Literature Review on the Hindrances to Effective Weaning

The early years of life are a period of very rapid growth and development. In this critical phase, nutrient preferences are formed which carry over into childhood and across and foundations are laid for a healthy adult life. Backlog energy, imbalances in macronutrient quality, and nutritional deficiencies may class inappropriate nutritional signals, leading to metabolic disturbances and affecting the obesity take a chance. For example, the intake of protein and saccharide-sweetened beverages in young children has been associated with an increased risk of overweight and obesity. In reality, scientific reports have shown that the dietary intakes of vegetables, α-linolenic acrid, docosahexaenoic acrid, atomic number 26, vitamin D, and iodine are low and the intakes of poly peptide, saturated fatty acids, and added sugar are high in young children living in Europe. A focus on improving feeding habits and approaches to support more than balanced nutritional intakes early in life may have significant public health benefits.

Introduction

A Stage of Rapid Growth and Development

The first period of life is characterized by very rapid growth and evolution. Many organs including the gastrointestinal tract, pancreas, adipose tissue, and brain are still in evolution throughout infancy and young childhood. The body size doubles and the body weight increases v-fold betwixt birth and three years of historic period. Due to the rapid growth and development of the child, the (relative) nutritional requirements are loftier. Effigy ane gives an overview of the additional nutrient needs of a immature kid (1-3 years of age) compared to an adult (per kg of body weight) [1].

Fig. one

Additional nutrient needs of a young child compared to an developed (70 kg) per kilogram of body weight. For case, a young child needs 5.v times more atomic number 26 per kilogram of torso weight compared to an adult.

Relevance of the Transition Period: From 'Milk Merely' to a More than Diversified Diet

In this disquisitional phase of life, the kid's diet rapidly changes. While it is initially primarily milk based, solids are gradually introduced to the nutrition and finally the kid will eat the family nutrition. A recent written report [two] comparison the early development of BMI betwixt normal weight and overweight children at the age of eight years conspicuously showed that BMI evolution already started to differ significantly betwixt groups during the first year of life and congenital upward consistently after. No evidence of a specific critical flow of development of overweight was observed. In a pocket-size longitudinal report past Péneau et al. [3], it was suggested that the beneficial effects of chest-feeding on later body fatness could be counteracted past an imbalanced nutrition after the chest-feeding period, a finding corroborated by recent findings of the Generation R Study [iv]. These findings signal that deviations in the developmental pathways leading to babyhood obesity are not express to any specific menstruation in childhood, which in fact supports a focus on appropriate nutrition and behavioral intervention strategies throughout childhood [five,6]. It is idea that the maturation of organs is adapted to the nutritional environment in this disquisitional period of development. An excess of energy, imbalances in macronutrient quality, and nutritional deficiencies are negative nutritional signals which may pb to, for case, metabolic disturbances or the development of obesity [7,8,9,ten].

Early life is too a crucial phase for the evolution of healthy eating habits. With repeated exposure and an bachelor multifariousness, the child learns to have many different tastes [eleven,12,13] and these preferences afterwards deport over into childhood and beyond [14,xv,sixteen,17].

In this review, we discuss the nutritional reality of older infants (aged half-dozen months to 1 year) and young children (aged 1-three years) in Europe and the possible consequences of different nutritional challenges for metabolic development.

Methodology

To obtain information on the diet and nutrient intakes of young children in European countries, an all-encompassing literature review was conducted. This literature review included structured searches for relevant published literature using a range of wellness care-related databases (PubMed, MEDLINE, Pascal, and Web of Science) every bit well as grayness literature obtained from international and national organizations [e.g. the Food and Agriculture Organization, UNICEF, the Globe Health Organization (WHO), the US Bureau for International Development, the CIA Earth Factbook, the World Banking concern, and websites of ministries of health and NGOs].

The information on diet and nutrient intakes obtained from this literature review was compared to nutritional recommendations. Reference values given by the European Nutrient Prophylactic Authorization (EFSA) [18,19,20,21] were used when bachelor; otherwise, intakes were compared to recommendations of the Nordic Quango of Ministers [1].

