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Feeding Guidelines for Infantsand Young Toddlers: A ResponsiveParenting ApproachGuidelines for Health ProfessionalsExecutive Summary, February 2017IntroductionIn the United States, a significant proportion of children2 years of age or younger are at risk of childhood obesity.Data from the 2011-2012 National Health and NutritionExamination Survey (NHANES) show that 8.1 percentof children ages 2 or younger were already above the 95thpercentile and 7.1 percent were at or above the 97.7thpercentile for weight based on their length.Early life diet and feeding behaviors play an important rolein establishing healthy food preferences and behaviors andpreventing childhood overweight and obesity. Yet there is adearth of evidence-based guidelines for infant and toddlerfeeding practices in the United States.The federal government’s current Dietary Guidelines forAmericans (DGA) do not include guidelines for infantsand toddlers less than 24 months. However, given newevidence showing that the first 1,000 days—or the periodfrom conception to age 2—are critical for childhoodobesity prevention, recommendations for this age groupare expected to be included beginning with the nextedition of the DGAs to be released in 2020.In 2016, Healthy Eating Research, a national program of theRobert Wood Johnson Foundation, convened an expertpanel to review the evidence that has emerged over the pasttwo decades for promoting healthy nutrition and feedingpatterns for infants and toddlers (ages 2 or younger). Thisexecutive summary summarizes guidelines presented in theexpert panel’s full report on what and how to feed infantsand toddlers within the context of the rapidly developingchild. These guidelines are based on current scientificevidence related to responsive parenting practices. Thesummary also addresses related behaviors such as physicalactivity, television and other media use (screen time), andsleep, as well as other important considerations includingfood allergies and food safety for infants and toddlers.Healthy Eating Research A National Program of the Robert Wood Johnson FoundationHealthy EatingResearchBuilding evidence toprevent childhood obesity

DefinitionsCOMPLEMENTARY FEEDING is a process that startswhen human milk or infant formula is complemented byother foods and beverages and ends when the young childtransitions fully to family foods. The complementaryfeeding period typically continues to 24 months of age.are foods and beveragesother than human milk or infant formula (liquids,semisolids, and solids) provided to an infant or youngchild to provide nutrients and energy.COMPLEMENTARY FOODSRESPONSIVE FEEDING is a key dimension ofresponsive parenting involving reciprocity between thechild and caregiver during the feeding process. It isgrounded upon the following three steps: (1) the childsignals hunger and satiety through motor actions, facialexpressions, or vocalizations; (2) the caregiver recognizesthe cues and responds promptly in a manner thatis emotionally supportive, contingent on the signal,and developmentally appropriate; and (3) the childexperiences a predictable response to signals.RESPONSIVE PARENTING is a parenting style that ismeant to foster the development of self-regulation andpromote cognitive, social, and emotional development.Self-regulation includes overlapping constructs thatcan affect feeding behaviors including self-control, willpower, effortful control, delay of gratification, emotionalregulation, executive function, and inhibitory control.The EvidenceThere are many factors influencing what infants and toddlersconsume. Caregivers need to be aware and understand: howinfants and toddlers develop food preferences and the role theyplay in influencing those preferences; how infants and toddlerssignal hunger and satiety; and the role of responsive feeding indeveloping healthy food habits. Further, caregivers also need tounderstand: how and when to feed complementary foods; sleeppatterns and their influence on healthy eating; physical activityneeds of infants and toddlers; and the need for limits on screentime. Detailed guidelines for caregivers on what and how tofeed infants and toddlers are included in Appendices 1 to 5.BreastfeedingDue to the health benefits that breastfeeding offers to childrenand women, the American Academy of Pediatrics (AAP)recommends that infants be breastfed exclusively from birth untilabout 6 months. Once complementary foods are introduced,it is recommended that breastfeeding continues until thechild is at least 1 year old. Among infants born in 2013, 81.1percent of women in the United States initiated breastfeeding;however, by six months the prevalence of women engaged in anybreastfeeding dropped to 51.8 percent, and by one year to 30.7percent. Differences in breastfeeding prevalence are observedacross income categories, states, and race/ethnicity.The most recent comprehensive meta-analysis that hadglobal representation and adjusted for key study design andcontextual factors, concluded