CA AAP Conference 11/17/12

1. First Foods
Bonnie Y. Modugno, MS, RD, CLE
www.muchmorethanfood.com #MMTF

2. FIRST FOODS Goals
• BREASTFEEDING
– Identify incidence of breastfeeding and factors
that influence duration and exclusivity
– Survey impact of current feeding practices
– Compare differences between formula and
breastfeeding
– Identify role of pediatrician

3. FIRST FOODS Goals
• Complimentary Foods
– Assess conventional food choices
– Survey traditional first foods
– Identify options to promote growth, metabolic
health and well being

4. Babies are born
to be breastfed
http://www.babyfriendlyusa.org/

5. Breastfeeding
The American Academy of Pediatrics
recommends
Exclusive breastfeeding for about 6 months
Continued breastfeeding as complementary
foods are introduced
Continuation of breastfeeding for 1 year or
longer as mutually desired by mother and infant.
Medical contraindications to breastfeeding are
rare.
Infant growth should be monitored with the WHO
Growth Curve up to 2 yrs of age
February 27, 2012 Pediatrics Vol. 129 No. 3 March 1, 2012

6. Growth Charts
CDC – boys 0-36 mos WHO – boys 0-24 mos
50 %
50 %

7. Exclusively Breastfeed Babies:
fast growers picked up on both charts
6
CDC WHO 5
4
3 Series
1
2
Series
1 2
0 Series
Category 1
Category 2
Category 3
Category 4
3

8. What about the fast
growers?
• “Early growth patterns, both
prenatally and post-
natally, are emerging as
important markers of later
obesity risk, with rapid
neonatal weight gain a clear
risk factor for later obesity
and metabolic syndrome.”
TJ Cole
Acta Paediatrica. Volume 96, Issue Supplement x454 pages 204, April 2007

9. BREASTFEEDING RATES TODAY (2009 births)
100
90
80
70
60
50
40 US
30 California
20
10 Oregon
0 Mississipi
http://www.cdc.gov/breastfeeding/pdf/2012BreastfeedingReportCard.pdf

10. Breastfeeding: Incremental Gains
90
80 • Breastfeeding …
70
60
should be promoted as
50 the norm within all
40
30 2008 maternal and child
20 2009
10
0
2020 target health care facilities.
http://www.cdc.gov/breastfeeding/pdf/2012BreastfeedingReportCard.pdf

11. Primary barriers to breastfeeding as intended
1. Inadequate support
– Too little prenatal education
– Inadequate support post partum
• Access
• Timing
• Cost
– Conflicting agendas in the
hospital/clinic setting

12. Breastfeeding:
Reality Check
• “The free samples are also
such a boobie trap, and I
would love to see them
banned. With my older
daughter, I went home with 3
cans of powdered formula
and a case of pre-made
formula.”
http://justanotherhat.blogspot.com/2012/08/brewing-breastfeeding-controversy.html

13. Percent of breastfed infants
receiving formula before 2 days of age
35
30
US
25
California
20 Oregon
15 Mississipi
10 New Hampshire
Montana
5
Texas
0
http://www.cdc.gov/breastfeeding/pdf/2012BreastfeedingReportCard.pdf

14. Breastfeeding:
Reality Check
• “I tried with all 3 of my kids but
found once I ran into
problems, I wasn't given the
support i needed, or the
resources, but was directed to
just switching to formula far too
often. I wish there was more
support for [breastfeeding] in
agencies, government aid, and
medical offices.”
http://justanotherhat.blogspot.com/2012/08/brewing-breastfeeding-controversy.html
Image: http://www.sleepytot.com/blog/do-formula-fed-babies-sleep-more

15. Baby Friendly Hospital Initiative
Home
•19,000 hospitals internationally About BFHI
The Ten Steps
•In US, 6% of babies born in 143
BF hospitals Baby-Friendly Hospitals and Birth Centers
Info for Hospitals and Birth Centers
•51/143 BF hospitals located in
California Info for Parents
Info for Breastfeeding advocates / health care
professionals
Why is breastfeeding important?
www.babyfriendlyusa.org/find-facilities

