First foods


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CA AAP Conference 11/17/12

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  • What if ?Babies consume more caloriesMoms more likely to be concerned they need to supplementConventional infant formulas/baby food may contribute to the problem
  • Only 1/5 women who intend to breastfeed are still breastfeeding at 12 months post partumI wrote a guest blog re: the breastfeeding/bottlefeeding controversy in NYC’s Latch On Campaign August 2012I want to share with you a couple of the comments.
  • Over 1/3 of all BF hospitals in US are in California
  • So where can mothers get help?
  • So where can mothers get help?
  • Lactation rooms or cubbies at all WIC CentersBreastfeeding group education for participantsBreastfeeding individual education for participantsBreastfeeding support groupsElectric breast pump loan programBreastfeeding HelplineBreastfeeding Peer Counselor Program
  • Reductionist approach may be part of the problem
  • Most common concern noted is higher protein content that breastmilk
  • But breast milk is not a homogeneous product
  • Tsimane women eat wild game, fresh water fish and native cultivars of vegetables and grain
  • Martin queries if formula should reflect the fatty acid profile of breast milk from the indigenous women rather than that of women who are eating a Western diet
  • The authors propose…
  • California WIC has prepared several materials addressing a potential link between breastfeeding and protection against obesityA variety of flavors and nutrient compositionBoth the flavor and macronutrient content of breast milk is variable
  • Differences in hormonal responses to breast milk
  • Impact on self regulation
  • Can you imagine formula instructions with a three fold variation ?
  • > 20% lower incidence of obesity at age four
  • “The American Academy of Pediatrics recommends that chemical management policy in the United States be revised to protect children and pregnant women and to better protect other populations.”
  • CHAMACOS studies have also revealed links between flame retardant concentrations in mothers’ blood and decreased fertility, lower birthweight babies and changes in thyroid hormone levels, even after controlling for exposure to pesticides and other environmental chemicals. And findings from other smaller studies have linked deficits in physical and mental development in young children to prenatal exposure to PBDEs.  UC Berkeley Press Release
  • PolybrominatedDiphenyl Ethers (PDEsB)
  • So now it’s time to introduce solids
  • Rice is recommended to minimize risk of allergic responseBut there are no good studies to show this is beneficial
  • Many publications continue to reinforce these conventional practices
  • So most babies eat infant cereals
  • The first ingredient is rice flour
  • Refined starches are used regularly and vigorously defended as safe for use in baby foods
  • Until very recently. In 2011 Dr. Green initiated his White Out CampaignDesigned to eliminate use of refined cereals in an infants diet.Not without controversy
  • Over 50% of physicians recommend infant cereal as a first food
  • The Feeding Infants and Toddler Study is a survey of current feeding trends. This is the 2008 data.+ longer duration of breastfeeding+ a delay in the introduction of complementary foods - low intakes of overall fruits and vegetables for all ages - low intake of iron-rich foods for 9- to 11.9-month-olds - use of cow's milk before age 1 year and the use of reduced-fat milks during the second year of life
  • Caregivers can moderate color, temperature, texture, and cultivate familiar flavors as baby is developmentally ready
  • It’s almost as if there are two different food supplies, and not as simple as organic vs. conventionalThe bigger difference seems to be whole foods vs. highly processed refined foods—even if they are organic
  • Greater processing typically leads to --reduction in total fiber content-- compromises the integrity of the grain
  • Sweetened cereals 6-9 mo 14% 9-12 mo 19%12-15 mo 31%15-18 mo 45 %18-24 mo 35%
  • We know infants and toddlers are not eating enough whole foodsThis is an algorithm that outlines an approach to introducing new foodsNew foods can take up to 12-16 exposures before they are acceptedHow many parents try 1, 2, 3 times and give up?They can be especially resistant to eating vegetables and proteinSome kids are picky eaters--mostly a sensory issue --deserves appropriate attention
  • The goal is to cultivate a palate that allows an adequate intake of --whole foods--good enough balance
