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Maternal and Child Nutrition Guidelines

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					Maternal and
Child Nutrition
Guidelines




Including
Pre-Conception and Pregnancy
Early Years (Babies and Children 0-5 Year Olds)
               1

Introduction
Section 1
Introduction
Contents
Section 1
Introduction
___________________
Scope of guidelines ......................................................................................................................................................................................................ii
Health data ............................................................................................................................................................................................................................... iii
Availability .................................................................................................................................................................................................................................... viii
Review .............................................................................................................................................................................................................................................. viii
Acknowledgements ..................................................................................................................................................................................................... viii


Section 2
Preconception and Pregnancy
___________________
                                                                                                                                                                                                                                                           1
                                                                                                                              ..............................................................................................................................



Preconception advice for men and women ......................................................................................................................... 2
Nutritional advice for pregnancy .............................................................................................................................................................. 6
Nutrition related problems during pregnancy ....................................................................................................................... 15
Food safety during pregnancy .................................................................................................................................................................... 16
Pre-natal advice on breastfeeding ....................................................................................................................................................... 19


Section 3
Infant Feeding (From Birth to 12 Months)                                                                                                                               .....................................................................................   21
___________________
Breastfeeding ......................................................................................................................................................................................................................... 22
Formula feeding ............................................................................................................................................................................................................... 38
Weaning onto solid foods .................................................................................................................................................................................... 48
Common feeding challenges in infants ....................................................................................................................................... 60


Section 4
Feeding Toddlers and Preschool Children (1-5 Year Olds)                                                                                                                                                                                                    70
                                                                                                                                                                                                                            ................................
___________________
Nutritional requirements of 1-5 year olds.........................................................................................................................................71
Food safety ............................................................................................................................................................................................................................... 78
Dental health ..........................................................................................................................................................................................................................79
Common feeding challenges in 1-5 year olds ................................................................................................................... 81


Section 5
Appendices & Index
___________________
Appendix 1 - Components in breast milk and infant formula milks
Appendix 2 - Food-related customs
                                                                                                                                                                                                                                                                    i
Scope
___________________
The aim of this document is to provide evidence-based and clear guidelines for
all health professionals and childcare staff to ensure that parents-to-be, parents
and carers receive consistent and accurate nutritional advice and information.
They have been developed by a multi-professional group and reflect current
best practice. This will help to promote good nutrition for parents, infants
and pre-school children, which in turn will benefit general health, growth
and development of the under fives in North Somerset.

They are a comprehensive resource covering:
                  Preconception and pregnancy



The evidence base for good nutrition in early years is strong for both short term health e.g.
prevention of constipation and anaemia, and long term prevention of chronic disease.
It is essential that good dietary habits are established at an early age and that parents
have the skills and knowledge to make appropriate choices and they are able to access
affordable, safe, nutritious food.

These guidelines are intended for healthy infants. Some common feeding problems are
covered such as iron deficiency, reflux and fussy eating behaviour, but these guidelines
may not be appropriate for those with severe feeding problems or complex needs who
may need more specialised interventions.

These guidelines are intended for use as a reference document by all health
professionals and childcare staff working with parents-to-be, parents, infants and
preschool children.
..................................................................................




                                                                                                ii
Health data for
North Somerset

Births in North Somerset                                                           Low birth weight babies
___________________                                                                ___________________
There were 2,325 live births in                                                    Babies born of low birth weight have an increased risk
North Somerset during 2009                                                         of infant mortality and range of conditions including
creating a General Fertility Rate                                                  severe neurological and cognitive disease, pulmonary
(GFR) of 63.8 (per 1000 women                                                      illness and long term health problems such as diabetes
aged 15 to 44), which is comparable                                                and heart disease. Low birth weight is highly correlated
to the England rate (64.7) but slightly                                            with levels of deprivation. In North Somerset, 7.4%
higher than the South West (60.3).                                                 of babies living in deprived areas are born of low
Over the last five years there has                                                  birth weight compared to 4.8% in the most
been an 8% rise in the GFR rate in                                                 affluent areas (see table - below).
North Somerset compared to a 9%                                                    ................................................................................

rise in England.

In 2009 Weston-super-Mare East
had the highest number of live
births 238; with a GFR of 78 per
1000 women aged 15 to 44.
The highest rate was in Portishead
East (97 per 1000 population),
which related to 97 births in one
year. The map below plots the
rate of live births by ward.
................................................................................




General Fertility Rate GFR
per 1000 women aged 15-44
by North Somerset ward
of residence 2009
___________________




                                                                                                                                                                      iii
Deprivation
___________________
The population weighted average                                                    But there is wide variation between
deprivation score from the Indices                                                 areas within North Somerset, with
of Multiple Deprivation 2007                                                       some areas being in the top 10%
(IMD2007) for North Somerset is                                                    most affluent areas in England
15.01, this makes North Somerset                                                   and two wards (Weston-super-Mare
the 215th most deprived local                                                      South and Weston-super-Mare
authority out of 354 areas within                                                  Central) being in the 10% most
England. North Somerset is                                                         deprived areas. The map below
not significantly more deprived                                                     shows the pattern of deprivation in
than the England average                                                           North Somerset using population-
(score of 19.9).                                                                   weighted average scores by ward.
................................................................................   ................................................................................




NHS North Somerset
Indices of Deprivation 2007:
Income Domain
___________________




                                                                                                                                                                      iv
Breastfeeding
___________________
Breastfeeding protects children from a range of health problems,
including childhood infections, obesity, allergies and diabetes.
During 2009/10 47% of infants in North Somerset were being
breastfed at their 6 to 8 weeks check up, compared to 45%
in England. The map below shows infant breastfeeding prevalence
(as a % of all children with a valid breastfeeding status recorded at
6-8 week check) by practice (2009-10).
................................................................................




Prevalence of breastfeeding
at 6-8 weeks
by North Somerset GP
practice 2009/10
___________________




The five most affluent wards in North
Somerset are Portishead Coast,
Portishead East, Nailsea East,
Easton-in-Gordano and Portishead
Redcliffe Bay with below average
IMD2007 scores.

At six weeks, breastfeeding rates in the
most affluent groups are significantly
higher (62%) compared to the most
deprived areas (35%) (see table - left).
................................................................................




                                                                                   v
Obesity
___________________
                                                                                   Levels of obesity in children
In recent years there have been                                                    in North Somerset
                                                                                   ___________________
sharp increases in the rate of
childhood obesity. In North
Somerset during 2009/10 the
National Child Measurement
Programme (NCMP) indicated that
the prevalence of overweight and
obese children in four and five year
old children is 13% and 9%
respectively. By ages ten and
eleven these figures increase further
to 14% overweight and 15% obese
children but are lower than the
England average.

Data from the NCMP show obesity
rates in both reception class and
year 6 children in the most deprived
areas are significantly higher than                                                 Prevalence of overweight and
in affluent areas, although obesity                                                 obese children in reception year
rates are also concerning in more                                                  by North Somerset ward of
affluent communities                                                                residence 2008/09 school year
                                                                                   ___________________
(see table - top left).

The graphs (see table - middle / bottom left)
show the geographical variation of
the prevalence of obese and
overweight children in Reception
and Year 6. This data is based
on the ward of residence
for children attending school in
Avon in 2008/09. Please note the
number of children classified as
obese or overweight by individual
wards is small and therefore the
confidence intervals should be
borne in mind when looking at
these prevalence figures.
................................................................................

                                                                                   Prevalence of overweight and
                                                                                   obese children in year 6
                                                                                   by North Somerset ward of
                                                                                   residence 2008/09 school year
                                                                                   ___________________




                                                                                                                      vi
Availability                                                                       Acknowledgements
___________________                                                                ___________________
These guidelines will be downloadable                                              We acknowledge and thank NHS Bristol for allowing
from www.n-somerset.gov.uk                                                         us to base these guidelines on the Bristol Maternal
                                                                                   and Child Nutrition Guidelines.
A printed copy should be available in all
locations where health care professionals                                          We acknowledge and thank NHS South Gloucestershire
and childcare staff who are working with                                           for allowing us to use material from their guidelines.
prospective parents, parents, infants and
preschool children are based.                                                      Thanks to Staff and children at Little Waves Nursery.
................................................................................   Thanks to Staff and children at The Secret Garden
                                                                                   Nursery and Pre-School.

                                                                                   Thanks to Childminder Lauren Tassell and the children in her care.
                                                                                   Thanks to Dr Penny Edrich.
Review of guidelines
___________________
                                                                                   The guidelines were adapted for use in North Somerset
The guidelines will be reviewed annually                                           by the Maternal and Child Nutrition sub-group of the
by the Childhood Obesity Action Group.                                             Childhood Obesity Action Group, which includes
Enquiries regarding the document:                                                  representation from:

e-mail:                                                                            NHS North Somerset Public Health Directorate
FIS@n-somerset.gov.uk                                                              NHS North Somerset Community Services
                                                                                   North Somerset Council Early Years team
                                                                                   Weston Area Health Trust Dietetics Department
tel:
01934 426947                                                                       ................................................................................


post:
Family Information Service,
North Somerset Council,
Town Hall,
Walliscote Grove Road,
Weston-super-Mare,
BS23 1UJ
...........................................................




Designer:
John O’Carroll
(john.ocarroll.design@virginmedia.com)

Photography:
Chris Bahn
(chris.bahn@bristol.gov.uk)
................................................................................




                                                                                                                                                                      vii
                2

Preconception
and Pregnancy
Section 2



The importance of ensuring that mothers and their babies
are well-nourished is widely recognised. The nutritional status
of a woman before conception and during pregnancy
influences the growth and development of her baby and forms
the foundations for her child’s later health (Gluckman et al. 2005).


The mother’s own health, both in the short and long term also
depends on how well nourished she is before, during and after
pregnancy (DH 2004a).


Poor nutrition during pregnancy has been linked to an increased
risk of having a baby with a low birth weight. The link between
low birth weight and infant mortality remains strong and if they
survive, low birth weight babies suffer from higher rates of childhood
illness and conditions such as hearing and visual impairment,
neuro-developmental delay and behavioural disorders
(Hack et al. 1995).


Several studies of school age children who had a low birth weight
have shown less developed language and social skills, more
behavioural and attention span problems, and lower IQ, cognitive
ability and academic achievement (Dahl et al 2006).


This section covers:




..................................................................................


                                                                                     1
advice for women                                                                     Each day aim for
                                                                                     _____________________
Mothers with a history of poor                                                       Bread, rice, potatoes and pasta and other
nutrition before conception will                                                     starchy foods – base meals on these foods
have low nutrient stores,                                                            and use wholegrain varieties as often as possible.
consequently the growing
baby may have reduced                                                                                       –
access to the nutrients needed                                                       aim for at least five portions per day.
for growth and development.                                                          Milk and dairy foods – aim for two or three
Therefore prior to conception                                                        portions per day of milk, cheese or yogurt using
women should be advised to                                                           low-fat varieties whenever you can.
follow a healthy balanced diet
based on the eatwell plate.                                                          Meat fish, eggs, beans, and nuts –
..................................................................................   aim for two portions of these each day.
                                                                                     Two servings of fish per week are
                                                                                     recommended of which one should be oily fish.
                                                                                                                                         –
                                                                                     limit these to small quantities and do not eat
                                                                                     in place of the other food groups.
                                                                                                     6-8 drinks per day (1½ - 2 litres) will
                                                                                     provide adequate fluid to prevent dehydration.
                                                                                     This includes all drinks: water, tea, coffee, milk,
                                                                                     soup, fruit juices, squashes and fizzy drinks.
                                                                                     More drinks may be needed in hot weather
                                                                                     and after physical activity.
                                                                                                                                               2
                                                                                     advice for men
Up to 50% of pregnancies are likely                                                  Fertility problems affect about 15% of couples and
to be unplanned (NICE PHG 11 2008)                                                   between 30-50% are due to male infertility. The
so ideally all adolescent girls and                                                  aetiology of male infertility remains largely unknown
women of reproductive age should                                                     as it is difficult to identify the role of single factors
be encouraged and advised to                                                         and various studies have shown conflicting data.
eat a nutritionally adequate diet
to optimise their nutritional status                                                 Lifestyle factors such as smoking, alcohol,
for any future planned or                                                            diet and socioeconomic factors may affect
unplanned pregnancies.                                                               sperm motility, fertility or pregnancy outcomes
                                                                                     (Thomas and Bishop 2007).

                                                                                     Gastro-intestinal complaints and low intake of fruit
                                                                                     and vegetables have been associated with low
should also be the same as during                                                    sperm counts (Wong et al 2003). Zinc, selenium
pregnancy (see page 7).                                                              and vitamin C may be particularly important in
                                                                                     sperm production (Tas et al 1996).
If planning a pregnancy start to take
supplements of folic acid and vitamin                                                The most prudent advice for men is to:
D as recommended for pregnancy                                                       (Thomas and Bishop 2007)
(see pages 6-7).
..................................................................................


                                                                                                       diet based on the five food groups
                                                                                                       (see eatwell plate) ensuring adequate
                                                                                                       fruit and vegetable intake

                                                                                                       intake of less than 28 units per week

                                                                                                       underweight men should gain weight
                                                                                                       and obese men should lose weight




                                                                                     Alcohol

                                                                                     pregnancy found an association between women’s
                                                                                     alcohol intake and decreased fertility even among
                                                                                     women who had five or fewer drinks a week.
                                                                                     This would indicate that fertility is reduced in a high
                                                                                     proportion of women due to their alcohol intake.
                                                                                     Women experiencing difficulties in conceiving
                                                                                     should be advised of the possible advantages
                                                                                     of avoiding alcohol completely (Jensen,1998).


                                                                                     alcohol altogether but if women choose to drink
                                                                                     alcohol it should be limited to one to two units
                                                                                     once or twice per week.
                                                                                     ..................................................................................

                                                                                     www.eatwell.gov.uk
                                                                                     ..................................................................................


                                                                                                                                                                          3
Effect of mother’s                                                                   Overweight and obesity
weight on conception
Women with a Body Mass Index (BMI)                                                   Overweight and obesity can affect
of 20-25 have been shown to have a                                                   ovulation and also the response
higher rate of pregnancy than those
with a BMI higher than 25 or lower                                                   study (Clark et al, 1998) showed that
than 20 (Zaadstra et al. 1993).                                                      when overweight women who were
..................................................................................   not ovulating followed a weight loss
                                                                                     and physical activity programme,
                                                                                     the outcome for most women was
                                                                                     natural ovulation, conception and
                                                                                     successful pregnancy.

Underweight                                                                          Being overweight does not prevent
                                                                                     all women from conceiving, however
Conception can occur in women                                                        the extra weight combined with the
well below average or ideal weight.                                                  weight of the baby can lead to
However, women who have a low                                                        problems during the course of the
BMI (BMI <20) are less likely to                                                     pregnancy (The Centre for Pregnancy
conceive (Zaadstra et al. 1993).                                                     Nutrition, University of Sheffield, 2005).
..................................................................................


                                                                                     Overweight pregnant women are
                                                                                     more likely to have a premature
                                                                                     or low birth weight baby.
                                                                                     Obese pregnant women are at
                                                                                     increased risk of complications
                                                                                     during pregnancy such as high
                                                                                     blood pressure, gestational
                                                                                     diabetes and pre-term delivery.




                                                                                                                                 4
                                                            Women with diabetes
and Clinical Excellence
___________________
The National Institute for Health and Clinical Excellence   Women with diabetes who are
recommends that women with a BMI over 30 should be          planning to become pregnant
informed of the increased risk to themselves and their      should establish good glycaemic
babies during pregnancy and child birth. They should        control before conception aiming
be encouraged to lose weight before becoming
pregnant (NICE PHG 11 2008). It is preferable for weight    6.1% to reduce the risk of
to be reduced well in advance (at least three to four       congenital malformations.
months) of conception to lessen the likelihood of
nutritional inadequacy.
                                                                                                                                                 1c
This guidance has been followed by specific advice           is above 10% should be strongly
on dietary interventions for weight management              advised to avoid pregnancy
before, during and after pregnancy (NICE PHG 27 2010).      (NICE CG63 2008). Women with
The guidance makes recommendations for women                diabetes and a BMI above 27
with a Body Mass Index (BMI) of 30 or more planning         should be encouraged to lose
a pregnancy. It recommends:                                 weight prior to conception.