that breastfeeding may protectchildren against the development of childhood obesity. Asexpected, the number of children in the general populationwho would benefit is small, given the numerous biological,economic, social, and lifestyle factors that affect the risk ofobesity; however, there is evidence indicating the protectivebenefit may be more pronounced among children with geneticpredisposition for obesity. These findings are highly consistentwith the current understanding of childhood obesity risk as alife-course process that starts at the time of conception.Shaping Food Preferences Among Infants and ToddlersUnderstanding how flavor and food preferences are establishedearly in life is crucial as early childhood dietary patterns trackinto later childhood and adolescence. The evidence suggests thatinfants born to mothers who consumed fruits and vegetablesduring pregnancy and while breastfeeding are more likely tolearn to accept these foods.Regardless of exposure during pregnancy and breastfeeding,repeated exposure to new and different food is necessary sothat infants and young children learn to like them, especiallyfor those that have bitter or sour taste profiles as is the casewith many vegetables.Likewise, it is vital to expose infants to different textures inorder to properly transition to table food—for example, movingfrom pureed to mashed to lumpy and to chopped soft solidfood during the first two years of life. By 2 years of age it isexpected that children will have fully transitioned to food thatcomprises the family diet. For this reason it is crucial for thefamily diet to include a plentiful supply of fruits and vegetables.The evidence regarding the shaping of food preferences in youngchildren supports providing pregnant women and caregivers ofinfants and toddlers with the following information: (a) mothersconsuming a healthy diet rich in vegetables and fruits duringpregnancy and while breastfeeding can help shape healthy foodpreferences among their offspring; (b) breastfed infants are morelikely than formula-fed infants to consume healthier diets by the2 Executive Summary Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach February 2017

time they reach school age; (c) infants and toddlers should beexposed repeatedly to healthy foods, including vegetables, untilthey learn to accept and like them; (d) healthy food, includingfruits, vegetables, and whole grains, should be readily availableto serve to infants (when developmentally ready, somewherebetween 4 and 6 months of age) at home and in child-caresettings where they may spend many hours of the day; and (e)infants and toddlers should not consume (or consume a verysmall amount of) food and beverages rich in added sugars (i.e.,desserts and sugary drinks), sodium, and added saturated fats.The Role of Feeding ContextInfants and toddlers rely entirely on their caregivers to learnwhat, when, and how to eat. Caregivers should decide whichtypes of food are made available to infants and toddlers andthe amount of food served, the frequency with which food isoffered, and the type and size of utensils used to eat (if any).Research has shown that feeding to soothe fussy infants hasbeen associated with excessive weight gain and that poor sleeproutines during the first two years of life are related to poordietary quality and obesity risk in early childhood.Allowing infants and toddlers to become familiar with healthyfood, such as vegetables, is key for the development of healthyfood preferences. Numerous attempts are needed for mostinfants to accept and learn to like new vegetables. The chancesof accepting a novel food may increase by pairing it with a foodor sauce the infant/toddler is already familiar with and likes (e.g.,red bell peppers or yellow squash with a preferred healthy dip).Evidence also shows that young children are more likely totry new and different foods when they observe their caregiverseating them enthusiastically, as opposed to when the food isoffered to them without having a role model present.The Role of Responsive FeedingBecause infants do not have the capacity to verbally communicatetheir feeding and psycho-emotional needs, it is imperative forcaregivers to learn to understand how and what their infantscommunicate with different behaviors. This requires a responsiveapproach for all caregivers including parents.Responsive feeding is a process that involves reciprocity betweenthe infant/toddler and caregiver during the feeding process andis grounded upon the following three steps: (1) the child signalshunger and satiety through motor actions, facial expressions,or vocalizations; (2) the caregiver recognizes the cues andresponds promptly in a manner that is emotionally supportive,contingent on the signal, and developmentally appropriate; and(3) the child experiences a predictable response to signals.Black and Aboud (2011) recommend the following specificresponsive feeding guidelines: (1) ensuring that the feedingenvironment is pleasant with few distractions (e.g., no televisionor