Results

Nutritional Intakes in Late Infancy and Young Childhood

The literature review showed that the dietary intakes of vegetables, due north-3 fatty acids, atomic number 26, vitamin D, and iodine were consistently lower in older infants and immature children, whereas the intakes of protein, saturated fatty acids (SFA), sodium, and free sugar were often higher than recommended.

Vegetables

Vegetables are important sources of vitamins and minerals, and diets rich in vegetables are known to assist protect against disease [22,23]. The recommended amounts of vegetables differ between countries but are generally effectually 75-100 g at 1 yr and increment to about 125-150 g at around 3 years of age [24,25].

Vegetables tend to be less well accepted by infants and young children, nigh likely due to their innate liking for sweet tastes. We institute that vegetable intakes in European infants and young children were ofttimes lower than the recommendations (fig. 2) [24,25,26,27,28,29,30].

Fig. 2

Vegetable intake of older infants and immature children in European countries [24,25,26,27,28,29,thirty] compared to recommendations.

n-3 Fatty Acids

The dietary recommendations of the EFSA for essential fat acids (EFA) are [18]:

• α-linolenic acid (ALA): adequate intake of 0.5% of energy (en%)

• linoleic acrid (LA): adequate intake of four en%

• docosahexaenoic acrid (DHA): adequate intake of 100 mg/day for infants and young children (aged <2 years)

• DHA and eicosapentaenoic acid (EPA): adequate intake of 250 mg for children >2 years of age.

The limited information found in the public domain on the intake of EFA indicates that intakes are below or close to the lower terminate of the recommended intake. Particularly intakes of EPA and DHA are far beneath the recommendations. For instance, in Kingdom of belgium, children aged 2.v-iii years consumed 0.5 en% (0.viii g) ALA, iv en% LA, 20 mg EPA, and 40 mg DHA per day. Austrian children anile 3-vi years consumed 0.5 en% (0.eight g) ALA, 20 mg EPA, and lxxx mg DHA per day [18].

Infants and children have higher iron requirements during the period of fast growth [31], just many older infants and young children do non consume big quantities of fe-rich foods such as red meat and dark-green leafy vegetables. A modeling study even concluded that it is impossible to attain the recommended iron intakes with a diet completely conforming to dietary guidelines for infants/young children [32].

The boilerplate daily iron intake of older infants and young children in European countries was found to be around 6-vii mg/twenty-four hours [25,28,29,30,33,34,35,36,37,38,39,40,41] and thus was only slightly lower than the recommended value of 8 mg/solar day (fig. 3) [1].

Fig. iii

Iron intake of older infants and young children in European countries [25,28,29,30,33,34,35,36,37,38,39,40,41] compared to recommendations [i].

Despite the small intake gap, an inadequate iron intake may still be relevant equally the brain is in rapid development during this period of life. Symptoms of iron deficiency (anemia) may be fatigue, lack of energy, headache, trouble sleeping, loss of appetite, paleness, reduced resistance to infection, and poor memory. In 6-month-old infants, iron deficiency anemia has been found to be associated with adverse effects on important measures of central nervous organization development at 12 and 18 months [42].

Vitamin D

As indicated in a higher place, young children need 7 times more vitamin D per kilogram of body weight (fig. ane) and 2.5 times more vitamin D per 100 kcal of food intake compared to adults [1]. Inadequate vitamin D intakes (fig. four) [25,29,xxx,33,34,35,36,37,39,40,41] and a deficient vitamin D status in older infants and young children have been observed in virtually all countries in Europe [43,44,45,46]. The electric current consensus based on these findings is that vitamin D should be regarded as a fundamental nutrient for these age groups. Well-nigh foods only contain traces of vitamin D, with the exception of oily fish, which is, however, not frequently consumed by older infants and young children. A number of Western countries recommend vitamin D supplements, only compliance with the apply of supplements has been found to be low, i.due east. ten-50% [47,48,49,l].

Fig. iv

Vitamin D intake of older infants and young children in European countries [25,29,30,33,34,35,36,37,39,xl,41] compared to recommendations [1].