                                                            The higher dose of folic acid
     Health professionals should use any                    supplement should be
     appropriate opportunities to provide                   recommended to women
     women with a BMI of 30 or more with                    with diabetes.
     information about the health benefits                   ..................................................................................
     of losing weight before becoming pregnant
     for themselves and the baby they conceive
     Trained health professionals should advise,
     encourage and help women with a BMI of 30
     or more to reduce weight before pregnancy
      Health professionals should offer
        weight loss
      a weight-loss support programme
      involving diet and physical activity.
      Local programmes available:
          - Slimming on referral
          - Specialist adult weight
            management service
     Health professionals should offer specific
     dietary advice in preparation for
     pregnancy, including the need to
     take daily folic acid supplements




                                                                                                                                                  5
develop and grow and to keep the mother fit and well. If the mother’s
diet during pregnancy is nutrient-deficient, there is a further increase in the risk
of inadequate nutrition for the growing baby. Poor rates of foetal and infant
growth have also been linked to higher rates of premature death among
adults and higher rates of cardiovascular disease and other conditions
such as diabetes and high blood pressure (Barker 2008).
The nutritional requirements of pregnant women can generally be met
by eating a healthy balanced diet based on the five food groups in
the eatwell plate (see page 2). They have additional requirements for the
following nutrients:
..................................................................................




Research has shown a link between low folic acid/folate intakes
and the development of neural tube defects (Medical Research
Council Vitamin Study Group, 1991).

To reduce the risk of neural tube defects, supplementation with folic
acid prior to conception and during the first 12 weeks of pregnancy
is recommended. There are 2 dose levels:

               5 mg per day for those women:




This high dose folic acid preparation is available on prescription only.

               0.4 mg per day for all other women

               These supplements are available over the counter
               and on prescription.

_____________________
Folate is the form of folic acid found in food. The folate content of
food decreases with long storage times and heat therefore cooking
may cause a considerable reduction in the folate available.
The current average intake from diet is about 200mg per day.
Women who may become pregnant should aim to increase their
dietary intake of folate, in addition to the folic acid supplement, by:


                  (brussel sprouts, spinach and broccoli), potatoes, pulses and oranges




                  pregnancy because it has very high levels of retinol

                                                                                          6
Vitamin D
Vitamin D is necessary for calcium absorption and
to make calcium available for bone development.
Dietary sources of vitamin D are limited and include:                at the booking appointment
                                                                     about the importance for their
                                                                     own and their baby’s health of
                                                                     maintaining adequate vitamin
                                                                     D stores during pregnancy and
                                                                     whilst breastfeeding
        are fortified by law
                                                                     women should be advised to
The ‘National diet and nutrition survey of British adults’           take 10 g vitamin D daily
(Ruston et al. 2004) found that about a quarter of British           in a dietary supplement
women aged 19–24 and a sixth of those aged 25–34
are deficient in vitamin D.
For most adults in the UK the main source is made in
the skin when it is exposed to the UVB rays in sunlight

September. Lack of vitamin D may adversely affect
bone mineralisation of the growing baby and the                               vitamins are available
accumulation of vitamin D stores for the early                 free to some pregnant women in
months of life. Therefore maternal skin exposure               North Somerset. Details about how
alone may not always be enough to achieve the                  to get the vitamins are available at
optimal vitamin D status needed for pregnancy.                 ante-natal appointments.


                                                                 The vitamin tablets contain:
The following groups are particularly at risk:


      provides an additional barrier for sunlight activation
                                                                      70mg Vitamin C
      such as those who remain covered when outside
      or are housebound


The effects of deficiency are:

      infants born to mothers deficient in vitamin D


      toddlers born to mothers deficient in vitamin D

      with vitamin D deficiency which eventually may
      result in osteomalacia (‘soft bones’)




                                                                                                       7
Vitamin A
Pregnant women should not take                                                      Women with good iron status prior to conception and who
supplements containing vitamin                                                      eat a healthy balanced diet will not need extra iron during
                                                                                    pregnancy. This is because the rising demands of iron by
                                                                                    the growing baby are met by:
associated with teratogenesis
(malformations in the unborn
child) DH, 1990.                                                                          menstrual bleeding ceases during pregnancy

However, women are                                                                        the level of absorption increases progressively
recommended to have an                                                                    as pregnancy advances. This increase in
additional 100 micrograms of                                                              absorption is more pronounced in women
                                                                                          who are anaemic
during pregnancy. This can be
                                                                                    The foetus accumulates most of its iron during the last
achieved by eating a healthy
                                                                                    trimester laying down stores for the first 6 months of life.
diet with plenty of vegetables
and fruit.                                                                          Iron supplementation may have side effects such as
                                                                                    constipation or nausea.
To avoid high doses of retinol,
pregnant women should avoid:                                                        Eating a balanced diet including iron rich foods should
                                                                                    be encouraged.
                    containing retinol

                                                                                                      to encourage are:
                  such as liver pâté
.................................................................................

                                                                                          lamb or pork




                                                                                    Note: Liver is high in iron but is not recommended
                                                                                    during pregnancy because of its high retinol content.



                                                                                    The iron in red meat and oily fish is absorbed better than
                                                                                    iron from plant foods. Women following a vegetarian
                                                                                    diet and those who eat little meat can increase their
                                                                                    iron absorption from cereal and vegetable sources by:

                                                                                          vitamin C with a meal e.g. orange juice with
                                                                                          beans on toast

                                                                                          tannins present in tea bind with the iron,
                                                                                          reducing its absorption




                                                                                                                                                  8
 Calcium
 Despite high requirements for calcium for the growing baby, additional calcium
 is not needed as the mother’s calcium absorption increases during pregnancy.



Calcium
Milk                                                                                  1 glass - 200mls
Cheese                                                                                25g or 1oz
Yoghurt                                                                               1 pot of 120 -150g
Tofu                                                                                  50g or 2½ oz
Calcium enriched soya milk                                                            1 glass - 200mls



 have achieved their peak bone mass. They should be encouraged
 to eat at least 3 servings of these calcium rich foods each day.

 Women who do not eat dairy products or calcium-enriched soya
 products should be referred to a registered dietitian for advice on
 achieving an adequate calcium intake during pregnancy.
 ..................................................................................




 Alcohol

 and especially in the early weeks where it is associated with teratogenesis
 (malformations in the foetus) and may cause miscarriage. Pregnant
 women are advised to avoid alcohol (NICE CG 62 2008), but women
 who do choose to drink should consume no more than 1 or 2 units
 of alcohol once or twice a week.
 ..................................................................................




 Energy
 Energy requirements during pregnancy are not as high as previously

 growth of the unborn child and to enable fat to be deposited in the mother’s
 body for later use during lactation. However, considerable reductions usually
 occur in physical activity and metabolic rate to help to compensate for
 these increased needs. The Department of Health recommends an extra
 200 calories per day from food for the final three months only (DH, 1991).

 Women with a low BMI at the start of pregnancy need to increase their
 food intake to provide more energy and nutrients for both themselves
 and their developing baby.
 ..................................................................................


                                                                                                           9
 Appropriate weight gain during pregnancy
 There are currently no UK evidence based recommendations
 on appropriate weight gain during pregnancy.

                                                                                              (IOM)   recommends (IOM 2009):

                                                                                                               Appropriate weight
                                                                                                               gain during pregnancy
Underweight                                                                           <18.5                    12.5 -18kg
Normal weight                                                                                                  11.5 -16kg
Overweight                                                                            <25 - 29.9               7 -11.5kg
Obese                                                                                  30                      5 - 9kg

 Women who gain weight within the IOM ranges are more likely to have
 better maternal and infant outcomes than those who gain more or less weight
 (Viswanathan et al. 2008).

 Gaining too little weight during pregnancy can result in infants being born
 with a low birth weight, which is associated with health problems for the child.

 Excess weight gain during pregnancy can increase the risk of gestational
 diabetes, pre-eclampsia and difficulties during delivery. It is also associated
 with postpartum weight retention in the short, intermediate, and long term
 (Viswanathan et al. 2008).
 ..................................................................................




                                                                                                                                       10
Overweight and obesity
_____________________
                                                  (NHS Choices 2007).
Maternal obesity is related to health inequalities, particularly
socioeconomic deprivation, inequalities within ethnic groups
and poor access to maternity services (Heslehurst et al 2007).
This is why it is important to support women who are overweight
or obese to lose weight before they become pregnant.

NICE recommends that overweight and obese pregnant women
are not encouraged to lose weight during pregnancy as this may
compromise their nutrient intake and that of the growing baby
(NICE PHG 27 2010).

Many pregnant women ask health professionals for advice
on what constitutes appropriate weight gain during pregnancy.
However, there are no evidence-based UK guidelines on
recommended weight-gain ranges in pregnancy.


                                       :


      visit to a health professional

      to the woman and her unborn child



      pregnancy for example ‘eat for two’

      and walking

      more a referral to a Dietitian or appropriately trained health
      professional for assessment and personalised advice on
      healthy eating
Pregnant women with a BMI of 30 or more receiving antenatal care
from community midwives in Weston-super-Mare can be referred to
our weight management for pregnant women scheme. Pregnant
women with a BMI of 40 or more can be referred to a dietician.




                                                                        11
Women at increased
nutritional risk during pregnancy
Women with pre-existing medical conditions
_____________________
                                                                                     Obese pregnant
Such conditions include:                                                             women who are
                                                                                     physically active
                                                                                     during pregnancy
                                                                                     reduce their risk of
                                                                                     gestational diabetes
These women should be referred to a dietitian prior                                  by 50% (Dye 1997)
to pregnancy and have their nutritional status
monitored closely throughout the pregnancy.
..................................................................................




Diabetes
_____________________
Diabetes in pregnancy is associated with health risks to
both the woman and the developing baby. Miscarriage,
pre-eclampsia and preterm labour are more common in
women with pre-existing diabetes.
Women with diabetes account for 2–5% of pregnancies in
England and Wales; about 90% of these are due to gestational
diabetes. The risk factors for gestational diabetes are:




          -
          -
          -


Women with any one of these risk factors should be offered testing for
gestational diabetes (NICE CG62 2008). In most cases gestational
diabetes will respond to changes in diet and physical activity.




                                                                                                            12
Adolescents                                                                          Black and minority ethnic groups
_____________________                                                                _____________________
                                                                                     Gestational diabetes is more
requirements because they need to complete                                           prevalent amongst women of
their own growth as well as providing for the foetus
                               The shorter the length                                Middle Eastern ethnic origin.
of time between the onset of menarche and                                            Pregnant women from these
pregnancy, the greater the nutritional risk.                                         groups should all be screened
                                                                                     for diabetes. Women who have
Pregnant teenage girls under the age of 18 years                                     recently arrived from developing
are eligible to join the Healthy Start scheme                                        countries may have parasitic
regardless of their financial circumstances.                                          infections, or have a poor
..................................................................................   nutritional status if they have
www.healthystart.nhs.uk
                                                                                     been subjected to famine.
                                                                                     ..................................................................................
..................................................................................




Vegetarian and vegan women
_____________________
Many vegetarian and vegan women’s diets are
significantly better than those of non-vegetarian
women; however some, in particular adolescents,
may decide to avoid meat and other animal foods
without taking care that the important nutrients they
are missing are provided from other sources.
Particular attention should be paid to achieving
adequate dietary sources of protein, iron,
omega 3 fats, calcium and vitamin B12.

Pregnant women who follow a vegan diet should
take care to ensure that they consume sufficient:

                            east
                  fortified yeast extracts, fortified soya milk,
                            extured
                  fortified textured soya protein and fortified
                             f
                  cereals. If these are not included in the diet
                  a vitamin B12 supplement may be needed

                          onds
                  and almonds each day or taking
                          m
                  a calcium supplement
                                                 .................................
..................................................................................




                                                                                                                                                                          13
Women who have previously
had a low birth weight baby
_____________________
It is important to ascertain whether or not the cause
of the reduced birth weight in a previous pregnancy
had a nutritional component such as poor gestational
weight gain and /or a reduced food intake. Short birth
intervals predispose to lower birth weights because
women may not have had time to replenish their
nutrient stores between pregnancies
..................................................................................




Women who are homeless, living in bed and
breakfast accommodation, or on low incomes
_____________________
These women may have the combined difficulty of
living on state benefits and living with limited cooking


is great difficulty in providing an adequate diet for
pregnancy while living entirely on state benefits.
..................................................................................




Women who have alcohol or drug problems are
less likely to eat a balanced diet.
..................................................................................




Women who give up smoking should take care not to
snack on high calorie foods in place of smoking as this
would put them at risk of gaining excess weight.
..................................................................................




Women who are restricting their food intake
for reasons such as slimming or self diagnosed food
allergies. Women should not cut out food groups without
advice from a registered dietitian as they omit important
nutrient sources (NICE CG 11 2008).
..................................................................................




Women who currently have, or have a recent
history of, an eating disorder such as anorexia
nervosa or bulimia nervosa may have low body
stores of some nutrients.
..................................................................................




                                                                                     14
problems in pregnancy
                                                                                     Cravings and taste changes
_____________________                                                                _____________________
Nausea and/or vomiting are                                                           Unless cravings and aversions are excessive
common occurrences in the                                                            and prevent a pregnant woman from eating
first 14-15 weeks of pregnancy.                                                       a nutritious diet, these are not usually harmful.
Nausea is thought to be caused                                                       ..................................................................................

by the changing pregnancy
hormones and can be triggered
by certain foods or smells.
It can also be caused by hunger.
Women with excess vomiting                                                           _____________________
should be referred to their GP if                                                    This is generally more common during the last three
there is any risk of dehydration.                                                    months (12 weeks) of pregnancy when pressure from
Tips for overcoming nausea                                                           the baby in the uterus can cause acid to be pushed
and vomiting:                                                                        back up from the stomach. It is also more common
                                                                                     in multiple pregnancies.

                  every two hours or so
                  throughout the day, that                                               Tips for helping relieve symptoms
                  include fruit and starchy
                  foods e.g. bread, toast,
                  plain biscuits and cereals
                  may help
                                                                                                       the pressure
                  preparation and/or cooking
                  may be preferable
..................................................................................
                                                                                                       up by extra pillows may also help




                                                                                     Constipation
                                                                                     _____________________

                                                                                     This is common at all stages of pregnancy and can
                                                                                     be relieved by increasing the fibre and fluid content
                                                                                     of the diet.




                                                                                                                      Wholegrain varieties starchy foods
                                                                                                                      like pasta, rice and cereals
                                                                                                                      Fruit and vegetables
                                                                                                                      Pulses such as beans and lentils




                                                                                                                                                                          15
General food hygiene guidelines
_____________________




    the fridge separate from cooked foods


    to manufacturers’ instructions

    24 hours - do not reheat more than once
                                              Salmonella infection is a common
                                              cause of food poisoning and is
    on the packaging
                                              particularly associated with chicken
                                              and raw eggs. To avoid salmonella:
    from work surfaces

                                                              defrosted in the fridge and
Extra care should be taken:                                   cooked until piping hot
                                                              right through
    e.g. cooked meats and prepared salads.
    If scrupulous food handling guidelines
    have not been followed, these foods can                   both white and egg are solid
                                              ..................................................................................
    easily become contaminated

    foods sold and chilled) should not be     To avoid Toxoplasmosis, which is
    eaten cold, but heated right through      an infection caused by a parasite
    and the leftovers discarded                found in raw meat, cat faeces and
                                              soil that can seriously affect the
    heated until piping hot right through     unborn baby, women should:


                                                                emptying cat litter trays




                                                              thoroughly to remove any soil
                                                              or dirt

                                                              raw meat



                                                              milking ewes that have
                                                              recently given birth
                                              ..................................................................................




                                                                                                                                   16
_____________________
Oily fish should be eaten once or twice per week
because they are a good source of omega 3 fats for
both the mother and the growing baby. They should be
limited to two servings per week because some of these
fish contain dioxins and PCBs (polychlorinated biphenyls)
that might affect the nervous system of the baby.

Tuna should also be limited to 4 medium sized cans
of tuna a week (with a drained weight of about 140g
per can) or fresh tuna steaks (weighing about 140g
when cooked or 170g raw).
..................................................................................




Caffeine should be limited to 200mg a day because
high levels of caffeine can cause miscarriage or lead
to low birth weight with an increased risk of health
problems later in life.
  The caffeine content of drinks and chocolate is

     1 shot of espresso coffee                                                       140mg
     1 mug of filter coffee                                                           140mg
     1 mug of instant coffee                                                         100mg
     1 cup of brewed coffee                                                          100mg
     1 mug of tea                                                                    75mg
     1 cup of tea                                                                    50mg
     1 can of cola                                                                   up to 40mg
     1 can of ‘energy’ drink                                                         up to 80mg
     1 bar of plain chocolate                                                        up to 50mg
     1 bar of milk chocolate                                                         up to 25mg



It is important to check labels as certain cold and flu
remedies also contain caffeine, talk to a midwife or
pharmacist before taking these.
..................................................................................




