Feeding Guidelines For Infants and Young Toddlers: A Responsive Parenting Approach

Feeding Guidelines for Infants
and Young Toddlers: A Responsive Healthy Eating

Research
Parenting Approach Building evidence to
prevent childhood obesity
Guidelines for Health Professionals
Executive Summary, February 2017
Introduction
In the United States, a significant proportion of children

2 years of age or younger are at risk of childhood obesity.
Data from the 2011-2012 National Health and Nutrition
Examination Survey (NHANES) show that 8.1 percent
of children ages 2 or younger were already above the 95th
percentile and 7.1 percent were at or above the 97.7th
percentile for weight based on their length.
Early life diet and feeding behaviors play an important role

in establishing healthy food preferences and behaviors and
preventing childhood overweight and obesity. Yet there is a
dearth of evidence-based guidelines for infant and toddler
feeding practices in the United States.
The federal government’s current Dietary Guidelines for

Americans (DGA) do not include guidelines for infants
and toddlers less than 24 months. However, given new
evidence showing that the first 1,000 days—or the period
from conception to age 2—are critical for childhood
obesity prevention, recommendations for this age group
are expected to be included beginning with the next
edition of the DGAs to be released in 2020.
In 2016, Healthy Eating Research, a national program of the

Robert Wood Johnson Foundation, convened an expert
panel to review the evidence that has emerged over the past
two decades for promoting healthy nutrition and feeding
patterns for infants and toddlers (ages 2 or younger). This
executive summary summarizes guidelines presented in the
expert panel’s full report on what and how to feed infants
and toddlers within the context of the rapidly developing
child. These guidelines are based on current scientific
evidence related to responsive parenting practices. The
summary also addresses related behaviors such as physical
activity, television and other media use (screen time), and
sleep, as well as other important considerations including
food allergies and food safety for infants and toddlers.
Healthy Eating Research A National Program of the Robert Wood Johnson Foundation
recommends that infants be breastfed exclusively from birth until
Definitions about 6 months. Once complementary foods are introduced,
it is recommended that breastfeeding continues until the
COMPLEMENTARY FEEDING is a process that starts child is at least 1 year old. Among infants born in 2013, 81.1
when human milk or infant formula is complemented by percent of women in the United States initiated breastfeeding;
other foods and beverages and ends when the young child however, by six months the prevalence of women engaged in any
transitions fully to family foods. The complementary breastfeeding dropped to 51.8 percent, and by one year to 30.7
feeding period typically continues to 24 months of age. percent. Differences in breastfeeding prevalence are observed
across income categories, states, and race/ethnicity.
COMPLEMENTARY FOODS are foods and beverages
other than human milk or infant formula (liquids, The most recent comprehensive meta-analysis that had
semisolids, and solids) provided to an infant or young global representation and adjusted for key study design and
child to provide nutrients and energy. contextual factors, concluded that breastfeeding may protect
children against the development of childhood obesity. As
RESPONSIVE FEEDING is a key dimension of expected, the number of children in the general population
responsive parenting involving reciprocity between the who would benefit is small, given the numerous biological,
child and caregiver during the feeding process. It is economic, social, and lifestyle factors that affect the risk of
grounded upon the following three steps: (1) the child obesity; however, there is evidence indicating the protective
signals hunger and satiety through motor actions, facial benefit may be more pronounced among children with genetic
expressions, or vocalizations; (2) the caregiver recognizes predisposition for obesity. These findings are highly consistent
the cues and responds promptly in a manner that with the current understanding of childhood obesity risk as a
is emotionally supportive, contingent on the signal, life-course process that starts at the time of conception.
and developmentally appropriate; and (3) the child
experiences a predictable response to signals.
Shaping Food Preferences Among Infants and Toddlers
RESPONSIVE PARENTING is a parenting style that is
meant to foster the development of self-regulation and Understanding how flavor and food preferences are established
promote cognitive, social, and emotional development. early in life is crucial as early childhood dietary patterns track
Self-regulation includes overlapping constructs that into later childhood and adolescence. The evidence suggests that
can affect feeding behaviors including self-control, will infants born to mothers who consumed fruits and vegetables
power, effortful control, delay of gratification, emotional during pregnancy and while breastfeeding are more likely to
regulation, executive function, and inhibitory control. learn to accept these foods.
Regardless of exposure during pregnancy and breastfeeding,