16. Common barriers to breastfeeding
2. Need to return to work
 Inadequate time to express milk
 No place to express milk
 No adequate storage
http://www.heraldsun.com/view/full_story/9192782/article-
“The Business Case for Breastfeeding” WORLD-BREASTFEEDING-WEEK--A-STEP-IN-THE-
RIGHT-DIRECTION?instance=main_article
DHHS/ Office of Women’s Health
http://www.cdph.ca.gov/healthinfo/healthyliving/childfamily/Pages/Californi
aLawsRelatedtoBreastfeeding.aspx

17. Primary barriers to breastfeeding as intended
3. Personal misgivings
– Ambivalence
– Fears
– Lack of confidence
– Influence of family and friends
– Time and energy

18. Breastfeeding:
Reality Check
• “When I had my son the lactation consultant visit
was a joke- it was about 5 minutes”
http://justanotherhat.blogspot.com/2012/08/brewing-breastfeeding-controversy.html

19. Breastfeeding:
Reality Check
• “I tried SO. STINKIN. HARD. to breastfeed but ran
into problems. The biggest hit, though, was the
$30/fee to visit a lactation consultant”
http://justanotherhat.blogspot.com/2012/08/brewing-breastfeeding-controversy.html

20. AAP Efforts
• Who has utilized the curriculum?
• Who else is available to support new mothers?
– Family/friend/neighbor/internet
– WIC
– Lactation educator/consultant
– Doula/Baby nurse

21. Exclusively Partially Minimal Non
•ELIGIBILITY Breastfeeding Breastfeeding Breastfeeding Breastfeeding
Milk (gallons) 5 gal + 1 quart 4 ½ gal + 1 quart 3 gal +1 quart 3 gal + 1 quart
185% Cheese (pounds) 2 2 1 1
Eggs (dozen) 2 1 1 1
Federal Juice 3 3 2 2
Poverty (11.5-12 oz (or two 64 oz shelf
stable)
(or two 64 oz shelf
stable)
(or one 64 oz
shelf stable)
(or one 64 oz shelf
stable)
concentrate)
Level
Breakfast Cereal 36 36 36 36
(ounces)
Whole Grains 1 1 0 0
Lactation (pounds)
Dry Beans and/or 2 lbs 2lb 1lb or 18 oz 1lb or 18 oz
resources Peanut Butter or 1lb and 18 oz or 1lb and 18 oz
available Canned Fish 30 oz 0 0 0
Fruits and $10 $8 $8 $8
Vegetables
(Cash Voucher)
http://www.phfewic.org/

22. If breast milk were packaged

23. What about formula
• Infant formula introduced
to the USA in the late
1860’s

24. How does formula
compare?
“The longest-established
mass marketed ultra-
processed product”
Thomas Farley, MD, MPH
NYC Health Commissioner
Breastfeeding:
The NYC Latch On Campaign
World Nutrition. October 2012, 3, 10, 445-455.

25. Infant Formula
ENFAMIL
• DHA level similar to worldwide breast milk average4,†, to support
mental, visual and immune system development
• Clinically shown to have a bifidogenic effect similar to that of breast milk5
in infants fed the formula between 30 and 90 days of age
• Proven to improve* respiratory health through the first 3 years of life
when infants were fed Enfamil PREMIUM Infant through 12 months6
• Clinically proven* growth7 similar to breastfed infants through 12
months, IQ scores and vision similar to breastfed infants up to 4 years of
age8 and support for the immune system6
• Easy to digest 60:40 whey-to-casein ratio, patterned after mature breast
milk9,‡
• Natural Defense Dual Prebiotics blend has 2 prebiotic ingredients-GOS
(galactooligosaccharides)
http://www.mjn.com

