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1. Alaptarea exclusiva pana la 6l si semne ca se poate incepe diversificarea:

Exclusive breastfeeding during the first six months is accepted as the nutrition standard forinfants according to the Dietary Reference Intakes, and is promoted by the World HealthOrgani ation !WHO" as a global public health recommendation !IO#, $%%&' WHO, $%%(")Exclusive breastfeeding from birth is recommended except in very fe* medical situations,and is important for the healthy gro*th and development of infants and toddlers !WHO,$%%(")

With exclusive breastfeeding, an infant is fed only breastmilk) +he infant is given no otherfood or li uid, not even *ater !WHO, $%%-") Infants *ho are exclusively breastfed may stillreceive vitamin and mineral supplements or medicines, in the form of drops or syrups) +heymay be given oral rehydration solution, if needed !WHO $%%-")

Exclusive breastfeeding to six months of age is associated *ith continued protection for theinfant against gastrointestinal infections and illness !.ramer et al), $%%(' .ramer / .akuma,$%%$" as *ell as respiratory tract infections !0hantry, Ho*ard, / 1uinger, $%%&") +he

breastfeeding mother also benefits from exclusively breastfeeding her infant to six months)Her *eight loss is more rapid after birth and there may be a delayed return of menses!.ramer / .akuma, $%%$")

By about six months of age, infants are developmentally ready for other foods (Naylor !orro", #$$1%. &he signs of physiological and developmental readiness include ('renier educ, #$$)%:

• Better head control•

Ability to sit up and lean for"ard• Ability to let the caregiver *no" "hen they are full (e.g., turns head a"ay%

• Ability to pic* up food and try to put it in their mouth

1t this stage, infants should be offered nutrient dense and safe complementary foods, along*ith continued breastfeeding !21HO, $%%(") +he first foods introduced should be iron3rich )

#. +espre laptele de vaca

+o reduce the risk of iron deficiency co* milk is not recommended for older infants beforenine to 4$ months of age) 0o* milk is lo* in iron, can displace iron3rich foods, and caninhibit iron absorption) 5se of co* milk as a main milk source for infants younger thansix months of age can cause gastrointestinal bleeding and increased occult blood loss in stool!#ichaelsen, $%%%' 6omon, 7elson, 8erfass, / 9eigler, $%%:' ;ondi / <ieu*, $%%=' 9iegleret al), 4===' >iang, >eter, 7elson, / 9iegler, $%%%' <eung, / 8auve, $%%(' 6ernandes, de#orais, / 1mancio, $%%-")

Once an older infant is regularly eating a *ide variety of iron3rich foods such as meat, meatalternatives, and iron fortified cereals, the introduction of co* milk is not associated *ith irondeficiency !?eung, / 9lotkin, $%%%' 1gostoni, / +urck, $%44")

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It is not @ust the early introduction of co* milk, but also the volume of co* milk consumedthat is a risk factor for iron deficiency !#aguire et al), $%4(' 1gostini, / +urck, $%44")Excessive consumption of co* milk has been identified as the most common risk factor forsevere anemia in young children !8andoval, ;erger, O kaynak, +ugal, / >ayabose, $%%$';ondi / <ieu*, $%%=")

6or young children, co* milk intake should not exceed A:% m< per day !.a al, $%%$' 0D0,4==-") 1t volumes in excess of A:% m<, co* milk can displace other foods that are sources of nutrients not found in milk) In addition to iron, fibre intake may be adversely affected, *hichcould lead to constipation !028, $%44") Offering milk in an open cup may help to avoidexcess consumption !#aguire et al), $%4(")

Boat milk poses the same risks for the development of iron deficiency as co* milk *henconsumed in excessive amounts by young children !0D0, 4==-")

. +espre grasimi in dieta bebelusului

Dietary fat restriction is not recommended for children younger than t*o years !2icciano etal), $%%%") +his is because it may compromise a young childCs intake of energy and essentialfats) +his can adversely affect gro*th and development !;utte et al), $%% ") +here is noevidence that such restrictions provide any benefits during childhood) 7utritious foods thatcontain fat, such as breastmilk, homogeni ed !()$: #)6)" co* milk, cheese, avocado andnut butters provide a concentrated energy source during a life stage *hen re uirements are

particularly high) 8imilar to the advice in 0anadaCs 6ood Buide , there is no need to restrictunsaturated fats such as vegetable oils, salad dressings, margarine and mayonnaise duringmeal preparation for young children)

