Complementary feeding of infants in their first year of life: focus on
the main pureed baby foods
FABÍOLA ISABEL SUANO DE SOUZA1, MICHELLE CAVALCANTE CAETANO2, THAÍS TOBARUELA ORTIZ2, SIMONE GUERRA LOPES DA SILVA2,
ROSELI OSELKA SACCARDO SARNI3*
1 PhD in Sciences from Unifesp. afiliate Professor at the Department of Pediatrics, School of Medicine of aBc, Santo andré, SP, Brazil 2 Masters in Sciences from Unifesp, São Paulo, SP, Brazil
3 PhD in Sciences from; Post-doctoral Professor at the Department of Pediatrics, School of Medicine of aBc, Santo andré, SP, Brazil
S
UMMARYStudy conducted at the Department of Pediatrics, School of Medicine of aBc, Santo andré, SP, Brazil
Article received: 2/6/13
Accepted for publication: 1/13/14
*Correspondence:
address: rua rené Zamlutti, 94, apto 52 - Vila Mariana São Paulo/SP, Brazil ZiP code: 04116-260 Phone/Fax: +55 11 55719589 [email protected]
http://dx.doi.org/10.1590/1806-9282.60.03.011
Conflict of interest: none
Objective: to evaluate the complementary feeding practices for infants,
focu-sing on the main pureed baby foods, and verify adherence to the guidelines adop-ted in Brazil.
Methods: through cross-sectional study, aspects of complementary feeding of
404 healthy infants between 4 and 9 months of age (São Paulo, Curitiba and Re-cife) were evaluated. Socio-demographic data, history and food habits were col-lected. Mothers described three recipes (preparations) usually used in key baby foods. The findings were compared with those recommended by the Brazilian Society of Pediatrics.
Results: the average age was 6.9±1.6 months. Among infants, 241/404 (59.6%)
were still breastfeeding. Among those who received another type of milk, 193/368 (52.4%) received whole cow’s milk, while 151/368 (41.0%) drank infant or fol-low-on formulas. Regarding baby food recipes salted reported by mothers, it was seen that 30% and 60% contained meat and vegetables, respectively. The percent-ages less suitable for feeding in general were observed for use of cow’s milk and added sugar, chocolate and cereal in feeding bottles; 79% and 80.5% of the fam-ilies interviewed would adopted such practices.
Conclusion: the early termination of exclusive/predominant breastfeeding and
the practice of an inadequate transition diet have shown a picture of quantita-tively and qualitaquantita-tively inadequate feeding, with the risk of causing serious nu-tritional problems in later ages, such as anemia and vitamin A deficiency, or ex-cess of nutrients, leading to obesity, diabetes and dyslipidemias.
Uniterms: feeding, infant, nutrition for at-risk groups, child nutrition disorders.
I
NTRODUCTIONThe introduction of new foods in the diet of a child after six months of age should complement the several quali-ties and functions of breast milk, which should prefera-bly be continued until the age of two years or older. The introduction of complementary feeding (AC) must not only meet the nutritional needs of the child, but also grually expose the family’s eating habits, which requires ad-aptation to a new stage of the life cycle so that new
fla-vors, colors, aromas and textures are presented.1
Complementary foods, when prepared specifically for the
child, are called transitional.2
Countless scientific evidence indicates the impor-tance of healthy nutrition in early life for the proper growth and development of children and the prevention of future chronic diseases into adulthood, a
phenome-non known as metabolic programming.3,4
moth-ers and caregivmoth-ers of infants is increasing. In line with this finding, the Brazilian Society of Pediatrics issued manu-als targeted to pediatricians to standardize infant
feed-ing5 and the Ministry of Health implemented the
Nation-al Strategy for HeNation-althy Complementary Feeding
(ENPACS),6 which seeks to strengthen efforts to support
and promote complementary feeding in the Brazilian Unified Health System - SUS.
Previous publications of the Ministry of Health and
our group7 emphasize the high frequency of inadequate
FC in the first year of a child’s life.1,7 The works
empha-size the early introduction of inappropriate foods, such as whole cow’s milk; inappropriate and low density con-sistency and bioavailability of micronutrients (e.g., dilute soups), insufficient fruit and vegetable supply; contami-nation during preparation and storage; simple carbohy-drates added to the bottles, and the offering of processed foods rich in simple carbohydrates, lipids and salt
con-sumed often by family.1,7
There are no studies available in our area assessing the suitability of transition foods in the face of the guide-lines proposed by the Brazilian Society of Pediatrics.