                                                                                                  17
_____________________                                    _____________________
                               such as brie              In December 2008 the Food
   and
   such as             and stilton and                   there is insufficient evidence
   (a type of goats cheese) due to risk of listeria      to advise any pregnant women
                      (cows, sheep or goats)             to avoid eating peanuts and
  or any products made from it due to risk of listeria   peanut products during
                                                         pregnancy and breastfeeding.
   Raw eggs and foods containing raw eggs                ..................................................................................
   such as mayonnaise and mousse due to
   risk of salmonella
                , e.g.                   and
            unless they are bought packaged
   and stamped with a use by date.
   Shellfish should only be eaten if part of
   a hot meal and cooked thoroughly

   This is because pâté can contain listeria.
       ,             and marlin due to high
   mercury levels

  important with poultry and products made
  from minced meat such as sausages and burgers.



_____________________
                     , including prawns that
   are part of a hot meal and have been
   cooked thoroughly




                 ,           and salad dressing
   made with pasteurised egg are safe.
   Home-made versions may contain raw eggs,
   so avoid. If you are not sure when eating out,
   ask staff for more information or avoid
           may be eaten during pregnancy,
   but is not suitable for babies under one year

                     -
        (such as Cheddar and Parmesan)




        (such as cheese spreads)
                                                                                                                                              18
NICE recommends that pregnant women should be
offered opportunities to attend participant-led antenatal
classes, including breastfeeding workshops. Before or
at 36 weeks gestation they should receive breastfeeding
information, including technique and good
management practices, as detailed in the

..................................................................................

www.babyfriendly.org.uk
(NICE CG62 2008)
..................................................................................



North Somerset antenatal care includes a one to one
discussion about breastfeeding to all pregnant women
before 32 weeks gestation.
..................................................................................




                                                                                     19
                                                NICE Public Health Guidance 11 Improving
pregnancy and lactation: an overview.           the nutrition of pregnant and breastfeeding
                                                mothers and children in low income              Bliss
81(5):1206S-1212S.                              households. March 2008.                         ................................................................................
                                                                                                www.bliss.org.uk
Barker DJ (2008) Human growth and               NICE Public Health Guidance 27 Dietary          ................................................................................
cardiovascular disease. Nestle Nutrition        interventions and physical interventions
Workshop Ser Pediatr Program.61:21-38.          for weight management before, during
                                                and after pregnancy. July 2010.                 British Dietetic Association
infertile women results in improvement                                                          Healthy Eating During Pregnancy Fact Sheet
                                                                                                ................................................................................
in reproductive outcome for all forms of        care:routine care for the healthy
infertility treatment. Human Reproduction,      pregnant women 2008.                            www.bda.uk.com
                                                                                                ................................................................................
13: 1502-1505.                                  http://www.nice.org.uk/Guidance/CG62.
Dahl LB, Kaaresen PI, Tunby J,                  NICE Clinical Guidance 63 Diabetes in
                                                pregnancy: management of diabetes
(2006) Emotional, behavioral, social,           and its complications from pre-conception       The Pregnancy Book
and academic outcomes in                        to the postnatal period. 2008.                  ................................................................................
adolescents born with very low birth            http://www.nice.org.uk/Guidance/CG63.           www.dh.gov.uk
weight. Pediatrics.118:e449-59.                                                                 ................................................................................

Department of Health (1990) Women
                                                low birth weight: a multifactorial model.
Department of Health Press Release No
                                                                                                ................................................................................
90/507: London.
                                                The National Children’s Homes and
Department of Health (1991) Report No 41                                                        pregnancy
Dietary Reference. Values for Food Energy       Poverty and Under Nourishment in                ................................................................................
and Nutrients for the UK. Report of the         Pregnancy. National Children’s Homes
Panel on Dietary Reference Values of the
Policy. HMSO. London.                           Thomas B & Bishop J Ed (2007), Manual           ................................................................................
                                                of Dietetic Practice. 4th edition. Blackwell    www.healthystart.nhs.uk
                                                Scientific Publications, Oxford.                 ................................................................................
and the Prevention of Neural Tube Defects.
Department of Health. HMSO. London.             Merkus HM, Steerrgers-Theuinessen RP.
                                                New evidence of the influence of
Department of Health (2004a)                    exogenous factors on sperm count in man.
Choosing a better diet: a food and health       European Journal of Obstetrics Gynecology
action plan. London: Department of Health.      and Reproductive Biology 2003; 110: 49-54.      information leaflet
                                                                                                ................................................................................
                                                                                                www.infochoice.org
                                                Velde ER, Habbema JD,Vreiswijk B, Kabatt        ................................................................................
                                                J. Fat and female fecundity:prospective
of Epidemiology; 146 (11) 961- 965.             study of the effect of body fat distribution
                                                on conception rates. British Medical Journal
                                                1993; 306: 484-487.                             ................................................................................
The developmental origins of adult disease.                                                                                                                                        -
Maternal and Child Nutrition 1:130–141.         Ruston D, Hoare J, Henderson L. et al. (2004)
                                                                                                ................................................................................
Hack M, Klein NK, Taylor HG (1995)              aged 19 to 64 years. HMSO: London.
Long-term developmental outcomes of low
birth weight infants Future Child. 5:176-96.    Weight Gain During Pregnancy:
                                                Re-examining the Guidelines.                    Tommy’s The Baby Charity
                                                Committee to Re-examine IOM Pregnancy           ................................................................................
Wilkinson J, Summerbell CD. (2007) Trends in    Weight Guidelines; Institute of Medicine;
maternal obesity incidence rates,               National Research Council. Washington DC.       ................................................................................
demographic predictors, and health
inequalities in 36,821 women over a
15-year period. BJOG.;114(2):187-94.
Heslehurst N, Lang R, Rankin J, Wilkinson JR,
Summerbell CD (2007) Obesity in
pregnancy: a study of the impact of
maternal obesity on NHS maternity
services. BJOG;114(3):334-42.
Institute of Medicine (1990) Nutrition During
Pregnancy. Part I: Weight Gain
Javaid MK, Crozier S, Harvey N et al. (2006)
Maternal vitamin D status during pregnancy
and childhood bone mass at age 9 years:
a longitudinal study. The Lancet 367:36–43.
Jensen T, et al (1998) Does moderate
alcohol consumption affect fertility?
Follow up study among couples planning
first pregnancy. BMJ 317: 505-510.
Koletzko B, Cetin I, Brenna JT (2007) Dietary
fat intakes for pregnant and lactating
women British Journal of Nutrition 98: 873-7.
Letsky E (1991) The Haematological
System In: Hytten F, Chamberlain G (eds.),
Clinical and Physiology in Obstetrics 2nd
edition pp39-82. Blackwell Scientific
Publications, London.



                                                                                                                                                                                       20
                          3

Infant Feeding
From Birth to 12 Months
Section 3
Infant Feeding
        ee
            o 12
From Birth to 1 Months




                                   rnatioonally
Breastfeeding is recognised internationally as the optimal way to
feed infants from birth and exclusive breastfeeding is recommended
                                    sive
                                    n estimated that if all UK infants
until 6 months of age. It has been est   timated
                                        ber
were exclusively breast fed, the numb hospitalised each month
                                   number
with diarrhoea would be halved, and the number hospitalised with
                                        by
a respiratory infection would be cut b a quarter (Quigley et al. 2007).
                                   tive to
Infant formula is the only alternative t breast milk during the first
6 months of life for term infants.


The Department of Health (2007a) recommends that babies should be
introduced to solid foods when they are developmentally ready,
and this is usually around 6 months. Breastfeeding mothers should
be supported to continue to breastfeed through weaning period;
formula milk is the only alternative until 12 months.


Healthcare professionals and childcare staff should ensure that
parents and carers have access to reliable advice and information
to be able to make an informed choice about how to feed their
infants. When a mother has decided how to feed her infant, she
should be supported in that choice and given advice on safe feeding.


This section covers:

                Breastfeeding
                Formula feeding
                Weaning onto solid foods
                Common feeding challenges
..................................................................................


                                                                                     21
Benefits of breast milk for the infants
and their mothers
Breast milk is a unique fluid which has a complex biology and contains
more than 200 known constituents. There are extensive health benefits for
mothers and babies in the short and the long term (see table below). Maximum
health benefits are afforded by exclusive breastfeeding to 6 months, then
continuing breastfeeding alongside solid foods to one year and beyond.

‘Exclusive breastfeeding from birth is possible except for a few medical
conditions, and unrestricted exclusive breastfeeding results in ample milk
production’ (WHO 2003).
..................................................................................




           Advantages of breastfeeding to the infant                                 Reference
                                                                                     Ip et al. 2007
     Optimal nutrition, growth and development reduced incidence                     Horta et al. 2007
     of gastrointestinal, urinary tract and respiratory infections                   Howie et al 1990
                                                                                     Marild et al 2004
     Helps to prevent and reduce the severity of allergic conditions                 Kull et al 2002,
     e.g. asthma and eczema                                                          Sears et al 2002

                                                                                     Duncan et al 1993,
     Reduced risk of otitis media (ear infections) until the age of 5 to 7 years     Aniansson et al 1994

     Reduced incidence of both insulin and non-insulin                               Aberblom et al 1999
                                                                                     Sadauskaite-Kuehne
     dependent diabetes                                                              et al \2004

     Prevents necrotising enterocolitis (NEC) in pre-term infants                    Lucas and Cole 1990

     Contains growth factors, which enhance the infant’s gut                         Sheard and
     development and maturation                                                      Walker 1988

     Reduced risk of constipation                                                    Lawrence 1994

     Reduced incidence of some childhood cancers                                     Davis 1998
     (e.g. leukaemia and lymphomas)                                                  Shu et al 1999

                                                                                     Ford 1993
     Reduced risk of Sudden Infant Death Syndrome                                    Horne et al. 2004

     Some evidence that babies who are not breastfed are                             Li et al. 2003
     more likely to become obese in later childhood                                  Michels et al. 2007

     Less likely to visit the doctor in the first two years of life                   Ball and Wright 1999




       Benefits for the mother

     Encourages emotional bonding between the mother and the infant                  Lawence 1994
     due to the release of endorphins which give a feeling of well being
     Delay in return to menstruation which allows maternal iron                      Unicef 1998
     stores to be replenished following pregnancy and childbirth
                                                                                     World Cancer
     Reduces risk of breast and ovarian cancer                                       Research Fund 2007

     Lower incidence of osteoporosis and hip fractures over the                      Cummings a
     age of 65 for women who have breast fed                                         Klineberg 1993

     Helps mothers return to their pre-pregnant weight                               Dewey et al. 1993


                                                                                                            22
Supporting mothers                                                                   Antenatal discussion
to breastfeed                                                                        _____________________

North Somerset is committed                                                          All pregnant women in North Somerset
to achieving UNICEF UK Baby                                                          have the opportunity to discuss the
Friendly Initiative accreditation                                                    benefits and management of
across both maternity and health                                                     breastfeeding with their midwifery
visiting services. These standards                                                   and/or health visiting team. This
will ensure that mothers have                                                        discussion ensures that pregnant
care and support based on best                                                       women are aware of the many health
practice standards. Staff in all                                                     benefits of breastfeeding for both
NHS establishments and childcare                                                     mothers and babies, and that
settings in North Somerset should                                                    information is provided about the
promote breastfeeding as the                                                         factors tha thelp breastfeeding to be
normal way to feed a baby.                                                           successful. Alongside this discussion,
Information about the Baby                                                           pregnant women are given a leaflet
Friendly Initiative can be                                                           ‘Off to the Best Start’.
                                                                                     ..................................................................................
accessed on:

..................................................................................

www.babyfriendly.org.uk.
..................................................................................




                                                                                                                                                                          23
Initiating breastfeeding                 How breastfeeding works?
_____________________                    ____________________
                                         Successful attachment, the process
Skin contact                             by which the baby scoops up
_____________________                    enough breast tissue into its mouth,
All mothers are encouraged to            is the key to successful breastfeeding.
have unhurried skin contact with
their babies as soon as possible
after birth. In preparation for this,                    learn effective attachment
all pregnant women be informed                           at the breast as it ensures a
of the physiological and emotional                       good milk supply and a
benefits of skin to skin contact:                         comfortable feed


                                                           can check that their nipple is
                                                           round (rather than pinched or
                                                           creased), as this is a sign of
                                                           good attachment
     breathing and heart rate

     of hormones that help the                             mothers receive help and
     new mother to bond with                               support. This is taught using
     her baby                                              visual aids such as a doll
                                                           and / or a knitted breast,
                                                           leaflets and verbal description
     being more successful                                 rather than by the health care
                                                           professional putting the baby
                                                           to the breast for the mother
The first breastfeed
_____________________                    ..................................................................................



The first breastfeed often occurs
during the first period of skin to skin
contact after delivery. Mother and
baby are alert to each other and
sometimes babies are able to self
attach to the breast. Midwives
support mothers with positioning and
attachment at this first breastfeed.




                                                                                                                              24
Baby-led feeding                                                                     Frequency of feeds
___________________                                                                  ___________________
                                                                                                     In the first 2 weeks of life, all
      follow baby led feeding, which                                                                 breastfeeding mothers are
      means allowing the baby to feed                                                                encouraged to feed their
      when s/he wishes, rather than feeding                                                          babies a minimum of 8 times
      to a schedule                                                                                  in 24 hours, including at night
                                                                                                     This ensures that effective
     the breasts receive lots of messages                                                            feeding and a good milk
     to make milk, as the frequent                                                                   supply is established
     removal of milk encourages further
     milk production. Baby-led feeding                                                               Many new mothers are surprised
     also helps mothers and babies                                                                   at how often a new baby wants
     to learn the skills of                                                                          to feed. A young baby naturally
     breastfeeding together                                                                          feeds around 8-12 times,
                                                                                                     or even more, in 24 hours
      as he/she desires is calm and                                                                  Health professionals need to
      relaxed whilst feeding                                                                         reassure parents that frequent
                                                                                                     feeds are normal and help in
                                                                                                     developing a good milk supply
      is more opportunity for both mother                                            ..................................................................................
      and baby to develop the skills of
      positioning and attachment

                                                                                     Ending the feed
                                                                                     ___________________
Feeding cues
___________________                                                                  An important aspect of baby-led
                                                                                     feeding is to ensure that the baby
Health professionals support mothers                                                 is allowed to feed for as long as s/he
with baby-led feeding by helping                                                     wants to. It is important that the baby
them to recognise early feeding                                                      is allowed to make the small fluttery
cues. These can sometimes be                                                         sucks at the end of the feed, as at
subtle and occur before crying.                                                      this point the baby is receiving the
                                                                                     higher fat part of the feed which sustains
Early feeding cues include:                                                          the baby until the next feed and
                                                                                     helps with good weight gain. If feeds
                           Rooting                                                   are halted by the mother too early,
                           Hand-to-mouth movements                                   babies can miss out on the higher
                           Sucking on fingers or fist                                  fat content at the end of the feed.
                           Wriggling                                                 At all feeds, the mother is encouraged
                           Restlessness                                              to allow the baby to feed at the first
                                                                                     breast until s/he spontaneously
If these are ignored or misinterpreted,                                              detaches; the mother then offers
the baby may go back to sleep or                                                     her second breast if the baby is
become very distressed. In this way                                                  awake and hungry.
                                                                                     ..................................................................................
the baby misses the opportunity to
stimulate the breast to make lots of milk.

Sometimes mothers may wish to feed
the baby before s/he is giving feeding
cues. This may be because of
over-full breasts or because of time
management issues, such as needing
to attend to other children. Feeding
the baby sooner than the baby is
asking for a feed is never a problem,
as long as the mother usually follows
baby-led feeding.
..................................................................................


                                                                                                                                                                          25
Breastfeeding patterns
as the baby grows
___________________

Cluster feeds

Cluster feeding occurs when babies
wish to feed frequently, and it can be
difficult for the mother to tell when
one feed ends and another begins.
Cluster feeding is very common
during the evening in the first few
weeks of life. Health professionals
should reassure parents that this is
normal neonatal behaviour and not
indicative of insufficient milk supply.
Extra family support can be
invaluable in helping the mother
cope during this time.


Growth spurts

Over the first few months many
babies have periods of a day or
two where they seem to want lots
of feeds. This may be to increase
milk supply and meet the baby’s
developmental needs. Mothers
are encouraged to continue with
baby-led feeding as this very
frequent feeding usually settles
within a short period.


Very frequent long feeds

If every feed lasts for an hour or more
and/or the baby never spontaneously        Keeping mothers and babies close
comes off the breast, then                 ___________________
attachment is not effective. In this
situation the mother needs skilled         In order to facilitate baby led feeding, all
help from a health professional or         pregnant women and new mothers are
qualified breastfeeding counsellor          encouraged to keep their babies close to
to improve attachment at the               them night and day. Keeping the baby
breast and boost milk supply.              close helps mothers:
                                                             To recognise feeding cues
Night feeds                                                  Form a close relationship
                                                             with their baby
Night feeds are important in                                 Reduces the risk of sudden
establishing a good milk supply                              infant death syndrome (SIDS)
as prolactin levels are higher at night.   All mothers are advised to share the
Many mothers find night feeds tiring        same bedroom with their baby for the
and need support to cope with this.        first 6 months of life.
Midwifery and health visiting staff
discuss night feeds with the mother        Mothers will be given information by
and suggest ways of minimising             health professionals about the risks
disruption, for instance by having the     and benefits of bed-sharing
baby in the same room, feeding
                                           ..................................................................................
lying down and safe bed sharing.


