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Infant - Food and Feeding

Desired Behaviors
Based upon evidence, a number of desired behaviors were identified as critical to helping families foster healthy active living for their infant. For each desired behavior you can explore the evidence, learn what parents told us about these behaviors, identify opportunities to promote healthy behaviors at the point of care, review how to start conversations and access messages and resources to support families. Also available to inform your counseling is the Onset and Patterns of Risk Behaviors during Infancy Timeline located above this section.

Onset and Patterns of Risk Behaviors

This timeline illustrates when and what kind of risk behaviors associated with overweight and obesity develop during infancy. Use this tool to help prioritize anticipatory guidance for families.​
To use: Point at the timeline dots below to see valuable information, click and hold a dot for Evidence. Important patient care information is available using the Acute/Medical Opportunities button at the bottom left. There is a close box at the top right of this window.
opportunities for care

Acute/Medical Opportunities

Acute/Medical Opportunities:  If your patient presents with any of the following, assess for and counsel on healthy active living behaviors.

  • Newborn with poor suck and hypotonia – screen for Prader-Willi
  • Rapid weight gain in for first four months
  • Plagiocephaly – may be indicative of not enough tummy time and too much time in restrained environment such as car seat, swing, or bouncy seat
  • Infants are not meeting motor developmental milestones

Parenting

​Evidence suggests that there is a decrease in sleep duration across infancy and early childhood (9).

  • Starting at 3 months good sleep hygiene should be fostered. Parents should understand that infants should get between 9-12 hours of sleep at night and 1-4 naps a day that last between 30 minutes and 2 hours (10).

Evidence

​9. Dollman J, Ridley K, Olds T, Lowe E. Trends in the duration of school-day sleep among 10- to 15-year-old south Australians between 1985 and 2004. Acta Paediatr. 2007; 96(7): 1011-1014. Also, Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to adolescence: Reference values and generational trends. Pediatrics. 2003;111(2):302-307.

10. National Sleep Foundation. Sleep in America. 2008. Available at http://www.sleepfoundation.org/sites/default/files/2008%20POLL%20SOF.PDF. Accessed May 13, 2011. Also, National Sleep Foundation. Children and sleep. 2011. Available at http://www.sleepfoundation.org/article/sleep-topics/children-and-sleep. Accessed May 2012.

Parenting

​Parents report liking growth charts but research indicates few actually understand growth charts or the concept of percentiles (12).

Evidence

​12. Ben-Joseph EP, Dowshen SA, Izenberg P. Do parents understand growth charts? A national, internet-based survey. Pediatrics. 2009;124(4).

Physical Activity

​Infants who spend too much time in confining equipment such as car seats, swings, bouncy seats, exersaucers, strollers may experience delayed motor skill development (5).

Evidence

​5. Garrett M, McElroy A, Staines A. Locomotor milestones and babywalkers: Cross sectional study. BMJ. 2002;324:1494.

Physical Activity

​Parents were unaware of the importance of unrestricted movement and its importance in developing motor skills, promoting appropriate physical development and expending energy (6).

Evidence

​6. Unpublished findings: Healthy active living for families project: Parent focus groups. American Academy of Pediatrics. 2011.

Media

​By age 1, 37% of children are watching TV daily, 19% of children already have a television in their bedroom, and 10% have been exposed to mobile devices (7, 8).

Evidence

​7. Zero to eight: Children’s media use in America. A Common Sense Media Research Study. 2011.

8. Rideout VJ, Hamel E. The Media Family: Electronic Media in the Lives of Infants, Toddlers, Preschoolers, and Their Parents. Menlo Park, CA: Kaiser Family Foundation; 2006.

Media

​14% of infants in this age group are watching more than two hours a day of media (7).

Evidence

​7. Zero to eight: Children’s media use in America. A Common Sense Media Research Study. 2011.

Feeding

80% of mothers expect to breastfeed yet national data indicates that 35% of women are exclusively breastfeeding, at 3 months, while only 14% are exclusively breastfeeding at 6 months (1,13).