26. Is breast milk more than a mix of nutrients?
Carbohydrate
Carbohydrate Source Glycemic
Index
Glucose 99 +/- 3
Sucrose 60 +/-21
Lactose 46 +/- 2
Fructose 19 +/- 2
Corn syrup (HFCS) 57-75
Maltose (Maltodextrin) 105 +/- 12
Fructo-oligosaccharides
Rice starch
Foster-Powell. Am J Clin Nutr January 2002 vol. 76 no. 1 5-56

27. Is breast milk more than a mix of nutrients?
PROTEIN
FORMULA
• Non fat milk
• Soy protein isolate
• Whey protein concentrate
• Individual amino acids

28. Amino Acids Comparison
(mg per 100 calories)
300
250
200
150
Human milk
100
Enfamil NB
50 Enfamil PI
0

29. Amino Acids Comparison (con’t-1)
(mg per 100 calories)
160
140
120
100
80
60 Human milk
40 Enfamil NB
20 Enfamil PI
0

30. Amino Acids Comparison (con’t-2)
(mg per 100 calories)
450
400
350
300
250
200
150 Human milk
100 Enfamil NB
50 Enfamil PI
0

31. Infant Formula: Sources of Fat
50
45
40
35
Palm Olein
30
Soy Oil
25
20 Coconut Oil
15 High Oleic Sunflower Oil
10 ARA/DHA Blend
5
0
Enfamil

32. Is breast milk more than a mix of nutrients?
FAT
8
7
6
5
4
3
2 Omega 3
1 Omega 6
0
gm/13.6 gm (1 Tbsp)
ESHA Food Processor, ©2012

33. • ―Fatty acid composition of milk varies with the
fatty acid composition of a mother’s diet and
fat stores‖
Melanie Martin, doctoral student
UCSB Department of Anthopology

34. Diet influences the nutrient profile of breast milk
25
20
15
Tsimane
10 Cincinnati
Enfamil
5
0
Omega 6 Omega 3 Ω6:Ω3
Martin, et al. Maternal and Child Nutrition, 2012; 8(3): 404
Conversation with MJM Nutrition Resource RD 10/31/2012

35. Diet influences the nutrient profile of breast milk
1.4
1.2
1
0.8 Tsimane
0.6 Cincinnati
0.4 Enfamil
0.2
0
DHA 22:6n-3 Trans fat 16:1 Trans fat 18:1
Martin, et al. Maternal and Child Nutrition, 2012; 8(3): 404
Conversation with MJM Nutrition Resource RD 10/31/2012

36. Gut Microbiome
and Obesity
• Humans are essentially free of bacteria
at birth
• Dietary habits are considered to be one
of the main factors that contribute to gut
microbiota.
• Microbial changes in the human gut are
one of the possible causes of obesity.
http://www.futuremedicine.com/doi/pdf/10.2217/fmb.11.142

37. Intestinal microbiota during infancy
• Factors that shape
microbiota
– maternal stress
– mode of delivery
– feeding method
– introduction of solid
foods
– antibiotic exposure
Christoph Reinhardt, Christopher S. Reigstad, and Fredrik Ba¨ckhed. Journal
of Pediatric Gastroenterology and Nutrition. 48:249–256 © 2009

38. Influencing gut microbiota
Favor bacteroidetes Favor firmicutes
(leanness) (obesity)
• Maternal well being • Maternal stress
• Vaginal delivery • C-section
• Breastfeeding • Formula feeding
• Less exposure to antibiotics • More refined carbohydrates
• Greater exposure to antibiotics
• High fat diet
Christoph Reinhardt, Christopher S. Reigstad, and Fredrik Ba¨ckhed. Journal of
Pediatric Gastroenterology and Nutrition. 48:249–256 © 2009

39. How Breastfeeding may protect
against obesity
1. Breastfed babies are more accepting of a
greater variety of foods
– Breastfed babies taste the variety of foods the mother is
eating
– Mother’s diet influences the macronutrient composition
of her milk
WIC WORKS: Policy Briefs by the California WIC Association; & PHFE WIC, Sept 2011