                                                                                                                                26
Teats, dummies                                                                       Supplementary formula feeds
and nipple shields                                                                   ___________________
___________________

Pregnant women and new mothers                                                       Pregnant women and new mothers
are informed that teats, dummies                                                     are informed of the importance of
and nipple shields can interfere with                                                exclusive breastfeeding as this
the baby’s ability to learn to                                                       ensures mothers and babies gain
breastfeed effectively so should be                                                  all the benefits of breastfeeding.
avoided during the establishment                                                     (See advantages of breastfeeding
phase; ideally until the baby is                                                     to the infant on page 22).
breastfeeding well and thriving.
                                                                                     Pregnant women and new mothers
                                                                                     are advised that giving supplementary
If the mother wishes to use a dummy,                                                 formula feeds to a breast fed baby
she should be advised that it should                                                 can interfere with the establishment
be used with caution as it may mask                                                  and maintenance of a good
feeding cues and therefore reduce                                                    milk supply.
the frequency of feeds, leading to
a reduction in milk supply. There is                                                 Supplements of formula milk within
no evidence on which to either                                                       the first six months increases the
recommend or discourage dummies                                                      incidence of eczema, asthma and
for use in the prevention of SIDS.                                                   juvenile onset diabetes
                                                                                     (Ip et al. 2007; Horta et al. 2007).

Nipple shields are associated                                                        No food or drink other than breast
with reduced milk transfer and                                                       milk should be given to a breast fed
hence reduced milk supply;                                                           baby unless it is medically indicated
therefore nipple shields should                                                      or the mother requests this when
not be recommended.                                                                  fully informed.
..................................................................................   ..................................................................................




                                                                                                                                                                          27
Peer support for
breastfeeding mothers
Breastfeeding counsellors                                                            Children’s centres
___________________                                                                  __________________
Breastfeeding counsellors are                                                        All children’s centres in North Somerset are signed
mothers who have themselves                                                          up to the North Somerset Breastfeeding policy
breast fed and have undergone                                                        ensuring that breastfeeding is welcome, and that
training to enable them to                                                           best practice is followed. Breastfeeding welcome
support other mothers.                                                               signs are displayed and staff receive training on
                                                                                     how to support mothers to breastfeed. Many of
Organisations that train
breastfeeding counsellors include                                                    the children’s centres host breastfeeding support
The National Childbirth Trust and The                                                groups and provide refreshments and play facilities
Association of Breastfeeding Mothers                                                 for older children.
                                                                                     ..................................................................................

Both of these organisations have
a network of local counsellors
who offer mother-to-mother
support. Contact numbers
for counsellors and of national
help lines can be found on
each organisation’s website.

National website addresses
for breastfeeding counselling
organisations are:
..................................................................................


www.laleche.org.uk
www.abm.me.uk
www.national-childbirth-trust.co.uk
..................................................................................



National Helpline number:
..................................................................................

0844 209 09 20
..................................................................................




Breastfeeding support groups
___________________
Many mothers report that they
stopped breastfeeding earlier than
they intended (Bolling et al. 2007).
Breastfeeding support groups are
available across North Somerset
to help and encourage mothers to
continue to breastfeed. Groups
are run by either NHS staff, Children’s
Centres, breastfeeding counsellors
or peer supporters. A list of local
groups can be found at:
..................................................................................

www.northsomerset.nhs.uk
..................................................................................




                                                                                                                                                                          28
Breastfeeding out
and about
Concerns about breastfeeding in
front of other people can mean that
some mothers do not breastfeed
outside the home. This serves to
reduce the number of breastfeeds
and can lead to early cessation
of breastfeeding. All new mothers
need the opportunity to discuss
feeding outside the home. Solutions
that other mothers have found
helpful in these situations are using
a scarf or shawl to maintain privacy
and visiting local places which are
breastfeeding friendly.

A North Somerset Breastfeeding
Welcome Here scheme has been
set up to ensure that mothers have
places where they can breastfeed
their babies when out and about.
The scheme involves a commitment
from local businesses taking part in
the scheme to uphold a mother’s
right to breastfeed. Businesses are
also required to clearly display a
poster and/or sticker to welcome
mothers that are breastfeeding.
To view a full list of venues
signed up, see:
..................................................................................

www.northsomerset.nhs.uk
..................................................................................




                                                                                     29
Ongoing support
for breastfeeding
in the postnatal period                              Expressing breast milk
                                                     ___________________

Throughout the early postnatal period health         All mothers are taught to
professionals continue to support a mother to        express their breast milk by hand.
develop the skills and confidence to manage her       This ensures that women are
own breastfeeding. Mothers are given information     able to manage some common
on how to recognise that their baby is getting       breastfeeding challenges, for
enough breast milk to help to build confidence        example, a full breast or a
in their ability to breastfeed their baby.           blocked duct, for themselves.
                                                     This will be taught in the early
                                                     postnatal period and revisited
                                                     by the health visiting team at the
Signs that breastfeeding is going well               primary visit. The pictures and
___________________
                                                     information in ‘Off to the Best
                                                     Start’ can be used as a teaching
     satisfied after most feeds                       aid to support effective delivery
                                                     of this information.
                                                     ..................................................................................
     without fuss at most feeds




     and her nipples are not sore

     a day (after 6 days old)

     at least twice a day




Normal stools for breastfeeding infants
___________________

Mothers are often concerned about their baby’s
pattern of passing stools and ask for reassurance
from health professionals.


     the baby should pass a soft yellow stool at
     least twice a day

     frequency to change and some babies may
     only have a dirty nappy once a week. If the
     baby is otherwise well, infrequent stools are
     not significant after one month

     become constipated, however it is common
     in exclusively bottle fed babies and can
     occur when an otherwise breastfed baby
     is given a supplementary bottle


                                                                                                                                          30
Storing expressed breast milk                                                        Storage of breast milk in hospital
___________________                                                                  ___________________
All mothers are given information about the storage                                  The very intensive use of fridges in
of expressed breast milk, as in ‘Off to the Best Start’                              a hospital setting means that the
(DH 2007b).                                                                          temperature of the fridges cannot
                                                                                     be guaranteed to remain below 4
                     Expressed breast milk should be collected and                   degrees. Therefore Bristol hospitals
                     stored in sterilised equipment. When expressing                 recommend that breast milk is stored
                     breast milk by hand it may be easier to collect                 for only 48 hours in a hospital fridge
                     the breast milk in a large sterilised measuring                 and at Weston hospital breastmilk is
                     jug or bowl. If using a pump then expressed                     stored for up to only 24 hours.
                     breast milk can be stored in the sterilised                     ..................................................................................
                     collecting bottle or bags.

                                                                                     Warming breast milk feeds
                     the main part of a fridge (i.e. not in the door),               ___________________
                     at 4ºC or lower
                                                                                     Breast milk should be warmed by
                                                                                     standing the feed in a jug of hot
                     in the freezer compartment of a fridge, and                     water for a few minutes.
                     up to 6 months in a domestic freezer, at minus                  Microwaving feeds is NOT
                     18ºC or lower                                                   recommended practice and
                                                                                     should be discouraged for the
                                                                                     following reasons:
                     days, the fridge preserves its properties more
                     effectively than freezing
                                                                                                     continue to heat after removal
                                                                                                     from the microwave
                     After 5 days in a fridge, milk will have begun
                     to change in flavour and composition                             ...............................................................................




                     defrosted in the fridge and should not be
                     re-frozen once thawed
..................................................................................




                                                                                                                                                                          31
Advice for overcoming breastfeeding challenges
__________________
If there are problems with breastfeeding, the mother and infant should be
referred for breastfeeding help to a professional or breastfeeding supporter
who has undertaken a specialist training in breastfeeding management.
This could be a midwife, health visitor or breastfeeding counsellor.
..................................................................................




Avoiding mastitis
__________________
Mothers should be encouraged to be breast aware and to check their
breasts regularly for lumps that may indicate a blocked duct. If the mother
finds a blocked duct she should be encouraged to make sure the baby
is feeding effectively on that side, making adjustments in positioning and
attachment as necessary to achieve this, and use hand expression and
gentle massage to unblock the duct.

A mother who complains of any of the following may be suffering from mastitis:


                                                                                     hot to touch
                                                                                       becoming red

                  temperature, shivering, becoming tearful and tired



If mastitis is suspected, the mother should contact her midwife or health
visitor as soon as possible for information and support. If mastitis does not
quickly resolve using self-help measures, or if symptoms worsen quickly,
then the woman may need to be prescribed antibiotic therapy by her GP         .
It is very important that the mother with mastitis continues breastfeeding,
as sudden cessation of breastfeeding will lead to worsening mastitis and
possibly breast abscess. Further guidance for treatment is available from
the breastfeeding network:
..................................................................................

www.breastfeedingnetwork.org.uk
www.northsomerset.nhs.uk
..................................................................................




                                                                                                      32
Returning to work
Many mothers continue to              If a mother is returning to work earlier than 5-6 months,
breastfeed successfully on            or for any other reason wants to help her baby learn
returning to work by:                 to accept a bottle, the following tips have been
                                      helpful to many mothers:

      before and after work
                                                        someone else other than the mother
      infant can be fed by cup or
      bottle while she is away                          mother is not present

      her work and arranging to                         may help
      breastfeed during breaks
      in her work day
                                      Planning for returning to work can be an emotional
                                      time for new mothers. It can be helpful to meet other
      flexible hours around            mothers at breastfeeding support groups who have
      breastfeeding                   experience of returning to work and the emotional
                                      adjustment involved.
      work or job sharing             If a mother informs her employer in writing that she
                                      wishes to breastfeed, support can be put in place to
It is not essential that all babies   allow her to express and store breast milk while at work.
learn to take milk from a bottle      The Workplace Regulations and Approved Code of
when their mother returns to work,    Practice require employers to provide suitable facilities
as many babies move straight          for pregnant and breastfeeding mothers to rest.
from breastfeeding to a cup or
a beaker at around 5-6 months         Information on the rights of mothers returning
of age. Using an open cup, or a       to work is available in the Department of Health
free flowing cup without a valve,      leaflet ‘Breastfeeding and Work’.
helps the baby to learn to sip and
is better for the baby’s teeth.       Information for employees and employers
                                      is available to download from:
                                      .................................................................................

                                      www.dh.gov.uk
                                      .................................................................................




                                                                                                                          33
Breastfeeding in
special circumstances
Premature babies                                                                   Breastfeeding twins and multiples
___________________                                                                ___________________
Mothers of infants born early                                                      In the same way that mothers make
need extra support to initiate and                                                 enough milk for one infant, they can
maintain lactation. The babies                                                     make enough for two or more babies.
will then learn to feed from the                                                   All the principles that underpin
breast when they are ready.                                                        successful breastfeeding with one
                                                                                   baby also apply in this situation.
Mothers in this situation are
encouraged to start expressing
early (usually before they leave                                                   Individual circumstances will need
delivery suite) and frequently                                                     to be taken into account, but most
(at least 8 times in 24 hours,                                                     mothers will start by feeding each
or 10 -12 times in 24 hours if                                                     baby separately until they are
the baby has been born very                                                        confident with positioning and
prematurely). Mothers are given                                                    attachment. Once that has been
support to do this effectively to                                                  achieved, feeding twins
ensure that their milk supply is                                                   together will shorten overall
maximised. When the baby is                                                        feeding times and may be
ready to breast feed they will be                                                  preferred by the mother for at
given full support to learn this skill.                                            least some of the feeds.

More information on breastfeeding                                                  More information on breastfeeding
premature infants is available from:                                               twins & multiples is available from:
................................................................................   ................................................................................

www.bliss.org.uk                                                                   www.tamba.org.uk
................................................................................   ................................................................................




                                                                                                                                                                      34
Medication during lactation                                       Breastfeeding and HIV
___________________                                               ___________________
Although there are few medicinal drugs that are                   In the United Kingdom, it is currently
unsafe to use during lactation, breastfeeding                     recommended that women known
mothers should not take drugs unnecessarily and                   to be HIV Antibody Positive (or those
should take advice from their doctor or pharmacist.               at high risk who have not been
                                                                  serologically tested), should be
                                                                  advised not to breastfeed but to use
Information can be obtained from:                                 infant formula for feeding their baby
                                                                  as the HIV virus can be passed to the
                                                                  infant via breast milk (CMO Report 2004).
                                                                  In developing countries where
                                                                  there are not the facilities to make
                                                                  up infant formula safely, HIV positive
                                                                  mothers are encouraged to
                  Phone:                                          breastfeed exclusively to reduce
                                                                  the risk of death through
                                                                  gastroenteritis due to bacterial
                  Medications and Mother’s milk (39)              contamination of infant formula.
                                                                  Specific advice will be required in
The ‘Drugs in Breast Milk’ national helpline                      circumstances where a mother is
can be accessed by both parents and health                        likely to be travelling back to her
care professionals on:                                            country of origin. If this is a country
...............................................................   in which formula feeding would not
0844 412 46 65                                                    be safe or culturally acceptable,
.............................................................     advice will be given by the specialist
The Breastfeeding Network has excellent                           HIV teams providing the woman’s
evidence based information sheets on                              medical and obstetric care.
common drugs / medications and breastfeeding.                     Once an HIV positive mother has
These can be accessed via:                                        made a choice between
...............................................................
                                                                  breastfeeding and formula feeding
                                                                  her infant, she should be advised
www.breastfeedingnetwork.org.uk                                   not to mix feed by offering both
.............................................................
                                                                  breast milk and infant formula.
                                                                  Mixed feeding carries the highest
                                                                  risk of HIV transmission to the infant.
                                                                  ................................................................................




                                                                                                                                                     35
Mother’s diet during lactation
                                                                                   The Department of Health
Eating a healthy balanced diet based on the five food                               recommends breastfeeding
groups will usually ensure nutritional requirements are met                        mothers should take a
except for vitamin D.                                                              10μg vitamin D per day
                                                                                   (DH COMA Report 1991).
The nutritional quality of breast milk is not significantly
affected by the mother’s diet unless she is undernourished.                        The Healthy Start vitamins for
                                                                                   women should be recommended
However mothers on very restrictive diets may require                              as they include 0.4mg folic acid
some supplementation.                                                              which will help to build up the
                                                                                   mother’s stores of folic acid for
Pregnancy and breastfeeding are times when families                                any future pregnancies.
are often well motivated to adapt their lifestyles, therefore
providing an opportunity to give information on healthy                            Breast fed infants should begin
eating to the whole family.                                                        vitamin D supplements from
................................................................................
                                                                                   6 months. Health professionals
                                                                                   may recommend starting the
                                                                                   supplements at 1 month in
                                                                                   babies who are nutritionally
                                                                                   at risk.
Vitamin D supplementation recommendations
___________________                                                                Information on their availability
                                                                                   should be given to families.
Some pregnant women in North Somerset are offered
Healthy Start Vitamins during pregnancy as infants whose
mothers are vitamin D deficient during pregnancy are
at risk of tetanic fits or rickets.
................................................................................


                                                                                                                       36
Foods to limit while breastfeeding
___________________
Oily fish should be eaten once or                                                   Alcohol is absorbed directly into the
twice per week because they are                                                    blood stream and passes into breast
a good source of omega 3 fats.                                                     milk. The highest level of alcohol in
However, breastfeeding women                                                       milk will occur between 30-90
should not have more than two                                                      minutes after ingesting alcohol.
portions per week because some                                                     Breastfeeding mothers who choose
of these fish contain dioxins and                                                   to drink alcohol should not ingest
PCBs (polychlorinated biphenyls)                                                   alcohol for about 2 hours before
which can be toxic (FSA 2008).                                                     breastfeeding and should keep
................................................................................   alcohol intake to a minimum.
                                                                                   Regular or binge drinking should
                                                                                   be avoided. (FSA 2008)
Oily fish includes salmon, trout,                                                   ................................................................................

mackerel, sardines, pilchards,
herring, kippers, eel, whitebait
and tuna. These fish count as
oily fish when they are canned,                                                     Caffeine in tea and coffee does
fresh or frozen with the exception                                                 not need to be avoided but
of tuna, which loses its oil content                                               some mothers find large amounts
as part of the canning process.                                                    unsettle their baby.
Breastfeeding mothers and women                                                    ................................................................................

planning a pregnancy should not
eat more than 4 medium sized
cans of tuna a week (with a
drained weight of about 140g                                                       Food intolerance
per can) or fresh tuna steaks                                                      ___________________
(weighing about 140g when                                                          It is very rare that a food that the
cooked or 170g raw) because                                                        mother eats can affect the baby
of the risk from heavy metals.                                                     causing an allergic response.
                                                                                   Common triggers are dairy products,
Shark, marlin and swordfish                                                         eggs and nuts. If a mother needs to
should be limited to one serving                                                   exclude a whole food group e.g. milk
per week due to their mercury                                                      and dairy products, then she should
content (DH 2002).                                                                 be referred to a registered dietitian
................................................................................   for advice to make sure her diet
                                                                                   remains adequate in all nutrients.