  • The direction I would like to see it go
  • First foods

    1. 1. First FoodsBonnie Y. Modugno, MS, RD, #MMTF
    2. 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. 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. 4. Babies are born to be breastfed
    5. 5. BreastfeedingThe American Academy of PediatricsrecommendsExclusive breastfeeding for about 6 monthsContinued breastfeeding as complementaryfoods are introducedContinuation of breastfeeding for 1 year orlonger as mutually desired by mother and infant.Medical contraindications to breastfeeding arerare.Infant growth should be monitored with the WHOGrowth Curve up to 2 yrs of age February 27, 2012 Pediatrics Vol. 129 No. 3 March 1, 2012
    6. 6. Growth ChartsCDC – boys 0-36 mos WHO – boys 0-24 mos 50 % 50 %
    7. 7. Exclusively Breastfeed Babies: fast growers picked up on both charts 6CDC WHO 5 4 3 Series 1 2 Series 1 2 0 Series Category 1 Category 2 Category 3 Category 4 3
    8. 8. What about the fastgrowers? • “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 ColeActa Paediatrica. Volume 96, Issue Supplement x454 pages 204, April 2007
    9. 9. BREASTFEEDING RATES TODAY (2009 births) 100 90 80 70 60 50 40 US 30 California 20 10 Oregon 0 Mississipi
    10. 10. Breastfeeding: Incremental Gains9080 • Breastfeeding …7060 should be promoted as50 the norm within all4030 2008 maternal and child20 200910 0 2020 target health care facilities.
    11. 11. Primary barriers to breastfeeding as intended1. Inadequate support – Too little prenatal education – Inadequate support post partum • Access • Timing • Cost – Conflicting agendas in the hospital/clinic setting
    12. 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.”
    13. 13. Percent of breastfed infantsreceiving formula before 2 days of age3530 US25 California20 Oregon15 Mississipi10 New Hampshire Montana 5 Texas 0
    14. 14. Breastfeeding:Reality Check • “I tried with all 3 of my kids but found once I ran into problems, I wasnt 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.” Image:
    15. 15. Baby Friendly Hospital Initiative Home•19,000 hospitals internationally About BFHI The Ten Steps•In US, 6% of babies born in 143BF hospitals Baby-Friendly Hospitals and Birth Centers Info for Hospitals and Birth Centers•51/143 BF hospitals located inCalifornia Info for Parents Info for Breastfeeding advocates / health care professionals Why is breastfeeding important?
    16. 16. Common barriers to breastfeeding2. Need to return to work  Inadequate time to express milk  No place to express milk  No adequate storage“The Business Case for Breastfeeding” WORLD-BREASTFEEDING-WEEK--A-STEP-IN-THE- RIGHT-DIRECTION?instance=main_article DHHS/ Office of Women’s Health aLawsRelatedtoBreastfeeding.aspx
    17. 17. Primary barriers to breastfeeding as intended3. Personal misgivings – Ambivalence – Fears – Lack of confidence – Influence of family and friends – Time and energy
    18. 18. Breastfeeding:Reality Check• “When I had my son the lactation consultant visit was a joke- it was about 5 minutes”
    19. 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”
    20. 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. 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)
    22. 22. If breast milk were packaged
    23. 23. What about formula • Infant formula introduced to the USA in the late 1860’s
    24. 24. How does formulacompare?“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. 25. Infant FormulaENFAMIL• 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)
    26. 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. 27. Is breast milk more than a mix of nutrients?PROTEINFORMULA • Non fat milk • Soy protein isolate • Whey protein concentrate • Individual amino acids
    28. 28. Amino Acids Comparison(mg per 100 calories) 300 250 200 150 Human milk 100 Enfamil NB 50 Enfamil PI 0
    29. 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. 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. 31. Infant Formula: Sources of Fat50454035 Palm Olein30 Soy Oil2520 Coconut Oil15 High Oleic Sunflower Oil10 ARA/DHA Blend 5 0 Enfamil
    32. 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. 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. 34. Diet influences the nutrient profile of breast milk252015 Tsimane10 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. 35. Diet influences the nutrient profile of breast milk1.41.2 10.8 Tsimane0.6 Cincinnati0.4 Enfamil0.2 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. 36. Gut Microbiomeand 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.