40. How Breastfeeding may protect
against obesity
2. Breastfed babies weigh less at one year
– Breast milk has different impact on insulin and other
metabolic hormones than formula
• Use of WHO growth charts compliments the lower growth profile
for breastfed babies
WIC WORKS: Policy Briefs by the California WIC Association; & PHFE WIC, Sept 2011

41. How Breastfeeding may protect
against obesity
3. Breastfed infants tend to gain less weight
and usually are leaner than are formula-fed
infants in the second half of infancy, likely a
result of infant self-regulation of energy
intake
WIC WORKS: Policy Briefs by the California WIC Association; & PHFE WIC, Sept 2011

42. Breast milk:
How much is enough?
• Successful, exclusively
breastfeeding babies show a
three-fold variation in the
amount of milk they take per
day, and in the frequency of
breastfeeds and amount of milk
consumed during each
breastfeed
How Breastfeeding Works. Jacqueline C. Kent. Journal of Midwifery & Women’s Health. Volume 52,
Issue 6, pages 564-570. November-December 2007.

43. WIC Children fully breastfed had
lowest rate of obesity at Age 4
30
25
20
Only Breast Milk
15
Breast Milk & Formula
10
Only Formula
5
0
WIC Babies

44. Food and Agent
Reported Sign or Symptom in Infant or Effect on
Lactation
Reference No.
Environmental Aflatoxin
Aspartame
None
Caution if mother or infant has phenylketonuria
354–356
357
Agents: Effects Bromide (photographic laboratory)
Cadmium
Potential absorption and bromide transfer into milk
None reported
358
359
Chlordane None reported 360
on Breastfeeding Chocolate (theobromine)
Irritability or increased bowel activity if excess amounts
(≥16 oz/d) consumed by mother
169, 361
DDT, benzene hexachlorides, dieldrin,
None 362–370
aldrin, epatachlorepoxide
Fava beans Hemolysis in patient with G-6-PD deficiency 371
Fluorides None 372, 373
Skin rash, diarrhea, vomiting, dark urine, neurotoxicity,
Hexachlorobenzene death
374, 375
Hexachlorophene None; possible contamination of milk from nipple washing 376
Pediatrics Lead Possible neurotoxicity 377–380
Mercury, methylmercury May affect neurodevelopment 381–383
Sept. 1, 2001 Methylmethacrylate None 384
Monosodium glutamate None 385
Vol. 108 No. 3 Polychlorinated biphenyls and Lack of endurance, hypotonia, sullen, expressionless
386–390
polybrominated biphenyls facies
776-789 Silicone Esophageal dysmotility 17–22
Tetrachloroethylene cleaning fluid
Obstructive jaundice, dark urine 391
(perchloroethylene)
Vegetarian diet Signs of B12deficiency 392

45. Table 2. PBDEs in human milk
World region PBDE levels
(range) Year(s)
• Europe • North America
– Sweden 0.9-28 1996-01 – USA 4-419 2001-2004
– Finland 0.9-5.9 1994-98 – Canada 0.9-956 2001-2005
– Russia 0.5-1.7 2003-04 • Asia
– Poland 0.8-8.4 2004
– Japan 0.1-291 1999-2004
– Czech Rep. 0.3-1.4 2003
– China 1.5-17 ND
– France 1.4-11.6 2005
– Indonesia 0.5-13 2001-2003
– Italy 1.6-4.1 1998-01
– Germany 0.8-24.6 2001-03 • Oceania
– Australia 6.1-18.7 2002-2003
ACTA BIOMED 2008; 79: 172-183
Levels of PBDEs are in ng/g lipid. Table adapted from Costa and Giordano (2), where original references are indicated.