Iodine

Inadequate iodine intakes and a deficient iodine status have been observed in young children in several European countries, amidst which are Germany, Republic of austria, France, the netherlands, and Turkey [25,38,51,52], whereas in other countries (eastward.g. the U.k.) the daily iodine intakes meet the recommended value of seventy-90 µg [53,54]. This could be related to the iodine levels (declared) in cow'south milk, which vary greatly throughout the different seasons and betwixt regions. For example, reference values for cow's milk in different countries range from 3.3 µg/100 g in Deutschland, through 7 µg/100 chiliad in the Netherlands, and up to 31 µg/100 k in the Britain.

Protein

From 0.5 to iii years of historic period, the required en% from protein decreases from around six to four.5 en% as recommended by the EFSA [20]. The EFSA too stated that the current data are insufficient to establish a tolerable upper intake level for poly peptide and concluded that intakes of up to twice the requirement (∼ten en%) are regularly consumed from mixed diets and are to be considered safe [20]. Agostoni et al. [55] stated in a commentary newspaper by the ESPGHAN Commission on Nutrition that, although not entirely consistent, poly peptide intakes ≥sixteen en% between the ages of 8 and 24 months may be associated with later overweight, whereas such associations were not seen with protein intakes <xv en%. Protein intake levels in older infants and young children were found to exist shut to this proposed upper limit for most countries (fig. 5) [24,25,28,29,30,33,34,35,37,38,39,40,41]. According to a recent systematic literature review carried out equally function of the 5th revision of the Nordic Nutrition Recommendations, at that place is suggestive, albeit limited, evidence that the intake of brute poly peptide, especially of dairy origin, has a stronger association with growth than the intake of vegetable protein [56]. In our analysis, however, express information was available on the source of protein intake, i.east. vegetable versus animal protein.

Fig. 5

Protein intake of older infants and immature children in European countries [24,25,28,29,30,33,34,35,37,38,39,forty,41] compared to the average requirements [20] and the proposed upper limit [55].

Saturated Fatty Acids

In European countries, the boilerplate intake of SFA in older infants and young children is 11-thirteen en%, which exceeds the recommended maximum intake level of ten en% (fig. 6) [24,25,28,29,30,33,34,35,37,38,39].

Fig. half-dozen

SFA intake of older infants and immature children in European countries [24,25,28,29,30,33,34,35,37,38,39] compared to the upper limit [1,eighteen].

Low dietary intakes of SFA, i.e. levels <10 en% and preferably lower [1,18], are recommended to reduce the long-term risk of eye disease [18]. Even at a immature age, high dietary intakes of SFA have been shown to increase plasma total and LDL cholesterol concentrations and could enhance vascular lipid deposition and the occurrence of early on vascular lesions [57,58,59,threescore]. In the Special Turku Coronary Hazard Factor Intervention Project (STRIP), 1,000 healthy infants were randomized to a low-saturated-fat, low-cholesterol nutrition counseling group and a control group and were followed every half-dozen-12 months throughout childhood. The results showed that cholesterol levels were significantly reduced throughout childhood and endothelial function was improved in 11-year-old boys randomized to the intervention group. There were no effects on growth, language skills, or motor functioning [58,60].

Sodium

The habitual intake of sodium for all populations across Europe, including young children, is high (fig. 7) [25,29,30,33,34,37,38,39,40,41] and exceeds the amounts required for normal function [one]. The sodium intakes of 1- to three-yr-olds range from 950 mg in Federal republic of germany to more than than 1,800 mg in Belgium and exceed the recommendation of 0.5 one thousand/MJ for 1- and 2-yr-olds. From two years of age onwards, the Nordic Council of Ministers set an upper limit of ane,400 mg of sodium per day, which is exceeded in both Belgium and Spain, i.e. the countries that included slightly older children.

Fig. 7

Sodium intake of older infants and young children in European countries [25,29,30,33,34,37,38,39,forty,41] compared to the upper limits (UL) [ane,xviii].