    37. 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. 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. 39. How Breastfeeding may protectagainst obesity1. 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. 40. How Breastfeeding may protectagainst obesity2. 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 babiesWIC WORKS: Policy Briefs by the California WIC Association; & PHFE WIC, Sept 2011
    41. 41. How Breastfeeding may protectagainst 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 intakeWIC WORKS: Policy Briefs by the California WIC Association; & PHFE WIC, Sept 2011
    42. 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. 43. WIC Children fully breastfed hadlowest rate of obesity at Age 4 30 25 20 Only Breast Milk 15 Breast Milk & Formula 10 Only Formula 5 0 WIC Babies
    44. 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 357Agents: Effects Bromide (photographic laboratory) Cadmium Potential absorption and bromide transfer into milk None reported 358 359 Chlordane None reported 360on 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 376Pediatrics Lead Possible neurotoxicity 377–380 Mercury, methylmercury May affect neurodevelopment 381–383Sept. 1, 2001 Methylmethacrylate None 384 Monosodium glutamate None 385Vol. 108 No. 3 Polychlorinated biphenyls and Lack of endurance, hypotonia, sullen, expressionless 386–390 polybrominated biphenyls facies776-789 Silicone Esophageal dysmotility 17–22 Tetrachloroethylene cleaning fluid Obstructive jaundice, dark urine 391 (perchloroethylene) Vegetarian diet Signs of B12deficiency 392
    45. 45. Table 2. PBDEs in human milkWorld 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. 46. Temporal Trend of PBDE’s in Swedish Breast Milk4.5 43.5 32.5 2 PBE-471.5 Sum of PBDE congeners 10.5 02003 IUPAC, Pure and Applied Chemistry 75, 2039-2046
    47. 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. 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. 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. 50. Arguments forcommercial 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. 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. 52. Percentage of children consuming infant cerealsFeeding Infants and Toddlers Study (FITS) 2002 2008.ADAJ 2010
    53. 53. Infant CerealNutrition FactsServ. Size 1/4 cup (16g) Servings Per Container 14Amount 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. 54. Are starch fillers used in baby food?Starches are easily digested carbohydrates, whichmay be present in baby foods in the form of flour(corn, wheat, rice), tapioca or rice…starches provide an important source of calories forgrowing infants. Food starches also help to moderateflavor and control texture.…The Food and Drug Administration has determinedthat food starches are safe and suitable for use inbaby foods
    55. 55. David Ludwig, director of the Optimal Weight for Life program at Childrens Hospital Boston, says "theres noDr Alan Greene’s Campaign to scientific basis for thisEliminate Rice Flour Cereal recommendation. Thats a myth.― Liz Szabo, USA TODAY 11/30/2010
    56. 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. 57. Percentage of children consuming complimentary foods by ageFeeding Infants and Toddlers Study (FITS), ADAJ 2010
    58. 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. 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. 60. What else are babies being fed?
    61. 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. 62. Finger foods
    63. 63. Considering finger foodsTowards whole foods: balance is keyInfant food GI GIScone 92 Cooked peas 48Pretzels 83 Chicken nuggets (Aust) 44Waffle 76 Pasta (al dente) 43Vanilla wafers 77 Banana (slightly under ripe) 42French fries 75 Apple 40Cheerios cereal 74 Pinto beans 39Graham crackers 74 Fish fingers 38Bagel 72 Yam 37Oatmeal 69 Pear 33Arrowroot biscuit 63 Yogurt – (Aust/sweetened) 27
    64. 64. Consumption patterns of infants and toddlers consuming foods at least once a day7060504030 6-8.9 mo20 9-11.9 mo10 0 12-14.9 mo 15-17.9 mo 18-24 mo Feeding Infants and Toddlers Study (FITS) ADAJ 2010
    65. 65. Algorithm for introducing new foodsKEY 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. 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. 67. First Foods Thank youBonnie Y. Modugno, MS, RD, #MMTF
    68. 68. Trends in Food Consumption of Infants (6-8.9 mos) Percentage of infants consuming at least once a day9080706050 20024030 20082010 0 Any fruit/juice 100% juice baby fruit real fruit Feeding Infants and Toddlers Study (FITS) 2002 2008. ADAJ 2010