6ish, particularly fatty fish, and breastmilk, depending on the motherCs dietary intake, aresources of the omega3( fats E21 !eicosapentaenoic acid" and DH1 !docosahexaenoic acid"!;utte et al), $%% ") +hese are produced by the body only in small amounts from other dietaryfats) While the optimal amount of E21 and DH1 for infants and young children has not beendetermined, parents and caregivers are encouraged to offer fish, as a good food source, and*ork up to t*o servings per *eek as a general guideline by $ months of age) 1dvise,ho*ever, that certain types of fish should be avoided, or at least limited to no more thanA: grams per month, because of the risk of overexposure to mercury) +hese fish include freshor fro en tuna, shark, s*ordfish, marlin, orange roughy and escolar) <earn more from theadvisory from Health 0anada )0onsult local, provincial, or territorial governments for

information about eating locally caught fish)

-. +espre sucurile de fructe

0hildren aged one to three form the highest percentage of fruit @uice consumers !Barriguet,$%%-") Drinking @uice has been associated *ith dental decay in young children !112, $%%4")6ruit @uice intake can displace intake of breastmilk and may contribute to inade uate intakesof nutrients from solid foods !8kinner, 9iegler, / 2on a, $%% ") Remind parents andcaregivers that young children have small stomachs and fill up uickly on beverages) ;ecauseof the fructose and sorbitol content of fruit @uices, excessive intake may also lead to diarrhea!112, $%%4")

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6ruit @uice lacks the fibre of *hole fruit) 6ruits and vegetables should be emphasised insteadof @uice as recommended in 0anadaCs 6ood Buide) Only 4%% fruit or vegetable @uice should

be offered)

Recommend offering *ater fre uently !1D1, $%% ") >uice should be offered much less

fre uently if at all) 1llo*ing children to carry a bottle, CsippyC cup, or @uice box aroundthroughout the day encourages constant consumption and over exposure of the teeth to sugar!1D1, $%% ' 112, $%%4") Offerings should be limited to no more than one or t*o times perday) 1pproximate daily amount could be 4$:34A: m<Fday !028, $%4(' 112, $%%4")

8*eetened beverages, such as pop, fruit drinks, punches and sports drinks have a high sugarcontent and lack vitamins and minerals) <ike fruit @uice, they can also increase the risk ofearly childhood caries, and should be limited) 5ns*eetened homogeni ed !()$: #)6)" milkis recommended over s*eetened milk, such as chocolate milk, or flavoured soy3based

beverages, such as chocolate and vanilla, *hich contain added sugar)

;everages containing caffeine or artificial s*eeteners should not be offered to youngchildren) 0offee, tea, some carbonated beverages, and hot chocolate may also containcaffeine or caffeine3related substances) 0affeine is a drug that acts as a stimulant) Other

beverages such as diet pop or fruit drinks contain artificial s*eeteners) +hese may interfere*ith a young childCs intake of nutritious, energy3dense foods needed for their rapid gro*th)

. +espre alergii

+here is no evidence that the order in *hich solid foods are introduced to older infants affectstheir risk of developing a food allergy) +his includes infants at risk of atopy !0han /

0ummings, 028 0ommunity 2aediatrics 0ommittee, $%4(' ;oyce et al), $%4%' 112, $%%-")0ommon food allergens , such as peanut, fish, *heat !including iron3fortified infant cereals*ith *heat", milk products, soy and *hole eggs, can be introduced from about six months ofage !0han, 0ummings / 028 0ommunity 2aediatrics 0ommittee, $%4(") 8everal of thesefoods, such as iron3fortified infant cereals *ith *heat, fish and *hole eggs, should be amongthe first solid foods offered because they are also a source of iron) 1t this age, these and other iron3rich foods, such as meat and meat alternatives and iron3fortified cereals are important tohelp meet the nutrient needs of the rapidly gro*ing older infant !De*ey / 0haparro, $%%A'#ein en3Derr et al), $%%&")

When introducing a food that is among the list of common food allergens, suggest that

parents and caregivers avoid offering more than one of these per day and *ait t*o days before they introduce another of the common food allergens) +his makes it easier to identify afood that may have caused a reaction)

When any ne* food is introduced, it is important that parents and caregivers *atch for signsof an allergic reaction ) +o reduce the risk of choking, also ensure that the foods offered arean appropriate texture and si e for the childCs age and development)