46. Temporal Trend of PBDE’s in Swedish Breast Milk
4.5
4
3.5
3
2.5
2 PBE-47
1.5 Sum of PBDE congeners
1
0.5
0
2003 IUPAC, Pure and Applied Chemistry 75, 2039-2046

47. First Foods: Introducing solids
The American Academy of Pediatrics reaffirms its recommendation of
exclusive breastfeeding for about 6 months, followed by continued
breastfeeding as complementary foods are introduced, with
continuation of breastfeeding for 1 year or longer as mutually desired
by mother and infant.
Pediatrics Vol. 129 No. 3 March 1, 2012
pp. e827 -e841

48. Which complementary foods first?
• Solid foods or supplemental foods
were not routinely offered to babies
less than one year of age before
1920.

49. The role of allergens:
• Some have advised not introducing dairy
products, eggs, wheat, nuts, and fish before the end of the first year of
life, and then introducing only a limited number of foods with a low
allergenicity, However, there are no well-designed studies to
demonstrate the benefit of such advice.
Pediatrics Vol. 106 No. Supplement 4 November 1, 2000 pp. 1285
• Controlled studies demonstrating that restrictive diets after 6 months of
age have an allergy-preventing effect have not been published (Halken
and Host, 2001), and for this reason no such restrictions were advised by
an international group of experts (WHO/IAACI, 2000).

50. Arguments for
commercial baby food
Standard formulation
Sterility
Lack of additives
“There is no nutritional difference
between commercial and
homemade baby food”
Yeung, et al
HJ Heinz Co.
CMA Journal/January 15, 1982. Vol 126 pg 113

51. Foods to Add How Much to Feed
•Birth to 4 months Breast milk or iron-fortified infant Feed on demand as long as
formula baby choose
•4 to 6 months Baby cereal—rice first, then 1–2 tablespoons
oatmeal or barley
•6 to 8 months •Vegetables— cooked, strained, •2–3 tablespoons
pureed, or mashed
•Fruits—strained or mashed
•Fruit juice—using a small cup •2–3 tablespoons
•Meats—cooked and strained or
chopped •3 ounces
•Dry beans—cooked and
mashed •1-2 tablespoons
•1–2 tablespoons
© 2009 Ohio State Univ Extension Updated by Julie Shertzer, Program Specialist, Human Nutrition,
July 2008. Original author: Lisa Pescara, Extension Educator, Family and Consumer Sciences.

52. Percentage of children consuming infant cereals
Feeding Infants and Toddlers Study (FITS) 2002 2008.
ADAJ 2010

53. Infant Cereal
Nutrition Facts
Serv. Size 1/4 cup (16g) Servings Per Container 14
Amount Per Serving
Calories 60 • Ingredients
RICE FLOUR, TRI- AND DICALCIUM
Total Fat: 0.5g PHOSPHATE, SOYBEAN OIL, SOY
Trans Fat: 0g LECITHIN, MIXED TOCOPHEROLS (TO
PRESERVE
Sodium: 0mg FRESHNESS), ELECTROLYTIC
Potassium: 15mg IRON, ZINC SULFATE, ALPHA
TOCOPHERYL ACETATE (VITAMIN E)
Total Carbohydrates: 13g NIACINAMIDE (A B
Dietary Fiber: 0g VITAMIN), PYRIDOXINE
HYDROCHLORIDE (VITAMIN
Sugar: 1g B6), RIBOFLAVIN (VITAMIN
Protein: 1g B2), THIAMIN MONONITRATE (VITAMIN
B1), FOLIC ACID (A B
VITAMIN), VITAMIN B12
(CYANOCOBALAMIN)

54. Are starch fillers used in baby food?
Starches are easily digested carbohydrates, which
may be present in baby foods in the form of flour
(corn, wheat, rice), tapioca or rice
…starches provide an important source of calories for
growing infants. Food starches also help to moderate
flavor and control texture.
…The Food and Drug Administration has determined
that food starches are safe and suitable for use in
baby foods