Already at the starting time of early childhood, the systolic blood force per unit area rises with increasing sodium intakes. Blood force per unit area measured in childhood predicts the claret pressure and even the development of early on atherosclerosis in machismo [1]. It may be of import to limit the sodium intakes in infancy and babyhood to prevent children from becoming accepted to and having a preference for a nutrition with a relatively high sodium content later in life.

Free Sugars

The different definitions that accept been used to appraise (added) sugar intake in the population arrive difficult to compare sugar intake levels amid European children. For case, in the United kingdom the term 'non-milk extrinsic saccharide' is used [30], whereas in Republic of finland they refer to 'sucrose' [33] and in the Netherlands to 'sugar and confectionery' [24]. However, by and large, older infants and young children consume much more than gratuitous sugars, i.east. sugars that are added to food by the manufacturer or consumer, as well equally sugars that are naturally present in honey, syrups, and fruit juices, as the recommended 10 en% as recently proposed by the WHO. The WHO even suggested that a reduction to <5 en% would have boosted benefits [61]. For instance, in Irish preschoolers the intake of sugar is 50 g/solar day, which equals about 19 en% [29] compared to the recommended 5-10 en% (fig. viii) [24,29,xxx,33].

Fig. 8

Free sugar intake of older infants and young children in European countries [24,29,30,33].

Costless sugars are non essential for infants and young children every bit their diet contains many sources of other carbohydrates.

Information technology is important to limit the intake of complimentary sugars in the diet of infants and children for 3 reasons.

Firstly, gratis sugars are merely added for their sweet sense of taste. Early on life is a sensitive period for the evolution of food preferences that conduct over into adulthood, and exposure to sugariness tastes early in life may lead to a preference for sweet tastes later in life [xvi,62]. Secondly, sweet products by and large have a poor nutritional contour, i.e. they contain so-called 'empty calories', and it has been demonstrated that children with a loftier en% coming from sugars have lower intakes of micronutrients (i.eastward. calcium, zinc, thiamin, riboflavin, niacin, and folate) and dietary fiber [63,64,65,66,67,68]. Thirdly, products containing gratuitous sugars are known to increase the chance of dental caries in children [69]. The beginning pace in the pathogenesis of dental caries is infection with the bacterial strain Streptococcus mutans[seventy,] and it has been shown that this bacterium produces more acrid with sucrose and glucose compared to milk sugar lactose [71,72]. Finally, the consumption of sugar, and especially saccharide-sweetened beverages, has been linked to the onset of childhood obesity [73].

Increased Take a chance of Childhood Obesity

The results of our evaluation showed a number of discrepancies between the recommendations for these young age groups and the existent food intakes in many European countries. Especially the imbalances in macronutrients, that may too drive some of the reported micronutrient deficiencies, can exist a concern. There has been a dramatic increase in the prevalence of babyhood overweight and obesity in the terminal 3 decades worldwide [74], and this may exist associated with college prevalences of cardiovascular and metabolic diseases afterward in life [75]. Although initially 'developmental origin of adult health and disease' (DOHaD) studies almost exclusively focused on the role of the fetal environment noncommunicable disease risk, it has become increasingly best-selling that the window of programming extends into the (early) postnatal catamenia [76,77,78].

Imbalances in food intake may be relevant equally they may claiming optimal organ growth and development of office during this postnatal period. The evolution and (functional) maturation of many (metabolic) organs including the gastrointestinal tract [78], brain [79], pancreas [lxxx], and adipose tissue [81] keep for a considerable time later on birth. For instance, adult differences in adipose cell numbers between lean and obese people gradually develop during childhood, already showing a 2-fold divergence in the number of cells at the age of two years [82].

Some specific epidemiological and animal findings also support the relevance of the postnatal menstruum every bit an contained contributor to the later affliction risk. Initial studies of the Dutch famine showed a clear stardom between early pregnancy and late pregnancy exposure and afterwards (illness) outcomes [83]. However, also women exposed to the Dutch famine between the ages of 0 and 9 years showed increased type 2 diabetes and overweight compared to unexposed women [84,85]. These observational information are supported by an analysis of individual growth trajectories showing that weight gain between 0 and ii years of age is most predictive of the later adiposity gamble [86]. Recent data from the Generation R Study confirm the specific contribution of postnatal growth to the risk of overweight and obesity at the age of 6 years [87].

