Maternal feeding practices during the first year and their impact on infants’ acceptance of complementary food

Highlights

• The impact of complementary feeding practices on food acceptance is described.

• During the weaning period, 90% of infants’ reactions to new foods are positive.

• New food acceptance increases with the number of foods introduced when weaning begins.

• The earlier vegetables are introduced, the higher the acceptance of new vegetables is.

Abstract

The introduction of weaning foods is a major transition in the development of infants’ eating behavior. Previous studies showed that greater variety at the beginning of the weaning period can later influence an infant’s acceptance of new foods. The aim of the present study was to describe maternal feeding practices in the first year (breastfeeding duration, age at the initiation of weaning, variety of new foods introduced) and to study whether they impacted infants’ later acceptance of new foods in a longitudinal survey of French children’s eating behavior.

Mothers (n = 203) were asked to record each food offered to their infants from the beginning of the weaning period to the age of 15 months and to score the acceptance of each food for the first 4 presentations. The foods were clustered into categories (i.e. fruits, vegetables…). The link between individual characteristics (maternal age, education level, parity, caregiver during weaning and infant gender) and exclusive breastfeeding duration, age at the initiation of weaning, age at the introduction of each food category, number of new foods introduced from all categories and the infant’s acceptance of each food was studied. Finally, the link between feeding practices and infants’ acceptance of new foods was analyzed.

Seventy-two percent of the infants were exclusively breastfed from birth for a median duration of 68 days. On average, the age at the initiation of weaning, 5 months, was in accordance with the current French recommendations. The number of new foods introduced was 13.4 per month on average and differed from one infant to another with no association with individual characteristics. The reactions to new foods were positive in 90% of the cases but differed according to food categories. In the early weaning period, fruits and vegetables were the least positively accepted foods; however, the average acceptance rate of these foods reflects infants’ positive reactions. The earlier vegetables were introduced, the higher the acceptance of new vegetables was. Finally, new food acceptance was significantly correlated with the number of different foods offered in the first two months of weaning, particularly for fruits and vegetables. These results highlight the ease of introducing new foods into a child’s diet in the period between 4 and 15 months and the role of maternal complementary feeding practices on infants’ acceptance of new foods.

Introduction

Nutritional status plays a major role in determining health throughout the entire lifespan, even as early as the intrauterine period (Barker, Osmond, Golding, Kuh, & Wadsworth, 1989). In children, nutritional status depends on parental feeding practices and on individual eating habits. Maternal feeding practices early in infancy have received close attention in the last decade, highlighting the role of breastfeeding and weaning practices in food acceptance when weaning begins (Mennella et al., 2001, Nicklaus, 2011, Schwartz et al., 2011b). The World Health Organization recommends exclusive breastfeeding until the age of 6 months (WHO, 2003). Current research suggests that beyond its nutritional benefits, breastfeeding may also contribute to the development of better eating habits. On the one hand, Neiva, Cattoni, Ramos, and Issler (2003) reported that the act of sucking during breastfeeding is important because it promotes the proper development of chewing and swallowing abilities. Moreover, bottle-feeding may delay the growth of the jawbones and contribute to a tooth-to-denture-base discrepancy (Inoue et al., 1995, Sakashita et al., 1996). Thus, breastfed infants are better able to accept the texture of new foods presented when the weaning process begins. On the other hand, prior research has shown that early flavor experiences during breastfeeding may facilitate the acceptance of new foods when weaning begins (Forestell and Mennella, 2007, Mennella et al., 2006, Mennella et al., 2001, Sullivan and Birch, 1994). The explanation for this finding is that breastfed infants are exposed to flavors in their mothers’ milk (Mennella and Beauchamp, 1997, Mennella et al., 2006). This effect may not be specific to any particular flavor; instead, it may be related to the variety of flavors in milk (Hausner, Nicklaus, Issanchou, Mølgaard, & Møller, 2010). Moreover, the initial difference in food acceptance during the weaning period between breast- and formula-fed infants may disappear after repeated exposure to complementary foods (Hausner et al., 2010, Maier et al., 2008).