Once a potential food allergen has been introduced successfully, advise parents andcaregivers to continue to offer the food regularly in order to maintain the childCs tolerance!0han, 0ummings, / 028 0ommunity 2aediatrics 0ommittee, $%4(") 2arents and caregiversshould continue to introduce ne* foods to help ensure exposure to a *ide variety of familyfoods by one year of age)

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6or infants and young children *ith a family history of food allergy, health care providersshould approach each case on an individual basis)

6. +espre gag

Bagging is a natural reflex that helps older infants avoid choking !Rapley, $%44") 1scomplementary foods are introduced, gagging may occur *hen the infant is not yet able tocollect the food bolus and move it back*ards *ith efficiency !#orris / .lein, $%%%")Occasionally, food sticks to the back of the tongue or falls over the back before the s*allo*is triggered, resulting in the protective action of a gag or cough !#orris / .lein, $%%%") +hismay cause anxiety for parents and caregivers, until they are able to distinguish bet*eengagging and actual choking !;ro*n / <ee, $%44") 1s long as an older infant is attentive,sitting upright, and is free from distractions, the risk of choking is the same as for an adult!Rapley, $%44") +here are ho*ever, some food shapes and textures that are choking ha ards and should not be offered to children younger than four years)

/. 0inger food

Offering finger foods among the first complementary foods encourages self3feeding from theoutset !+o*nsend / 2itchford, $%4$' Rapley, $%44") +his approach is thought to takeadvantage of the critical period for oral and motor development, during *hich the older infantis ready to reach out for and CmunchC the food !Rapley, $%44' 8achs, $%44, WHO, 4==-'Wright, 0ameron, +siakas, / 2arkinson, $%44")

Reassure parents and caregivers that self3feeding is a developmental and experimental

process for the older infant and young child) +hey may not actually consume a significantamount of the finger foods) 6or older infants, it is important that finger foods are part of a dietthat provides a variety of textures !Wright, 0ameron, +siakas, / 2arkinson, $%44' WHO,4==-")

0ommon concerns about self3feeding include the mess created and food *aste !;ro*n /<ee, $%44") #essy mealtimes are part of the learning process) +o reduce *aste, encourage

parents and caregivers to offer small amounts of food and then offer more based on the childCscues)

). &extura alimentelor

1s an older infantCs neuromuscular system matures, the types and textures of complementaryfoods they are able to consume *ill gro* !WHO, 4==-") Infants process foods using fourage3related methodsG suckling, sucking, munching, and che*ing) 1n infant from birth tosix months *ill have the oral motor skills to suckle, suck, and s*allo* !WHO, 4==-")

During the initial stages of complementary feeding, the older infant develops up and do*nmandibular movements *hich allo* them to CmunchC) +hese movements permit consumptionof some solid foods, such as crackers, toast, and ready3to3eat breakfast cereals, regardless of*hether teeth have appeared !#orris / .lein, $%%%' WHO, 4==-") It is important that parentsand caregivers provide a variety of soft textures !such as lumpy, and tender3cooked and finelyminced, pureed, mashed or ground" and finger foods from six months of age) 8afe fingerfoods includeG pieces of soft3cooked vegetables and fruits' soft, ripe fruit such as banana'

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finely minced, ground or mashed cooked meat, deboned fish, and poultry' grated cheese' and bread crusts or toasts) 6or safety reasons, there are some food shapes and textures that shouldnot be offered to children younger than four years)

1lthough an older infant is capable of consuming more solid foods, the time re uired to

complete a feeding may take longer than *ith foods that are pureed !WHO, 4==-") 1n olderinfantCs efficiency in consuming purees *ill peak at about 4% months, but their ability toconsume other solid food textures *ill continue to improve until about $ months of age!WHO, 4==-") Bagging is a natural reflex that older infants may experience and should bediscussed *ith parents and caregivers)

;et*een about eight and 4$ months, the older infant develops lateral movements of thetongue) +hese allo* the older infant to move food to the teeth) +his movement enables bitingand che*ing of chopped foods and a greater variety of finger foods !WHO, 4==-")

It is important for parents and caregivers to progress uickly to foods *ith a lumpy texture)Delaying the introduction of lumpy textures beyond the age of nine months is associated *ithfeeding difficulties in older children and a lo*er intake of nutritious foods such as vegetablesand fruit !0oulthard, Harris / Emmett, $%%=")