                                                                                   In December 2008 the Food
                                                                                   Standards Agency advised that
                                                                                   there is insufficient evidence to
                                                                                   advise any breastfeeding mother
                                                                                   to avoid eating peanuts and
                                                                                   peanut products unless she is
                                                                                   herself allergic to peanuts.
                                                                                   ................................................................................




                                                                                                                                                                      37
Formula feeding                                                                    Choosing a formula
Breastfeeding should always be                                                     The standard formulas are made
promoted as the first choice for                                                    from skimmed cows milk powder
feeding an infant. It is important                                                 with added fats and nutrients to
however, that if the family choose                                                 make the composition nutritionally
to use infant formula to feed their                                                adequate for infants. Formulas
infant they are to be shown /                                                      are modified as knowledge and
advised how to do this safely and                                                  technology progresses. However
correctly during the post-natal period.                                            their composition must always
They should be given the Department                                                comply with strict criteria set by
of Health leaflet called ‘Bottle                                                    European Union regulations, which
Feeding’. They should also be                                                      are updated as scientific research
shown how to make up a feed                                                        advances. These are published for
and sterilise equipment, even if                                                   each UK country and the current
they think they already know, as                                                   Infant Formula and Follow-on
some of the advice may have                                                        Formula (England) Regulations 2007
changed from the last time they                                                    can be accessed on the IDFA website:
did this.                                                                          ................................................................................

                                                                                   www.idfa.org.uk
Consideration of the infant’s                                                      ................................................................................

individual needs and feeding on
demand are important. Newborn                                                      These regulations allow standard
infants need to feed frequently on                                                 formulas to be based on only cows
demand. The volume should be                                                       milk protein or soya protein. Goats
gradually increased until weaning                                                  milk is not allowed as a source of
when frequency and number of                                                       protein as the evidence to support
feeds decrease. It is essential that                                               its use was considered insufficient
an infant is never left unattended                                                 by the European Food Safety.
whilst feeding and they should                                                     ................................................................................

always be held whilst bottle
feeding. From six months of age
a feeding cup should be introduced
and encouraged. The use of bottles
should be discouraged from the age
of one year. Solids should never
be added to a bottle feed.

Infant formula in the UK comes
as dried powder to be mixed with
water or as a sterile ‘ready to feed’
liquid which is more expensive.
They are usually given in a bottle
with a teat or in a cup - both should
be sterilised prior to being filled with
the formula milk due to the risk of
bacterial contamination in feeding
infant formula.
................................................................................




                                                                                                                                                                      38
Infant formulas - suitable from birth
___________________

There is a choice between whey or casein dominant formula.
It is recommended that a whey dominant formula should be used
because its amino acid and mineral content is closest to breast milk

Whey dominant infant formula is often labelled with a ‘1’ and is promoted
for new born babies. This type of formula is based on the whey of cows milk
and the ratio of proteins in the formula approximates to the ratio of whey
to casein found in human milk (60:40).

There is no evidence that changing from whey-based breast milk to any
other type of formula is necessary or beneficial. First milk is nutritionally
complete for bottle-fed babies until they are weaned around 6 months
of age and can be continued alongside solid food until babies are
a year old.

Casein dominant infant formula is often labelled with a ‘2’ and
promoted as suitable for hungrier babies. Although the proportions of
the macronutrients (fat, carbohydrate, protein etc) are the same as
is found in whey dominant formula, more of the protein present is in
the form of casein (20:80).

The higher casein content causes large relatively indigestible curds to
form in the stomach and is intended to make the baby feel full for
longer. However, there is no evidence that babies settle better or
sleep longer if given this milk (Taitz 1989, Thorkelsson 1994).

Overall there is insufficient evidence to support changing from a whey
to a casein dominant formula or for switching brands (DHSS 1998).
................................................................................




                                                                                   39
Differences between brands
___________________
The formula manufacturers research and develop their products
in different ways (Carver 2003) and each company promotes the
benefits of their formula to Healthcare Professionals based on
different additions such as:


                                                                     are added to all
                  infant formula except for organic formulae. The two LCP’s that have
                  been identified through research to be vital for optimum brain and
                  eye development are Docosahexaenoic (DHA) and Arachidonic
                  acid (AA) which are naturally found in breast milk

                  Nucleotides may play a role in the development of the immune
                  system and the gastro-intestinal system through enhancing a
                  healthy gut flora

                  Prebiotics are types of fibre that remain undigested in the gut and
                  they promote the growth of bacteria (e.g. bifidobacteria) in the gut
                  flora that have a positive effect on digestion and absorption. They
                  are present in breast milk and those that are added to infant formula
                  are usually galacto-oligiosaccharides and fructo-oligiosaccharides

                  Alpha lactalbumin protein is the main type of whey protein in
                  breast milk. Cows milk whey proteins are mainly beta lactalbumin



For nutritional components in breast milk and infant
formula milks see Appendix 1.

The differences between brands are minimal and healthcare
professionals cannot promote one brand over another.
................................................................................




                                                                                          40
Soya based infant formulae may be chosen by parents as an alternative
to a cows milk formula but they are not recommended for infants under 6
months for the following reasons:

                  Phytoestrogens found in soya have been linked with changes in
                  the reproductive organs of experimental animals

                  For infants with cow’s milk allergy or intolerance there is a risk of
                  cross reactivity with soya formula

However a GP or a dietitian may recommend Soya Milk if there is a clinical
need while the infant is still under 6 months of age. In 2004 the Chief Medical
Officer advised that:

‘Soya-based formulae should only be used in exceptional circumstances
to ensure adequate nutrition. For example, they may be given to infants
of vegan parents who are not breastfeeding or infants who find
alternatives unacceptable’

After six months the risk associated with using soya formula is likely to be
reduced, as the dose of phytoestrogens per kg of body weight will be
lower once the infant is taking solids.
................................................................................




Follow-on formulas are only suitable for infants over 6 months as they
are higher in protein, iron and vitamin D than infant formula.

Formula or follow-on formula can be given as the main milk drink between
6-12 months, however it’s not necessary to change, as a balanced
weaning diet along with a standard infant formula will provide adequate
nutrition. Follow-on formula should not be used as a substitute
for a good weaning diet.
................................................................................




Cows milk should not be introduced as the main milk drink before 12 months
of age. It is lower in iron than formula milks and infants who are given cows
milk as their main milk drink before 12 months of age are at higher risk of iron
deficiency anaemia. Cows milk can be used in the preparation of weaning
foods such as milk puddings and white sauces.

There are also a range of specialised infant formulas for infants with
certain medical conditions and they should only be used on the advice
of a doctor or dietitian.
................................................................................




                                                                                          41
Sterilisation of                                                                   There are three acceptable
feeding equipment                                                                  Methods of sterilising equipment
Careful sterilisation of feeding
equipment is essential to prevent                                                  1. Cold water sterilising
bacterial contamination of infant
formula which can cause                                                            Follow the manufacturer’s instructions.
gastroenteritis. Gastroenteritis is
more common in formula fed                                                         The sterilising solution should be
infants than breast fed infants.                                                   changed every 24 hours.
                                                                                   The feeding equipment should be
                                                                                   left in the sterilising solution for at
                  feeding infants needs to be                                      least 30 minutes.
                  sterilised because it is difficult                                Ensure there is no air trapped in the
                  to clean thoroughly and any                                      bottles or teats when putting them
                  remaining traces of milk can                                     in the sterilising solution.
                  cause bacterial contamination
                                                                                   All parts of the equipment should
                                                                                   be kept immersed in the solution
                liners are for single use only                                     with a floating cover.
                and should not be reused.
                The cap and teat should                                            2. Steam sterilising /
                be sterilised                                                         microwave steriliser

Before sterilisation all bottles and                                               Follow the manufacturer’s instructions.
teats should be thoroughly washed
                                                                                   Ensure that the openings of the
and rinsed. The practice of rubbing                                                bottles and teats are facing down
teats with salt to remove traces                                                   in the steriliser.
of feed is not recommended.
Even after rinsing some of the                                                     Once the steam steriliser has been
salt may remain leading to the                                                     opened, any equipment not used
risk of hypernatraemia.                                                            straight away should be re-sterilised
................................................................................
                                                                                   before use.

                                                                                   3. Boiling water

                                                                                   Equipment is sterilised by boiling in
                                                                                   water for 10 minutes. Equipment
                                                                                   must remain completely immersed
                                                                                   in the boiling water.

                                                                                   Unsuitable sterilising methods:

                                                                                         a special steamer, as they do
                                                                                         not sterilise feeding equipment

                                                                                         be guaranteed to reach
                                                                                         high enough temperatures
                                                                                         for an adequate time period
                                                                                         to ensure sterilisation




                                                                                                                             42
                                                                                   Making up
feed formulae                                                                      powdered formula
                                                                                   Powdered infant formula is not sterile. Current guidelines
                  is sterile until opened                                          for making up powdered infant formula can be
                                                                                   accessed on the Food Standards Agency website:
                                                                                   ................................................................................
                stored in a refrigerator kept
                at 5oC or below for up to                                          www.food.gov.uk
                                                                                   ................................................................................
                24 hours
                                                                                   Care should be taken not to over
                must be sterilised as                                              or under concentrate the feed:
                described above
................................................................................

                                                                                                   in the tin with the milk powder

                                                                                                   for each 30ml (1 fl oz) boiled water

                                                                                                   milk powder in the scoop as this will over
                                                                                                   concentrate the feed

                                                                                   Over concentration of feeds can result in constipation,
                                                                                   hypernatraemia, vomiting and excess weight
                                                                                   gain. Under-concentrating feeds will not provide
                                                                                   the infant with sufficient calories or nutrients for growth
                                                                                   and development.
                                                                                   ................................................................................




                                                                                                                                                                      43
    Suitable water for making up powdered feeds
    ___________________

                  bottled water, should be boiled, but only once,
                  and allowed to cool, covered, for up to 30 minutes

                  more research is available on the risks of the
                  potential ingestion of silver (found in the cartridges)
                  and on the levels of sodium (found in the resin)

                feeds because this may increase the sodium
                content of the water

                be used to make up formula feeds due to
                potentially high levels of carbon dioxide, sodium,
                nitrate, fluoride and sulphate

                Mineral Water’ are expected to conform to
                essentially the same standards as the public water
                supply and are therefore suitable for preparing
                formula feeds for infants: the sodium content
                should be less than 200mg/l
...............................................................................




    Preparing formula feeds abroad
    ___________________

    The customer care line of each formula company
    can advise whether their formula is available in the
    country to which the family are travelling.

    Parents should always be advised to take at least one
    unopened can of powder with them to allow some
    time in which to establish a supply abroad.

    As in the UK, tap water and bottled water should
    be boiled for making up a formula feed using
    powdered formula. The label on the bottled
    water should be checked to make sure that the
    sodium level is less than 200mg/l. Bottled water
    should be still and unflavoured.
...............................................................................




                                                                                  44
Storing prepared infant formula
Storing prepared infant formula is no longer recommended but there may
be times when feeds need to be prepared in advance. The prepared feeds
must be stored in the main part of a refrigerator (not in the door) and kept
at 5oC or below. The maximum storage time is 24 hours and any prepared
feed not used after this time should be discarded.

Warming refrigerated feeds
___________________

Refrigerated feeds should be warmed by standing the feed in a jug of hot
water for a few minutes.

Microwaving formula feeds is NOT recommended practice and should be
discouraged for the following reasons:


                after removal from the microwave


                  be undetected and scald the infant
...............................................................................




                                                                                  45
Feeding milk formula to infants
As with breast fed infants, infants who are bottle fed,
particularly newborns, should be allowed to regulate
their own intake of formula feeds and
parents should be advised:




     rather than encouraging him/her to finish each bottle



     same closeness found with breastfeeding



     and may need to be sat up to be winded during the pauses



Key points for feeding from a bottle:



     the baby should open its own mouth



     prop feeding; they should always be held whilst bottle-feeding

     formula should be discarded



     that bottles can be discontinued by around the age of 12 months




                                                                       46
Formula amounts to offer
___________________
Fluid Requirements:

      Age                                                         ml/kg body weight/24 hours

      Pre-term                                                   150-200
      0-6 months                                                 150
      7-12 months                                                120

(Adapted from, Nutritional Requirements for Children in Health and Disease. Great Ormond
Street Hospital for Children NHS Trust. 2000)

Newborns may take very small volumes of formula. The volume of feeds
demanded will gradually increase until weaning when the frequency
and number of feeds should be decreased.


Average feeding amounts and frequency are:

      Approximate age                                                          Approximate single feed volume   Number of
                                                                                                                feeds day

                                                                               mls                ozs

      1-2 weeks                                                                50-70              2-3           7-8
      2-6 weeks                                                                75-110             3-4           6-7
      2 months                                                                 110-180            4-6           5-6
      3-5 months                                                               170-220            6-7           5
      6 months                                                                 220-240            7-8           4



Extra fluid
___________________

In exceptionally hot weather infants may become thirsty in between
their usual feeds. They can be offered drinks of cooled, boiled water.
Flavoured or sweetened waters should not be offered.
................................................................................




Introducing a cup
___________________

From about six months of age a feeding cup can be introduced and
encouraged for milk feeds. Breastfeeding should be encouraged to
continue. If a mother decides to change to formula from this age or
older she could use a cup rather than a bottle.

Bottles of milk should be phased out from around the age of one year
as toddlers may begin to associate bottles of milk with comfort and can
become stubborn about giving them up.
................................................................................


                                                                                                                            47
Vitamin supplementation                                                            Introduction of solid food
All formulas are fortified with                                                     Weaning is the process that begins the transition
vitamins A & D and most formula                                                    from breast or infant formula feeding to eating a
fed infants will receive enough of                                                 balanced family diet. The Department of Health
these two vitamins in their formula                                                has made the following recommendations on
milk during the first 6 months of life.                                             infant feeding and the introduction of solid foods:
All formula fed infants should begin
a supplement of vitamins A & D
from 6 months once they are                                                                        for the first six months of an infant’s life for
drinking less than 500mls formula                                                                  all healthy infants
per day (DH COMA 1994).

Families should be advised where                                                                   introduction of solid foods for a normal healthy
to access the NHS Healthy Start                                                                    infant, whether they have been breastfed or
children’s vitamin drops. Those                                                                    given infant formula milk
families who are entitled to receive
Healthy Start vouchers are entitled
to these vitamin drops free.                                                                       6 months and never before 4 months
................................................................................

www.healthystart.nhs.uk
................................................................................
                                                                                                   if used) should continue through out the first
                                                                                                   year along with appropriate types and
                                                                                                   amounts of solid foods


                                                                                                   these recommendations should be supported
                                                                                                   to optimise their infant’s nutrition


                                                                                   The introduction of solid foods alongside an infant’s
                                                                                   milk feeds is to:


                                                                                                   breast milk or infant formula no longer supplies
                                                                                                   them in sufficient amounts to sustain normal
                                                                                                   growth and optimal health and development


                                                                                                   tastes and textures, based on family foods, at
                                                                                                   a time when they are receptive to them

                                                                                   Mothers should all be encouraged to continue
                                                                                   breastfeeding throughout weaning (Agostoni et al. 2008).
                                                                                   ................................................................................




                                                                                                                                                                      48
When to introduce solid foods

breast or infant formula fed. At this age a baby’s digestive system and
kidneys are still developing and weaning too soon may increase the risk
of infections and allergies.

In practice the developmental signs that suggest that an
infant is ready to accept solid foods are:




                     a good indicator of being ready for solid foods. It is normal for babies
                     aged three to five to begin waking in the night when they have
                     previously slept through. If babies seems hungrier at any time before six
                     months, offer extra breastfeeds. Many mothers find that as their baby
                     grows and gets heavier it can be very useful to make sure the baby’s

                     to build up milk supply again really quickly so that it is meeting their needs.
                     Trying an extra feed for a formula-fed baby can also meet their needs

................................................................................




Weaning before six months
Around six months is the ideal time to introduce solid foods. If babies are
introduced to solid foods before six months, the following foods should be
avoided as they may cause allergies or illnesses.


                     (for example bread, rusks and some breakfast cereals)




................................................................................