repeated exposure to new and different food is necessary so
The Evidence that infants and young children learn to like them, especially
for those that have bitter or sour taste profiles as is the case
There are many factors influencing what infants and toddlers with many vegetables.
consume. Caregivers need to be aware and understand: how
infants and toddlers develop food preferences and the role they Likewise, it is vital to expose infants to different textures in
play in influencing those preferences; how infants and toddlers order to properly transition to table food—for example, moving
signal hunger and satiety; and the role of responsive feeding in from pureed to mashed to lumpy and to chopped soft solid
developing healthy food habits. Further, caregivers also need to food during the first two years of life. By 2 years of age it is
understand: how and when to feed complementary foods; sleep expected that children will have fully transitioned to food that
patterns and their influence on healthy eating; physical activity comprises the family diet. For this reason it is crucial for the
needs of infants and toddlers; and the need for limits on screen family diet to include a plentiful supply of fruits and vegetables.
time. Detailed guidelines for caregivers on what and how to
feed infants and toddlers are included in Appendices 1 to 5. The evidence regarding the shaping of food preferences in young
children supports providing pregnant women and caregivers of
infants and toddlers with the following information: (a) mothers
Breastfeeding consuming a healthy diet rich in vegetables and fruits during
pregnancy and while breastfeeding can help shape healthy food
Due to the health benefits that breastfeeding offers to children preferences among their offspring; (b) breastfed infants are more
and women, the American Academy of Pediatrics (AAP) likely than formula-fed infants to consume healthier diets by the
2 Executive Summary | Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach | February 2017
time they reach school age; (c) infants and toddlers should be Black and Aboud (2011) recommend the following specific
exposed repeatedly to healthy foods, including vegetables, until responsive feeding guidelines: (1) ensuring that the feeding
they learn to accept and like them; (d) healthy food, including environment is pleasant with few distractions (e.g., no television
fruits, vegetables, and whole grains, should be readily available or other screens); (2) ensuring that the child is seated comfortably,
to serve to infants (when developmentally ready, somewhere ideally facing others; (3) ensuring that the expectations from the
between 4 and 6 months of age) at home and in child-care caregiver and child are communicated clearly and consistently;
settings where they may spend many hours of the day; and (e) (4) ensuring that the food is healthy, tasty, developmentally
infants and toddlers should not consume (or consume a very appropriate, and offered on a predictable schedule so the child is
small amount of) food and beverages rich in added sugars (i.e., likely to be hungry; (5) encouraging and attending to the child’s
desserts and sugary drinks), sodium, and added saturated fats. signals of hunger and satiety; and (6) responding to the child’s
feeding needs in a prompt, emotionally supportive, contingent,
and developmentally appropriate manner.
The Role of Feeding Context
Nonresponsive feeding is strongly discouraged as it is
Infants and toddlers rely entirely on their caregivers to learn characterized by a lack of reciprocity between the caregiver
what, when, and how to eat. Caregivers should decide which and child. Nonresponsive feeding can lead to: (a) the caregiver
types of food are made available to infants and toddlers and taking control and dominating the feeding situation by
the amount of food served, the frequency with which food is controlling and pressuring behaviors; (b) the child controlling
offered, and the type and size of utensils used to eat (if any). the situation leading to indulgence; or (c) the caregiver ignoring
Research has shown that feeding to soothe fussy infants has the child and becoming uninvolved. When caregivers control
been associated with excessive weight gain and that poor sleep the feeding, not only do they potentially override the child’s
routines during the first two years of life are related to poor internal hunger and satiety regulatory cues, but it is thought
dietary quality and obesity risk in early childhood. that they may interfere with the child’s emerging autonomy and
striving for independence based on the learning of new skills.
Allowing infants and toddlers to become familiar with healthy Each of these undesired outcomes of nonresponsive feeding
food, such as vegetables, is key for the development of healthy have been associated with the development of poor dietary
food preferences. Numerous attempts are needed for most habits and/or increased childhood obesity.
infants to accept and learn to like new vegetables. The chances
of accepting a novel food may increase by pairing it with a food How caregivers respond to other behaviors, such as sleeping/
or sauce the infant/toddler is already familiar with and likes (e.g., waking patterns, and the soothing techniques used to calm
red bell peppers or yellow squash with a preferred healthy dip). distressed infants, can influence the infant’s ability to learn
to properly self-regulate food intake. Understanding sleeping
Evidence also shows that young children are more likely to patterns of infants and how rapidly they change during the first
try new and different foods when they observe their caregivers year of life (relatively short sleep/wake cycles in early infancy,
eating them enthusiastically, as opposed to when the food is with most infants sleeping through the night by 6 months) has
offered to them without having a role model present. also been identified as central for preventing unhealthy eating
behaviors and obesity risk in young children.
The Role of Responsive Feeding A review of evidence from randomized control trials (RCTs)
focused on responsive parenting practices supports the view
Because infants do not have the capacity to verbally communicate that infants and toddlers should not be pressured to eat or
their feeding and psycho-emotional needs, it is imperative for finish the food served to them. The RCTs emphasize the
caregivers to learn to understand how and what their infants importance of allowing the infant and toddler to participate
communicate with different behaviors. This requires a responsive in family meals and to avoid distractions during mealtimes,
approach for all caregivers including parents. including TV viewing and other electronic screens. These
studies (see full report for references and summaries of
Responsive feeding is a process that involves reciprocity between studies) reiterate the importance of mealtimes being a warm
the infant/toddler and caregiver during the feeding process and and pleasant experience with plenty of verbal and non-verbal
is grounded upon the following three steps: (1) the child signals interactions between the caregiver and the infants and toddlers.
hunger and satiety through motor actions, facial expressions, The RCTs also emphasized the importance for caregivers to help
or vocalizations; (2) the caregiver recognizes the cues and infants and toddlers learn to follow routine feeding and sleeping
responds promptly in a manner that is emotionally supportive, schedules. This approach is likely to not only be crucial for the
contingent on the signal, and developmentally appropriate; and self-regulation of food intake but also of emotions.
(3) the child experiences a predictable response to signals.
Executive Summary | Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach | February 2017 3
Introducing Infants to Complementary Foods Recognizing Infants’ and Toddlers’ Hunger and
Satiety Cues
There is broad consensus that complementary foods (commonly
referred to as solid foods) should be introduced once the infant Responsive feeding of infants and young toddlers relies heavily
is: able to sit without support and has good head and neck on learning how they communicate hunger and fullness. Infants’
control; has the ability to munch or chew and to use the tongue primary form of communication is crying, and research has
to move pureed food to the back of the mouth for swallowing; shown this causes distress to caregivers who often interpret crying
no longer has the extrusion reflex (i.e., does not automatically as a sign of hunger. In early infancy, crying should be interpreted
push solids out of the mouth with her/his tongue); as a sign of hunger only if it is accompanied by additional cues,
demonstrates ability to bring hands and toys to the mouth for including: hand-to-mouth movements, mouthing, rooting,
exploration; and indicates a desire for food, such as showing sucking noises/motions, fast breathing, clenched fingers and
eagerness to participate in family mealtimes and trying to grab fists over chest and tummy, and flexed arms and legs. Infants use
food to put in her/his mouth. The vast majority of infants reach different signals to indicate that they are full, such as closing their
these developmental milestones between 4 and 6 months of mouths when food is offered and turning their head away from
age. The ability to sit without support is considered to be a key the food. As infants become older and enter toddlerhood, hunger
cue for assessing readiness for introduction of complementary cues also include leaning towards food, visually tracking food
foods as it correlates strongly with the rest of the cues and also with eyes, limb movements showing excitement, opening mouth
with physiological development including gastrointestinal, as the spoon approaches, and asking for or pointing to food. In
renal, and immunological system maturation. Experts also agree general, feeding cues progress as the child ages from behaviors
that complementary foods should not be introduced before that are subtle and primarily oral (e.g., mouthing) to those that
4 months of age as the infant’s body is not physiologically or are active and tend to involve greater body movements (e.g.,
developmentally ready. Early introduction of solids also may reaching, pointing). If ignored, early and active cues are followed
increase the risk of childhood obesity. by late cues, such as crying and struggling, which indicate
heightened levels of agitation.
Other Important Considerations for Infants and Toddlers
Sleep Considerations for Infants and Toddlers are difficult to make due to the wide range of normal variation
in duration and patterns of sleep in early life, and insufficient
Healthy sleep habits increase sleep duration and prevent sleep evidence for associations with health outcomes.
problems. Lack of sleep among children under two has been
identified as a risk factor for the development of childhood obesity.
For example, in the U.S. Project Viva cohort study, children with Physical Activity Considerations for Infants
less than 12 hours of daily sleep between age 6 and 24 months and Toddlers
had almost double the odds of obesity at age 3 years compared
with those sleeping at least 12 hours per day. Promoting healthy The evidence available in 2016 indicates that infancy is a time
sleep has been found to be effective at improving feeding when movement and active play facilitate the motor, social, and
behaviors and weight outcomes among infants and toddlers. cognitive development needed for healthy growth and well-
being. Toddlerhood is a time when children are eager to actively
Healthy sleep requires adequate duration, appropriate timing, explore and learn from their environments. For this reason,
good quality, regularity, and the absence of sleep disturbances or proper infant and toddler development relies heavily on early life
disorders. An expert panel convened by the American Academy opportunities to explore and move frequently. Motor, social, and
of Sleep Medicine recently developed evidence-based sleep cognitive development are fundamental for developing healthy
guidelines for children and adolescents. To promote optimal eating habits, thus physical activity and active play opportunities
health, infants ages 4 to 12 months should sleep a total of 12 are strongly linked to the proper implementation of responsive
to 16 hours per day (or 24 hour cycle), including naps, on feeding guidelines. As with feeding behaviors, caregivers should
a regular basis. Children 1 to 2 years of age should sleep 11 also be role models for their infants and pay attention to their
to 14 hours per 24 hours (including naps) on a regular basis. own sedentary (e.g., screen time) and physical activity behaviors.
General recommendations for infants younger than 4 months
Screen Time/Sedentary Behavior Considerations from dangerous pathogens found in food including
for Infants and Toddlers Campylobacter, Clostridium Botulinum, Cryptosporidium, E.
Coli 0157, E. Coli non-0157, Listeria, Salmonella, Shigella,
Typical sedentary behaviors of children 2 years old or younger and Yersinia. Food illnesses can be lethal for infants and
refer to: time spent sitting while playing or engaging in learning toddlers because they are often accompanied by diarrhea, which
activities; time spent on screens, such as watching TV or in front in turn can quickly deplete the young child’s vital body fluids
of a digital device screen (e.g., electronic tablet, smartphone, (i.e., severe dehydration). Foodborne illnesses can also cause
computer screen); and time spent restrained in a car seat, high serious discomfort and seriously disrupt feeding routines and
chair or stroller, or inside of a play pen or crib while the child behaviors as they often lead to nausea, vomiting, stomach
is awake. It is important that health professionals working with pain and cramps, fever, and chills. Two other important food