;y 4$ months of age, young children should be offered a variety of family foods *ithmodified textures, such as ground, mashed, or chopped foods, *ith a tender consistency!#orris / .lein, $%%%") ;et*een 4$ and 4- months, young children *ill ac uire full che*ingmovements !WHO, 4==-")

. 2ranirea bebelusilor

CResponsive feedingC means that a parent or caregiver responds in a prompt, emotionallysupportive, and developmentally appropriate manner to the childCs hunger and satiety cues!Di8antis, Hodges, >ohnson, / 6isher, $%44") +his behaviour is not confined to one stage ofinfant or child development' it applies to breastfeeding on cue, introducing complementaryfoods, and feeding an older child)

3esponsive feeding

+o avoid under3 or overfeeding, parents and caregivers need to be sensitive to the hunger andsatiety cues of infants and young children) Responsive feeding !21HO, $%%(' Engle / 2elto,

$%44"G

• 1llo*s the child to guide feeding• ;alances helping *ith encouraging self3feeding, in a *ay that is appropriate for the

childCs level of development

• Involves eye contact and positive verbal encouragement, but not verbal or physicalcoercion

• 5ses eating utensils that are age3appropriate, as *ell as culturally appropriate

• Responds to early hunger and satiety cues

• #inimi es distractions during meals and feedings

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• +akes place in a comfortable and safe environment

• Is sensitive to the child, including changes in the childCs physical and emotional state

• Offers different food combinations, tastes, and textures

Responsive feeding may influence a childCs early development in self3regulating energyintake !Di8antis, Hodges, >ohnson / 6isher, $%44' IO#, $%44' +o*nsend / 2itchford,$%4$") 7on3responsive feeding relationships may override an infantCs internal hunger andsatiety cues and interfere *ith their emerging autonomy !;lack / 1boud, $%44' IO#, $%44")2ressuring infants to eat by using excessive verbal encouragement !such as clean your

plate " may lead to negative attitudes about eating and poor eating habits !0erro, 9eunert,8immer, / Daniels, $%%$" as *ell as excessive feeding and excess *eight gain !;irch, 4==$'8atter, 4==&' Hurley, 0ross, / Hughes, $%44") On the other hand, parents and caregivers *horestrict higher3fat, energy3dense foods due to concern about overeating may adversely affectself3regulation and actually increase the childCs intake of the foods *hen they are offered

!IO#, $%44")

3oles and responsibilities of parent and child during feeding

+he development of healthy eating skills is a shared responsibility !8atter, $%4$' 8atter,$%%%") 6or young infants, parents are responsible for *hat milk source is offered, and thechild, *ith infant3led or on3cue feeding, is responsible for everything else !that is, *hen,*here, and ho* much")

6or the older infant and young child, parents and caregivers provide a selection of nutritiousfoods, prepared and served in a safe manner, in addition to the childCs milk source) ;y one

year of age, parents and caregivers take responsibility for *hen and *here food is eaten by providing regular meals and snacks) 1t every age the child decides ho* much they *ant toeat and *hether they *ant to eat at all !8atter, $%%%")

+o support healthy eating skills, encourage parents and caregivers to recogni e and respondappropriately to their hunger cues, such as restlessness or irritability and to satiety cues suchas turning the head a*ay, refusing to eat, falling asleep, or playing !8atter, $%%%") +hey needto trust the childCs ability to decide ho* much to eat and *hether to eat !8atter, $%4$") +hiskind of support promotes the development of autonomy !8atter, 4==&")

1$. &recerea de la biberon la cana normala

When introducing ne* fluids, other than commercial infant formula, after six months of age,it is best to offer them in an open cup ) 2arents and caregivers can keep offering commercialinfant formula in a bottle, because some older infants may at first have difficulty consumingthe same volumes *ith an open cup)

+he transition from bottle feeding to an open cup should take place by about 4$ months!IO#, $%44' 112, $%%=") +his transition should be complete for all fluids no later than 4-months of age !IO#, $%44") 5se of an open cup promotes the development of maturedrinking skills !#orris / .lein, $%%%") Encouraging the use of an open cup can help reduce

nighttime and long3term use of bottles, particularly *hen they contain fluids other than *ater,*hich can decrease the risk of early childhood caries !1D1, $%% ") It can also help reduce

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