Evidence

1. Unpublished findings: Feeding and infant and toddlers study. 2008.


13. Black MM, Aboud FE. Responsive feeding is embedded in a theoretical framework of responsive parenting. J Nutr. 2011;141:490-494.​

Feeding

​2nd Critical period where women stop breastfeeding primarily due to psychosocial issues and/or because they feel they have met the critical period of 6-8 weeks in terms of immune benefits of breastfeeding (1).

Evidence

​1. Unpublished findings: Feeding and infant and toddlers study. 2008

Feeding

A substantial number of families introduce solids early, especially if they perceive the infant as fussy (3). Formula fed infants are at more risk for early introduction of solids (14).

Evidence

3.

14. Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW. Timing of solid food introduction and risk of obesity in preschool-aged children. Pediatrics. 2011​

Feeding

By 6 months, 80% of families have already introduced juice into the infant's diet, however 20% of infants will have already been introduced at this point (4).

Evidence

4. Siega-Riz AM, Deming DM, Reidy KC, et al. Food consumption patterns of infants and toddlers: Where are we now? J Am Diet Assoc supplement. 2011.​

Feeding

​At 9 months there is considerable drop off of vegetable and fruit consumption and increase in consumption of non-nutritive finger and snack foods (4).

Evidence

​4. Siega-Riz AM, Deming DM, Reidy KC, et al. Food consumption patterns of infants and toddlers: Where are we now? J Am Diet Assoc supplement. 2011.

Feeding

​At 9 months 43% of 9-12 months old consume desserts, sweets or sweetened beverages daily (4).

Evidence

​4. Siega-Riz AM, Deming DM, Reidy KC, et al. Food consumption patterns of infants and toddlers: Where are we now? J Am Diet Assoc supplement. 2011.

Feeding

Critical period where women stop breastfeeding most commonly over concerns about enough milk, challenges with transition home and lack of confidence, pain, and/or lack of sleep (1).

Evidence

1. Unpublished findings: Feeding and infant and toddlers study. 2008​

Feeding

3rd critical period where women stop breastfeeding primarily due to transition back to work (1,2).

Evidence

1. Unpublished findings: Feeding and infant and toddlers study. 2008.

2. Kimbro, RT. On-the-job moms: Work and breastfeeding initiation and duration for a sample of low-income women. Matern Child Health J. 2006;10(1): 19-26.​

Feeding

​4th critical period for breastfeeding cessation due to baby self-weaning and/or mother’s desire to have her body back (1).

Evidence

​1. Unpublished findings: Feeding and infant and toddlers study. 2008.

Feeding

​By 17% of infants in the age group have already been prematurely introduced to drinking cow’s milk and 33% do not drink any water (4,11).

Evidence

​4. Siega-Riz AM, Deming DM, Reidy KC, et al. Food consumption patterns of infants and toddlers: Where are we now? J Am Diet Assoc supplement. 2011.


11. Skinner JD, Ziegler P, Ponza M, Jada. Transitions in infants’ and toddlers’ beverage patterns. 2004.

Feeding

Critical period where responsive feeding should be fostered including self-feeding and self-regulation (13).

Evidence

13. Black MM, Aboud FE. Responsive feeding is embedded in a theoretical framework of responsive parenting. J Nutr. 2011;141:490-494.​

Breastfeeding:

  • ​Exclusive breastfeeding for the first year
click for full information

Evidence

  • ​Breastfed babies who are breastfed for at least 6 months are less likely to be overweight.
  • The duration of breastfeeding also is inversely related to the risk of obesity.
  • A reduction of 40% in the incidence of type 2 diabetes mellitus is reported, reflecting the long-term positive effect of breastfeeding on weight control and feeding self-regulation.
  • 80% of mothers expect to breastfeed yet only 14% are exclusively breastfeeding at 6 months.
  • Critical periods for breastfeeding cessation are transition home from hospital, 6-8 weeks, transition back to work, and between 6-8 months due to self-weaning and/or introduction of solids.

Opportunities for Care

​Support new mothers in breastfeeding. Provide lactation services at your office or know about sources of lactation support in your community.

Provide ongoing encouragement for breastfeeding at well visits. Ask patients about challenges or concerns.

Let mothers know It is wonderful that they are breastfeeding their baby. And that breastfeeding is great for their baby and has health benefits for them too.
 