parents of young children are well trained to provide adequate safety concerns for infants and toddlers are food-related mouth
advice to parents on how to decrease sedentary behaviors, burns (from offering fluids or solid food that are excessively
especially those related to screen time and the time that children hot) and choking. Food safety for infants and toddlers relies
spend restrained in equipment or in an area that restricts almost entirely on their caregivers. Thus, as part of dietary
movement. The AAP recommends caregivers: (1) avoid using advice targeting the first two years of life, it is important to
screen media for children younger than 18 months, with the communicate clear evidence-based food safety guidelines
exception of video-chatting facilitated by an adult caregiver; (2) targeting caregivers of infants and toddlers. The expert panel
choose high-quality programming/apps to use together with recommendations regarding food safety for infants and toddlers
their 18- to 24-month old toddlers (letting toddlers use media are presented in Appendix 6.
by themselves should be avoided); (3) avoid exposing infants
and toddlers to screens during meals and for one hour before
bedtime; (4) avoid using media to calm their children; (5) keep Food Allergy Considerations for Infants and Toddlers
bedrooms, mealtimes, and parent–child playtimes screen-free
for children and parents; and (6) avoid exposing toddlers to apps Pregnancy and early life are highly sensitive periods for the
with advertising and/or unhealthy messages. development of the immune system and related outcomes,
including risk for the development of food allergies. Thus, it is
A review of 24 studies assessing the prevalence of sedentary understandable that in the past, experts have recommended that
behaviors in children under 2 years of age found that most dairy products and other highly allergenic food like eggs, peanuts,
sedentary behaviors at this age were based on parental self- and fish not be introduced until after an infant’s first birthday.
report of screen time. The review found a wide range of screen
time exposure per day among infants and toddlers (37 min to Recent systematic reviews, however, have found that maternal
330 min/day). This review concluded that most children had diet during pregnancy and the period mothers are breastfeeding
high exposure to TV and screen time by 2 years of age. The was not associated with the development of food allergies in
2012 Canadian guidelines for children ages 0 to 4 recommend children. Recent evidence has also shown that there is no reason
that for healthy growth and development parents should to delay introduction of allergenic foods beyond 12 months
minimize the time that their infants and young children spend and perhaps not even beyond 4 to 6 months of age, when most
on sedentary activities while awake. In summary, caregivers infants are ready to be introduced to complementary foods.
should avoid using screen media for children younger than 18 Additional evidence suggests that exposing infants during
months, with the exception of video-chatting facilitated by an the first year of life to common allergenic food may actually
adult caregiver, and prolonged sitting or being restrained is not decrease the risk of subsequent development of allergies to
recommended for more than one hour at a time. those food items. Given the many unknowns with regards to
the development of food allergies, it is still important to be
cautious when introducing infants to the solid food items that
Food Safety Considerations for Infants and Toddlers are most commonly associated with food allergies. For example,
the American Academy of Allergy, Asthma & Immunology
Children under 5 years of age are highly vulnerable to recommends introducing the first tastes at home rather than at
foodborne illness because their immune systems are still childcare or a restaurant. The expert panel recommendations
developing and they produce less stomach acid that kills regarding food allergy considerations for infants and toddlers
harmful bacteria. Children under 5 years of age have the are presented in Appendix 7.
highest incidence rates of any age group of infections
Implementation Considerations For Responsive Feeding Guidelines
Early Care and Education Programs responsive parenting/feeding principles. It is also important
for public health workers, including home visiting nurses and
In 2012, 60 percent of children from birth to 5 years of age community health workers, to be engaged in educating and
were under non-parental care during the week at child-care supporting caregivers with the implementation of responsive
centers (41%), home care by a relative (26%), and/or home parenting/feeding guidelines. The combination of counseling
care by a non-relative (5%) and there is some overlap within with text messaging and web-based support and information
these groups because children may have to multiple care has strong potential to improve the ability of the primary health
arrangements. (NCES, available at: http://nces.ed.gov/nhes/tables/ care system to better address the childhood obesity epidemic
nonrelative_care.asp). These programs are collectively referred to by sharing current, accurate recommendations for infant and
as Early Care and Education programs (ECE) and they play a toddler feeding guidelines based on responsive parenting/
key role in the implementation of responsive parenting/feeding feeding principles.
practices and dietary guidelines targeting infants and toddlers.
One study in ECE settings measured healthy eating outcomes Marketing of Food, Beverages, and Infant Formula to
(i.e., daily offering of fruits and vegetables, and avoiding Young Children and Their Caregivers
offering fast food, sugary food, or desserts). It also examined
three responsive feeding practices (i.e., allowing children to Marketing by the food industry has been identified as a powerful
eat when hungry, sitting down with children during mealtime, factor affecting the food and beverages that caregivers offer to
and allowing children to leave their food unfinished) for both young children. Even though most food marketing research has
infants and toddlers. It showed that infant-care providers been done with preschoolers or older children, there is strong
were more likely than toddler-care providers to follow evidence that marketing unhealthy food to caregivers of infants
responsive feeding and healthy eating practices. A relevant and toddlers is likely to also be highly effective. For example,
policy finding from this study was that providers working at mailings of vouchers for free infant formula and/or providing
centers participating in the federal Child and Adult Care Food cases with free samples of formula to postpartum mothers
Program (CACFP) were more likely to practice responsive without their prior consent is likely to undermine their ability
feeding and healthier eating practices with both infants and to breastfeed even if they were considering or intending to do so.
toddlers. For example, practices such as sitting with children at The marketing of energy-dense foods of poor nutritional quality
meals and limiting fast food were significantly associated with to caregivers of young children may also negatively affect the
CACFP participation. ability of infants to learn to self-regulate their food intake with
perhaps lifelong implications.
The Health Care System For this reason, food industry marketing practices need to be
aligned with the national goal of improving infant/toddler
The health care system surrounding pregnant women, mothers, feeding practices. It is important to further document marketing
infants, and toddlers needs to be substantially strengthened approaches and the nature of the food and beverage products
at the facility (e.g., Baby-Friendly Hospitals) and community being offered to caregivers of infants and toddlers in today’s
(e.g., local health departments, primary health care centers, marketplace and assess the impact of these products and
community health worker networks, Special Supplemental marketing approaches in the responsive parenting/feeding
Nutrition Program for Women, Infants, and Children (WIC)) context. In the meantime, it is recommended that states consider
levels. Obstetricians and pediatricians have a central role to the principles outlined in recent guidelines seeking to prevent
play in addressing the childhood obesity epidemic. Studies have unethical marketing of food and beverages to the detriment of
shown that pediatricians have serious time constraints given children’s well-being. Those guidelines emphasize the need for
the large amount of information that they need to convey in food products marketed to children to meet specific nutrition
a very short period of time during each well child visit. For criteria and for the implementation of measures to protect
this reason, it is important for nurses and other health care children against unethical marketing of unhealthy food products
providers, besides pediatricians, to also be well trained in rich in added sugars, sodium, and/or saturated fat.
Conclusion
The first 1,000 days of life represent a highly sensitive period of In order to foster optimal child development and prevent
time for children to learn to accept and like healthy food. Given excessive weight gain, it is also important for additional
that the food and beverages infants and toddlers are exposed to responsive parenting principles, including physical activity,
depend primarily on their caregivers, it is crucial that caregivers soothing, and sleep, to be considered as these have also
have access to the foods and tools necessary to foster healthy been shown to influence early life feeding behaviors and
eating practices, such as those recommended in this expert weight outcomes.
panel report. While previous guidelines in the United States
and other countries have included responsive parenting/feeding The primary audience for the complete recommendations
principles, the evidence-based guidelines produced by the presented in this report is caregivers, including, but not limited
expert panel provide the most comprehensive and pragmatic to caregivers in the home setting. These guidelines can also
approach to date for communicating to caregivers what and be applied through child-care settings where many infants
how best to feed infants and toddlers, while also taking into and toddlers are now being served. The guidelines also make
account the rapidly changing developmental stages during the recommendations about system changes that are needed to
first two years of life. adequately support parents and caregivers in implementing the
recommended guidelines.
Expert Panel Members
Rafael Pérez-Escamilla, PhD, MS (Panel Chair) Martha Ann Keels, DDS, PhD
Professor of Epidemiology and Public Health Associate Consulting Professor, Department of Surgery
Director, Global Health Concentration Adjunct Associate Professor, Department of Pediatrics
Director, Office of Public Health Practice Duke University, Durham, NC
Yale School of Public Health, New Haven, CT Adjunct Associate Professor in Pediatric Dentistry
UNC School of Dentistry, Chapel Hill, NC
Sofia Segura-Pérez, MS, RD (Panel Co-Chair)
Associate Unit Director Angela Odoms-Young, PhD
Community Nutrition Unit Associate Professor, Kinesiology and Nutrition
Hispanic Health Council, Hartford, CT Department of Kinesiology and Nutrition
College of Applied Health Sciences
Stephanie Anzman-Frasca, PhD University of Illinois at Chicago, Chicago, IL
Assistant Professor of Pediatrics
Jacobs School of Medicine and Biomedical Sciences Ian M. Paul, MD, MSc
University at Buffalo, Buffalo, NY Professor of Pediatrics and Public Health Sciences
Chief, Division of Academic General Pediatrics
Shari Barkin, MD, MSHS Vice Chair of Clinical Affairs, Department of Pediatrics
William K. Warren Foundation Endowed Chair Penn State College of Medicine, Hershey, PA
and Professor of Pediatrics
Director, Division of General Pediatrics Lorrene Ritchie, PhD, RD
Director, Pediatric Obesity Research Director and Cooperative Extension Specialist
Vanderbilt University School of Medicine, Nashville, TN Nutrition Policy Institute
Division of Agriculture and Natural Resources
Leann Birch, PhD, MA University of California, Berkeley, CA
William P. ‘Bill” Flatt Professor in Department
of Foods and Nutrition Anna Maria Siega-Riz, PhD
College of Family and Consumer Sciences Professor of Public Health Sciences and Obstetrics
University of Georgia, Athens, GA and Gynecology
School of Medicine
Katrina Holt, MPH, MS, RD, FAND University of Virginia, Charlottesville, VA
Research Professor of the Practice
McCourt School of Public Policy Madeleine Sigman-Grant, PhD, RD
Georgetown University, Washington, DC Associate Editor, Journal of Nutrition Education and Behavior
Professor Emeritus with University of Nevada-Reno
Jennifer Orlet Fisher, PhD, MA Maternal & Child Health Extension Specialist
Professor, Department of Social Behavioral Sciences University of Nevada-Reno, Reno, NV
Associate Director of the Center for Obesity Research Education
Director, Family Eating Laboratory Elsie M. Taveras, MD, MPH
Temple University, Philadelphia, PA Chief, Division of General Academic Pediatrics,
Department of Pediatrics
Rachel K. Johnson, PhD, MPH, RD Massachusetts General Hospital for Children, Boston, MA
Robert L. Bickford Jr. Green and Gold Professor of Nutrition Associate Professor of Pediatrics, Harvard Medical School
Department of Nutrition and Food Sciences Associate Professor of Nutrition, Harvard School of Public
College of Agriculture and Life Sciences Health, Boston, MA
Professor of Pediatrics
College of Medicine Shannon Whaley, PhD
University of Vermont, Burlington, VT Director, Research and Evaluation Division
Public Health Foundation Enterprises WIC Program,
Irwindale, CA
Panel Conveners Panel Support
Mary Story, PhD, RD Emily Welker, MPH, RD