other screens); (2) ensuring that the child is seated comfortably,ideally facing others; (3) ensuring that the expectations from thecaregiver and child are communicated clearly and consistently;(4) ensuring that the food is healthy, tasty, developmentallyappropriate, and offered on a predictable schedule so the child islikely to be hungry; (5) encouraging and attending to the child’ssignals of hunger and satiety; and (6) responding to the child’sfeeding needs in a prompt, emotionally supportive, contingent,and developmentally appropriate manner.Nonresponsive feeding is strongly discouraged as it ischaracterized by a lack of reciprocity between the caregiverand child. Nonresponsive feeding can lead to: (a) the caregivertaking control and dominating the feeding situation bycontrolling and pressuring behaviors; (b) the child controllingthe situation leading to indulgence; or (c) the caregiver ignoringthe child and becoming uninvolved. When caregivers controlthe feeding, not only do they potentially override the child’sinternal hunger and satiety regulatory cues, but it is thoughtthat they may interfere with the child’s emerging autonomy andstriving for independence based on the learning of new skills.Each of these undesired outcomes of nonresponsive feedinghave been associated with the development of poor dietaryhabits and/or increased childhood obesity.How caregivers respond to other behaviors, such as sleeping/waking patterns, and the soothing techniques used to calmdistressed infants, can influence the infant’s ability to learnto properly self-regulate food intake. Understanding sleepingpatterns of infants and how rapidly they change during the firstyear of life (relatively short sleep/wake cycles in early infancy,with most infants sleeping through the night by 6 months) hasalso been identified as central for preventing unhealthy eatingbehaviors and obesity risk in young children.A review of evidence from randomized control trials (RCTs)focused on responsive parenting practices supports the viewthat infants and toddlers should not be pressured to eat orfinish the food served to them. The RCTs emphasize theimportance of allowing the infant and toddler to participatein family meals and to avoid distractions during mealtimes,including TV viewing and other electronic screens. Thesestudies (see full report for references and summaries ofstudies) reiterate the importance of mealtimes being a warmand pleasant experience with plenty of verbal and non-verbalinteractions between the caregiver and the infants and toddlers.The RCTs also emphasized the importance for caregivers to helpinfants and toddlers learn to follow routine feeding and sleepingschedules. This approach is likely to not only be crucial for theself-regulation of food intake but also of emotions.Executive Summary Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach February 2017 3

Introducing Infants to Complementary FoodsThere is broad consensus that complementary foods (commonlyreferred to as solid foods) should be introduced once the infantis: able to sit without support and has good head and neckcontrol; has the ability to munch or chew and to use the tongueto move pureed food to the back of the mouth for swallowing;no longer has the extrusion reflex (i.e., does not automaticallypush solids out of the mouth with her/his tongue);demonstrates ability to bring hands and toys to the mouth forexploration; and indicates a desire for food, such as showingeagerness to participate in family mealtimes and trying to grabfood to put in her/his mouth. The vast majority of infants reachthese developmental milestones between 4 and 6 months ofage. The ability to sit without support is considered to be a keycue for assessing readiness for introduction of complementaryfoods as it correlates strongly with the rest of the cues and alsowith physiological development including gastrointestinal,renal, and immunological system maturation. Experts also agreethat complementary foods should not be introduced before4 months of age as the infant’s body is not physiologically ordevelopmentally ready. Early introduction of solids also mayincrease the risk of childhood obesity.Recognizing Infants’ and Toddlers’ Hunger andSatiety CuesResponsive feeding of infants and young toddlers relies heavilyon learning how they communicate hunger and fullness. Infants’primary form of communication is crying, and research hasshown this causes distress to caregivers who often interpret cryingas a sign of hunger. In early infancy, crying should be interpretedas a sign of hunger only if it is accompanied by additional cues,including: hand-to-mouth movements, mouthing, rooting,sucking noises/motions, fast breathing, clenched fingers andfists over chest and tummy, and flexed arms and legs. Infants usedifferent signals to indicate that they are full, such as closing theirmouths when food is offered and turning their head away fromthe food. As infants become older and enter toddlerhood, hungercues also include leaning towards food, visually tracking