If mothers are returning to work assure them that with careful planning and a few resources they can make breastfeeding work.
 
Remind families that babies reap the benefits of breastfeeding for their entire first year!

Conversation Starters

Newborn, early months:
  • It is so great that you are breastfeeding your baby. It can be very rewarding but challenging too. How is breastfeeding going for you? Do you have any concerns about breastfeeding your baby?
  • Can you tell me about a typical feeding experience? Tell me how your family and friends (spouse, grandparents, etc) are supporting you with feeding your baby?
For 2 or 4 month visit:
  • It is wonderful that you are continuing to breastfeed your baby. Are you exclusively breastfeeding?
  • Are you returning to work? Many women continue to successfully breast feed after returning to work. Tell me about your feelings about this. Are there any questions I can answer to help you during this time of transition?
  • Are you having any challenges maintaining exclusive breastfeeding?
For 6 and 9 month visit:
  • It is wonderful that you are still breastfeeding. Is there anything can I do to support you in your breastfeeding?

Related Parent Resources

HALF Message(s):

Lots of parents are surprised to find out that babies who are breastfed for at least 6 months are less likely to be overweight or obese as they get older. Breastfeeding can be a lot of work, but it’s a great way to bond with your baby and help him stay healthy.

HALF Resources:

  • For realistic parent derived strategies for breastfeeding refer parents to the following sections on healthychildren.org/growinghealthy.
    Quick Tips: Keep Your Child Healthy widget. Simply select Breastfeeding to generate the results.
  • Food and Feeding Infants.
    Also take advantage of the Healthy Active Living for Families app to create personalized patient education for your patient.

​Bottle Feeding:

  • Practice appropriate bottle feeding practices:
    • Avoid bottle propping
    • Only breastmilk or formula in bottle unless otherwise directed by physician
click for full information

Evidence

  • ​Inadequate feeding practices associated with bottle feeding of infant formula or use of bottle feeding as a methods to soothe infants can contribute to greater energy intake.
  • It is not uncommon for mothers add cereal to the bottle in the belief that doing so will help the infant sleep longer.
  • A substantial number of families introduce solids early especially if they perceive the infant as fussy.
  • Inattention to a child’s hunger and satiety cues has been associated with infant overfeeding.

Opportunities for Care

​If parent reports fussiness, counsel parent about importance of responding with an array of strategies, not just feeding.

If parent reports sleeping problems, counsel about bedtime routines, healthy sleep practices, and realistic sleep expectations based upon baby's age.

Let parents know that it is important that it will get better.

Encourage parents to make feeding time responsive and pleasant for them and their baby.

Conversation Starters

It can be difficult when a parent and baby are not getting enough sleep. Can you tell me how this is going for you?

It can be difficult when a baby cries a lot. How is it going with your baby? Would you like to talk about some ways to soothe your baby that don’t involve feeding?

Can you tell me about what feeding time is like for you and your baby?

Tell me how your family and friends (spouse, grandparents, etc) are supporting you with feeding your baby.

How would you describe your baby? Is she content, fussy, sleepy, etc?

Related Parent Resources

HALF Message(s):

Some parents (and grandparents!) worry that young babies aren’t getting enough to eat. But there’s no need to worry — babies under age 6 months get everything they need from breast milk or formula.

HALF Resources:

For realistic parent derived strategies for bottle feeding refer parents to the following sections on healthychildren.org/growinghealthy
  • Quick Tips: Keep Your Child Healthy widget. Simply select Bottle Feeding to generate the results.
  • Food and Feeding Infants.

Also take advantage of the Healthy Active Living for Families app to create personalized patient education for your patient.

Food Introduction:

  • ​Introduce solid foods around 6 months of age
  • Expose baby to a wide variety of healthy foods
    • Also offer a variety of textures
click for full information

Evidence

  • ​A substantial number of families introduce complementary solid foods around 3-4 months, especially if the infant is perceived as fussy.
  • Formula fed infants are at more risk for early introduction of solids.
  • Introduction to solids prior to 4 months is associated with increased weight gain and adiposity, both in infancy and early childhood.
  • Research indicates that it is important to expose children to a wide variety of flavors and textures.
  • Many babies and toddlers need to be exposed to foods multiple times before accepting them.
  • Babies and toddlers are more likely to eat foods they see their peers and parents eating.