Introducing weaning foods is a process that allows children to transition from milk to a variety of foods. The timing and order of introduction of complementary foods are important matters that mothers discuss with their infants’ pediatricians (Le Heuzey et al., 2007, Skinner et al., 1997). Recommendations may vary across countries as to when to start introducing infants to weaning food; generally, the recommendations range from between 4 and 6 months to the 6th month and later (Schwartz, Scholtens, Lalanne, Weenen, & Nicklaus, 2011). In several countries, mothers do not always wait until this age to start feeding foods other than milk (Alder et al., 2004, Anderson et al., 2001, Le Heuzey et al., 2007, Maier et al., 2007b). There is no single recommendation about the best way to introduce these foods, and organizations from different countries recommend different weaning strategies (Schwartz et al. 2011b). Some authors have claimed that vegetables should be introduced before fruits because the infants’ innate preference for sweet foods may interfere with vegetable acceptance (Desor, Maller, & Turner, 1977). More generally, one may wonder whether the order in which different food categories are introduced may impact food acceptance. The effects of the age at which complementary foods are first introduced on eating behavior and new food acceptance have not been thoroughly documented. Some authors have suggested that there is a favorable period when children accept specific foods. Milk with unpleasant flavors, such as casein hydrolysate formula, is easily accepted at the age of 2 months but not at the age of 7 months (Mennella, Griffin, & Beauchamp, 2004); cereals are accepted differently by infants of different ages (Harris, Thomas, & Booth, 1990). Moreover, several studies were conducted to specifically assess the effect of the early introduction of fruit and vegetables on later fruit and vegetable acceptance or consumption. A positive relationship between the early introduction of fruits and later fruit consumption was revealed (Blossfeld et al., 2007, Cooke et al., 2004). Similarly, Skinner, Carruth, Bounds, Ziegler, and Reidy (2002) observed that the early introduction of fruits has an impact on later fruit consumption, but this effect was not observed for vegetables.

It is not only the age of introduction of complementary foods that influences the acceptance of weaning foods; the repeated presentation of a variety of foods also has an impact. Exposure to a variety of vegetables (compared to exposure to a single vegetable) increases the acceptance of a new food (Gerrish and Mennella, 2001, Maier et al., 2008). The resulting improved acceptance of a new food was still visible up to 2 months after the exposure to a variety of foods, and breastfeeding enhanced the effect of variety on later acceptance of new foods (Maier et al., 2008). Similarly, repeated exposure to a variety of fruits encourages later acceptance of fruits (Mennella, Nicklaus, Jagolino, & Yourshaw, 2008). There are conflicting opinions about the generalizability of exposure to a variety of foods from a given category to new foods from another category. Some authors concluded that it is possible to generalize the effects, showing that repeated exposure to a variety of vegetables favors later acceptance of a new meat (Gerrish and Mennella, 2001, Maier et al., 2008) and that daily fruit exposure enhanced the infants’ initial acceptance of carrots (Gerrish & Mennella, 2001). Mennella et al. (2008) did not observe the latter result with green beans, suggesting that generalization may be more difficult with some foods (Nicklaus, 2011). Maier et al. (2008) showed that it may be the number of daily changes that leads to greater acceptance of new foods rather than the overall number of different foods.

In accordance with this literature, the objectives of the present study were (i) to describe early maternal feeding practices in a French sample, including the duration of exclusive breastfeeding if it had occurred, the age at which the mothers introduced complementary foods and the variety of the foods they introduced, and (ii) to evaluate the consequences of mothers’ feeding practices on infants’ acceptance of new foods introduced into their diets from the beginning of weaning to the age of 15 months. Based on the results reported in the literature, we expected that breastfeeding duration and the variety of foods offered at the beginning of the weaning period would have a positive impact on the acceptance of new foods.