Fiammetta Vecchi

Introduction of Complementary Feeding in 5 European Countries

Objectives: Little is known about the practice of introducing complementary feeding across Europe. We aim at describing times of solid introduction in healthy infants in 5 European countries. Materials and Methods: Between October 2002 and June 2004, 1678 healthy term infants were either breast-fed (BF) for at least 4 months (n = 588) or study formula–fed (FF) (n = 1090) with different protein contents. Three-day-weighed food protocols were obtained at ages 1, 2, 3, 4, 5, 6, 7, 8, 9, and 12 completed months. Results: Solids were introduced earlier in FF infants (median 19 weeks, interquartile range 17–21) than BF infants (median 21 weeks, interquartile range 19–24). Some 37.2% of FF infants and 17.2% of BF infants received solid foods at 4 completed months, which is earlier than recommended in Europe. Solids had been introduced at 7 completed months in 99.3% of FF infants and 97.7% of BF infants, respectively. Belgium had the highest percentage of solids feeding in FF infants at 3 (15.8%) and 4 (55.6%) completed months, and in BF infants at 4 (43%) and 5 (84.8%) completed months. Multiple regression showed low maternal age, low education level, and maternal smoking to predictors an early introduction of solids at 3 and 4 completed months. Conclusions: Complementary feeding is introduced earlier than recommended in a sizeable number of infants, particularly among FF infants. Country- and population-specific approaches to adequately inform parents should be explored.

Breast milk composition and infant nutrient intakes during the first 12 months of life

Background/Objectives:The objective of this study was to quantify human milk supply and intake of breastfed infants up to age 12 months. In addition, human milk composition was quantified per energetic macronutrient and fatty-acid composition in a subsample of lactating mothers.Subjects/Methods:One hundred and seventy-four Italian breastfed children were followed using test-weighing and 3-day food protocols from birth to age 12 months. From a subsample of 30 mothers breast milk samples were collected at child ages one (T1), two (T2), three (T3) and six (T6) months, and were analyzed for the amount of protein, digestible carbohydrates, total lipids and fatty-acid composition.Results:One hundred and forty-two (82%) filled in at least one 3-day food protocol within the first 12 months of life and complied with test-weighing of all milk feeds. The number of valid food protocols declined from 126 infants at 1 month to 77 at 12 months of age. Only galactose, non-protein nitrogen and protein decreased significantly from age 1 to age 6 months of lactation. Maternal body mass index and age affected fatty-acid levels in human milk. Median human milk intake decreased from 625 ml at T1, over 724 ml at T3 to 477 ml/day at T6. Average energy and %energy from protein intake per day increased from 419 kcal (s.d. 99) and 8.4% (1.0) at T1, respectively, to 860 kcal (145) and 16.1% (2.6) at T12.Conclusions:These data provide a reference range of nutrient intakes in breastfed infants and may provide guidance for defining optimal nutrient intakes for infants that cannot be fully breastfed.

Methodology for Longitudinal Assessment of Nutrient Intake and Dietary Habits in Early Childhood in a Transnational Multicenter Study

Objectives: The aim of this study was to describe developed methods for repeated longitudinal assessment of feeding habits and nutrient intakes of children in a multicenter trial in different European countries and to assess feasibility. Patients and Methods: Nutrient intake and dietary habits of formula-fed and breast-fed infants were assessed in 5 European countries (Belgium, Germany, Italy, Poland, and Spain). Prospective age-adapted 3-day weighed food records were used from birth to 2 years of age (1, 2, 3, 4, 5, 6, 7, 8, 9, 12, 18, and 24 months). Standard operating procedures were developed to check each days food record for quality. Dietitians were trained by using standardized food records. Data entry and nutrient analyses were performed with a dedicated software developed for this project. Results: Of 1368 study participants, at least one 3-day food record was available; of 25,367 1-day food records, data on quality could be evaluated. Overall, between 81% and 97% (depending on the country) of the food records had been completed with high accuracy. The implementation of solid foods and regular family foods decreased the recording quality significantly during the 2-year time course (P < 0.001). The standardized training shows coefficients of variation up to a maximum of about 41%, indicating differences in data entry. Conclusions: The experiences gathered indicate that collecting dietary and behavioral data in a large number of infants from different cultures is a challenging but feasible task in which permanent supervision and training is vital. However, we conclude that the established methodology is suitable to obtain valuable results on current infant nutrition practice in Europe.