                                                                                                       49
Introducing new foods

Weaning is a learning process and infants will only learn to accept and
enjoy new tastes and textures if they are given the opportunity to try them.
Some infants are kept on pureed foods for too long and those who are not
offered lumps and finger foods by 9 months are more likely to be fussy eaters
at the age of 3 years compared to those that were weaned appropriately
(Northstone 2001).

................................................................................




                                  Skills babies will learn                         New food textures to introduce

                              Taking food from a spoon
                    Moving food from the front of the                                     Smooth purees
                    mouth to the back for swallowing
                                 Managing thicker purees                                   Mashed foods
                                   and mashed food

                   Moving lumps around the mouth                                    Mashed food with soft lumps
                                             Chewing lumps                                Soft finger foods
              Self-feeding using hands and fingers
                                                                                         Liquids in a lidded
                                        Sipping from a cup                                 beaker or cup



            Chewing minced and chopped food                                              Hard finger foods

                Self-feeding attempts with a spoon                                     Minced and chopped
                                                                                           family foods




                                                                                                                    50
Getting started
Solids may be introduced at any
time during the day that is
convenient for the carer and
infant. The infant should be wide
awake and not too hungry so
either between feeds or mid way
through a feed.
................................................................................




Small amounts of mashed
vegetable, mashed fruit or cereal
mixed with milk after or in the
middle of a milk feed should be
offered. Mix a little of the baby’s
usual milk to the food to achieve
desired consistency.

If the food is hot, it should be
allowed to cool, stirred, and tested
before being given to the baby.

At first, only offer the equivalent
of a couple of teaspoons of food
once a day.

Babies can help themselves to
mashed foods. Some mothers
may spoon-feed their baby but
they will soon be able to do it
themselves. Babies should be
allowed to feed themselves, using
their fingers, as soon as they show
an interest. If a spoon is being used,
wait for the baby to open their mouth
when offering the food.
................................................................................




                                                                                   51
First foods
    Food can be puréed (using a sieve, hand blender or liquidiser),
    mashed or offered as a finger food
    Finger foods should be given even if babies don’t have teeth
    (foods containing sugar should be avoided)

 Examples of finger food
 Soft fruit pieces
 e.g. mango, melon, banana, soft ripe pear, peach, papaya and kiwi

 Cooked vegetable sticks
 e.g carrot sticks, green beans, courgette sticks, potato and sweet potato

 Cooked vegetable pieces
 e.g. cauliflower and broccoli florets

 Cooked pasta pieces

 Fingers of toast

 Cheese cubes

 Soft roasted vegetable sticks.
 e.g. potato, sweet potato, parsnip, pepper, carrot, courgette


Feeding hints for parents
___________________

    Allow plenty of time for feeding
    Don’t force feed babies. If food is rejected, wait and try again later
    Go at the baby’s pace - babies have to learn how to move food
    from the front of their tongue to the back so that they can swallow it.
    Some babies learn this quicker than others and most babies know
    when they’ve had enough to eat
    Talk to babies whilst they are being fed


    cut into sticks
    Give a range of foods and textures to taste
    Foods should be introduced one at a time

    frozen in small amounts such as ice cube trays or small containers
    for convenience
                                                            salt should
    not be added
    Infants can chew soft lumps with their hard gums

    are mainly used for biting
    Hard and crunchy foods should be avoided as infants at this
    age can bite off lumps but not yet chew them properly,
    which could lead to choking
                                                                              52
Introducing more foods
___________________

Once babies are used to eating vegetables and fruit, a range of foods
from the following groups should be offered over the day. Suitable foods
from each group are:

                Potatoes and cereal based foods including bread, rice, couscous,
                pasta, porridge and other breakfast cereals
                Fruits and vegetables
                Milk products such as yogurt, cheese, custard and milk puddings
                Meat, fish, well-cooked eggs, pulses (peas, beans and lentils)
                and vegetables


By the age of 6 months, an infant’s iron stores that were laid down
during pregnancy are no longer adequate to meet the infant’s
iron requirements. It is therefore important to encourage the
iron rich foods from the meat and alternatives as well as iron
fortified breakfast cereals and green vegetables. To increase
absorption of iron from plant based foods, food or drink
rich in vitamin C should be given at the same meal.
................................................................................




Drinks with meals
___________________

                A free flowing beaker should be introduced
                for drinks around 6 months of age
                Water is the ideal drink to be offered at meal
                times from 6 months and should be offered
                and available at all times
                Continue to offer breast milk or formula milk
As babies eat more solids, the amount of milk they want will reduce.
Once babies are eating plenty of solids several times a day, they may
take less milk at each feed or even drop a milk feed altogether.
................................................................................




                                                                                   53
From about nine months                               ___________________
    Aim for 3 meals per day                          Some infants will respond with
                                                     surprise to a new taste. Parents
    Infants should take part in as many              should be reassured that infants
    family meals as possible                         will learn to like new tastes if they
    Encourage a wide variety of tastes               are offered them on a regular
                                                     basis. Parents who do not offer
    and textures                                     foods that their infant has refused
    Offer a snack between meals at mid-morning       the first or second time may narrow
    and mid-afternoon - for example fingers of        the range of foods the infant
    fruit, vegetables or toast                       will accept.
                                                     ................................................................................

    Continue to offer breast milk or formula milk
    Babies eat different amounts on different days
    therefore allow them to eat to appetite          Gagging and coughing
                                                     ___________________
    Harder finger foods such as raw ripe fruit
    and vegetable sticks and family foods such       Gagging is a normal reflex present
    as sandwiches are also suitable                  at birth. It is a protective reflex
                                                     preventing objects from
                                                     obstructing the airway. Initially
The typical number of servings to be included        the gag may be stimulated by
from each food group per day is:                     touching the mid-section of the
                                                     tongue. When infants are learning
                                                     to manage new textures they may
Potatoes and cereal based foods       3-4 servings   gag or cough up food that needs
Fruits and vegetables                 3-4 servings   more chewing. This is part of the
Milk puddings, yogurt, cheese         1-2 servings   learning process and parents
Meat, fish, eggs, pulses & nuts        2 servings     should be advised not to panic;
vegetarian alternatives                              the infant might just need more
                                                     experience to cope easily with
                                                     that texture. If an infant gags or
                                                     coughs frequently, families may
                                                     need further assessment from
                                                     a Speech and Language Therapist.

                                                     Infants must never be left
                                                     unattended with foods
                                                     as they can choke.

                                                     Children should be seated in
                                                     a supported chair with their legs
                                                     at right angle to their body and
                                                     in a calm atmosphere when eating.
                                                     When parents or carers are feeding
                                                     children they should be facing them.
                                                     Cutting food into short lengths rather
                                                     than small pieces will also reduce
                                                     the risk of choking and are easier
                                                     for infants to manage if they are
                                                     self-feeding.
                                                     ................................................................................




                                                                                                                                        54
Parents’ cooking skills                                                            Suitable drinking cups
___________________                                                                ___________________
Commercial baby foods, such as                                                     Drinks can be offered from a cup from about 6 months.
cans, jars and dried food may be
convenient in some circumstances                                                                   Either in a free flowing lidded cup or an open cup
but their exclusive use should be
discouraged as learning to like family                                                             Avoid lidded cups with valves as these are often
foods is a key aim of weaning.                                                                     difficult for infants to get liquids out

                                                                                                   Bottle drinking should be phased out around an
staff need to encourage and                                                                        infant’s first birthday. This is to help prevent tooth
support any parents who would                                                                      decay known as ‘bottle caries’ in the toddler years
like to improve their cooking skills.                                              ................................................................................

................................................................................




                                                                                   Milk feeds
___________________                                                                ___________________
Low-fat foods are not suitable for                                                 Breast milk or formula milk continue to be an important
babies or children under two. Fat is                                               part of an infant’s nutritional intake, however, these
an important source of calories and                                                feeds should naturally decrease as the quantity
some vitamins which they need.                                                     of solid food increases.
................................................................................
                                                                                   Follow-on formula can be given in place of infant
                                                                                   formula after 6 months, however this is not
                                                                                   necessary. Formula intake should be about
                                                                                   500-600ml per day (DH 1994).
                                                                                   ................................................................................




                                                                                                                                                                      55
     Infants should be able to see and to explore their
     food at mealtimes - sitting them in a highchair will
     enable them to do this
     Finger foods should be offered at each meal
     Infants should be allowed to touch and play
     with soft or liquid foods in their bowl or plate
     Feeding infants can be messy, however this is
     an important part of the learning process




Developing self feeding skills
Self feeding should be encouraged from the beginning
of weaning by offering finger foods and allowing infants
to have their own spoon even when they are being fed
by a carer.

Infants who are allowed to become involved in learning
to self feed will feel more engaged in the feeding
process and will be less likely to want to end the meal
because they have become bored.

Some infants need help with feeding as they may not
be able to feed themselves adequate quantities of
food fast enough to satisfy their hunger.




Understanding when
an infant has had enough
Infants can regulate their calorie needs if allowed to.

Parents and carers should be aware of following signals
that their infant is telling them s/he has had enough:

     Keeps his mouth shut when food is offered
     Turns his head away from the food being offered
     Puts his hand in front of his mouth
     Pushes away a spoon, bowl or plate containing food
     Holds food in his mouth and refuses to swallow it

Parents should be dissuaded from encouraging infants
to eat more than they want and force feeding should
never occur.

                                                            56
Food safety
   Hand washing should always be the first step in
   preparing food or drinks

   Bottles and teats for formula milks should always
   be sterilised
   Plates, bowls, drinking cups and cutlery do not
   need to be sterilised but should be scrupulously cleaned
   Freshly cooked food can be stored for up to 24
   hours in the fridge

   hot right through and then cooled before feeding.
   Food should not be reheated more than once
   Frozen food should be thawed in the fridge.
   Thawed frozen food should not be refrozen
   Eggs, meat, fish and shellfish should all be well
   cooked right through
   Shark, sword fish and marlin should not be given
   because of their high mercury content
   Honey should not be given until the age of 1 year as
   very occasionally it may contain spores of botulinum.
   After 1 year of age the gut is mature enough to
   prevent the botulinum bacteria from multiplying

                                   should not be given
   until after 1 year as they may cause food poisoning

         if offered, should be limited to one small
   serving per week because of the high levels of
   vitamin A




                                                              57
Foods to limit                                                                     Vegetarian diets
                                                                                   in infancy
Sugar
___________________                                                                Infants can successfully be weaned onto a vegetarian
                                                                                   diet as long as a good source of iron food is offered
Sugar should not be added to
                                                                                   at each meal for example:
milk or manufactured baby foods.
In home made puddings and
cooked fruit a small amount may
be added if necessary to reduce                                                                    oats or egg at breakfast
the tart flavour of sharp fruits.
................................................................................                   green vegetables at lunch and tea
                                                                                   ................................................................................




Salt and salty foods
___________________
Breast milk, formula milks and most
foods naturally contain some sodium
which infants need to grow. The Food
Standards Agency recommend that
infants should have no more than
1g of salt (equivalent to 400mg
sodium) per day.

To avoid excess sodium:


                food for infants either during
                cooking or at the table

                foods that are made for adults
                and older children such as
                bacon and pasta sauces

                should not be given to infants.
                As well as being high in salt
                they are low in key nutrients
................................................................................




Nuts
___________________
Whole nuts, including peanuts,
should not be given to children
under five in case of choking.

For infants of atopic families where
the potential risk of nut allergy is
increased, current advice is that food
containing peanuts (groundnuts) and
peanut butter, should be avoided
until the child is 6 months of age.
................................................................................




                                                                                                                                                                      58
Vitamin supplements
The Department of Health recommend that
all infants begin a vitamin A & D supplement:


                months if their mother was well nourished
                during pregnancy. If there is any doubt
                about a mother’s vitamin status during
                pregnancy then breast fed infants
                should begin this supplement at one
                month of age


                supplement once they are over 6 months
                and drinking less than 500mls formula per day

All families of infants should be advised how to
access the Healthy Start Children’s vitamin drops.
................................................................................




                                                                                   59
Common feeding          Unsettled infants / Colic
challenges in infants

                        Many young infants have a period during the day
                        when they are unsettled and cry with discomfort
                        but appear not to be hungry. This is often referred
                        to as colic. It occurs commonly in the late afternoon
                        and evening.

                        Causes of colic are unknown, but it is thought to
                        be due to swallowing large amounts of air during
                        feeding which then becomes trapped in the digestive
                        tract and causes bloating and severe abdominal pain.
                        Comforting and soothing the baby with a massage
                        or a warm bath sometimes helps.

                        Healthcare professionals should:


                                        and bowel movements



                                        attachment in breast fed infants

                                        made up correctly



                                        correctly during and after the feed

                        Colic preparations are available in retail pharmacies but
                        there is no scientific evidence base to support their use.
                        ................................................................................




                                                                                                           60
Posseting and
Gastro-oesophageal
reflux
Posseting is seen in most young                                                    GORD usually resolves with time but may continue
infants. It occurs when the                                                        throughout infancy and beyond in some children.
stomach contents regurgitate                                                       Management by the primary health care team is
back up into the mouth without                                                     usually sufficient and should include reassurance
any harmful effects. Infants with                                                  to the parent.
mild posseting will gain weight
and thrive normally (Puntis, 2000).
                                                                                                   and attachment may help improve
More severe reflux/regurgitation,                                                                   GORD. Observe a feed to check the
resulting in distress to the infant is                                                             feeding technique. If necessary refer
called gastro-oesophageal reflux                                                                    to a breastfeeding adviser
disease (GORD). In this case the
stomach contents come up into
the oesophagus but not always                                                                      for breast fed infants
into the mouth. This causes
discomfort or pain to the infant                                                                   overfed with large volumes or over
but the carer will not necessarily                                                                 concentrated feeds
be aware that it is happening.
................................................................................
                                                                                                   thickened feed. This can be done in one
                                                                                                   of two ways:
                                                                                                                    1:     Adding a thickener, such as Thixo-D
                                                                                                                           or Instant Carobel (Cow & Gate) to the
                                                                                                                           normal formula just before feeding
                                                                                                                    2:     Changing to a formula that thickens
                                                                                                                           in the stomach e.g. Enfamil AR
                                                                                                                           (Mead Johnson) or SMA Staydown (SMA Nutrition)


                                                                                                   prescribe anti-reflux medications such as
                                                                                                   Gaviscon. Note: Gaviscon works in a similar
                                                                                                   fashion to the formulae Enfamil AR (Mead Johnson)
                                                                                                   or SMA Staydown (SMA Nutrition)

                                                                                   If the problems persist, despite having taken the
                                                                                   above measures, or if the infant has faltering growth
                                                                                   it is recommended that the Health Visitor or GP
                                                                                   should make a referral to the paediatrician.
                                                                                   ................................................................................




                                                                                                                                                                            61
Gastro-enteritis and diarrhoea
Acute gastro-enteritis is an infectious disease of the alimentary tract,
producing damage to the mucosa, either structural or functional and
of variable extent and severity (Cade, 2000). The main aim in managing
gastro-enteritis in infants is the correction of dehydration and maintenance
of hydration and electrolyte balance. Infants of less than 6 months are
particularly vulnerable to gastro-enteritis and dehydration and may require
hospital admission.

Gastro-enteritis is uncommon in infants who are exclusively breast fed.
In the rare event, it is important that breastfeeding is continued,
as discontinuation of breastfeeding is a major risk factor for the
development of dehydration (Faruque, 1992). Severe cases may
require the addition of oral rehydration fluids.

Infant formula feeds may
but only under the guidance of a medical practitioner and an oral
rehydration solution (e.g. Dioralyte or Rehydrat) given to replace lost fluids
(i.e. after vomiting or diarrhoea) to meet the infant’s fluid requirement.
Formula feeds should then be re-commenced at full strength and not
diluted (Walker-Smith et al. 1997). If infants have started solids, it may also
be necessary to discontinue these for a similarly short period of time.

Diarrhoea or loose stools can occur in infants who are unwell for
example when they are teething. Continued diarrhoea (>7days)
after acute gastroenteritis may be associated with a temporary
intolerance to lactose in some infants. Breast feeding should continue
but formula fed infants could be changed to a lactose free formula
(McDonald, 2007). Advice on excluding foods containing milk and lactose
will be needed for infants who are already being weaned.
This should only be undertaken under the supervision of a
medical practitioner and following the advice from a dietitian.
................................................................................