Director, Healthy Eating Research Research Associate, Healthy Eating Research
Professor, Global Health and Community and Duke Global Health Institute, Durham, NC
Family Medicine
Associate Director of Education and Training Vivien Needham
Duke Global Health Institute, Durham, NC Program Assistant, Healthy Eating Research
Duke Global Health Institute, Durham, NC
Megan Lott, MPH, RDN
Senior Associate of Policy and Research,
Healthy Eating Research
Duke Global Health Institute, Durham, NC
This issue brief is based on the full report of this expert panel. Acknowledgments
The full list of citations can be found in the full report:
The expert panel was supported by Healthy Eating Research, a
Pérez-Escamilla R, Segura-Pérez S, Lott M, on behalf of the national program of the Robert Wood Johnson Foundation.
RWJF HER Expert Panel on Best Practices for Promoting We also express our appreciation to our liaisons from the
Healthy Nutrition, Feeding Patterns, and Weight Status Pregnancy and Birth to 24 Months Project (P/B-24) at the
for Infants and Toddlers from Birth to 24 Months. Feeding U.S. Department of Agriculture Center for Nutrition Policy
Guidelines for Infants and Young Toddlers: A Responsive Parenting and Promotion (USDA-CNPP) (Maureen Spill, PhD) and
Approach. Durham, NC: Healthy Eating Research, 2017. our colleagues at the U.S. Department of Health and Human
Available at http://healthyeatingresearch.org. Services Centers for Disease Control and Prevention (DHHS-
CDC) (Heather Hamner, PhD, MS, MPH; Cria Perrine,
PhD) who observed the guidelines’ development process and
Suggested Citation responded promptly and efficiently to queries made from the
panel. We are very grateful to those involved with the USDA/
Pérez-Escamilla R, Segura-Pérez S, Lott M, on behalf of the DHHS P/B-24 Project for providing and allowing us to use
RWJF HER Expert Panel on Best Practices for Promoting their working definition for complementary feeding and
Healthy Nutrition, Feeding Patterns, and Weight Status complementary foods. We would also like to thank Claire
for Infants and Toddlers from Birth to 24 Months. Feeding Gibbons, PhD, MPH (Robert Wood Johnson Foundation),
Guidelines for Infants and Young Toddlers: A Responsive Parenting Jamie B. Bussel, MPH (Robert Wood Johnson Foundation),
Approach. Guidelines for Health Professionals. Durham, NC: and Tracy A. Fox, MPH, RD (Food, Nutrition and Policy
Healthy Eating Research, 2017. Available at Consultants, LLC) for their guidance and counsel throughout
http://healthyeatingresearch.org the expert panel process.
Appendix 1.
Infant Feeding Guidelines: What to Feed From Pregnancy to One Year
Prenatal & Postnatal
■■ Healthy eating during pregnancy and while breastfeeding, including consuming plenty of vegetables and fruits, will help shape
your child’s preferences for healthy and nutritious food.
■■ Eating fatty fish during pregnancy and while you breastfeed will provide your baby with more omega 3 fatty acids which are
needed for the optimal development of her/his brain. Guidelines for safely eating fish during pregnancy and while breastfeeding
can be found at http://www.fda.gov/food/foodborneillnesscontaminants/metals/ucm393070.htm and https://www.epa.gov/fish-
tech/epa-fda-advisory-mercury-fish-and-shellfish.
0 to 6 Months
■■ For the first 6 months (or until the introduction of solid food), most babies only need breast milk (or formula). Breast milk provides
nearly all the nutrients needed for optimal growth, and strengthens the infant’s immune system. The composition of breast milk
changes as your baby grows to match her/his individual nutritional needs. Breastfeeding is recommended to continue until your
baby is at least 1 year old.
■■ It is recommended that exclusively breastfed infants receive a daily supplement of vitamin D (400 IU), since this vitamin is low in
breast milk. Infant formulas are fortified with vitamin D. However, if your baby consumes less than 1 liter per day of formula, your
doctor may advise a vitamin D supplement for your baby.
■■ If you are not feeding your baby breast milk, iron-fortified formula is the next best choice to satisfy your baby’s nutritional needs during
the first six months of life. Do not feed low-iron formulas (those that have less than 6.7 milligrams of iron per liter) to your baby.
■■ Newborns consume about 1 to 2 ounces of formula per feeding occasion during the first month of life. This amount increases
to about 2 to 3 ounces per feeding during the second month, and then gradually increases to 4 to 6 ounces by 5 months. Pay
attention to your baby’s hunger and fullness signals and never pressure her/him to finish the bottle. Your baby does not need to
finish the formula in the bottle.
■■ Be cautious about the volume of formula or expressed breast milk given at each feed. Studies have shown that bottle size
matters. The bigger the bottle used, the more likely the baby will be to consume more than needed.
■■ It is not recommended to offer fruit juices or sugar-sweetened beverages before your baby’s first year of life.
■■ Only breast milk or formula should be fed with a bottle to babies. Don’t add cereal to the milk in your baby’s bottle. This practice
will not improve the sleep of your baby at night and it may interfere with how well nutrients in breast milk or formula are absorbed.
6 to 12 Months
■■ When your baby is between 4 and 6 months old, pay attention to her/his developmental signs to find out if your baby is ready
to start eating solid food. Signs your baby is ready include sitting up unsupported, munching and chewing food, and the ability
to swallow food, grasp items, and bring food to her/his mouth. If your baby pushes solids out with her/his tongue when food is
offered (thrust reflex), and/or gags when a spoon or food is placed in her/his mouth then she/he is not yet ready to be introduced
to solid food.
■■ Sometime between 4 and 6 months (when your baby is developmentally ready) your baby’s nutritional needs can no longer be
met by breast milk or formula alone. At this time, gradually start introducing solid food by offering 1 to 2 teaspoons of a pureed or
mashed food, slowly increasing the amount while paying attention to your baby’s hunger and fullness signals. If your baby is still
hungry after consuming the small amount of solids recommended, then feed breast milk or formula.
■■ Mothers who choose to breastfeed are encouraged to continue breastfeeding until their babies are at least 1 year old.
■■ From 6 to 12 months, breast milk or formula continues to be the most important source of nourishment for your baby. Solid food
needs to be introduced gradually. Solid food will initially provide about one-third, increasing to over half, of the total calories that
your baby needs by the time she/he is 1 year old. Examples of the amount of solids needed between 6 and 12 months can be
found at: http://www.fns.usda.gov/sites/default/files/cacfp/CACFP_infantmealpattern.pdf.
■■ Exclusively breastfed babies need to get started on solid foods that are rich in iron and zinc sometime between 4 and 6 months,
because by that time breast milk does not provide enough of these nutrients. Iron-zinc fortified baby cereals or pureed/mashed
meats are recommended as first solid foods for exclusively breastfed babies. In general, about 2 servings per day of cereal (2
tablespoons/serving) OR 1 to 2 ounces of meat per day is recommended to meet the need for these nutrients. However, each
baby needs different amounts to start. Pay attention to your baby’s hunger and fullness signals to find out how much your baby
needs to eat.
Appendix 1. Infant Feeding Guidelines: What to Feed From Pregnancy to One Year (cont.)
6 to 12 Months (cont.)
■■ If you choose to formula feed, it is recommended that you give your baby formula fortified with iron and zinc. The gradual
introduction of solid food to your baby sometime between 4 and 6 months of age is important because it supports her/his ability
to learn to eat a variety of healthy food with different textures and flavors. Introduction of solid food also helps with your baby’s
development, including social skills.
■■ After introducing iron- and zinc-fortified baby cereals or mashed meats, there is no particular order to follow for introducing solid
food. At this point, your baby is able to digest and absorb the nutrients from healthy food belonging to different food groups.
However, it’s important to keep in mind that the earlier vegetables are introduced (once your baby is ready to consume solid
food), the more she/he is likely to easily accept them.
■■ When introducing a new vegetable, it is recommended to mix it first with a familiar food such as breast milk, formula, or cereal.
Combining new food items that are more difficult to accept by babies, such as some vegetables, with food they are already
familiar with can help your baby accept and learn to like vegetables more readily.
■■ Introduce your baby to a variety of food from all the food groups (vegetables, fruits, grains, meats/protein, dairy) by the time she/
he is 7 to 8 months old.
■■ Offering a variety of vegetables and fruits and avoiding food of limited nutritional value, such as those high in calories, sugar, salt,
and fat (e.g., French fries, sugary cereals, cookies), helps your child gain a healthy amount of weight.
■■ What your baby eats at around 9 months is indicative of what she/he will like to eat when school-aged. Offer your baby a variety
of vegetables and fruits and whole grain products (e.g., brown rice, whole grain cereals).
■■ It is important to introduce your baby to a large variety of vegetables and fruits prepared in different healthy ways and textures
before she/he turns 1 year old. This will expose your baby to an array of flavors and textures that will make it easier for her/him to
accept and learn to like healthy food from all the food groups (fruits, vegetables, whole grains, dairy, and protein). Your baby will
also learn to self-control the desire for unhealthy food that has excessive amounts of added sugars, sodium (salt), saturated fat,
and calories.
■■ Sometime between 6 and 8 months, introduce your baby to pureed or mashed food, and gradually transition into lumpy food
and soft finger food. Then, between 8 and 12 months, your baby can start eating minced, chopped food and hard finger food.
Experiencing different textures will help your baby with her/his chewing skills, and with learning to accept and like different healthy
food. Encourage your baby to self-feed as soon as she/he is ready.
■■ Between 6 and 11 months, babies eat about every two to three hours or about five or six occasions during the day.
■■ Besides offering 6 to 8 ounces of breast milk or iron-fortified formula, at each meal you can offer your baby:
–– Up to 4 tablespoons of iron-fortified infant cereal or protein foods (meats, eggs, legumes) or dairy foods such as cottage
cheese (up to 4 ounces), cheese (up to 2 ounces), or yogurt (up to 8 ounces)
AND
–– Up to 2 tablespoons of vegetables or fruit
■■ For a smaller meal or snack you can offer breast milk or formula (2 to 4 ounces), AND:
–– Up to ½ slice of whole grain bread or up to 2 whole grain crackers, or up to 4 tablespoons of iron-fortified infant cereal
AND
–– Up to 2 tablespoons of vegetables or fruit, or a combination of both
■■ Once your baby starts solid food, it is recommended to offer a total of 4 to 8 ounces per day of plain drinking water in a cup. This
will help your baby get familiar with the taste and to learn to like plain water.
■■ When preparing food for your infant, do not add salt or sugar. Likewise, when choosing baby food that is already prepared,
choose options without (or with limited amounts of) added salt or sugars. This will help your baby learn to like the natural flavors
of food and help your child avoid consuming excessive amounts of salt and sugar later on in life.
■■ Feed your baby only healthy food that provides plenty of vitamins, minerals, and fiber, including fresh vegetables, fruits, and age-
appropriate whole grain products. Also, make sure to feed your baby nutritious food that provides an adequate amount of protein
(such as eggs, fish, meat) and energy.
Appendix 1. Infant Feeding Guidelines: What to Feed From Pregnancy to One Year (cont.)
Foods to Avoid or Limit
■■ Cow’s milk should NOT be offered before the child turns 1 year old because it may cause intestinal bleeding.
■■ Plant-based beverages (e.g., soy, rice, almond milks) are NOT recommended for your child in place of breast milk or formula,
unless prescribed by your pediatrician (e.g., commercially prepared soy-based infant formula). These beverages are not designed
to meet the nutritional needs of your child to the same extent as breast milk or infant formula.
■■ It is recommended to offer mashed fresh fruits instead of fruit juices since they have a higher nutritional value. Also, keep in mind
that fruit juices and sugar-sweetened beverages are a concentrated source of calories that may displace other food with better
nutritional value, or discourage your baby from eating other nutritious food that is not sweet. AVOID introducing fruit juices during
the first year of life. Avoiding sugar-sweetened beverages can also help prevent dental cavities.
■■ It is strongly recommended to offer NO sugar-sweetened beverages such as flavored drinks (including Kool-Aid, fruit drinks,
sodas, horchata (sweetened rice water), sports drinks, sweetened teas, or any other sugar-sweetened beverages) to your baby
during the first year of life. Doing so could reinforce your baby’s strong preference for sugary food and beverages and make it
more difficult for her/him to learn to like healthy food such as vegetables, fruits, and plain water.
■■ Before choosing food for your baby, check the food label and ingredient list. Choose food with no or very limited amounts of
added sugars and sodium (salt).
■■ Honey should NOT be given to children under 12 months old since it may cause a serious condition known as botulism.
■■ Supervise your child during feeding time and avoid offering food items that are a choking hazard such as nuts, grapes, popcorn,
hot dogs, and hard candies.
Spoon, Cup, and Self-Feeding
■■ Between 6 and 12 months, it is recommended to transition infants from using a bottle to a cup.
■■ By 12 months, your baby should be able to spoon feed herself/himself and hold a cup with both hands.
■■ At around 6 months, you can use a baby spoon to start offering pureed food, and water in a sippy cup held by an adult.
■■ At around 8 months, your baby will start to try to spoon-feed by herself/himself, and she/he most likely will be able to drink from
a cup with less spilling.
■■ Babies prefer to use their hands to explore solid food. Although this is messy, it allows the child the opportunity to explore and
learn to like healthy food. Encourage your baby to self-feed.
Appendix 2.
Toddler Feeding Guidelines: What to Feed During the Second Year of Life
Developmentally Appropriate Feeding
