Pureed Fruit Pouches for Babies

Breast-feeding is the optimal form of infant feeding, with numerous benefits for maternal and child health (1–3). From an age of about 6 month onwards “breast milk alone is no longer sufficient to meet the nutritional requirements of infants” (1), and complementary feeding should be introduced to provide additional energy and critical nutrients such as iron, zinc, iodine, or long-chain polyunsaturated fatty acids for supporting continued healthy growth and development (3,4). In addition to the widely used homemade complementary foods, many commercial food products for infants and young children are available. WHO has provided guidance on ending the inappropriate promotion of such foods for infants and young children (5). In recent years, a rapidly increasing number and variety of a new type of commercial complementary foods has been offered, that is, pureed, semiliquid foods for infants, and young children packed in squeezable plastic pouches usually equipped with a spout and screw cap (Fig. 1). These pureed pouch products promise added convenience to families: after unscrewing the lid, the contents can be directly squeezed into an infant's mouth, or infants can suck out the contents directly from the spout, thereby enabling fast feeding on the go. This new method of infant feeding has proved very popular; even reusable pouches are now sold for feeding infants with homemade pureed baby food from a squeezable bag.FIGURE 1: Example of a pureed fruit pouch offered for infants and young children.What might appear as a great idea for adding convenience and reducing parents’ time spent with infant feeding raises some serious concerns. The complementary feeding period is not only about provision of nutrients, but it is also is the period of learning the transition from exclusive milk feeding to the varied family diet consumed in early childhood, with rapid advancement of oropharyngeal motor learning and development, and of acquiring feeding and eating behavior skills (4). If infants are fed predominantly by sucking from a pouch, this may delay and impair learning to eat from a spoon; exploring foods with tongue; lips, and hands; and chewing. Some observations point to a critical time window for the introduction of lumpy solid foods. Delayed introduction of lumpy foods after the age of about 9 to 10 months was linked to increased feeding difficulties and low intakes of eating vegetables and fruits at later ages (6). Therefore, it is not advisable to provide complementary feeding mostly by sucking—similar to milk feeding. Feeding infants a variety of food textures and lumpy foods by spoon feeding and finger foods provides great opportunities for intensive reciprocal interaction between parent and infant, for listening and talking, and for learning to sense each other's signals (responsive feeding) (7,8), which may be missed if infants are left on their own to suck from a pouch. Major concerns arise also from the typical composition of baby foods in pouches. Manufacturers tend to stress the natural and often organic nature of these foods, and the absence of artificial additions, gluten, lactose, or other components often considered by the public as less desirable. These products, however, often have a high energy density, high sugar content, and a very sweet taste. This adds to the already unbalanced composition of commercial complementary feeds, where two thirds of marketed products were reported to be sweet foods (9). Many of the pouch products for infants and young children provide pureed fruit. Although some pureed foods in pouches are offered with grains and vegetables, even they tend to have a very sweet taste and to be high in sugar content, and they also need to be liquid or semiliquid to be delivered through the spout. Whole meals provided by fruit only are not usually recommended as part of complementary feeding, because they do not supply appreciable amounts of those nutrients which need to be provided in addition to continued breast-feeding, in particular iron, zinc, iodine, and long-chain polyunsaturated fatty acids . Therefore, fruits are usually recommended only as an addition to a cereal or as a small portion to accustom infants to a variety of flavors and textures, provided after a mixed meal based on vegetables, meat, or fish (3). Parents may consider a fruit pouch equivalent to offering a piece of fresh cut fruit to their baby, which is not the case. The composition of 10 such products with high sugar contents found in retail stores in Denmark (Table 1) indicates an energy density of 45 to 95 kcal/100 g, which often is much higher than the typical energy density of fresh fruit (eg, 54 kcal/100 g apple), presumably due to removal of water or fiber during the production process, and/or the preferential use of fruits with high sugar contents. The combination of a high energy density with an easy consumption by sucking, as opposed to having to chew and swallow pieces of fruit, can lead to a high intake of energy and sugar in the form of fructose during a short time period. Therefore, regular infant feeding with pureed fruit from pouches may bear the risk to induce overfeeding and an excessive infant weight gain, which has been associated with a markedly increased risk of later obesity (10,11). Many such products have extremely high sugar contents ranging from 84% to 98% of total energy content (Table 1), which seems inadequate for a meal provided to babies. Apparently most if not all of the sugar content is composed of sugars found naturally in fruits, and not of “added sugars” supplemented during processing of the foods. Although the term “added sugar” is useful for regulatory and policy purposes, we do not consider it to describe the quality and suitability of complementary foods because any content of sugars, be it from prepared fruits and other ingredients or from added isolated sugars, has similar untoward metabolic, dental, and other health effects (12).TABLE 1: Energy density (kcal/100 g) and sugar contents (percentage of energy) in 10 fruit puree pouch products with high natural sugar contents sold in retail stores in Denmark in May 2017A pureed food with high sugar content is more likely to stick on dental surfaces than chewed foods with abrasive qualities, and thereby may pose an increased risk for the development of dental caries. Also, the repeated exposure to the very sweet taste of such products may induce potential programming effects on later taste and food choices. Early dietary experience of sweet tasting foods and drinks was linked to a stronger preference of sweet foods later (13), which is undesirable because of the associated risk increase for dental caries, obesity, and associated diseases (14). The very high sugar intake with feeding a whole complementary feeding meal based on pureed fruits must be expected to increase blood glucose and insulin levels to an even greater extent than occurring with eating an equal amount of intact fruit, because the preserved matrix of natural fruits tends to slow down absorption, as compared to absorption from mushed foods. For example the glycemic index of mashed potatoes is 83 and thus far higher than the glycemic index of boiled potatoes with only 49 (5). A high glycemic load stimulates high infant insulin secretion that can induce an undesirable high infant weight gain velocity and increased later obesity risk (15). High habitual dietary sugar intake over lifetime has also been associated with an increased adiposity-related cancer risk (16). In the project VIVA birth cohort study, maternal sugar intake in pregnancy and offspring sugar intake in early childhood were inversely associated with child cognition (17). Different fruits vary in the composition of sugars, but fruits are generally rich in fructose, along with variable contents of glucose and sucrose (18). It appears likely that the high fructose intake with pureed fruit pouches has greater adverse metabolic effects than similar intakes of other carbohydrates, because fructose appears to promote de novo lipogenesis, hepatic steatosis, and nonalcoholic fatty liver disease (19–21), and also a fructose-induced increase in asthma risk has been reported (22). Although further work is needed to define and fully understand the health impact of dietary sugars (23), based on the currently available data a limited dietary sugar intake is strongly recommended (14). We conclude that infants and young children should not regularly suck pureed foods from a plastic pouch, but rather be given the opportunity to explore a variety of foods given by spoon feeding or as finger foods, supported by a reciprocal, responsive relationship between parent and infant. We recommend the use of well-prepared home-made complementary foods with limited amounts of sugar but high contents of nutrients that are of critical importance for the age, and that offer diverse flavor and texture experiences. If commercial complementary foods are used, they should be selected based on the same guiding principles. Readymade pureed fruits should usually not substitute for a whole meal, but only be used as an addition to a meal, for example, as an addition to a cereal, and they should be fed by a spoon and not by sucking out of a pouch. Implementation of regulatory standards for these types of products may be required to protect child health.