The Baby's First Bites RCT: Evaluating a Vegetable-Exposure and a Sensitive-Feeding Intervention in Terms of Child Health Outcomes and Maternal Feeding Behavior During Toddlerhood.

BACKGROUND: Parenting interventions during the first years of life on what and/or how to feed infants during complementary feeding can promote healthy eating habits. OBJECTIVES: An intervention promoting repeated exposure to a variety of vegetables [repeated vegetable exposure (RVE); what] and an intervention promoting responding sensitively to child signals during mealtime [video-feedback intervention to promote positive parenting-feeding infants (VIPP-FI); how] were compared, separately and combined (COMBI), with an attention control condition (AC). Primary outcomes were vegetable consumption and self-regulation of energy intake; secondary outcomes were child anthropometrics and maternal feeding practices (sensitive feeding, pressure to eat). METHODS: Our 4-arm randomized controlled trial included 246 first-time Dutch mothers and their infants. Interventions started when infants were 4-6 mo old and ended at age 16 mo. The present study evaluated effects at 18 (t18) and 24 (t24) mo of age. Vegetable acceptance was assessed using three 24-h dietary recalls, self-regulation of energy intake by an eating-in-the-absence-of-hunger experiment and mother-report, and maternal feeding behavior by observation and mother-report. RESULTS: Linear mixed model and ANOVA analyses revealed no follow-up group differences regarding child vegetable intake or self-regulatory behavior. The proportion of children with overweight was significantly lower in the COMBI group, compared with the VIPP-FI group at t18 (2% compared with 16%), and with the AC group at t24 (7% compared with 20%), although this finding needs to be interpreted cautiously due to the small number of infants with overweight and nonsignificant effects on the continuous BMI z-score measure (P values: 0.29-0.82). Finally, more sensitive feeding behavior and less pressure to eat was found in the VIPP-FI and COMBI groups, compared with the RVE and AC groups, mostly at t18 (significant effect sizes: d = 0.23-0.64). CONCLUSIONS: Interventions were not effective in increasing vegetable intake or self-regulation of energy intake. Future research might usefully focus on risk groups such as families who already experience problems around feeding.This trial is registered at clinicaltrials.gov as NCT03348176.

Factors Associated With Food Texture Acceptance in 4- to 36-Month-Old French Children: Findings From a Survey Study.

Food texture plays an important role in food acceptance by young children, especially during the complementary feeding period. The factors driving infant acceptance of a variety of food textures are not well-known. This study summarizes maternal reports of children's ability to eat foods of different textures (here: acceptance) and associated factors. Mothers of 4- to 36-month-old children (n = 2,999) answered an online survey listing 188 food-texture combinations representing three texture levels: purees (T1), soft small pieces (T2), hard/large pieces, and double textures (T3). For each offered combination, they reported whether it was spat out or eaten with or without difficulty by the child. A global food texture acceptance score (TextAcc) was calculated for each child as an indicator of their ability to eat the offered textured foods. The results were computed by age class from 4-5 to 30-36 months. The ability to eat foods without difficulty increased with age and was ranked as follows: T1> T2 > T3 at all ages. TextAcc was positively associated with exposure to T2 (in the age classes between 6 and 18 months old) and T3 (6-29 months) and negatively associated with exposure to T1 (9-36 months). Children's developmental characteristics, as well as maternal feeding practices and feelings with regard to the introduction of solids, were associated with texture acceptance either directly or indirectly by modulating exposure. Children's ability to eat with their fingers, gagging frequency, and to a lesser extent, dentition as well as maternal feelings with regard to the introduction of solids were the major factors associated with acceptance. This survey provides a detailed description of the development of food texture acceptance over the complementary feeding period, confirms the importance of exposure to a variety of textures and identifies a number of additional person-related associated factors.

A systematic review of practices to promote vegetable acceptance in the first three years of life.