                                                                                   62
                                                                                   Management of constipation
Constipation                                                                       In formula fed infants
                                                                                   ___________________
Constipation is defined as difficulty,
delay or pain when opening bowels.
In the first 3-4 months infants should                                                   diary for 2-3 days. Check the volume of
pass frequent, loose, bright yellow                                                     feed given /kg actual body weight/24 hours
stools, at least 2-3 times in 24hrs.                                                    against recommended quantity tables
From 3-4 months, stools will                                                            (see page 47). If it is inadequate then
become less frequent. It is not                                                         feeds should be increased to the
unusual for an infant to go several                                                     recommended requirement
days without a bowel movement
and providing the infant is well and
happy this is of no significant                                                          made up according to the manufacturer’s
concern. After the introduction of                                                      instructions and not being over concentrated
solid food, stools may change in                                                        or under concentrated
frequency and colour.
Constipation is rare in breast fed                                                      constipating than whey dominant milks so
infants but if it occurs it may                                                         a change from casein dominant to whey
indicate inadequate milk intake                                                         dominant formula may help
due to poor attachment and/or
positioning. A breastfeed should
be observed by someone                                                                  should be offered in hot weather
experienced in breastfeeding
management to check positioning
and attachment and to ensure                                                            the following are included in their diet:
the infant is able to access breast
milk efficiently. Additional fluids
other than breast milk are not                                                               Fruit and vegetables
recommended.                                                                                 Cereals are being offered including
Constipation is a more frequent                                                              wholegrain varieties such as
problem in formula fed infants.                                                              porridge, Weetabix and Shreddies
Infants changing from breastfeeding                                                          Bran should not be given to infants
to formula feeding often develop                                                             as it may cause abdominal
constipation. One cause may be                                                               discomfort, bloating and diarrhoea
the calcium salts in the formula                                                             Drinks or water are being offered
which can harden stools in some                                                              with meals
infants. Other causes may be:

                                                                                   Over the counter treatments for constipation
                of the infant formula                                              such as syrup of figs and milk of magnesia are
                                                                                   dangerous to infants and should not be used.
                including under feeding                                            If conservative management with diet fails to
                                                                                   resolve constipation, then the infant should be
                                                                                   referred for further medical opinion.
                however this is rare
................................................................................




                                                                                                                                       63
Food hypersensitivity
(food allergy and food intolerance)
About 2-5% of infants are sensitive to certain foods but many more parents
suspect that a food is causing problems for their infant (Venter 2006).
The foods that most commonly cause problems are milk, eggs, soya,
fish, wheat and peanuts (COT 2000). Many infants grow out of it by
12 months so it is important that the condition is monitored carefully
to ensure special diets are not continued for longer than necessary.
................................................................................




Symptoms
___________________
Symptoms of immediate onset allergy may occur up to 1 hour after food
ingestion and include skin manifestations (urticaria, itching, rash), vomiting,
angioedema and anaphylaxis. Delayed onset reactions are harder
to diagnose and may not manifest until hours or days after the ingestion
of the offending food. Possible symptoms include eczema, chronic
diarrhoea, colic / abdominal pain and faltering growth.
................................................................................




Diagnosis
___________________
The gold standard test is the placebo-controlled double blind challenge.
In clinical practice, however, open challenges are usually performed.
Food challenges are an integral part of diagnosis in order to:



                result confirms the need to exclude that food from the diet

                of symptoms confirms that a restricted diet is not needed


Once diagnosed a food causing symptoms should be excluded,
however this should only be carried out under the supervision of
a medical practitioner.

Advice from a registered dietitian is needed to ensure the infant’s
milk and weaning food intake continues to provide all the necessary
nutrients for optimising growth and development.

In breast fed infants the mother may need to exclude foods from her diet.
Breastfeeding mothers who are excluding dairy foods may need a
calcium supplement to ensure adequate calcium: 1250-1350mg daily.

Formula fed infants can usually be changed to an appropriate specialised
feed available on prescription. Soya formula is not recommended for
infants with cow’s milk allergy or intolerance as there is a risk of cross
reactivity with soya formula.
................................................................................




                                                                                   64
Monitoring growth                                                                  When to weigh
                                                                                   ___________________
The new UK-World Health
Organisation (WHO) 0-4 years                                                                       part of the assessment of feeding and
growth charts were introduced                                                                      thereafter as needed
in England for all new births from
May 2009. The charts, which                                                                                 a weight loss of 10% or more
have been developed for the                                                                        needs careful assessment
Department of Health by the
Royal College of Paediatrics
and Child Health, are based                                                                        that feeding is effective and that the child is well
on the growth of breast fed
infants and will replace growth
                                                                                                   be weighed at around 8,12 and 16 weeks and
charts that were based on the
                                                                                                   1 year at the time of routine immunisations
growth of predominantly
formula-fed babies.
................................................................................                   weights measured too close together can
                                                                                                   be misleading



                                                                                   When to measure length or height
                                                                                   ___________________

                                                                                                     whenever there are any worries about a
                                                                                                     child’s weight gain, growth or general health


                                                                                   What is a normal rate of weight gain and growth?
                                                                                   ___________________

                                                                                                   baby’s weight often does not follow a particular
                                                                                                   centile line especially in the first year. Weight is
                                                                                                   most likely to track within one centile space.


                                                                                                   weight loss and a weight centile fall, but on
                                                                                                   recovery the child’s weight usually returns to its
                                                                                                   normal centile within 2 to 3 weeks. However a
                                                                                                   sustained drop or increase through two or more
                                                                                                   weight centile spaces is unusual (fewer than 2%
                                                                                                   of infants) and should be carefully assessed by
                                                                                                   the primary care team, including
                                                                                                   measuring length/height

                                                                                   Training and education from the Royal College

                                                                                   materials can be downloaded from the website
                                                                                   ................................................................................

                                                                                   www.growthcharts.rcpch.ac.uk *
                                                                                   ................................................................................


                                                                                   * They include PowerPoint slides, video clips, notes for tutors
                                                                                     and growth chart plotting exercises.
                                                                                   ................................................................................



                                                                                                                                                                      65
Faltering growth                                                                   Management of faltering
                                                                                   growth in formula fed infants
                                                                                   ___________________
The term “faltering growth” is applied                                             Take a diet history and/or ask parents to keep
to infants and young children who                                                  a feed and food diary.
do not achieve normal or expected
rates of growth. This could include:

                                                                                                   used and that it is being made up correctly
                                                                                                   with good hygienic practices
                markedly discrepant

                                                                                                   is suitable
Indications of faltering growth are:

                gain or no weight gain
                                                                                                   check suitability

                crying infant                                                      If there are no obvious dietary causes of faltering
                                                                                   growth or the above measures do not result in
                                                                                   improvement in weight gain, the infant should be
                and skin turgor                                                    referred to a paediatrician.
                                                                                   ................................................................................

                a few times/day


The management of faltering
growth is quite different for
breast and formula fed infants.
................................................................................




Management of faltering
growth in breast fed infants
___________________
North Somerset is in the process
of developing guidelines for breast
fed infants. In the meantime,
please refer to the ‘Prevention
and management of poor weight
in the breastfed baby’ guidelines
available at:
................................................................................

www.bristol.nhs.uk
................................................................................




                                                                                                                                                                      66
Feeding pre-term infants
                                                                                   Formulas for pre-term infants
                                                                                   ___________________
Infants born pre-term (less than 37                                                For pre-term infants requiring formula, a low birth
weeks gestation) or with a low birth                                               weight version should be used if birth weight is less
weight (LBW), below 2.5kg, have                                                    than 2.0kg. These formulae have a higher nutrient
special nutritional needs, which vary                                              density than standard infant formulae
according to the infant’s maturity
and any subsequent complications.                                                  A nutrient enhanced discharge formula may
                                                                                   be used once the infant weighs 2-2.5kg.
A comprehensive review of the                                                      This is available on prescription when the infant
nutritional requirements of pre-term                                               is discharged from hospital. This formula can
and LBW infants has been published                                                 be continued until 6 months, corrected age
by Tsang et al. (Tsang et al. 2005).                                               or advised by dietitian or paediatrician.
................................................................................   ................................................................................




Breastfeeding                                                                      Vitamin supplementation
pre-term infants                                                                   for pre-term infants
___________________                                                                ___________________
Breastfeeding or giving the mother’s                                               Pre-term infants may require additional
own expressed breast milk (EBM) is                                                 vitamin and iron supplements, as directed
particularly encouraged because                                                    by the consultant paediatrician or dietitian.
of the growth factors within it and                                                ................................................................................

because it reduces the risk of
necrotising enterocolitis (NEC).
For this reason, all mothers are
encouraged to express breast
milk until their infant is old enough
or well enough to feed directly
from the breast. Low birthweight
infants may benefit from infant
breast milk fortifiers to enhance
growth and bone mineral density.
................................................................................




                                                                                                                                                                      67
Weaning pre-term Infants
The time to begin weaning a pre-term infant may
be a clinical decision made by the paediatrician.
Pre-term babies have high nutritional needs that are
unlikely to be satisfied from milk alone for the 4-6
months after their Estimated Date of Delivery (EDD).
Current recommendations are that weaning should
begin at an earlier post conception age than for term
infants. It is usually between five and eight months old,
the age from the pre-term infant’s birth date and not
from their corrected age date (King & Aloysius 2009, King
2009). As the infant’s gut is being used for milk feeds
from an earlier age, it matures earlier and will have
adapted to cope with solid foods. Weaning should
then progress as for term babies, introducing new
textures to give infants the opportunity to learn to
manage them in their mouth. Pre-term babies are
more likely to have feeding problems than term babies.
................................................................................

www.bliss.org.uk
................................................................................




Growth monitoring
of pre-term infants
Please refer to page 65 for guidance on growth
monitoring. Key new features of the new UK-WHO
growth charts:


                gestation plot all measurements in the
                preterm section

                the separate low birth weight charts
................................................................................




                                                                                   68
References
                                                                                                     Further Information is available from:
Aberblom H.K et al (1999 ) Emergence             Evidence report/technology assessment
of diabetes associated auto antibodies in        153. Rockville: Agency for Healthcare               Bliss
                                                                                                     ................................................................................
the nutritional prevention of IDDM (TRIGR)       Research and Quality.
project. 59th Annual Scientific Sessions of                                                           www.bliss.org.uk
the American Diabetes Association. June.                                                             ................................................................................
                                                 King CL & Aloysius A (2009) Joint consensus
San Diego.                                       statement on weaning preterm infants.
                                                 http://bapm.org/nutrition/guidelines.php
Agostoni C, Decsi T, Fewtrell M, Goulet O,                                                           British Dietetic Association
Kolacek S, Koletzko B, Fleischer Michaelsen      King CL (2009) An evidenced based guide             Weaning Fact Sheet
F, Moreno L, Puntis J, Rigo J, Shamir R,         to weaning preterm infants. Paediatrics &           ................................................................................
Szajewska H, Turck D, van Goudoever J            Child Health 19:9, pg 405-414.
(2008) Complementary Feeding:                                                                        www.bda.uk.com
                                                                                                     ................................................................................
A Commentary by the ESPGHAN                      Kull I, Wickman M, Lilja G, Nordvall S L, and
Committee on Nutrition Journal of Pediatric      Pershagen G.(2002) Breastfeeding and
                                                 allergic diseases in infants—a prospective
                                                 birth cohort study Archives of Diseases in          Department of Health
Aniansson G., Andersson B et al (1994).          Childhood: 87; 478-481.                             Birth to Five Book
A prospective cohort study on breastfeeding                                                          Off to Best Start Leaflet
and otitis media in Swedish infants. Pediatric   Lawrence R. Breastfeeding A guide for               Bottle Feeding Leaflet
Infectious Diseases Journal 13:183-8.            the medical profession (1994); 4th Edition
                                                 Mosby. St. Louis. M1 USA pg 273.                    Best Beginnings DVD
Ball T. M. & Wright A. L. (1999) Health care                                                         ................................................................................
costs of formulae fed infants in the first year   Li L, Parsons TJ, Power C.(2003) Breast             www.dh.gov.uk
of life. Paediatric;103 (4pt2) 807-6.            feeding and obesity in childhood: cross             ................................................................................
                                                 sectional study BMJ 327: 904-5.
Bolling K, Grant C, Hamlyn B and Thornton
A (2007) Infant Feeding Survey 2005.             Lucas A et al. (1994) A randomised
                                                 multi-centre study of human milk versus             Food Standards Agency website
                                                                                                     ................................................................................
Coutsoudis A et al. (2001) Method of             formula and development on pre-term
feeding and transmission of HIV-1 from           infants. Archives of Diseases in Childhood;         www.eatwell.gov.uk/agesandstages/baby
mothers to children by 15 months of age:         70: 141-146.                                        ................................................................................
prospective cohort study from Durban,
South Africa. AIDS 15: 379-87.                   Lucas A. and Cole T.J. (1990) Breast milk
                                                 and necrotising enterocolitis. Lancet; 336:         Healthy Start
Coutsoudis A et al (2002). Free formula milk     1519-23.                                            ................................................................................
for infants of HIV-infected women: blessing                                                          www.healthystart.nhs.uk
or curse? Health Policy and Planning 17:                                 ,
                                                 Northstone K, Emmett P Nethersole F and             ................................................................................
154-160.                                         the ALSPAC study team (2001): The effect of
                                                 age of introduction to lumpy solids on foods
Cummings R and Klineberg R (1993).               eaten and reported feeding difficulties at 6
Breastfeeding and Other Reproductive             and 15 months. J Hum Nutr Diet 14, 43-54.           NHS Choices
                                                                                                     ................................................................................
Factors and the Risk of Hip Fractures in
Elderly Women. International journal of          Marild S et al (2004) Protective effect of          www.nhs.uk/planners/breastfeeding/
Epidemiology 22 (4), pp 684-691.                 breastfeeding against urinary tract infection.      pages/breastfeeding.aspx
                                                 Acta Paediatric; 93(2): 164-8.                      ................................................................................
Davis M K (1998) Review of the evidence for                                                          www.nhs.uk/conditions/bottle-feeding/
an association between infant feeding and                                                            pages/introduction.aspx
childhood cancer International Journal of        feeding, solid foods and hospitalisation in         ................................................................................
Cancer Suppl;11:29-33.                           the first 8 months after birth. Archives
                                                 Diseases in Childhood; 94:148-150.                  www.nhs.uk/conditions/babies-weaning/
Department of Health (1994) Weaning and                                                              Pages/Introduction.aspx
the weaning diet. HMSO, London.                  Sadauskaite-Kuehne V et al (2004)                   ................................................................................
                                                 Longer breastfeeding is an independent
Department of Health (2007a)                     protective factor against development
Weaning London: DH.                              of type 1 diabetes mellitus in childhood.           Royal College of Paediatric
                                                 Diabetes Metab Res Rev; 20(2): 150-7.
Department of Health (2007b)                                                                         and Child Health
Off to the best start. London: DH                Sears G, Greene J.M. et al (2002)
                                                 Long-term relation between breastfeeding            ................................................................................
Dewey K, Heinig M and Nommsen L                  and development of atopy and asthma                 www.rcpch.ac.uk/Research/UK-WHO-
(1993) Maternal weight-loss patterns during      in children and young adults: a longitudinal
prolonged lactation American Journal of          study. Lancet; 360: 901-907.                        Growth-Charts
                                                                                                     ................................................................................
Clinical Nutrition, Vol 58, 162-166.
                                                 Shaw V and Lawson M 2007 Clinical
Duncan B, Ely J et al (1993) Exclusive           Paediatric Dietetics 3rd ed. London Blackwell.
breastfeeding for at least 4 months protects                                                         Start4life
against otitis media. Pediatrics; 91: 867-72     Sheard N. F. and Walker W.A. (1998)                 ................................................................................
                                                 The role of breast milk in the development          www.nhs.uk/start4life
        .K.
Ford R.P Taylor B.J. (1993) et al                of the gastro-intestinal tract. Nutrition Review;   ................................................................................
Breastfeeding and the risk of sudden infant      46: 1: 1-8.
death syndrome. Int J Epidemiol; 22: 885-9
                                                 Shu Xo, Linet M, Steinbuch M et al. (1999)          Twins and Multiple Birth Association
Horne R S C, Parslow P M, Ferens D, Watts        Breastfeeding and risk of childhood acute           ................................................................................
A-M and Adamson T M. (2004) Comparison           leukaemia. Journal of National Cancer               www.tamba.org.uk
of evoked arousability in breast and formula     Institute;91:1765-72.                               ................................................................................
fed infants. Archives of Disease in
Childhood 89 :22-25.                             Tsang, R.C. Uauy R Koletzko B et al. Nutriton
                                                 of the Preterm infant: Scientific Basis and
Horta BL, Bahl R, Martines JC et al. (2007)      Practical Guidelines, 2nd edn. Cincinnati,          UNICEF UK Baby Friendly Initiative
Evidence on the long term effects of                                                                 ................................................................................
                                                 Ohio:Digital Educational Publishing, 2005.
breastfeeding: systematic reviews and                                                                www.babyfriendly.org.uk
meta-analyses. Geneva: World Health              UNICEF (1998) Preventing Iron Deficiency in          ................................................................................
Organization.                                    Women and Children. A UNICEF/UNU/WHO/
                                                 MI Technical workshop October 1998: 44.
        .W.
Howie, P et al (1990) Protective effect of
breastfeeding against infection. BMJ; 300:       WHO (2003) Global Strategy for Infant and
11-6.
Ip S, Chung M, Raman G et al. (2007)
Breastfeeding and maternal and infant
health outcomes in developed countries.