The present study aims at evaluating the practices re-lated to complementary feeding of infants aged 4-9 months, focusing on the main pureed baby foods, and verifying compliance with the recommendations current-ly adopted in Brazil.
M
ETHODSThrough cross-sectional study, aspects related to comple-mentary feeding of 404 infants between 4 and 9 months of age were evaluated. The subsample was selected from a survey conducted in 2010 with 1,800 mothers of chil-dren between 4-36 months of age, socioeconomic class-es A, B, C and D, in the citiclass-es of São Paulo, Curitiba and Recife. This initial sample was non-probabilistic, inten-tional by quotas, and weighted according to the Brazil-ian Census Bureau (IBGE).
Healthy infants who were not exclusively breastfed, not in school or daycare, and whose mothers were respon-sible for the preparation of their food and agreed to par-ticipate were included in the study (Figure 1).
Using structured and pre-coded questionnaires, data related to demographics, history and food practices were collected by previously trained professionals. Mothers were asked to describe in detail the ingredients used to prepare the fruit purees and main baby foods. Each moth-er reported three preparations (recipe 1, recipe 2 and 3 recipe). The preparations were evaluated in terms of food groups chosen by the mothers for the baby food recipes
(cereals and tubers, legumes, meats and vegetables) ac-cording to the guidelines of the Brazilian Society of
Pe-diatrics.5
To assess the adequacy of aspects related to comple-mentary feeding, a score was developed based on the
guide-lines of the SBP.5 The six items considered appropriate
in the score were: 1) to continue breastfeeding; 2) not to offer whole cow’s milk; 3) not to add cereals, chocolate or sugar to the bottles; 4) to offer natural fruit juice re-specting the maximum daily volume of 100 mL; 5) to of-fer fruits mashed, scraped or natural without adding sug-ar; and 6) refer the use, at least in one of the main recipes of baby food, of all the nutritional food groups (cereals or tubers, legume, meat or egg and vegetables) recom-mended by the SBP. Each item considered appropriate was assigned 1 point (range 0 to 6).
The data were entered into an Excel spreadsheet (Mi-crosoft Office), validated, consolidated and subsequent-ly anasubsequent-lyzed using SPSS 20.0 Statistical Package. For sta-tistical analysis, we used frequency tables with absolute numbers and percentages. Categorical variables were pre-sented as absolute value and percentage, parametric con-tinuous variables were presented as mean (standard de-viation) and non-parametric as median (minimum and maximum). Chi-square test was used to compare categor-ical variables. The level of significance was set at 5%.
R
ESULTSThe general characteristics of the 404 infants are shown in Table 1. The average age was 6.9±1.6 months and male gender predominated, 221/404 (54.7%). In most families, the child being evaluated was the first child, 214/404 (52.9%), and the predominant social class was categorized as C1, 190/404 (47.0%). The mean duration of exclusive breastfeeding was 3.4±1.7 months.
Infants 4 – 9 months (n = 600)
Validated questionnaires (n = 590)
Included (n = 404)
Excluded (n = 10) Incomplete data: 10
Excluded (n = 186)
Mothers do not prepare food: 68 Child in daycare/school: 36 Incomplete data (baby food): 82 Infants 4 – 36 months (n = 1800)
São Paulo (n = 600), Curitiba (n = 600), Recife (n= 600)
TABLE 1 General characteristics of the study population
Variables N = 404 %
Location São Paulo 138 34.2 n=404 Curitiba 144 35.6 Recife 122 30.2
Age range 4 – 6 months 158 39.1 n=404 6 – 9 months 246 60.9
Gender Male 221 54.7
n=404 Female 183 45.3
Social class A1 9 2.2
n=404 A2 9 2.2
B1 27 6.7
B2 80 19.8
C1 190 47.0
C2 89 22.0
Number of children
1 214 53
n=404 2 102 25.2
3 47 11.6
> 3 41 10.1
Breastfeeding Breastfed in the past
163 40.3
n=404 Still breastfeeding
241 59.7
Among infants, 241/404 (59.6%) were still being breast-fed, and the average number of feedings per day was 5.0±2.5 times. Only 36/241 (14.9%) of infants were exclu-sively breastfed.