BACKGROUND: Although most children do not meet vegetable intake recommendations no clear universal guidelines exist on the best method of introducing and promoting vegetables in infants. OBJECTIVE: To identify strategies to promote vegetable acceptance in children from the start of complementary feeding until 3 years of age. DESIGN: A comprehensive search strategy was performed using the databases Scopus and Pubmed. Articles published before March 2018 measuring vegetable intake and/or liking were included. RESULTS: 46 papers, 25 experimental (intervention) studies, and 21 observational studies were included. Intervention studies revealed that repeated exposure increased acceptance of the target vegetable, whereas exposure to variety was found to be particularly effective in increasing acceptance of a new vegetable. Starting complementary feeding with vegetables increased vegetable acceptance, whereas starting with fruits did not. Visual exposure to an unfamiliar vegetable increased the acceptance of that vegetable even without consuming it, while visual exposure to a familiar vegetable did not. A stepwise introduction of vegetables resulted in better initial acceptance of vegetables than introducing vegetables directly. Observational studies showed that vegetable consumption was associated with frequency of exposure, exposure to variety, and modelling. A majority of studies found a positive association between breastfeeding and vegetable acceptance, but only two out of seven studies found an association between age of vegetable introduction and their acceptance. CONCLUSIONS: Based on the papers reviewed, we conclude that introducing vegetables at the beginning of complementary feeding, giving a different type of vegetable every day and ensuring repeated exposure to the same vegetable following an interval of a few days are the most promising strategies to promote vegetable intake in children starting complementary feeding until they are 3 years of age.

The eyes have it: Infant gaze as an indicator of hunger and satiation.

Infant gaze serves as a measure of attention to food cues in adults and children and may play a role in signalling infant hunger and satiation. Maternal responsiveness to infant satiation cues, including gaze, supports healthy appetite development and may reduce obesity risk. However, mothers often experience difficulty in interpreting feeding cues, and there have been few attempts to study cues systematically. This study aimed to develop a reliable coding scheme for categorising and tracking infant gaze behaviours during complementary feeding (CF). Twenty infants aged between six and eighteen months were filmed during typical meals on two occasions at home. The Infant Gaze at Mealtime (IGM) coding scheme was devised from the analysis of a sample of videos, a piloting and testing process, and the feeding cues and developmental psychology literature. Inter and intra-rater reliability tests of the scheme with 20% of the study videos revealed high levels of reliability. When applied to the full sample of 225 video clips, the IGM coding scheme revealed a significant decrease over time in the frequency of infants gazing at food and a significant increase in exploratory gaze behaviour within a meal. These changes were consistent across main and dessert courses, suggesting they may be indicative of changes in infant feeding state. The results suggest that infant gaze may offer a means of identifying infant hunger and satiation and, as an easily observed behaviour, an effective tool for mothers and professionals for promoting responsive feeding.

Sensory characteristics of human milk: Association between mothers' diet and milk for bitter taste.

It is unknown how consumption of bitter foods and beverages in the maternal diet influences sensory properties of fresh human milk. The aims of this study were (1) to determine the sensory characteristics of fresh human fore and hind milk, (2) to establish relationships between sensory properties and composition of fresh human milk, and (3) to assess the relationship between bitterness of the maternal diet and human milk. Twenty-two lactating mothers generated sensory terms to describe perception of their milk and received training on sensory attribute intensity rating. Mothers kept a 24-h food diary followed by a sensory self-assessment of their fore and hind milks. The odor of human fresh milk was described as neutral, creamy, and sweet, taste as sweet and bitter, and mouthfeel as thin, watery, smooth, and fatty. Sweetness was equivalent to 1.53 g of sucrose/100 mL and was not significantly different between fore and hind milk. Fore milk was significantly less creamy, less fatty, thinner, more watery, and lower in vanilla flavor intensity than hind milk. Carbohydrate content of human milk was positively correlated with sweetness and glutamic acid content with umami. The bitterness of the diet consumed 24 h before lactation was moderately positively correlated with bitterness of fore milk, but not hind milk. We conclude that the consumption of bitter foods may influence the bitterness of human fore milk, which may be another way for breastfed children to learn to accept bitter vegetables and, hence, develop healthier food preferences.

Short Communication: Differences in Levels of Free Amino Acids and Total Protein in Human Foremilk and Hindmilk.

Free amino acids (FAAs) in human milk are indicated to have specific functional roles in infant development. Studies have shown differences between human milk that is expressed at the beginning of a feed (i.e., foremilk) and the remainder of the milk expressed (i.e., hindmilk). For example, it is well established that human hindmilk is richer in fat and energy than foremilk. Hence, exclusively feeding hindmilk is used to enhance weight gain of preterm, low birthweight infants. Whether FAAs occur differently between foremilk and hindmilk has never been reported, but given their bioactive capacities, this is relevant to consider especially in situations where hindmilk is fed exclusively. Therefore, this study analyzed and compared the FAA and total protein content in human foremilk and hindmilk samples donated by 30 healthy lactating women. The total protein content was found to be significantly higher in hindmilk (p < 0.001), whereas foremilk contained a significantly higher total content of FAAs (p = 0.015). With regards to individual FAAs, foremilk contained significantly higher levels of phenylalanine (p = 0.009), threonine (p = 0.003), valine (p = 0.018), alanine (p = 0.004), glutamine (p < 0.001), and serine (p = 0.012) than hindmilk. Although statistical significance was reached, effect size analysis of the milk fraction on FAA levels in milk revealed that the observed differences were only small. To what extent these differences are of physiological importance for infant development remains to be examined in future research.

