23 February 2024, Singapore - Singapore’s first set of Guidelines for Eating and Feeding in Infants and Young Children up to two years was launched today at the MCHRI¹ Asia Pacific Maternal and Child Health Conference and IPRAMHO² International Meeting 2024 in KK Women’s and Children’s Hospital (KKH).

The Guidelines, unveiled by Dr Janil Puthucheary, Senior Minister of State, Ministry of Health and Ministry of Communications and Information, highlights the lasting impact of nutrition on the child’s health, especially in the first 1,000 days of a child’s life, from the beginning of pregnancy until the child’s second birthday.

“The first 1,000 days is a golden window. It is when the child experiences most drastic changes in their development, both physically and mentally. It is also the earliest opportunity that caregivers have, to help a child build lifelong eating habits. A child who is fed appropriately during this golden window is better set up to grow and develop well while they also begin to cultivate healthy eating habits that are sustainable, all the way through to adulthood,” said Associate Professor Chua Mei Chien, Head and Senior Consultant, Department of Neonatology, KKH and Chairperson of the Singapore Guidelines for Eating and Feeding in Infants and Young Children Workgroup.

We are what we eat, when we eat, how we eat
In a recent KKH study³ of over 1,000 caregivers in Singapore, it was found that sugar-sweetened beverages were consumed very early in life from infancy, with one in four children consuming them a few times a week. This increases to daily for some who are above one year old.

The study also showed that 65 per cent of caregivers would encourage the child to finish feeding, regardless of their hunger and fullness cues.

In addition, 60 per cent of children were not introduced a variety of textures to their children till they were one year old, with nearly 40 per cent of the children not introduced to a variety of flavours during mealtimes. (Refer to Annex B for details of the survey)

“It is important for parents to recognise hunger and fullness cues as they are determinants of excessive weight gain and metabolic diseases in children as they get older, while being aware of the optimal window to introduce complementary foods to a young child can minimise the risk of developing allergies and growing up to be a fussy eater,” said Associate Professor Chua.

It has been established that the ideal period to introduce complementary foods to infants is between four and six months of age but not any earlier, as it may increase the risk of food allergies and excessive weight gain^4 5. Moreover, the introduction of complementary foods after nine months of age has been associated with food refusal and picky eating reported later in childhood^{6 7 8}. In addition, adopting a vegetable-first approach when introducing complementary foods increases vegetable acceptance in the child, with potential benefits for later food preferences and intake⁹.

“No one is born a fussy eater nor with a sweet tooth. What to feed, when to feed, and when to stop feeding are deliberate choices that parents and caregivers must make for young children who will not know better otherwise,” added Associate Professor Chua.

Setting the foundation to lifelong healthy eating
Developed by the KKH-led IPRAMHO, Singapore’s first set of Guidelines for Eating and Feeding in Infants and Young Children is aimed at empowering healthcare professionals, parents, and caregivers, to help children form healthy eating habits from infancy, with the aid of specific nutrition goals and feeding milestones.

The key recommendations for the Guidelines include:

1. Focus on early feeding practices for infants and young children to foster healthy eating behaviours and habits, supporting optimal growth and promoting long-term health.
• Cultivate heathy eating habits from an early age to ensure appropriate weight gain during the crucial developmental phase and minimise risk of childhood obesity and metabolic disorders.
  
  
2. Emphasise positive role-modelling in parents and caregivers to guide the development of healthy eating behaviours.
   
   
3. Attain eating habits that encompass children enjoying a variety of food at appropriate mealtimes while exercising autonomy in settings that are developmentally appropriate. 
   
   
4. Ensure a diverse range of age-appropriate textures and flavours to provide an essential balance of nutrition, while emphasising the importance of healthy food preparation.
   
• Avoid introducing fruit juices and sugar-sweetened beverages in the first two years of life.
• Exclusively breastfeed infants for the first six months of life.
• Introduce complementary foods (in addition to milk) at around four to six months.
• No earlier than four months to reduce the risk of food allergies and excessive weight gain.
• No later than nine months, as this has been associated with food refusal and picky eating in later childhood.
• Introduce vegetables as the initial complementary food.
  
  
5. Be attentive and responsive to hunger and satiety cues from birth. Encourage autonomy in feeding to nurture positive mealtime experience.
• Learn and respond to the child’s hunger and fullness cues to allow them to set the pace of feeding (from birth) and determine the amount of food to be consumed (from six months).
  
  
6. Establish regular, family-centred mealtimes in a calm and distraction-free environment.
    
7. Encourage a gradual transition from round-the-clock feeding towards eating in the day as the infant approaches their first year.
   

(Refer to Annex A for the full details of the Guidelines.)

Building a Healthier SG with child nutrition
“At KKH, we take a life course approach towards sustainable population health from preconception, pregnancy, childbirth, to the development of the child through adolescence and adulthood. Over the years we have been introducing a series of guidelines for mental and physical wellness, that will help women and children achieve good long-term health outcomes. This year, in conjunction with KKH’s 100 years of excellence in maternity care, we introduce Singapore’s first set of Guidelines for Eating and Feeding in Infants and Young Children. We are laying the foundation to transform national health, investing in our future, for our generation and generations to come,” said Professor Tan Kok Hian, Head and Senior Consultant, Perinatal Audit and Epidemiology Unit, KKH, and Lead Principal Investigator of IPRAMHO.

The Guidelines will be made available to healthcare professionals through College of Paediatrics and Child Health Singapore (CPCHS); Singapore Paediatric Society (SPS); Perinatal Society of Singapore (PSS); Singapore Medical Association (SMA); Singapore Nutrition and Dietetics Association (SNDA) and Health Promotion Board (HPB).

¹SingHealth Duke-NUS Maternal and Child Health Research Institute.
²Integrated Platform for Research in Advancing Maternal and Child Health Outcomes is one of the main programmes by MCHRI.
³Quah PL, Loy SL, Ong C, Chan DWK, Chua MC, Yap KP, Tan KH. Integrated Variety Autonomy Setting Timing feeding practices in infants and toddlers’ study (I-VAST). Asia Pacific Maternal and Child Health Conference & Integrated Platform for Research in Advancing Maternal & Child Health Outcomes (IPRAMHO) International Meeting 2024; Singapore 2024.
⁴Fewtrell M, Bronsky J, Campoy C, et al. Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. Journal of pediatric gastroenterology and nutrition 2017;64(1):119-132.
⁵Fewtrell M, Bronsky J, Campoy C, et al. Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. Journal of pediatric gastroenterology and nutrition 2017;64(1):119-132.
⁶Du Plessis L, Kruger H, Sweet L. II. Complementary feeding: a critical window of opportunity from six months onwards. . South African Journal of Clinical Nutrition 2013;26(S):S129-S140.
⁷Bąbik K, Patro-Gołąb B, Zalewski BM, et al. Infant feeding practices and later parent-reported feeding difficulties: a systematic review. Nutrition Reviews 2021;79(11):1236-1258.
⁸Coulthard H, Harris G, Emmett P. Delayed introduction of lumpy foods to children during the complementary feeding period affects child's food acceptance and feeding at 7 years of age. Maternal & child nutrition 2009;5(1):75-85.
⁹Chambers L, Hetherington M, Cooke L, et al. Reaching consensus on a ‘vegetables first’ approach to complementary feeding. Nutrition Bulletin 2016;41(3):270-276.