                                                                                                                                                                                        69
                 4

Feeding Toddlers and
Preschool Children
1-5 Year Olds
Section 4
Feeding Toddlers and
Preschool Children
1- 5 Year Olds



Toddlers and preschool children between 1 and 5 years
have high nutrient requirements relative to their size, as
they are still undergoing rapid growth and development
and usually very active. Good nutrition is important for
children of this age:




This section covers:
                Nutritional requirements of 1-5 year olds
                Food safety
                Dental health
                Common feeding challenges
................................................................................




                                                                                   70
Nutritional requirements
of 1-5yr olds



Their average energy requirements are:
                        Age                                                               Kilo calories / day
                                                                                   Boys                         Girls




................................................................................




                                                                                                                        71
The 4 food groups and the nutrients they provide are:

                                                                                                                    Recommended
      Food groups                                                                  Food included   Main nutrients   servings



     Bread, rice, potatoes,
     pasta and other
     starchy foods




     Fruit and vegetables




     Milk and dairy




     Meat, fish, eggs,
     beans and other
     non-dairy sources
     of protein




................................................................................




                                                                                                                                  72
Bread, rice, potatoes, pasta
and other starchy foods                                                            Milk and dairy foods
___________________                                                                ___________________




                                                                                   ................................................................................




................................................................................




Fruit and vegetables
___________________




................................................................................




                                                                                                                                                                      73
Meat, fish, eggs, beans and other   Foods and drinks high
non-dairy sources of protein       in fat and/or sugar
___________________                ___________________




                                   ................................................................................




                                   Salt and sodium
                                   ___________________




                                                      for 1-3 year olds

                                                      for 4-6 year olds




                                   ................................................................................




                                                                                                                      74
Vegetarian and vegan diets                                                         Vegan diets
                                                                                   ___________________




................................................................................




Vegetarian diets
___________________




                                                                                                                                                  are not
                                                                                   recommended



                                                                                   ................................................................................




                                                                                                                                                                      75
Vitamin supplements                                                                Drinks




                                                                                   Water and milk
................................................................................




                                                                                   Pure fruit juices




                                                                                   Avoid all soft drinks like squashes,
                                                                                   fizzy drinks, energy drinks and
                                                                                   flavoured waters,




                                                                                   Avoid tea, coffee, cola or any
                                                                                   other drinks with added caffeine




                                                                                   ................................................................................




                                                                                                                                                                      76
Mealtime routines




                    5.1


                          77
Food Safety
Choking
___________________




................................................................................




Specific foods and ingredients
___________________




    Colours:                                                                       The foods that present themselves
                                                                                   time and time again in choking
                                                                                   incidents are:




    Preservative:



................................................................................


                                                                                                                       78
Dental Health




..............................................................................




To reduce the risk of dental decay
___________________




                           A child should never be left alone sucking on a bottle




Medicines
___________________




................................................................................
                                                                                    79
Brushing teeth
___________________




................................................................................




Children under the age of 3 years
___________________




Children over the age of 3 years
___________________




Registering with a dentist
___________________




                                                                                   www.northsomerset.nhs.uk

                                                                                                              80
Iron deficiency
anaemia              Preventing iron deficiency
                     ___________________




                     ................................................................................




 Symptoms of iron
 deficiency include




                                                                                                        81
Obesity
          Causes of obesity in under fives
          ___________________




          ................................................................................



          Risk factors for developing obesity
          ___________________




          ................................................................................




                                                                                             82
Preventing and treating
obesity in under fives in North Somerset
___________________




                                                                                   www.northsomerset.nhs.uk




        Health professionals and early years settings




                                                           Change4Life

                                           Start4life


................................................................................
www.nhs.uk/change4life
www.nhs.uk/start4life
................................................................................




                                                                                                              83
Healthy family lifestyles are the key to success
___________________


Encourage physical activity
___________________




                                                                                   www.n-somersetcsd.org.uk

       www.go4life.org.uk



Encourage healthy eating
___________________




................................................................................




Limit sedentary behaviour                                                                                     in children under five
___________________                                                                                           ___________________




................................................................................                              ................................................................................


                                                                                                                                                                                                 84
Fussy eating and food neophobia




................................................................................




            Causes of fussy eating
            ___________________
            Giving frequent drinks of milk or juice:




            Frequent snacking:




            Snacks being given when a meal is refused:

            Coercing children to eat more




                                                                                   85
Simple strategies for management
of fussy eating and neophobia      Additional support
___________________                ___________________




                                   ...............................................................................




                                                                                                                     86
Faltering growth




          Faltering growth




................................................................................




            When to refer
            ___________________




                                                                                   87
Gastroenteritis and                                                                Constipation
toddler diarrhoea




                                                                                   ................................................................................




                                                                                           Dietary changes to suggest
                                                                                            ___________________




................................................................................




                                                                                                                                                                      88
Food hypersensitivity:
food allergy and food intolerance                                                  Diagnosis
                                                                                   ___________________




................................................................................




Food allergy
___________________




................................................................................




Food intolerance
___________________




................................................................................




                                                                                   ................................................................................




                                                                                                                                                                      89
Cultural diets




................................................................................




                                                                                   90
References
             Further Information is available from:

             British Dietetic Association                                                       National Daycare and
                                                                                                Nurseries Association
             ................................................................................   ................................................................................
             www.bda.uk.com                                                                     www.ndna.org.uk
             ................................................................................   ................................................................................




             Comic Company                                                                      NHS Choices
                                                                                                ................................................................................
             ................................................................................   www.nhs.uk/LiveWell/Childhealth1-5
                                                                                                ................................................................................
             www.comiccompany.co.uk
             ................................................................................

                                                                                                Pre-school Learning alliance
                                                                                                ................................................................................
             Caroline Walker Trust                                                              www.pre-school.org.uk
                                                                                                ................................................................................



                                                                                                School Food Trust
                                                                                                ................................................................................
                                                                                                www.schoolfoodtrust.org.uk/research/
             ................................................................................
                                                                                                advisory-panel-on-food-and-nutrition-
             www.cwt.org.uk                                                                     in-early-years.
             ................................................................................   ...............................................................................



                                                                                                Start4life
             ................................................................................   ................................................................................
             www.cwt-chew.org.uk                                                                www.nhs.uk/start4life
             ................................................................................   ................................................................................




             Change4life
             ................................................................................
             www.nhs.uk/change4life
             ................................................................................




             Department of Health



             ................................................................................
             www.dh.gov.uk
             ................................................................................




             Food Standards Agency website
             ................................................................................
             www.eatwell.gov.uk/agesandstages/
             children/yrtoddler
             ................................................................................




             Harlow Printing
             ................................................................................
             www.healthforallchildren.co.uk
             ................................................................................




             Healthy Start
             ................................................................................
             www.healthystart.nhs.uk
             ................................................................................




             National Childminding Association
             ................................................................................
             www.ncma.org.uk
             ................................................................................




                                                                                                                                                                                   91
           5

Appendix
Section 5
Appendices


Appendix 1
Components in breast milk
and infant formula milks
___________________

                                                                                             Infant formulas -
      Components                                         Role in breast milk
                                                                                            suitable from birth
                                                                                         Present in whey dominant
                                                     Main proteins in breast milk.
                                                                                         formula in the ratio 60:40
                             Whey & Casein
                                                         The ratio of whey to
                                                                                        Present in casein dominant
                                                           casein is 40:60
                                                                                           formula in ratio 20:80
                                                          Main component
                            Alpha-lactalbumin                                          Added to some infant formulas
                                                           of whey protein
                                                        Very small proportion            Main component of whey
                            Beta lactalbumin
                                                         of the whey protein            protein in other formula milks
                                                   Help babies to absorb nutrients
                                                      in breast milk. Lactoferrin is
                                                   an iron binding protein. It binds
                                                   the iron rendering it unavailable
                               Lactoferrin                                                      Not present
                                                     to pathogenic gut bacteria.
                                                       Bacterial growth is thereby
        Protein                                         inhibited reducing the risk
                                                     of gastro-intestinal infections
                                                      Remain relatively constant
                                                   throughout lactation regardless
                         Immunoglobulins             of the amount of breast milk
                       (anti-infective proteins)       provided by the mother.                  Not present
                                                      This happens because the
                                                     concentration increases as
                                                         total volume reduces
                                                   An amino acid essential for the
                                                      myelination of the central
                                                      nervous system and brain.
                                                                                                   Present
                                 Taurine             In newborns, bile acids are
                                                   almost exclusively conjugated
                                                          with taurine, which
                                                           helps excretion



                                                                                                                         1   i
                                                                                                  Infant formulas -
     Components                                               Role in breast milk
                                                                                                 suitable from birth
                                                          Provides about 50% of the
                                    Total fat                                                   Present at same level
                                                         energy content of breast milk
                                                          Long chain polyunsaturated
         Fats              Long Chain Polyunsaturated
                                                        fatty acids that are important in
                              fatty acids: DHA & AA                                              Present in all except
                                                         brain and retina development
                            (Docosahexanoic acid &                                                 organic formulas
                                                           and in myelinization of the
                                 Aricadonic Acid)
                                                                 nervous system
                                                         The sugar in breastmilk and
                                                          is about 7% by weight. Is
    Carbohydrate                    Lactose                    digested to the                  Present at same level
                                                         monosaccharides galactose
                                                                and glucose
                                                          These are especially high in
                                                           the breast milk of mothers
                                                          who give birth prematurely,
                                                        e.g. epidermal growth factor is
    Growth factors                                                                                   Not present
                                                        a polypeptide, which stimulates
                                                               the proliferation of
                                                        epidermal and epithelial tissues
                                                                 in the gut lining
                                                            Anti-viral factor present
       Interferon                                                                                    Not present
                                                                  in breast milk
                                                        Essential precursors for DNA and
                                                         RNA and are important for the
                                                          function of cell membranes
                                                         and the normal development
                                                         of the brain. They may act as
     Nucleotides                                                                                   Present in some
                                                           co-factors for the growth of
                                                        Lactobacillus bifidus bacterium
                                                         which reduce the presence of
                                                        pathogens, such as Escherichia
                                                             Coli, in the faecal flora
                                                         Has a role in the antibacterial
                                                        activity of breastmilk and is also
       Lysozyme                                                                                      Not present
                                                                responsible for the
                                                        development of intestinal flora
                                                                                              Added in higher amounts
                                                                                              as there is only about 10%
                                                         Because of Lactoferrin babies
                                                                                                absorption from infant
          Iron                                           up to 6 months can get all the
                                                                                               formula. The excess iron
                                                        iron they need from breast milk
                                                                                                 remaining in the gut
                                                                                             encourages bacterial growth
                                                        Are the body’s defence against
                                                         infection. These are made in
Living white blood cells                                                                             Not present
                                                         response to any infection that
                                                            the mother is exposed to
                                                           Naturally low as the main
                                                        source of vitamin D is from skin
                                                          synthesis when outside. It is       Added in higher amounts
       Vitamin D
                                                        recommended breastfeeding                as a supplement
                                                         mothers take a supplement
                                                                (see page 36)
                                                        Essential for the catabolism of
                                                           long-chain fatty acids. It
                                                        enables fatty acids and ketone
       Carnitine                                            bodies to be oxidised to                   Present
                                                          provide alternative fuels to
                                                         glucose. This helps prevent
                                                          neonatal hypoglycaemia
                                                            Types of fibre that remain
                                                            undigested in the gut and
                                                          they promote the growth of          Galacto-oligiosaccharides
      Prebiotics                                         bacteria (e.g. bifidobacteria)        and fructosaccharides are
                                                           in the gut flora that have a         added to some formulas
                                                          positive effect on digestion
                                                                 and absorption


                                                                                                                           ii
Appendix 2
Food-related customs
___________________

                       Jewish            Sikh            Muslim            Hindu      Buddhist    Rastafarian


                         No
      Eggs                                Yes              Yes            It varies   It varies     It varies
                     bloodspots


      Milk/               Not
                                          Yes              Yes              Yes         Yes         It varies
     Yoghurt          with meat


                          Not
     Cheese                               Yes            It varies          Yes         Yes         It varies
                      with meat


    Chicken            Kosher           It varies         Halal           It varies     No          It varies


     Lamb/
                       Kosher           It varies         Halal           It varies     No          It varies
     Mutton


      Beef             Kosher             No              Halal             No          No          It varies



      Pork               No              Rarely            No              Rarely       No            No


                     With scales,
                                                                         With fins
       Fish           fins and           It varies        It varies                    It varies       Yes
                                                                        and scales
                     back bone


    Shellfish             No             It varies        It varies        It varies     No            No


     Butter/
                       Kosher             Yes              Yes              Yes         No          It varies
     Ghee


      Lard               No               No               No               No          No            No


     Cereal
                         Yes              Yes              Yes              Yes         Yes           Yes
     Foods


      Nuts/
                         Yes              Yes              Yes              Yes         Yes           Yes
     Pulses


      Fruit/
                         Yes              Yes              Yes              Yes         Yes           Yes
   Vegetables


     Fasting             Yes              Yes              Yes              Yes         Yes           Yes

.
Strict Hindus and Sikhs will not eat eggs, meat, fish and some fats.
Some Rastafarians are vegan.
Jains have restrictions on some vegetable foods – check with individual.
Fasting is unlikely to apply to young children
(Eating well under 5s in Childcare Training Materials, Caroline Walker Trust).
                                                                                                                iii
INDEX
Academic achievement - 1                      National Child Measurement Programme (NCMP) - vi
Alcohol - 3,9,14,37                           Nausea and vomiting - 15
Allergy - 12,22,37,49,58,64,89                Necrotising enter colitis (NEC) - 22
Anemia - 81                                   Neophobia - 85
Anorexia Nervosa - 14                         Neural tube defects - 6
Asthma - 27                                   Neuro-development delay - i
                                              Nipple shields - 27
Baby Friendly - 19,23                         Nuts - 58,74,75
Baby led feeding - 25
BMI (Body Mass Index) - 4,5,9,10,12           Obesity - 4,5,11,12
Bulimia Nervosa - 14                          Omega 3 fats - 17,37,74,75
Breastfeeding support group - 28
                                              Peanuts - 18,37,58
Caffeine - 17,37,76                           Portion size - 55,73
Calcium - 9,13,43,75                          Prader-willi syndrome - 82
Caloric requirement - 71                      Pre-eclampsia - 12
Cardiovascular disease - 6                    Premature babies - 34,67,68
Cat care - 16
Change 4 life - 83                            Reflux - 61
Choking - 54,78                               Retinol - 8
Childhood obesity - iv,vi,22,82,83
Colic - 60                                    Salmonaella - 16
Constipation - 8,15,30.43.63.88               Salt - 58,74
Cows milk - 41                                Selenium - 3
Cups - 55                                     Skin to skin contact - 24
                                              Smoking - 3, 14
Dehydration - 62                              Soya - 9,13,38,41
Dental caries - v.79                          Sterilising equipment - 42,57
Deprivation - iii                             Sudden infant death syndrome (SIDS) - 26,27
Diabetes - 5,6,12,22,27                       Sugar - 58
Diarrhoea - 62,88                             Sunlight - 7
Drug Misuse - 14
Dummy - 27                                    Teenage parents - 28
                                              Teenage pregnancy - 3,13
Eatwell plate - 2,36                          Teeth brushing - 79,80
Eczema - 27                                   Toothpaste - 80
Emotional bonding - 22                        Toxoplasmosis - 16
Expressed Breast Milk (EBM) - 67
                                              Underweight women - 4,10
Faltering growth - 61,66,86,87
Feeding cues - 25,46,49                       Vegan - 13,75
Folic acid - 3,5,6,7                          Vegetarian - 13,58,75
Food colourants - 78                          Visual impairment - 1
Food intolerance - 37,64                      Vitamin A - 8,48,59,71,73,74,75
Food hypersensitivity - 64                    Vitamin B12 - 13,90
Food safety - 16                              Vitamin C - 3,7,8,53,72,73,75,81
Fussy eating - 84,86                          Vitamin D - 3,7,36,48,59,71,74,75

Gastro intestinal complaints - 3,62           Water - 44,76
Gastrointestinal reflux syndrome (GORD) - 61   Weighing babies - 65
Gestational diabetes - 10                     Work - 33
Goats milk - 38                               World Health Organization (WHO) growth charts - 65

Health inequalities - v
Healthy start -11,12,48,59,76
High blood pressure - 6
HIV - 35
Honey - 18,57

Infant mental health - 22
Infertility - 3,4
Iron - 8,53,58,67,72,74,81,88,90

Lactose - 88
Low birth weight - 1,10,14,17,67

Mastitis - 32
Multiply births - 34




                                                                                                   iv

				
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