Patterns and predictors of food texture introduction in French children aged 4-36 months.

The aims of this study were to describe which and when food textures are offered to children between 4 and 36 months in France and to identify the associated factors. An online cross-sectional survey was designed, including questions about 188 food texture combinations representing three texture levels: purées (T1), soft small pieces (T2) and hard/large pieces and double textures (T3). Mothers indicated which combinations they already offered to their child. A food texture exposure score (TextExp) was calculated for all of the texture levels combined and for each texture level separately. Associations between TextExp and maternal and child characteristics and feeding practices were explored by multiple linear regressions, per age class. Answers from 2999 mothers living in France, mostly educated and primiparous, were analysed. Over the first year, children were mainly exposed to purées. Soft and small pieces were slowly introduced between 6 and 22 months, whereas hard/large pieces were mainly introduced from 13 months onwards. TextExp was positively associated with children's number of teeth and ability to eat alone with their finger or a fork. For almost all age classes, TextExp was higher in children introduced to complementary feeding earlier, lower for children who were offered only commercial baby foods and higher for those who were offered only home-made/non-specific foods during the second year. Our study shows that until 12 months of age the majority of French children were exposed to pieces to a small extent. It provides new insights to further understand the development of texture acceptance during a key period for the development of eating habits.

How Infants and Young Children Learn About Food: A Systematic Review.

Early childhood is a critical time for establishing food preferences and dietary habits. In order for appropriate advice to be available to parents and healthcare professionals it is essential for researchers to understand the ways in which children learn about foods. This review summarizes the literature relating to the role played by known developmental learning processes in the establishment of early eating behavior, food preferences and general knowledge about food, and identifies gaps in our knowledge that remain to be explored. A systematic literature search identified 48 papers exploring how young children learn about food from the start of complementary feeding to 36 months of age. The majority of the papers focus on evaluative components of children's learning about food, such as their food preferences, liking and acceptance. A smaller number of papers focus on other aspects of what and how children learn about food, such as a food's origins or appropriate eating contexts. The review identified papers relating to four developmental learning processes: (1) Familiarization to a food through repeated exposure to its taste, texture or appearance. This was found to be an effective technique for learning about foods, especially for children at the younger end of our age range. (2) Observational learning of food choice. Imitation of others' eating behavior was also found to play an important role in the first years of life. (3) Associative learning through flavor-nutrient and flavor-flavor learning (FFL). Although the subject of much investigation, conditioning techniques were not found to play a major role in shaping the food preferences of infants in the post-weaning and toddler periods. (4) Categorization of foods. The direct effects of the ability to categorize foods have been little studied in this age group. However, the literature suggests that what infants are willing to consume depends on their ability to recognize items on their plate as familiar exemplars of that food type.

Exposure to texture of foods for 8-month-old infants: Does the size of the pieces matter?

This study examined the effect of meals varying in amount, size, and hardness of food pieces on the development of the chewing capabilities of 8-month-old infants. The study also examined changes in shivering, gagging, coughing, choking, and their ability to eat from a spoon. In an in-home setting two groups were given commercially available infant meals and fruits, purees with either less, smaller and softer or more, larger and harder pieces. Both groups were given these foods for 4 weeks and were monitored several times during this period. After the 4-week exposure period infants in both groups were given the same five test foods. Structured questionnaires with questions on eating behavior and the child's development were conducted 6 times in the 4 to 12-month period and video analyses of feedings were conducted 4 times between 8 and 9 months. After the 4-week exposure period, the group that had been exposed to the foods with more, larger and harder pieces showed a significantly higher rating for chewing a piece of carrot and potato for the first time, but not for a piece of banana nor for mashed foods. Shivering, gagging, coughing, choking, and ability to eat from a spoon were not different between the two groups. These results contribute to the insight that exposure to texture is important for young children to learn how to handle texture. PRACTICAL APPLICATIONS: (a) The study shows the feasibility of testing the effects of texture interventions on chewing capability and oral responses such as gagging, coughing, and choking in infants. (b) The study contributes to the insight that exposure to food texture to learn how to handle texture is important for infants and showed that exposing children to a higher amount of larger pieces improves their chewing capability for a piece of carrot and potato, at least immediately after the intervention.