■■ One- to 2-year-olds have small tummies and can only eat small portions at a time, so they should eat five to six times a day (this
can be from meals and healthy snacks). Sliced fresh fruit (e.g., apples, peaches, strawberries), cooked vegetables or vegetables
with dip (e.g., carrots, broccoli, peas), and whole grain crackers with cheese are all good ideas of healthy snacks.
■■ By 1 year of age, children need about 1,000 calories every day. However, each child has different needs, so pay attention to her/
his hunger and fullness signals. Examples of healthy meal patterns that provide adequate amount of nutrients and calories for 1-
to 2-year-olds can be found at: http://www.fns.usda.gov/sites/default/files/cacfp/CACFP_childadultmealstandards.pdf.
■■ Once your child is 1 year old, structure eating occasions—she/he needs to eat three meals and two to three healthy snacks at
about the same time every day. Following a regular schedule will help your child learn when and what to expect to eat during the
day. However, don’t worry if your child decides to skip a meal or snack. What is important is for you to remember to offer the food
and let her/him decide how much she/he wants to eat.
■■ As much as possible make sure that your child’s meals are part of your family meals. Toddlers learn to eat table food and socialize
during family meals.
Milk
■■ The American Academy of Pediatrics recommends giving pasteurized whole cow’s milk to 1- to 2-year-olds. However, your health
care provider may recommend pasteurized reduced fat milk (2%) instead if there is a family history of obesity or heart problems.
■■ Offer cow’s milk with no added sugars (e.g., no flavored milks). Added sugars may interfere with the development of your toddler’s
preferences for healthy food (such as vegetables and fruit) and may cause oral health problems, including dental cavities, and lead
to extra calorie intake.
■■ Give your toddler cow’s milk in a cup instead of a bottle. Offering milk in a cup instead of a bottle can help your toddler improve
his/her motor skills.
■■ Too much milk may decrease your toddler’s appetite for other food needed to meet nutritional needs. Keep your child’s total milk
consumption to no more than 2 cups (16 fluid ounces) per day while offering a variety of healthy food.
■■ At each meal, or as part of a snack, offer your toddler ½ cup (4 ounces) of milk.
■■ You can offer ½ to ¾ cup of yogurt in place of milk during meal or snack times, but serve only plain yogurt or yogurt without
excessive total sugars (no more than 23 grams per 6 ounces). Plain yogurt can be mixed with fruits to increase its acceptance by
your toddler.
■■ It is fine to continue breastfeeding beyond one year if desired by parent and child. The frequency of breastfeeding and how long
each nursing episode lasts typically decreases quite a bit during this time as your child consumes more solid food.
■■ Bottle feeding is strongly discouraged after 12 months. Try to wean your child from the bottle by the time she/he is 1 year old.
Doing so will reduce the risk of dental cavities and other dental problems later on.
Water, Fruit Juice, and Sugar-Sweetened Beverages
■■ Water is the best option to quench your child’s thirst. Your toddler needs about 2 cups of water per day to cover her/his fluids
needs. Use a cup to offer water. Do not serve sugar-sweetened beverages (e.g., soft drinks, sports drinks, fruit drinks, energy
drinks, sweetened teas). Your toddler is still learning to accept and like healthy food and beverages, and consuming sugar-
sweetened beverages can interfere with this process.
■■ Whenever possible, offer fresh fruit instead of 100% fruit juice to your toddler since whole fruit provides less sugar and more fiber
than juice. Avoid fruit canned in heavy syrup or with sugar added. Excessive fruit juice and fruit with added sugar can displace
other nutritious food and lead to dental cavities.
■■ If you decide to offer 100% fruit juice to your toddler, limit intake to no more than 4 ounces per day and offer it with a cup,
not a bottle.
■■ Don’t put your toddler to sleep with a bottle or sippy cup. This can cause dental cavities and other oral health problems.
Appendix 2. Toddler Feeding Guidelines: What to Feed During the Second Year of Life (cont.)
Dietary Diversity
■■ Plan meals and snacks to provide a variety of healthy food from all food groups (fruits, vegetables, meats/protein, dairy, whole grains).
■■ Multivitamins are not needed if your child is eating a healthy nutritious diet. If your doctor or health care provider recommends giving
multivitamins to your child, choose brands that are low in sugar. Talk to your dentist if you don’t know which ones are low in sugar.
■■ Include a variety of vegetables, especially dark green, red, and orange types. These vegetables are rich in many nutrients that
are difficult to get in adequate amounts from other food. Exposure to a variety of vegetables will also help your child learn to like
vegetables. Offer ¼ to ½ cup of vegetables at most eating occasions.
■■ Offer a variety of fruits of different colors. Offer your child ¼ to ½ cup of fruit at each eating occasion.
■■ Provide a variety of poultry, fish, meats, and meat alternates (e.g., beans, lentils, tofu) to your toddler. Offer ½ to 1 ounce of
poultry, fish, meat or meat alternate at most meals and snacks. Avoid feeding your toddler food that is high in sodium (salt) such
as processed meats like ham, lunch meats, and packaged breaded chicken and fish.
Snacks
■■ Offer only nutritious snacks to your toddler. Remember that at this age, snacks are a very important source of nutrients for growth
and development and help to shape eating habits for life. At most snacking occasions, include a fruit or a vegetable combined
with food from the grain or dairy group.
Whole Grains and Fiber, Omega 3 Fatty Acids
■■ Offer your toddler whole grain food, such as whole wheat bread, whole wheat pasta, corn tortillas, or brown rice. These food
items are rich in fiber which is often missing from children’s diets. Offer ½ to 1 slice of whole grain bread, or ¼ to ½ cup of whole
grain cereal or pasta at most meals and snacks.
■■ Offer your toddler deboned fish such as salmon, white tuna, and trout. Fish is a good source of healthy fats known as omega 3s
that are very important for brain development.
■■ Choose food for your toddler prepared with healthy oils, such as olive, canola, corn, or sunflower oil.
Limit Sugar and Sodium and Avoid Trans Fats
■■ Avoid adding too much salt or sugar to your toddler’s food. Otherwise your child will develop a strong preference for salty and
sweet food and beverages. Remember that the food that you prepare can be seasoned with natural herbs and spices (e.g., basil,
oregano, cumin, chili, ginger) instead of salt, sugar, honey, and other sweeteners.
■■ Read food labels and the list of ingredients when choosing already prepared food for your toddler. Avoid food that has high
amounts of any type of added sugars, including high fructose corn syrup (e.g., sugar-sweetened beverages like Kool-Aid, sodas,
sports drinks) or sodium (e.g., packaged macaroni and cheese) or that contains any amount of trans fats (e.g., French fries). The
American Heart Association and the Academy of Nutrition and Dietetics both recommend that children under 2 years old should
not consume any added sugars from food or beverages.
■■ Limit your toddler’s consumption of snacks high in sodium and with added sugars. Remember that your toddler is still learning to
develop eating habits for the rest of her/his life.
Appendix 3.
Responsive Parenting/Feeding Guidelines for Caregivers:
How to Feed in the First 6 Months
Responsive Feeding; Hunger and Satiety Cues
■■ Responsive feeding involves recognizing and understanding your baby’s hunger and satiety cues and associated behaviors and
responding accordingly through a warm and nurturing relationship.
■■ Babies are born with a natural ability that helps control their appetite. It’s important for you to learn how to interpret and respond
accordingly to your baby’s hunger and fullness signals. Being able to do that takes some learning.
■■ Misinterpreting your baby’s hunger and fullness signs can reduce your baby’s ability to self-control her/his appetite and lead to
overeating as she/he grows up.
■■ Help your baby learn to eat only in response to hunger and stop when full, so that she/he doesn’t learn to eat for reasons other
than hunger.
■■ Crying by itself cannot be interpreted as a sign of hunger. Additional cues that may indicate that your baby is hungry at this age
are: bringing hands to mouth, rooting reflex (ability that babies are born with to help with breastfeeding; it involves turning their
heads toward anything that strokes their cheek or mouth), sucking noises, fast breathing, clenching fingers, flexing arms and legs.
■■ Although many parents interpret crying as a sign that the baby is hungry, it is important to remember that babies cry for many
reasons—they may be wet, uncomfortable, or tired.
■■ When your baby cries, before offering food, try to soothe to calm her/him down and first check for things that are making your
baby uncomfortable. Doing this may help you avoid overfeeding your baby or setting up the expectation that crying will always
lead to feeding.
■■ Your baby will let you know when she/he is full and no longer wants to eat. For example, at this age she/he may push you away,
stop sucking, extend or relax her/his arms, legs, and fingers, or simply fall asleep.
■■ Babies have tiny stomachs, so they need to feed often throughout the day.
Baby’s Wake/Sleep Cycles
■■ Parents may feel overwhelmed when their babies cry or seem fussy.
■■ During a typical day between 4 months and 1 year, a baby sleeps from 12 to 16 hours distributed across frequent wake/sleep
cycles.
■■ During the first month of life, it’s normal and part of healthy development for babies to wake up three or more times at night, and
sleep for short periods of time during the day.
■■ As your baby approaches 6 months, it’s normal for her/him to sleep through the night.
■■ As your baby grows, she/he will sleep for longer periods of time during the night. However, at times your baby’s sleep patterns
may fluctuate. She/he will typically get back on track, so be consistent with how you respond to your baby’s waking at night.
■■ Strategies recommended for responding appropriately to night waking include: waiting a minute to see if baby settles on her/
his own and then going in and trying soothing techniques besides feeding if not showing hunger signs (lengthening the wait
time as the child develops); feeding if hungry; making nighttime visits short and relatively “quiet” so that the baby doesn’t expect
stimulation time in the middle of the night.
Soothing Techniques to Calm a Baby
■■ Use soothing techniques to calm a crying baby, such as rocking, swinging, swaddling, repeating a word, shushing, or changing
her/his environment.
■■ Some, but not all, babies may need a pacifier to calm down.
■■ If your baby was recently fed and is crying or fussy make sure to check for things that are making her/him uncomfortable, such as
a wet diaper, and try to calm her/him down using soothing techniques.
Appendix 3. Responsive Parenting/Feeding Guidelines for Caregivers: How to Feed in the First 6 Months (cont.)
Temperament
■■ Knowing your baby’s temperament and causes of fussiness can help you to interpret the soothing and feeding needs she/he is
communicating, and help your baby develop and grow well.
■■ Your baby’s fussiness is not always related to hunger. For example, it may be related to being wet, too warm or cold, tired,
overstimulated, teething, or being ill.
■■ Some babies have a fussier personality or temperament than others or experience times that they are more fussy than usual.
Fussiness could be interpreted as a baby being hungry when it’s not, and could lead to overfeeding.
Pressure to Finish a Feed
■■ Don’t force your baby to finish the bottle or continue eating from your breast, since this will interfere with the baby’s natural ability
for appetite control down the road. Remember that your baby knows when to stop feeding.
Bottle Use
■■ Be cautious about the volume of formula or breast milk given at each feed. Studies have shown that bottle size matters. The
bigger the bottle used, the more likely babies will be fed more than what they need.
■■ It is not recommended to mix cereal with formula or breast milk in a bottle. There is no evidence that this helps babies sleep
longer and it could be a choking hazard.
■■ Feeding cereal in a bottle can diminish your baby’s ability to regulate her/his appetite resulting in overfeeding and gaining weight
excessively.
■■ Feeding cereal in a bottle to infants 0 to 6 months may cause discomfort as their tummies may not be ready for the cereal.
■■ Do not practice “bottle propping” (leaning the bottle against a pillow or other support at the stage when babies cannot hold the
bottle on their own). This practice is an example of nonresponsive feeding.
■■ You should not put your baby to bed with a bottle. This practice can affect the health of the baby’s teeth and is an example of
nonresponsive feeding.
Introduction to Solid Food
■■ It is not recommended to introduce solid food before baby is 4 months old as the baby’s body is not ready and this adds
unnecessary calories to her/his diet.
■■ Infants should be fed only breast milk and/or formula for about 6 months. However, babies may be ready to be introduced to solid
food between 4 and 6 months if they are able to sit with good head control and showing other signs of readiness.
■■ Babies are likely to be ready to be introduced to solid food if they can sit up well with little or no support, have good head control,
do not automatically push solids out of their mouths, and are able to munch and swallow. They may also show interest in food,
including trying to grab it and put it in their mouths.
Feeding Environment
■■ Feed your baby in a pleasant environment where you can interact warmly with your baby.
■■ Do not pressure your baby to finish the bottle or food on the plate.
■■ Do not give a bottle or food to your baby as a reward for behaving the way you want. Only offer food in response to your baby’s
hunger signals.
■■ Do not feed your baby in front of the TV. Meals should be a bonding and social occasion where both parent and baby benefit
from the nurturing interactions that occur during a feed.
■■ Remember to interact warmly and to be responsive to your child’s behaviors while feeding.
■■ Avoid distractions while feeding your baby, including using your smartphone. Your baby requires your full attention and interaction
while eating.
Appendix 4.
How to Feed During 6 to 12 Months
Responsive Feeding, Meals, and Sleeping Routines
■■ Expect that at around 6 months your baby will be able to sit, chew, and swallow semi-solid food. These are skills your baby needs
to have before starting to eat solid food.