Opportunities for Care

If parent reports fussiness and/or sleeping problems, counsel about the importance of appropriate complimentary food introduction. Share potential calming and soothing strategies for infants, as well as coping strategies for parents.

Encourage parents to wait until around 6 months to introduce solids.

Remind parents that this is a very important time and the kinds of foods your baby eats now help him to enjoy healthy foods later. 

Counsel about the importance of introducing a wide variety of foods, especially vegetables and fruits. As the infant grows, it is important to expose the baby to variety of textures.

Explain that sometimes it takes a baby 10-15 tries over time before they will actually accept a new food.

Explain that this 10-15 tries is over a period of months and to not get discouraged.

To address concerns about waste, discuss strategies that limit wasted food, such as not feeding directly from a jar but removing a small serving from a jar to a different container.

You can reassure parents that it is okay if the infant doesn’t like something the first time, and it is important to keep offering it.

Conversation Starters

​Tell me how your family and friends (spouse, grandparents, etc) are supporting you with feeding your baby.

How would you describe your baby? Is she content, fussy, sleepy, etc?

Well Visit 2 and 4:
Can you tell me a little about your plans to introduce your baby to solid foods?

6 month visit:
It is wonderful that your baby is ready to embark or beginning to eat solid food. It is an exciting milestone! Do you have any concerns or questions?

Tell me a little bit about your experiences so far.  

Can you tell me about your feeding experiences so far? Are you having fun? Do you have any concerns?

Can you describe what foods your baby likes and dislikes?

What do you do when your baby seems to dislike or not try a new food?

How do you introduce new foods to your baby?

Related Parent Resources

​HALF Message(s):

Lots of parents are excited to start their babies on solid foods. Others are nervous.  Starting to eat solid foods (like baby cereal and baby food) is an important part of your baby’s development. Did you know that babies who start eating solid food too early are more likely to be overweight or obese in childhood and adulthood? This is one more important reason to wait until your baby is really ready before giving him solid foods.

HALF Resources:

For realistic parent derived strategies for solid food introduction refer parents to the following sections on healthychildren.org/growinghealthy
  • Quick Tips: Keep Your Child Healthy widget. Simply select Starting Solid Foods to generate the results.
  • Food and Feeding Infants.
    Also take advantage of the Healthy Active Living for Families app to create personalized patient education for your patient.

HALF Message(s):

Introducing your baby to new foods can be both fun and frustrating.  Some parents worry about wasting food and money if their babies don’t like a lot of foods at first.  Good news: a new eater only needs 1-2 tablespoons of each food and will gradually increase to 3-4 tablespoons as she gets older.  By getting your baby used to lots of different foods, you’ll help him build a healthy diet for life.

​Healthy Snacking:

  • After 9 months, offer 2-3 healthy and nutritious snacks per day
  • Maintain fruit and vegetable consumption after finger foods are introduced
click for full information

Evidence

  • ​Almost all older infants snack regularly, but the quality of the snacks is variable.
  • The most common snack foods are often finger foods such as cereal, cookies, crackers, and French fries. 
  • Eating at regular intervals helps to foster self-regulation and reduces overeating.
  • At 9 months, there is a considerable drop in fruit and veggie consumption, and an increase in non-nutritive finger and snack foods.

Opportunities for Care

​Counsel on appropriate feeding recommendations and the importance of regular healthy and nutritious meals and snacks.
 
When discussing routines, mention the importance of planning for regular and healthy snacks.
 
Explain that snacks are an opportunity to provide critical nutrients babies need.
 
Counsel that snack and meal times should be supervised and ideally occur seated at a table, not in transit (i.e. stroller or car seat).
 
By 9 months, counsel on the importance of maintaining fruits and veggies as part of the baby's diet.
 
Discuss strategies to use healthy finger foods as snack foods, rather than just prepackaged snack items.
 
Snacks are an important part of the baby's nutrition. Suggest that parents offer a fruit and/or veggie for at least one snack every day.
 