Communicating hunger and satiation in the first 2 years of life: a systematic review.

Responsive feeding has been identified as important in preventing overconsumption by infants. However, this is predicated on an assumption that parents recognise and respond to infant feeding cues. Despite this, relatively little is understood about how infants engage parental feeding responses. Therefore, the aim of this systematic review was to identify what is known about infant communication of hunger and satiation and what issues impact on the expression and perception of these states. A search of Medline, CINAHL, Web of Science, PsycINFO, Science Direct and Maternal and Infant care produced 27 papers. Eligibility criteria included peer reviewed qualitative and/or quantitative publications on feeding behaviours, hunger, and satiation/satiety cues of typically developing children in the first 2 years of life. Papers published between 1966 and 2013 were included in the review. The review revealed that feeding cues and behaviours are shaped by numerous issues, such as infants' physical attributes, individual psychological factors and environmental factors. Meanwhile, infant characteristics, external cues and mothers' own characteristics affect how feeding cues are perceived. The existing literature provides insights into many aspects of hunger and satiation in infancy; however, there are significant gaps in our knowledge. There is a lack of validated tools for measuring hunger and satiation, a need to understand how different infant characteristics impact on feeding behaviour and a need to extricate the respective contributions of infant and maternal characteristics to perceptions of hunger and satiation. Further research is also recommended to differentiate between feeding driven by liking and that driven by hunger.

Development of healthy eating habits early in life. Review of recent evidence and selected guidelines.

Encouraging healthy eating habit development early in life is a way to prevent the onset of diet-related diseases. This review focuses on the period ranging from the beginning of complementary feeding until the age of 3 years. Its first objective was to review relevant themes in the most recent literature on the development of healthy eating habits in this period. Its second objective was to evaluate to what extent international and national feeding guidelines cover these themes. Analysed guidelines included WHO, European Network for Public Health Nutrition, US and two European national guidelines (UK and France). They were evaluated using a 4-pt scale and compared. Well-covered themes in current literature include the influence of exposure on later acceptance, the role of variety and parental styles. Themes that occur more rarely include the role of texture, the development of autonomy, the optimization of variety, acceptable consumption levels of sweet and salty foods, and the way to cope with food refusal. Guidelines in general cover most of the themes, but some of the national guidelines are incomplete. Finally, guidelines should give more practical tips to parents, especially to help them establish a responsive feeding behaviour.

Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake.

BACKGROUND & AIMS: Many older adults and patients do not achieve sufficient nutritional intake to support their minimal needs and are at risk of, or are suffering from, (protein-energy) malnutrition. Better understanding of current treatment options and factors determining nutritional intake, may help design new strategies to solve this multifactorial problem. METHODS: Medline, Science Citation Index, ScienceDirect and Google databases (until December 2008) were searched with the keywords malnutrition, elderly, older adults, food intake, energy density, variety, taste, satiety, and appetite. RESULTS: 37 Factors affecting nutritional intake were identified and divided in three categories; those related to the environment, the person, and the food. For older adults in nursing homes, encouragement by carers and an appropriate ambiance seem particularly important. Meal fortification, offering variety, providing frequent small meals, snacks and particularly Oral Nutritional Supplements (ONS) between meals are other possibilities for this group. Product factors that stimulate intake include palatability, high energy density, low volume, and liquid format. CONCLUSION: The current review gives a comprehensive overview of factors affecting nutritional intake and may help carers to improve nutritional intake in their patients. The product factors identified here suggest that especially small volume, energy and nutrient dense ONS can be effective to improve nutritional intake.

The role of alpha-amylase in the perception of oral texture and flavour in custards.