■■ Sometime between 6 and 12 months your baby will be able to self-feed either with a spoon or by holding age-appropriate finger
food. Encourage your baby to do so.
■■ From 6 to 12 months, continue following your baby’s hunger and fullness signals. Remember that adequately responding to her/
him in a prompt and caring way will help your baby develop healthy eating habits.
■■ While paying attention to your baby’s hunger and fullness signs, keep in mind that your baby’s appetite may change during
periods of fast growth or when she/he is feeling sick.
■■ Hunger signs for 6- to 12-month-old babies include opening mouth when spoon gets near; reaching for the spoon or food;
pointing to food; getting excited when food is presented; and expressing a desire for specific foods with words or sounds.
■■ Fullness signs for 6- to 12-month-old babies often involve shaking of their head, turning head away from food, and not opening
mouth when spoon is close to indicate that no more food is desired.
■■ Establish a consistent regular schedule for your baby’s meals, snacks, and sleep times. Establishing routines can help your baby
set up good habits and learn when to expect to eat.
■■ Actively engage in conversations with your baby while feeding her/him and as you change routines throughout the day. Explain to
your baby what you are doing and what is coming next, and warmly respond to his/her verbal cues. These interactions will help
her/him to understand expectations and facilitate transitions.
■■ By 6 months, many babies sleep longer periods of time during the night, but they may still wake up. During night awakenings,
first give your baby an opportunity to self-soothe back to sleep before picking her/him up. If this does not work, before feeding try
using other soothing strategies that work for your baby.
■■ If your baby does not seem to be hungry during night awakening, check for things that may be making her/him uncomfortable
and soothe her/him to help her/him go back to sleep. Remember to keep night awakenings short and quiet.
■■ When your baby cries try to use soothing strategies to calm her/him down such as: (1) swaddling, (2) side or stomach position
while awake, (3) shushing, (4) swinging, and (5) sucking from a pacifier.
Mealtime as a Pleasant Experience
■■ Make sure to create a comfortable, stress-free, caring environment with few distractions when your child is eating.
■■ Make mealtime a pleasant experience for you and your baby. Talk warmly to your baby during feeding, and respond to her/his
sounds or words. Encourage, but don’t force, your baby to eat.
■■ Your baby will learn that you understand and will respond to her/his hunger and fullness signs. This will help you in building a
positive trusting relationship with your baby.
■■ Make your baby’s eating experience part of family meals. Preparing healthy meals for the whole family will introduce your baby to
these food items.
■■ During family mealtimes, place your child seated facing the other family members so that she/he has an opportunity to interact
with them.
Appendix 4. Responsive Parenting/Feeding Guidelines for Caregivers: How to Feed During 6 to 12 Months (cont.)
Introducing Your Baby to Different Flavors and Textures Using Responsive Feeding
■■ From around 6 months to 12 months, your baby will progress from assisted feeding to self-feeding. During this time offer your
baby food of different flavors and textures.
■■ Take your time feeding your baby, and be patient while offering new healthy food. Don’t give up if your baby doesn’t accept the
food the first time you offer it. Try again during a different eating occasion. It may take as many as 15 to 20 tries before your baby
learns to like a new food.
■■ Eating habits are established early in life, so it is important that parents only offer healthy food to their babies. Offer your baby
a variety of soft/cooked vegetables, fruits, and other healthy food with different flavors and textures so that she/he learns to
like them.
■■ Provide healthy, tasty food that is appropriate for your child’s age at regular times and in a pleasant environment, and let your
baby decide how much she/he wants to eat.
■■ Support your baby’s attempts to self-feed. Let your baby explore different food items and tastes with her/his hands. This is messy
but very important for your baby to develop healthy eating habits.
■■ When introduced to new food, some babies will make “faces” that look like they do not like the food. This is a normal part of
learning to like new food and does not mean your baby will dislike the food. Be patient and keep offering the food.
■■ Remember that it may take more tries for your baby to learn to like vegetables than other healthy food like fruits. Continue offering
a variety of vegetables and other healthy food, and let your child decide when she/he is ready. The most important thing is that
you keep offering vegetables. Be patient and keep trying.
Parental Role Modeling
■■ Babies imitate their caregivers. Eat a variety of healthy food in front of your baby, and always show a positive attitude towards
healthy food.
■■ Never force your baby to eat. Let her/him choose what and how much she/he wants to try and eat.
■■ Correctly interpreting hunger and fullness signs will allow your baby to learn how much food she/he needs to consume, and
prevent her/him from eating for reasons other than hunger.
Do Not Practice Restrictive Feeding with your Baby
■■ Some parents may be concerned about their babies not gaining enough or gaining too much weight. Trust your baby’s hunger
and fullness cues. Work with your pediatrician to resolve any weight gain concerns.
Screen Time and Physical Activity
■■ Avoid TV and other screen time during mealtimes. This can interfere with the opportunity for the baby, you, and other
members of the family to socialize and interact with each other. These interactions are very important for your baby’s
development and in the establishment of healthy eating habits.
■■ Engage in fun, developmentally appropriate active play with your baby every day.
■■ Provide supervised times during the day for your infant to freely move and explore the world around her/him.
Establishing Sleep and Feeding Routines
■■ It may take some time for you and your baby to establish a sleep and feeding routine. Once it happens, it’s important to be
consistent as having regular schedules can help babies be less fussy and develop healthy sleeping and feeding patterns.
■■ Expect normal growth spurts that may temporarily disrupt your baby’s regular schedule. Teething near 6 months of age may
also be temporarily disruptive. Try keeping your baby’s sleep and feeding routines as consistent as possible but be sensitive
to your baby’s needs during these transition times.
Appendix 5.
How to Feed During 12 to 24 Months
Responsive Mealtime Routines
■■ Establish a feeding routine for your child’s meals and snacks. Children of this age usually consume three meals and two or three
healthy snacks every day.
■■ Meal and snack time should be a pleasant experience for your toddler. Take the time your child needs to have a non-rushed and
enjoyable mealtime or snacking experience in a stress-free environment with few distractions (e.g., without TV or other distracting
screens).
■■ Eat with your toddler and let her/him be part of family meals. Talk to your toddler during meals and respond to her/his verbal and
non-verbal requests. Continue to pay attention to hunger and fullness signs. Don’t pressure your toddler to finish her/his plate.
■■ Provide a healthy food environment at home for your toddler. Offer healthy meals and snacks to the entire family and don’t have
unhealthy food around her/him, including sugar-sweetened beverages, sweets, salty snacks, and fried food/snacks.
■■ Screen time and media use during feeding is strongly discouraged since it can interfere with the caregiver-child interactions that
your toddler needs to experience in order to learn to eat healthy.
Self-Feeding and Transitioning to Table Food
■■ Let your child self-feed with age appropriate utensils such as baby spoons, toddler plates, and child size cups (e.g., sippy cups).
This is important for your toddler’s fine motor skills development and allowing her/him to decide when to start and stop eating in
response to her/his own hunger signals.
■■ By 1 year, your child is expected to have started transitioning into “table or family food” (non-pureed food items, such as chopped
cooked spinach, cooked green peas, diced cooked carrots, diced fruits, small bits of chicken, pasta, etc.). Your child should be
fully transitioned to “table or family food” by 2 years.
Learning to Like Healthy Food
■■ During the transition to family food, continue to expose your baby to healthy food including plenty of vegetables and fruits, and
avoid offering unhealthy food such as sugar-sweetened beverages, sweets, salty food/snacks, and fried food/snacks that are high
in added sugars, calories, and/or salt.
■■ It is normal for a child to continue to reject new food items the first time they are offered, especially those that taste bitter such as
vegetables. Don’t forget that it may continue to take some children up to 15 or 20 tries before accepting a new food.
■■ Let your child use all her/his senses to explore new food. Smelling, licking, touching, and playing with new foods is needed by
children to learn to like them. It does take time, and patience with messiness.
■■ Picky eating, including wanting just a few food items, is a common behavior among toddlers. During this period, children go
through major transitions in what and how they like to eat. Sometimes they even start refusing food they once liked (food jags). Be
patient with your toddler. Continue to uphold feeding routines, provide a variety of healthy food and textures, and encourage her/
him to try new foods or accept again food they previously liked. But do not pressure her/him, and continue allowing her/him to
determine how much to eat.
■■ Children learn from observing their caregivers’ behaviors. Caregivers and the family as a whole (as young children will model older
children as well as caregivers) are strongly encouraged to always eat healthy food and beverages (both inside the home and
when eating out). It’s also important to avoid making negative comments, facial expressions, or reactions about healthy food and
beverages in front of your child.
■■ Offer healthy food in a form appropriate for your child’s age, and in a manner that is easy to chew and swallow.
Appendix 5. Responsive Parenting/Feeding Guidelines for Caregivers: How to Feed During 12 to 24 Months (cont.)
Appetite Control and Pressure to Eat
■■ Children may eat less at one meal but compensate at another meal by eating more. Indeed, some 1-year-olds only eat a single
larger meal per day with smaller amounts at other times. Offer your child the recommended portion of healthy food from the
different food groups (fruits, vegetables, grains, proteins, dairy) at each meal, and let her/him decide how much to eat.
■■ Don’t pressure your toddler to eat, and don’t show signs of frustration or anger if your child decides not to eat the food that you
offer her/him. There is always a next time to try to offer the new food again.
■■ To minimize food waste, offer small tastes when new food is offered. You can always give more to your child if she/he is still
hungry. Also, if you are having a problem with fresh fruits and vegetables going bad before being consumed, consider using
frozen fruits and vegetables.
■■ Praising your child for eating a healthy food may encourage her/him to learn to like it. However, it is not recommended to use
food as a reward (e.g., giving candy as a reward for eating vegetables or for the child to stop crying) or “bribe” (e.g., offering a toy
in exchange for finishing all the food on the plate). Doing this can interfere with your child’s ability to learn how to control her/his
appetite.
■■ Offering sweets or sugar-sweetened beverages may be very tempting when your child is crying a lot or having a tantrum. Avoid
doing so as it may prevent your child from learning how to eat healthy and also control her/his own emotions.
Sleep Routines
■■ Set consistent bedtime and nap routines. From 12 to 24 months, children sleep between 11 to 14 hours per day, including at
night and naps. Children should be able to sleep throughout the night by this point. Children that have enough sleep are more
likely to eat and grow healthy.
Screen Time and Physical Activity
■■ From 12 to 24 months, screen time and media use should be limited as it can prevent your toddler from being physically
active and eating healthy. Also remember that your child’s language and social development is greatly facilitated by the social
interactions that you have with your child, including conversations.
■■ Video-chatting with relatives away from home can provide benefits to the development of your child if you or another adult
caregiver supervises the child.
■■ If you want to use digital media with your 18- to 24-month-old toddler choose high-quality programming/apps and use them
together with your child. Don’t let your child use the media by herself/himself.
■■ Do not expose your toddler to screens during meals and for one hour before bedtime.
■■ Avoid using media to calm your child.
■■ Keep bedrooms, mealtimes, and playtimes screen-free for you and your child.
■■ Avoid exposing your toddlers to apps with advertising and/or unhealthy messages.
■■ Caregivers are encouraged to be role models to their toddlers by limiting their own media use during those times when they are
interacting with them.
■■ Provide opportunities for your toddler to be active throughout the day every day, with structured (adult-guided) and unstructured
(free play) activities taking place both indoors and outdoors where she/he can move and play freely and safely. Play, walk,
dance, be active with your child and let her/him do physical activities on her/his own. Remember that toddlers like to move
around independently but still need close supervision when doing activities on their own.
■■ Toddlers are very energetic, moving constantly; they like to explore their environments, looking around and inside objects. Daily
and frequent age-appropriate, supervised, safe activities including jumping, walking, and pushing things around, throwing balls,
and dancing to music help toddlers release their energy. These activities also help with their motor development.
■■ Equipment that limits or controls a child’s movements, such as car seats, high chairs, cribs, small playpens, and strollers, should
be used only for what they were designed to do (safety, transportation, eating, sleeping) and not simply for confining the child to
a space.
Appendix 6. Food Safety for Infants and Toddlers
Food Safety Guidelines for Caregivers of Infants and Toddlers: Preventing Foodborne Illnesses
PASTEURIZATION AND COOKING TEMPERATURES
■■ Do not offer your child unpasteurized juice, milk, or dairy products.

