin and mineral supplements can help infants and toddlers with special nutrient needs or marginal intakes achieve adequate intakes, but care must be taken to ensure that supplements do not lead to excessive intakes. This is especially important for nutrients that are widely used as food fortificants, including vitamin A, zinc, and folate.

Average portions of foods commonly eaten by infants and toddlers in the United States.

OBJECTIVES: To examine average portion sizes consumed per eating occasion by infants and toddlers. Average portions reported for toddlers were compared to average portions for comparably aged children reported in the 1994 to 1996 and 1998 Continuing Survey of Food Intakes by Individuals. In addition, reported average portions were compared with minimum required portion sizes for meals served to infants and toddlers in the Child and Adult Care Food Program (CACFP). DESIGN: Data from 24-hour recalls collected in the 2002 Feeding Infants and Toddlers Study (FITS) were analyzed. Average portion sizes were determined for major food groups and individual foods that were reported by at least 5% of the population. Most foods were reported separately; however, sandwiches were disaggregated into their components. Gram weights of portions consumed were converted, on a food-by-food basis, to household units so that foods with different volume-to-weight ratios could be analyzed together. SUBJECTS/SETTING: A national random sample of 3,022 US infants and toddlers 4 to 24 months of age. STATISTICAL ANALYSES PERFORMED: For each food and food group, average portion sizes per eating occasion were computed for up to six age groups. An average per-eating occasion portion was determined for each child who consumed a given food by summing the total amount of food consumed over the day and dividing by the number of eating occasions. These estimates were then summed across all children who consumed the food and divided by the total number of consumers. The number of eating occasions was defined as the total number of times a child had anything to eat or drink during the day, excluding eating occasions that included only water and/or supplements. RESULTS: For most foods, there was a gradual increase in the average portion as age increased. Average portions reported for FITS toddlers were consistent with those reported for comparably aged children in the most recent Continuing Survey of Food Intakes by Individuals. The average portions reported for FITS infants and toddlers were consistent with CACFP-recommended portion sizes for formula, juice, meats, and cheese. For milk (toddlers only), cereal, breads, fruits, and vegetables, average portions reported in FITS were consistently larger than CACFP portion sizes. Distributions showed that, in many cases, the per-eating occasion portion sizes of 50% to 90% of FITS infants and toddlers exceeded the CACFP portion sizes. CONCLUSIONS: Dietitians, pediatricians, and health educators can use the data presented in this article to provide guidance to parents and caregivers about reasonable portion sizes for infants and toddlers. The data should also be useful to those who plan meals for infants and toddlers in child care settings and to researchers studying dietary intakes of infants and toddlers. Advice about reasonable portion sizes should always be tempered with appropriate cautions about avoiding coercive "clean your plate" feeding practices. Parents and caregivers should be encouraged to offer infants and toddlers appropriate portions of healthful foods from the basic food groups, with a special emphasis on fruits, vegetables, and whole grains, and allow them to eat until they are satiated.