Among those who received another type of milk, in addition to being breastfed, 193/368 (52.4%) received whole cow’s milk, while 151/368 (41.0%) drank infant or follow-on formulas.
Regarding the salted baby food recipes reported by mothers, 30% and 60%, respectively, contained meat and vegetables (Figure 2).
40% 30%
20%
10%
0% 50% 60%
85,1%
71% 73%
66,1%
59,7% 61,1% 59,4%
56,4% 58,4%
24,5%28,5% 30%
70% 100%
80% 90%
Cereais Hortaliças Carnes Leguminosas
Receita 1 Receita 2 Receita 3
FIGURE 2 Percentage of food groups reported by the mothers to prepare the main baby foods, 3 recipes - preparations (n = 404).
There was no statistically significant difference in the du-ration of breastfeeding or groups of foods used to pre-pare the babies’ food in terms of socioeconomic level and city studied (data not shown).
Table 2 shows the percentage of adequacy of the six topics to assess complementary feeding of infants. The mean score in the population assessed was 2.0±1.2 and the worst percentages of adequacy were observed for use of cow’s milk and additions (in bottles); only 79 (19.5%) of the mothers interviewed did not adopt these practic-es (Table 2).
D
ISCUSSIONThis study highlights some characteristics in complemen-tary feeding of infants aged 4-9 months and not exclu-sively breastfed in relation to the guidelines issued by the Brazilian Society of Pediatrics.
The period of introduction of complementary foods is highly risky for the child and the offering of unhealthy food items, combined with potential contamination while the food is being handled or prepared, favors the occur-rence of diseases such as obesity, diarrhea and malnutri-tion. Nutritional quality is another risk, emphasizing the greater need for micronutrients. With the rapid growth seen in the first year of life, iron and zinc requirements increase beyond the contents of breast milk. About 50 to
TABLE 2 Percentage of mothers who followed the guidelines of the Brazilian Society of Pediatrics (N=404)
Items included in the score N (%)
To continue breastfeeding 241 (59.7%)
Not to offer whole cow’s milk 84 (21.0%)
Not to add cereals, chocolate or sugar to the bottles 79 (19.5%) To offer natural fruit juice respecting the maximum daily volume of 100 mL 217 (53.7%) To offer fruits mashed, scraped or natural without adding sugar 126 (31.2%)
Refer the use, at least in one of the main recipes of baby food, of all the nutritional food groups (cereals or tubers, legume, meat or egg and vegetables)
supply of cow’s milk is superior to that of human milk (1.2 g/100 kcal). Observational studies show an association be-tween a protein intake above 14% of total energy
consump-tion and future development of obesity.15 Excessive
con-sumption of protein, especially from milk, stimulates the synthesis of growth factors such as insulin and IGF1,
stim-ulating the differentiation of preadipocytes into adipocytes.16
Another mistake often observed in the studied sample was adding cereal, chocolate and sugar to infant formulas, which should not receive additions. Unfortunately, this
practice is very common in our country.7 The carbohydrate
content of human milk at all stages of lactation, as well as its functional aspects, is lower than that in formulas
(usu-ally 7.6 g/100 mL).17 Unnecessary addition of carbohydrates
to complementary feeding, in addition to increasing the energy value of foods offered to infants, unfavorably influ-ences the child’s future preferinflu-ences and eating habits and
therefore should be discouraged.16,18
Only 32% of children consumed natural fruit with no addition of carbohydrates. Early and frequent exposure to fruits and vegetables increases its consumption in later
life.19,20 Similarly to what was observed with infant
formu-las, often there was the addition of carbohydrates to fruits. The present study has some limitations such as the mothers’ recall bias regarding recipes used to prepare the babies’ food, and the study’s cross-sectional model.
The early termination of exclusive/predominant breastfeeding and the practice of an inadequate transi-tion diet have shown a picture of quantitatively and qual-itatively inadequate feeding, with the risk of causing se-rious nutritional problems in later ages, such as anemia and vitamin A deficiency, or excess of nutrients, leading to obesity, diabetes and dyslipidemias. Growing evidence of the impact of food in early life and the future develop-ment of diseases represent a window of opportunity for prevention strategies in the context of public health. Thus, strategies to promote breastfeeding and practices of healthy complementary feeding are essential to ensure the individual’s health in the short and long term.