Discuss potential choking hazards and strategies to offer healthy foods in bite size portions.

Conversation Starters

​What kinds of foods do you offer your child for snacks?

What kinds of foods does your child want for snacks?

What part do snacks play in your eating plan for your child?

How do you feel about snacks as treats or rewards?

How often does he have snacks? What other kinds of foods do you offer?

How does your child respond to being offered fruits? Vegetables?

What do you do if your child refuses to eat fruits and/or vegetables?

What kind of snacks does your child get in child care? What about when they are staying with grandparents or with other family members?

Related Parent Resources

​HALF Message(s):

Have fun with finger foods. Let your baby try feeding herself. Offer healthy snacks 2-3 times per day.

HALF Resources:

For realistic parent derived strategies on healthy snacking and finger foods refer parents to the following sections on healthychildren.org/growinghealthy

  • Quick Tips: Keep Your Child Healthy widget. Simply select Healthy Snack and Routines and Schedules to generate the results.
  • Food and Feeding Infants.
    Also take advantage of the Healthy Active Living for Families app to create personalized patient education for your patient.

​Foster Self-feeding:

  • Babies are encouraged to use spoons and fingers to feed themselves
  • Babies are encouraged to drink from a cup starting at 6 months of age
  • Parents recognize hunger and satiety cues
click for full information

Evidence

  • ​Babies have an innate ability to self-regulate their food. 
  • Responsive feeding helps foster self-regulation.

Opportunities for Care

​Discuss responsive feeding, hunger and satiety cues with parents.

Encourage parents to foster babies self-feeding by using fingers, spoons, and cups. Explain that using their hands and trying to use a spoon are important parts of how a baby learns to self-feed and regulate how much they eat.

Acknowledge that self-feeding can sometimes be messy and take a bit longer. Strategize with parents about setting certain meals and snacks aside for their child to hone these skills, and remind parents when they opt to feed their child to be aware of fullness cues. 

Conversation Starters

​How is your baby doing with a spoon?

Can you describe how you go about encouraging your baby to feed herself?

What is it like at mealtimes when your baby feeds herself? How do you feel about it, and how does your baby feel about it?

What would be helpful to you and your baby to encourage self feeding?

Related Parent Resources

​HALF Message(s):

Let your baby try feeding herself as soon as she’s ready — usually around 8 or 9 months old.

HALF Resources:

For realistic parent derived strategies on self-feeding refer parents to the following sections on healthychildren.org/growinghealthy
  • Food and Feeding Infants

​Healthy Drinks:

  • Babies should drink breastmilk or formula for the first year of life
  • Try to avoid introducing juice until child is a toddler. If juice is introduced, wait until 6-9 months and limit consumption to 4-6 ounces
  • Avoid introduction of sugar-sweetened beverages
click for full information

Evidence

  • ​Almost 80% of babies 6-9 months drink juice regularly.
  • Children who consume such fruit juices have higher energy intakes.

Opportunities for Care

​Remind parents that breastmilk, formula and water are the best beverage choices at this time. Suggest that water is a great choice for practicing drinking from a cup and encourage families to foster use of cups over bottles and sippy cups.

If they want to introduce juice, help parents understand what a 4-6 ounce serving looks like, and that this is the amount for one day.

Conversation Starters

​Does your child drink juice? How much do you offer?

How do you feel about your child drinking sugar sweetened beverages like soda, sports drinks, and juice?

What beverages does your family drink at meals and between meals? What about when eating out?

When you eat out, what beverages does your child drink?

What beverages does your child drink at child care? With other friends and family members?

Related Parent Resources

​HALF Message(s):

Breast milk and formula are the best choices for your baby. When it’s time for him to start using a cup (around 6 to 9 months), give him breast milk, formula, or water.

HALF Resources:

For realistic parent derived strategies on healthy drinking refer parents to the following sections on healthychildren.org/growinghealthy
  • Quick Tips: Keep Your Child Healthy widget. Simply select Bottle Feeding and Healthy Snacks to generate the results.
  • Food and Feeding Infants
    • Also take advantage of the Healthy Active Living for Families app to create personalized patient education for your patient.

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