Intake of energy providing liquids during the first year of life in five European countries

BACKGROUND Intake of energy providing liquids (EPL) other than breast milk or formula to infants is discouraged because it may displace milk intake. Data on actual practice is lacking. AIM To describe the current practice of EPL supply to infants in five European countries. METHOD Breastfed (BF) infants and infants fed using two formulae (FF) with different protein content were recruited from October 2002 to June 2004. Three-day weighed food protocols of 1368 infants were obtained monthly at the ages of 1 to 9 and again at 12 completed months. RESULTS At the age of 4 months, 13% of BF and 43% of FF infants received EPL. FF infants started EPL earlier (median 17 weeks) than BF infants (median 30 weeks). EPL intake was associated with a lower intake of formula milk and solids (kcal/d) in the first year of life. Multiple regression analysis showed significant differences in EPL introduction between the individual countries. CONCLUSION In contrast to recommendations, EPL is frequently given during the first months of life to breastfed and particularly to formula fed infants. Infants given EPL showed lower intakes of infant formula and solids. Caregivers should receive better counselling on appropriate infant feeding.

Introduction of potentially allergenic foods in the infant's diet during the first year of life in five European countries.

Background: Little information is available on infants’ age at first introduction of potentially allergenic foods as part of complementary feeding. We aimed to analyze age at the introduction of potentially allergenic foods in healthy term infants relative to recommendations in 5 European countries. Method: Recruitment was conducted from October 2002 to June 2004. A total of 1,678 infants [588 breastfed (BF) and 1,090 formula-fed (FF) infants] were studied. In 1,368 infants, at least one 3-day weighed food diary at the age of 1–9 and 12 completed months was available. Results: Six percent of BF infants and 13% of FF infants consumed some potentially allergenic food already prior to the recommended minimum age of 4 months, and 4% of BF infants and 11% of FF infants had already received gluten. There were significant differences in the timing of the introduction of potentially allergenic foods between the countries at the age of 4–6 months (p < 0.001). Conclusion: The time of first introduction of potentially allergenic foods in infants differed significantly between countries, and they were introduced much earlier than recommended in some countries. FF infants received potentially allergenic foods earlier than BF infants. Better information and counseling of parents is desirable.

Protein intakes and their nutritional sources during the first 2 years of life: secondary data evaluation from the European Childhood Obesity Project

Background/Objectives:High protein intake in infancy affects future obesity risk and other health outcomes. We aim to describe total protein intake and its sources in a birth cohort in five European countries over the first 2 years of life.Subjects/Methods:A total of 746 formula-fed infants were included. Three-day weighed dietary records at 6, 7, 8, 9, 12, 18 and 24 months of age were used. Kruskal–Wallis, ANOVA and Friedman’s tests were used to assess possible differences in nutritional intake among countries and over time.Results:Dairy products were the main components of the infants’ diets. Cow’s milk was rarely introduced before 12 months of age, whereas infants’ formula was the main contributor of protein intake. Food choices and protein intake differed among countries (P<0.001). Protein intake often exceeded European recommendations from 9 months onwards, partly because of the substitution of dairy protein (mainly infant formula) by meat protein. Two nutritional patterns were identified that were characterised by differences in energy, fat, protein and animal protein intake. Finally, food consumption was not always in line with protein intakes, and thus infants from some countries showed high consumption of specific food groups but relatively low protein intakes.Conclusions:During weaning, over-limited substitution of dairy products with other sources (especially meat) resulted in relatively high protein intakes in formula-fed infants. Differences in preferences of specific protein sources from complementary foods existed among European countries. Great opportunities in improving early nutrition were revealed, although cultural and geographical differences should always be considered.

Micronutrient intake adequacy in children from birth to 8 years. Data from the Childhood Obesity Project

BACKGROUND In European countries, suboptimal intake has been reported for several micronutrients (as calcium, iron, zinc, vitamin B12, D and folate) in both adulthood and childhood. No studies to date have prospectively compiled nutrient intake from healthy children in different European countries using the same methodology. AIM To describe the adequacy of micronutrient intake during the first eight years of life in children from 5 European countries. METHODS Prospective observational trial analyzing data from the EU Childhood Obesity Project. Infants were enrolled within the first two months of life and were followed regularly to age 8 years. Dietary intake was collected periodically with 3-day food records. Nutrient intake adequacy was estimated for calcium, phosphorus, iron, zinc, magnesium, iodine, folate and vitamins B12, A and D, following the American Institute of Medicine (IOM) guidelines at group (prevalence of adequacy >80%) and individual (high probability of adequate intake >80% of the children) level; the assessment was based on the Estimated Average Requirements of nutrients of the FAO, WHO and United Nations University (FAO/WHO/UNU) or the IOM if FAO/WHO/UNU data were not available. RESULTS Intake data were available for a decreasing number of children, from 904 at 3 months to 396 at 8 years. Iron, iodine, folate and vitamin D were inadequately consumed when assessing adequacy at group level; at individual-level less than 80% of the children showed high probability of adequate intake for iron, iodine, folate and zinc at all ages, and calcium from 12 months onwards. CONCLUSIONS Accurate dietary intake and adequacy assessment methodology in this prospective cohort of European children found iron, calcium, vitamin D, folate, iodine and zinc to be inadequately consumed in childhood, as described previously by epidemiologic studies. Further studies are needed to elucidate health consequences of these deficiencies. CHOP trial was registered at clinicaltrials.gov as NCT00338689.