■■ Do not offer your child undercooked meats, poultry, eggs (e.g., runny eggs), or seafood. Recommended cooking temperatures
can be found at http://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-
food-handling/safe-minimum-internal-temperature-chart/ct_index.
FOUR STEPS TO KEEP FOOD SAFE FROM BACTERIA
■■ Always follow these four steps to keep food safe from bacteria:
–– CLEAN: Wash hands and food preparation/serving surfaces often. Fruits and vegetables should be thoroughly rinsed with
warm water before offering to child.
–– SEPARATE: Keep raw meats, poultry, eggs, and fish separate from other ready-to-eat food.
–– COOK: Cook food to the proper internal temperatures (https://www.foodsafety.gov/keep/charts/mintemp.html).
–– CHILL: Keep cold food in the refrigerator and get other food into the refrigerator within two hours of being opened or prepared.
More information available at: https://www.foodsafety.gov/keep/index.html.
COLD STORAGE GUIDELINES
■■ The following cold storage guidelines should be followed:

–– Expressed breast milk at https://wicworks.fns.usda.gov/wicworks/Topics/FG/Chapter3_Breastfeeding.pdf, http://www.cdph.
ca.gov/programs/wicworks/Documents/NE/WIC-NE-EdMaterials-PumpingAndStoringBreastmilkForYourBaby.pdf
–– Infant formula at https://wicworks.fns.usda.gov/wicworks/Topics/FG/Chapter4_InfantFormulaFeeding.pdf, http://www.cdph.
ca.gov/programs/wicworks/Documents/NE/WIC-NE-EdMaterials-WhenYouFeedMeFormula.pdf
–– Strained fruits and vegetables (prepared at home or from open jarred food): should be kept a maximum of two to three days in
the refrigerator.
–– Strained meats (prepared at home or from open jarred food) and eggs: should be kept a maximum of one day in the refrigerator.
–– Meat and vegetable mixed dishes: should be kept a maximum of one to two days in the refrigerator.
–– The refrigerator temperature should be kept between 32 to 39 degrees Fahrenheit.
HANDLING OF LEFTOVERS
■■ At each feeding occasion, serve the portion that your child is likely to eat separate from the jar or bowl. This way you can avoid
the unconsumed portion getting mixed up with your baby’s saliva, and save for a future feeding. Discard any unconsumed food
that was part of the portion offered to the child.
■■ Always throw away any leftover formula or breast milk. Leftover formula or breast milk that has not been refrigerated can grow
germs and make your baby sick. Do not feed your baby breast milk or formula left at room temperature for more than one hour.
Note: Adapted from FoodSafety.gov (https://www.foodsafety.gov/risk/children/).
Appendix 6. Food Safety for Infants and Toddlers (cont.)
Food Safety Guidelines for Caregivers of Infants and Toddlers: Preventing Mouth Burns
■■ When microwaving solid food, do so in a dish and for short time intervals (e.g., test after 15 seconds on high). Let food stand for
30 seconds after microwaving and before offering to child; stir before serving.
■■ Before serving cooked food or re-heating solid food for your child, always test the temperature of the food to be offered. They
should feel lukewarm.
■■ There is no medical reason for warming expressed human milk or formula. If you do so, don’t warm by microwaving bottles with
breast milk or formula. They don’t heat evenly and can burn your child’s mouth.
■■ You can heat bottles with breast milk or formula by putting the bottle under hot running water from the tap for about two minutes.
You can also heat bottles by warming water in a pan on the stovetop, then removing it from the heat and putting the bottle in the
water until it feels lukewarm.
Note: Adapted from FoodSafety.gov (https://www.foodsafety.gov/risk/children/) and California WIC Program (https://wicworks.fns.usda.gov/wicworks/Sharing_Center/spg/
CA_report2006.pdf).
Food Safety Guidelines for Caregivers of Infants and Toddlers: Preventing Food Choking
■■ Supervise your infant during feeding time and avoid offering food items that are a choking hazard.
■■ Toddlers can choke on food items that have certain shapes (small and round) and/or textures (hard, very slippery or elastic).
Examples of common choking hazards are grapes, nuts, peanuts, popcorn, hard candy, carrots, hot dogs, meatballs, and
chewing gum. Avoid offering these food items, or cut the round food in half or quarters before serving.
■■ Sit your child in a high chair or secure to a seat for meals and snacks and supervise her/him at all times while eating. Remember
that eating while walking may increase risk of choking.
■■ If you offer fish to your toddler, which is strongly recommended, make sure it’s completely deboned.
Note: Guidelines adapted from AAP Committee on Nutrition (2013).
Appendix 7. Food Allergy Considerations for Infants and Toddlers
■■ There is no need for pregnant or breastfeeding women to avoid consuming common allergenic food items such as eggs, milk,
peanuts, tree nuts, fish, shellfish, and wheat. Doing so does not help lower the risk of food allergies in children.
■■ If the biological parent has allergies to any food items, talk to your child’s doctor about any precautions you need to take regarding
the introduction of common allergenic food items (such as products with peanuts, eggs, dairy, or wheat) to your infant.
■■ Ask your child’s doctor if you are considering using hydrolyzed or “hypoallergenic” infant formulas as these formulas have not
been found to help prevent food allergies in infants.
■■ You can introduce common allergenic food items to your baby when she/he is ready to eat solid food (usually between 4 and 6
months of age). These food items include dairy products such as yogurt or cow’s milk protein formula, eggs, soy, wheat, peanut
butter, fish, and shellfish.
■■ Introduce common allergenic food items to your baby after other solid food has been fed and tolerated, and with the first
taste being at home. If no reaction occurs, then you can gradually increase the amount at a rate of one new food every three
to five days.
■■ You do not need to avoid acidic food for your baby, such as berries, tomatoes, citrus fruits, and vegetables, that may cause a
rash around the mouth or buttocks. The rash is the result of irritation from the acid in the food, not from an allergic reaction to
the food.
■■ Some infants and toddlers do develop food allergies. If your infant or toddler develops signs of a food allergy (e.g., skin rashes,
trouble breathing, nausea, vomiting, or loose stools in response to feeding) seek medical care and advice right away. You may
also be referred to an allergist/immunologist—a doctor with experience in food allergy—for further evaluation.
■■ Your doctor may recommend a comprehensive evaluation and the development of a personalized plan to introduce solid food to
your infant.
Note: Guidelines adapted from American Academy of Allergy, Asthma & Immunology (2015) and Australasian Society of Clinical Immunology and Allergy (2016).
About Healthy Eating Research About the Robert Wood Johnson Foundation
Healthy Eating Research (HER) is a national program For more than 40 years the Robert Wood Johnson
of the Robert Wood Johnson Foundation. Technical Foundation has worked to improve health and health
assistance and direction are provided by Duke care. We are working with others to build a national
University and the University of Minnesota School of Culture of Health enabling everyone in America to live
Public Health under the direction of Mary Story, PhD, longer, healthier lives. For more information, visit
RD, program director, and Laura Klein, MPH, deputy www.rwjf.org. Follow the Foundation on Twitter at
director. HER supports research to identify, analyze, and www.rwjf.org/twitter or on Facebook at
evaluate environmental and policy strategies that can www.rwjf.org/facebook.
promote healthy eating among children and prevent
childhood obesity. Special emphasis is given to research
projects that benefit children and adolescents and
their families, especially in lower-income and racial and
ethnic populations at highest risk for obesity. For more
information, visit www.healthyeatingresearch.org or follow
HER on Twitter at @HEResearch.