Financial support:
Nestle Nutrition Institute
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ESUMOAlimentação complementar de lactentes no primeiro ano de vida: ênfase nas papas principais
Objetivo: avaliar as práticas relacionadas à alimentação complementar de lactentes, com ênfase nas papas prin-70% of zinc, and 70 to 80% of iron, should come from
ad-ditional sources through food.5 The Department of
Nu-trition at the Brazilian Society of Pediatrics recommends that the main baby food offered from the sixth month of life be composed of at least one of the following food groups: cereals and tubers, legumes, meat or egg and
veg-etables (beans and greens).5
In our study we found adequacy of 70%, 30%, 60% and 70% in the main recipes of baby food for the groups of cereals and tubers, legumes, meat and vegetables, re-spectively. Difficulties with appropriate complementary feeding practices have been described in studies in our
midst7 and in developed countries, such as the US.8 In
or-der to meet the nutritional needs of the infant, it is im-portant to diversify the composition of the major food groups, aiming at the concept proposed by the SBP of
multiple combinations.5
Systematic reviews highlight the importance of in-terventions for nutritional education focusing on
com-plementary feeding of infants in the first year of life.9,10
A recent study was conducted with 500 mothers of in-fants less than one year old in the city of São Leopoldo, state of Rio Grande do Sul, Brazil, randomly assigned to two groups: intervention (10 home visits targeting nutri-tion educanutri-tion based on guidelines of the Ministry of Health - “Ten Steps to healthy eating for infants aged zero to two years”) and control. Nutritional intervention for mothers of infants reduced the consumption of foods with high energy and was associated with a best suited
lipid profile at eight years of age.11
The mean duration of exclusive breastfeeding in this study was 3.4 months. Exclusive breastfeeding in the first six months of life is associated with a lower risk of aller-gic disease and sudden infant death syndrome. Further-more, it seems to accelerate neurocognitive development and protect against chronic diseases such as type 1
dia-betes, lymphoma and Crohn’s disease.12 Moorcroft et al.,
in a systematic review involving 24 studies, reported an association between early introduction of new foods and
future development of obesity.13 Another important
as-pect concerns the eating behavior of children receiving milk or formula in bottles compared to breastfed chil-dren. Recent study showed that bottle feeding for infants was associated with greater weight gain regardless of the
type of food (breast milk or formula).14
cipais, e verificar a concordância com as recomendações atualmente adotadas no Brasil.
Métodos: por meio de estudo transversal, foram
avalia-dos os aspectos da alimentação complementar de 404 lac-tentes saudáveis entre 4 e 9 meses de vida (São Paulo, Re-cife e Curitiba). Coletaram-se dados sociodemográficos de antecedentes e hábitos alimentares. As mães descreve-ram três receitas (preparações) que costumam utilizar nas papas principais. Os achados foram comparados ao pre-conizado pela Sociedade Brasileira de Pediatria.
Resultados: a média de idade foi de 6,9±1,6 meses.
Cer-ca de 241 lactentes (59,6%) permaneciam em aleitamen-to materno. Entre os que recebiam outro tipo de leite, 193 dos 368 (52,4%) recebiam leite de vaca integral, e 151 dos 368 (41%), fórmulas infantis ou de seguimento para lac-tentes. Em relação às receitas de papas salgadas relatadas pelas mães, foi possível observar que 30 e 60% delas con-tinham leguminosas e carnes, respectivamente. Os pio-res percentuais de adequação na alimentação, em geral, foram observados para uso de leite de vaca e adição de açúcar, achocolatado e cereais em mamadeiras; 79 e 80,5% das famílias entrevistadas adotavam essas práticas.
Conclusão: o abandono precoce do aleitamento
mater-no exclusivo/predominante e a prática de uma dieta de transição inadequada têm mostrado um quadro de con-sumo quantitativa e qualitativamente inapropriado, com riscos de acarretar graves problemas nutricionais nas fai-xas etárias posteriores, como anemia e hipovitaminose A, ou excessos de nutrientes, como obesidade, diabete e dis-lipidemias.
Unitermos: alimentação; lactente; nutrição de grupos de
risco; transtornos da nutrição infantil.
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