foodwith eyes, limb movements showing excitement, opening mouthas the spoon approaches, and asking for or pointing to food. Ingeneral, feeding cues progress as the child ages from behaviorsthat are subtle and primarily oral (e.g., mouthing) to those thatare active and tend to involve greater body movements (e.g.,reaching, pointing). If ignored, early and active cues are followedby late cues, such as crying and struggling, which indicateheightened levels of agitation.Other Important Considerations for Infants and ToddlersSleep Considerations for Infants and ToddlersHealthy sleep habits increase sleep duration and prevent sleepproblems. Lack of sleep among children under two has beenidentified as a risk factor for the development of childhood obesity.For example, in the U.S. Project Viva cohort study, children withless than 12 hours of daily sleep between age 6 and 24 monthshad almost double the odds of obesity at age 3 years comparedwith those sleeping at least 12 hours per day. Promoting healthysleep has been found to be effective at improving feedingbehaviors and weight outcomes among infants and toddlers.Healthy sleep requires adequate duration, appropriate timing,good quality, regularity, and the absence of sleep disturbances ordisorders. An expert panel convened by the American Academyof Sleep Medicine recently developed evidence-based sleepguidelines for children and adolescents. To promote optimalhealth, infants ages 4 to 12 months should sleep a total of 12to 16 hours per day (or 24 hour cycle), including naps, ona regular basis. Children 1 to 2 years of age should sleep 11to 14 hours per 24 hours (including naps) on a regular basis.General recommendations for infants younger than 4 monthsare difficult to make due to the wide range of normal variationin duration and patterns of sleep in early life, and insufficientevidence for associations with health outcomes.Physical Activity Considerations for Infantsand ToddlersThe evidence available in 2016 indicates that infancy is a timewhen movement and active play facilitate the motor, social, andcognitive development needed for healthy growth and wellbeing. Toddlerhood is a time when children are eager to activelyexplore and learn from their environments. For this reason,proper infant and toddler development relies heavily on early lifeopportunities to explore and move frequently. Motor, social, andcognitive development are fundamental for developing healthyeating habits, thus physical activity and active play opportunitiesare strongly linked to the proper implementation of responsivefeeding guidelines. As with feeding behaviors, caregivers shouldalso be role models for their infants and pay attention to theirown sedentary (e.g., screen time) and physical activity behaviors.4 Executive Summary Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach February 2017

Screen Time/Sedentary Behavior Considerationsfor Infants and ToddlersTypical sedentary behaviors of children 2 years old or youngerrefer to: time spent sitting while playing or engaging in learningactivities; time spent on screens, such as watching TV or in frontof a digital device screen (e.g., electronic tablet, smartphone,computer screen); and time spent restrained in a car seat, highchair or stroller, or inside of a play pen or crib while the childis awake. It is important that health professionals working withparents of young children are well trained to provide adequateadvice to parents on how to decrease sedentary behaviors,especially those related to screen time and the time that childrenspend restrained in equipment or in an area that restrictsmovement. The AAP recommends caregivers: (1) avoid usingscreen media for children younger than 18 months, with theexception of video-chatting facilitated by an adult caregiver; (2)choose high-quality programming/apps to use together withtheir 18- to 24-month old toddlers (letting toddlers use mediaby themselves should be avoided); (3) avoid exposing infantsand toddlers to screens during meals and for one hour beforebedtime; (4) avoid using media to calm their children; (5) keepbedrooms, mealtimes, and parent–child playtimes screen-freefor children and parents; and (6) avoid exposing toddlers to appswith advertising and/or unhealthy messages.A review of 24 studies assessing the prevalence of sedentarybehaviors in children under 2 years of age found that mostsedentary behaviors at this age were based on parental selfreport of screen time. The review found a wide range of screentime exposure per day among infants and toddlers (37 min to330 min/day). This review concluded that most children hadhigh exposure to TV and screen time by 2 years of age. The2012 Canadian guidelines for children ages 0 to 4 recommendthat for healthy growth and developme

2 Executive Summary | Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach | February 2017 Definitions COMPLEMENTARY FEEDING is a process that starts when human milk or infant formula is complemented by other foods and beverages and ends when the young child