The role of salivary alpha-amylase in odour, flavour, and oral texture sensations was investigated in two studies in which the activity of salivary amylase present in the mouth of human subjects was either increased by presenting custards with added alpha-amylase or decreased by presenting custards with added acarbose, an amylase inhibitor. For starch-based vanilla custard desserts, amylase resulted in increased melting and decreased thickness sensations, whereas acarbose had the opposite effect, i.e., decreased melting and increased thickness. Other affected attributes included creamy mouth feel, creamy after feel, and fatty after feel. Creaminess, which is considered to be a highly desirable food quality, decreased by as much as 25% with added amylase and increased by as much as 59% with added acarbose. Neither additional amylase nor acarbose affected sensations for a nonstarch-based carboxy methylcellulose (CMC) vanilla custard dessert. This indicates that the effects of amylase on viscosity-related sensations of starch-based custards, such as perceived melting and thickness, are caused by amylase-induced breakdown of starch. Partial Least Square (PLS) analysis indicated that the effects of amylase and acarbose on perceived creaminess are not only driven by their effects on perceived melting and thickness, but also by their effects on perceived flavour.

Sensory-specific satiety in obese and normal-weight women.

BACKGROUND: Sensory-specific satiety has been found to play an important role in food choice and meal termination, and it might be a factor contributing to obesity. OBJECTIVE: We hypothesized that obese and normal-weight people have different sensitivities to sensory-specific satiety for high-fat foods. DESIGN: Sensory-specific satiety was measured in 21 obese [x body mass index (BMI; in kg/m(2)): 33.1] and 23 normal-weight (BMI: 22.8) women who were matched for restrained eating behavior, physical activity, age, and smoking behavior. Food intake, appetite ratings, and liking scores before and after an ad libitum lunch were measured. Products differed in fat content and taste (ie, low-fat sweet, low-fat savory, high-fat sweet, and high-fat savory), and the subjects tested all 4 products. In the first study, sandwiches were tested; in the second study, snacks were tested. RESULTS: Sensory-specific satiety for all products was observed in both subject groups. No significant differences were observed between the obese and normal-weight subjects in either sensory-specific satiety or food intake for any of the products or product categories tested. Taste (sweet or savory) had a significantly (P < 0.05) stronger effect on sensory-specific satiety than did fat content. Appetite ratings strongly decreased after lunch, and appetite for a meal or snack after lunch was significantly higher in obese than in normal-weight subjects, whereas scores before lunch did not differ significantly. CONCLUSIONS: Obese and normal-weight people do not differ in their sensitivity to sensory-specific satiety, and factors other than fat content have the greatest effect on sensory-specific satiety.

The effect of oral and product temperature on the perception of flavor and texture attributes of semi-solids.

This study examined the effect of oral and product temperature on the perception of texture and flavor attributes. A trained panel assessed 21 texture and flavor attributes in one high-fat and one low-fat product of two semi-solids: custard dessert and mayonnaise. The products were evaluated at 10, 22 or 35 degrees C in combination with oral temperatures of 27, 35 and 43 degrees C. Results showed that modulation of product and oral temperature had significant effects on a number of attributes. Flavor intensities, melting mouth feel, and fat after feel increased, while subjective thickness decreased with increasing product temperature. Neither product- nor oral temperature had an effect on over-all creaminess. Oral temperature affected a number of mouth feel attributes: melting, heterogeneous and smooth. Furthermore, large differences existed in ratings between the high- and low-fat products of custard and mayonnaise, and they were more prominent in mayonnaise. We conclude that the effect of oral temperature on the perception of sensory attributes in semi-solids was small, but present, while the product temperatures influenced the ratings greatly.

A comparison of the effects of added saliva, alpha-amylase and water on texture perception in semisolids.

The effect of adding saliva or a saliva-related fluid (alpha-amylase solution and water) to custard prior to ingestion on the sensory ratings of odour, flavour and lip-tooth-, mouth- and after-feel sensations was investigated. Saliva had previously been collected from the subjects and each subject received his/her own saliva. Sixteen subjects from a trained panel assessed 17 flavour and texture attributes of soy- and milk-based custard desserts. Immediately prior to administration, two different volumes (0.25 and 0.5 ml) of three different saliva-related fluids (saliva, alpha-amylase solution and water) were added to the product. The added volumes represented an approximately 33% and 66% increase of the volume of saliva present in the mouth during ingestion. The results show that addition of a fluid affected the mouth-feel attributes of melting, thickness and creamy. Melting was the only attribute on which the type of fluid had an effect, where saliva elicited a stronger melting effect than the alpha-amylase solution and water. The volume of the added fluid affected a number of attributes (thick and creamy mouth-feel and fatty after-feel). It can be concluded that in general the sensory attributes of semisolids were relatively stable. Mouth- and after-feel sensations were partly affected, while odour, flavour and lip-tooth-feel sensations were not affected by an increase in volume of saliva or other saliva-related fluid during ingestion.