Creature studies have shown that [88] depression protein in the postnatal diet reduces the developed fat mass, whereas the same diet during the fetal flow is associated with agin outcomes in machismo. Similarly, moderate energy restriction during lactation has been shown to protect against enhanced adult fat accumulation in rats, whereas energy restriction during gestation has had the opposite outcome [89]. These observations illustrate that growth depends on unlike fuels in fetal and postnatal life and is related to the timing of the development of private organs and their nutritional needs during these different stages. Acceptable nutritional intakes to support these different periods of organ growth and functional maturation are essential to achieving optimal organ chapters.

The Toddler Period: Diet and Obesity Risk

An of import part of the daily energy intake during the commencement 3 years of life is derived from dietary fat. During the outset iv-6 months of life, human milk (or baby milk formula) is the sole source of diet for the infant, providing 40-50 en% as fat. Dietary lipids provide energy for growth, supply the EFA LA (C18:2 n-six) and ALA (C18:3 n-iii), and ensure acceptable absorption of fat-soluble vitamins. Between half dozen months and 2 years of age, the WHO recommends 30-40 en% from fat, although it was recently suggested that the energy derived from fat should be gradually reduced to a maximum of xxx% to better match energy requirements and reduce the weight gain velocity co-ordinate to the latest reference growth standards.

Observational data have linked low fatty intakes at x months and 2 years of age to increased trunk trunk fat deposition and higher leptin resistance in young adulthood, supporting the significance of fatty as the main free energy provider in the early diet [90]. These data also conspicuously illustrate that the nutritional requirements to support optimal growth and development at this age differ from those advised for older children and adolescents.

A high protein intake at the ages of 12 and xviii-24 months was independently related to a college BMI and per centum of torso fatty and to a higher risk of having a BMI or percentage of trunk fatty above the 75th percentile at the historic period of 7 years. The quality of the protein may exist relevant as well, as both full protein and a high intake of animal merely not vegetable poly peptide were associated with increased torso fatty at vii years [91,92].

Studies conducted in populations of children have demonstrated positive associations between the intake of sugar and BMI development [93,94,95]. Yet, the number of studies investigating the relationship between the total sugar intake in children and the obesity adventure is modest, likely related to the fact that limited sugar intake information are available.

Frequent exposure to foods and beverages containing sugar may have longer-term furnishings that could contribute to the hazard of developing childhood obesity, but not all scientific testify is consequent. In infants with a poor nutrient status, the intake of products high in saccharide has been associated with a potential adventure of developing micronutrient deficiencies due to their lower nutrient density compared to products lower in sugar [63,64,65,66,67,68].

Discussion and Decision

In summary, the dietary intakes of vegetables, northward-iii fatty acids, iron, vitamin D, and iodine are low and the intakes of protein, SFA, sodium, and free sugar are high in older infants and young children living in Europe. These findings are relevant taking into account the specific nutrient needs during these early stages of life, supporting the optimal evolution of organs and their part. Possible long-term consequences of these nutrient gaps could bear upon the evolution of a healthy gustation and eating habits too as the torso composition.

For this review, nosotros were dependent on the available dietary intake information across Europe. Several European countries, such as Kingdom of norway, Portugal, and Switzerland, lack national data on infants' and children's food and nutrient intakes and surveys are often out of date: 8 out of 13 dietary surveys are more than 5 years old. Moreover, the methodologies of the different dietary surveys differ from country to country and are therefore difficult to compare. For example, dietary surveys differed in historic period categories, dietary assessment methodology, sample size, and definitions of nutrients. Some surveys were limited to a specific geographical area or population and were not necessarily representative of the entire country. For example, the Belgian survey was done in Flanders, Belgium, only.

In order to obtain a articulate overview of the nutritional reality of young European children, loftier-quality, representative nutrient and food intake information are needed. Dietary surveys should be performed on a regular basis in each European state to follow longitudinal trends in food and nutrient intakes.

Disclosure Statement

All authors are full time employees of Danone Nutricia Early on Life Nutrition.

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