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Feeding Guidelines for Infants

and Young Toddlers: A Responsive Healthy Eating

Executive Summary, February 2017

In the United States, a significant proportion of children

Early life diet and feeding behaviors play an important role

The federal government’s current Dietary Guidelines for

In 2016, Healthy Eating Research, a national program of the

Regardless of exposure during pregnancy and breastfeeding,

Other Important Considerations for Infants and Toddlers

Mary Story, PhD, RD Emily Welker, MPH, RD

Prenatal & Postnatal

Foods to Avoid or Limit

Spoon, Cup, and Self-Feeding

Developmentally Appropriate Feeding

Water, Fruit Juice, and Sugar-Sweetened Beverages

Whole Grains and Fiber, Omega 3 Fatty Acids

Limit Sugar and Sodium and Avoid Trans Fats

Responsive Feeding; Hunger and Satiety Cues

Baby’s Wake/Sleep Cycles

Soothing Techniques to Calm a Baby

Pressure to Finish a Feed

Introduction to Solid Food

Responsive Feeding, Meals, and Sleeping Routines

Mealtime as a Pleasant Experience

Parental Role Modeling

Do Not Practice Restrictive Feeding with your Baby

Screen Time and Physical Activity

Establishing Sleep and Feeding Routines

Responsive Mealtime Routines

Self-Feeding and Transitioning to Table Food

Learning to Like Healthy Food

Appetite Control and Pressure to Eat

Screen Time and Physical Activity

■■ Do not offer your child unpasteurized juice, milk, or dairy products.

FOUR STEPS TO KEEP FOOD SAFE FROM BACTERIA

COLD STORAGE GUIDELINES

■■ The following cold storage guidelines should be followed:

Note: Adapted from FoodSafety.gov (https://www.foodsafety.gov/risk/children/).

Note: Guidelines adapted from AAP Committee on Nutrition (2013).

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