55. David Ludwig, director of the
Optimal Weight for Life program
at Children's Hospital
Boston, says "there's no
Dr Alan Greene’s Campaign to scientific basis for this
Eliminate Rice Flour Cereal
recommendation. That's a myth.―
Liz Szabo,
USA TODAY
11/30/2010

56. Survey of Pediatricians
• What do you recommend for baby’s first food?
White Rice
Whole Grain
A vegetable
% of respondents
A fruit
Egg Yolk
Meat
Other
0 10 20 30 40
Medscape Pediatrics Commentary: Starting Solid Foods: Are We Doing It Right? July 6, 2011/ 2012

57. Percentage of children consuming complimentary foods by age
Feeding Infants and Toddlers Study (FITS), ADAJ 2010

58. Considering first foods
Infant food GI GL
Rice cereal (US) 95 6
Sweet potato (Australia) 66 17
Oat porridge (Sweden) 55 15
Taro (Pacific Islanders) 55 4
Hominy (Pima Indian) 40 12
Casava (Kenya) 46 12
Lentils (India) 29 5
Pinto beans (Mexico) 14 4
Fermented Maize (Ghana) 12 7
Hummus (Turkey) 6 0

59. Unconventional first foods
Rethinking First Foods
Avocado
Pureed meat based gruels, soups
Pureed chicken, beef, pork, lamb
Mashed, pureed fish
Eggs, egg yolk
Yogurt, Greek yogurt
Tofu
Mashed, beans, lentils
Mashed cooked vegetables

60. What else are babies being fed?

61. The impact of processing
1.2 Bulger
wheat
1
Wh Wheat
0.8 ckd cereal
0.6 Farina ckd
0.4 cereal
0.2 Infant rice
cereal
0
Fiber (gm) per 25 Infant
kcal whole
wheat

62. Finger foods

63. Considering finger foods
Towards whole foods: balance is key
Infant food GI GI
Scone 92 Cooked peas 48
Pretzels 83 Chicken nuggets (Aust) 44
Waffle 76 Pasta (al dente) 43
Vanilla wafers 77 Banana (slightly under ripe) 42
French fries 75 Apple 40
Cheerios cereal 74 Pinto beans 39
Graham crackers 74 Fish fingers 38
Bagel 72 Yam 37
Oatmeal 69 Pear 33
Arrowroot biscuit 63 Yogurt – (Aust/sweetened) 27

64. Consumption patterns of infants and toddlers
consuming foods at least once a day
70
60
50
40
30 6-8.9 mo
20 9-11.9 mo
10
0 12-14.9 mo
15-17.9 mo
18-24 mo
Feeding Infants and Toddlers Study (FITS) ADAJ 2010

65. Algorithm for introducing
new foods
KEY New Different
NF NF
Food New Food GIVE UP ?
NF N NF N NF N NF N 10 - 12x Y N
Y Y Y Y
GIVE UP
Repeat Repeat Repeat Repeat Repeat
successfully successfully successfully successfully successfully
3-5 times 3-5 times 3-5 times 3-5 times 3-5 times
before next before next before next before next before next
new food new food new food new food new food
NF NF NF NF NF

66. First Foods:
Supporting better metabolic health for all babies
 Effective and timely
support for breastfeeding
 Nutrition support for mom
post partum
 Encourage first foods to be
prepared from whole foods
 Caution parents re:
commercial baby foods
 Encourage balance for all
meals and
snacks, especially for
those babies w/ higher
metabolic risk

67. First Foods
Thank you
Bonnie Y. Modugno, MS, RD, CLE
www.muchmorethanfood.com #MMTF

68. Trends in Food Consumption of Infants (6-8.9 mos)
Percentage of infants consuming at least once a day
90
80
70
60
50
2002
40
30 2008
20
10
0
Any fruit/juice 100% juice baby fruit real fruit
Feeding Infants and Toddlers Study (FITS) 2002 2008.
ADAJ 2010