Healthy Start - Nutritional policy.pdf - A HEALTHY START

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					                        A HEALTHY START

            An evidence base for professionals dealing with
                pre school children’s nutritional needs




July 2006
                                         CONTENTS


                                                           PAGE

Acknowledgements                                             1

A healthy start - Introduction                               2

Pre-conceptual nutrition                                     4

Breast feeding                                               8

Formula milk                                                 9

Drinks in the first year of life                            12

Premature and low birth weight infants                      13

Complimentary feeding                                       14

Nutrition in Faltering growth                               20

Nutrition guidelines for children aged one to five years    23

Menu planning including healthy lunch boxes                 26

Feeding vegetarian and vegan infants and young children     28

Nutritional related problems                                31

Appendix 1 – Breast feeding policy

Appendix 2 – A guide to potty training




                                               1
                               ACKNOWLEDGEMENTS


The members of the original Nutritional Group:-

       Suresh Babu                  -   Consultant Paediatrician
       Victoria Deprez              -   Paediatric Dietician
       Ann Ellis                    -   Public Health Specialist
       Janet Holland                -   Health Visitor
       Rebecca Reynolds             -   School Nurse Healthy Schools.

Additional advice from:-

       Luretta Johnson          -       Midwife
       Helen Smithson Whitehead -       Dental Public Health.

Secretarial support from:-

       Lynda Crisp
       Marilyn Dunn.


This document has been complied utilising recent research/evidence but also in conjunction
with the Doncaster Infant Feeding Policy. References will be made to the above policy
where detailed information has been used.




                                             2
A healthy start

Introduction

Infant feeding is important not only for the immediate health of the infant but also in
establishing good eating habits for a lifetime. This will in turn lessen the risk of:-

       •   Cancer
       •   Diabetes
       •   Heart disease
       •   High blood pressure
       •   Dental caries
       •   Obesity.

Aim

       •   To provide a evidence base for professionals working in this area.

It is acknowledged that individual adaptations may be necessary but that, if advice varies
from the policy, it is recorded so that other professionals know what has been advised and
why.

Development

This guidance was drawn up in consultation with a large number of representatives from
health professionals in Lincolnshire concerned with infant and child feeding practices. These
include doctors (paediatricians and general practitioners), health visitors, dieticians,
midwives and public health specialists and reflects a consensus of opinion. It is mindful of
current Government documentation especially Choosing Health 2004 and the National
Service Framework for Children, Young People and Maternity Services 2004. This
document will support practitioners attempting to work with families and communities in
order to encourage a healthy diet.

Context

The prevalence of obesity in children aged two to ten years has increased from 9.6% in 1995
to 15.5% in 2002 (Health Survey England 2002). Children who are obese are more likely to
become obese adults. The Government has set a national target to halt by 2010 the year on
year increase in obesity in the population as a whole (National Standards, Local Actions,
Health and Social Care Standards and Planning Framework 2005/06 – 2007/08.

Work carried out by practitioners in this area of healthy diets will have a knock on effect to
the others listed at the beginning.

Breast feeding

The Government is committed to the promotion of breast feeding which is the best form of
nutrition for infants to ensure a good start to life. The Government has set a target to
increase beast feeding initiation by 2% annually through the NHS Priorities and Planning
Framework 2003 – 2006. This focuses in particular on women from disadvantaged
backgrounds.


                                              3
Good practice suggests:-

       •   Exclusive breast feeding for the first six months of an infant’s life

       •   Six months is the recommended age for the introduction of solid foods for infants

       •   Breast feeding or milk substitutes should be used beyond six months along with
           appropriate types and amounts of complementary foods.

Parents who are unable to or who choose not to follow these recommendations should be
supported to optimise their infant’s nutrition. This supports the Lincolnshire Breast Feeding
Policy 2006.




                                                4
Introduction to pre-conceptual care

“A child’s nutritional future begins with the mother’s nutritional status in adolescence and
pregnancy” (UNICEF maternal nutrition and low birth weight 2004). The mother’s nutritional
and health status will affect the foetus’ ability to grow therefore poor maternal nutrition and
health results in… “poor foetal growth”.
                                                                               (UNICEF 2004)

Given this information it is obviously important that advice on diet and lifestyle are given prior
to conception. It has been found that pre-pregnancy preparation has reduced the incidence
of congenital mal formation, pre-term birth and intra uterine growth retardation. More
worryingly is the link between low birth weight and mortality remains high and if they do
survive these children appear to suffer from a higher incidence of illness and disabling
conditions (UNICEF 2004).. Evidence suggests that as these children become adults they
may be at greater risks of developing cardiovascular disease, diabetes and high blood
pressure.

                                             (Irving et al 2004, Hopkins 2005, BBC news 2005)


Pre-conceptual nutrition

•   Bread and cereals – Daily requirement 4 - 6 portions.

    This food group includes rice, pasta and breakfast cereal and all provide energy and
    good sources of B vitamins. These are a good source of fibre and vitamin C.

    In order to ensure sufficient Vitamin C is being absorbed ensure one portion of fruit
    intake is citrus or drink a glass of orange.

•   Meat, fish and proteins – Daily requirement 2 – 3 portions.

    This is an excellent source of protein and is required for baby to grow. Along with meat
    and fish this group also includes eggs, nuts and pulses. Important food sources in this
    category are kippers, mackerel, salmon, sardines, pilchards and tuna, referred to as oily
    fish. Being rich in omega-3 fatty acids these are beneficial in the baby’s brain, nervous
    system and eye development. However, it is important to limit these foods in pregnancy
    due to their high levels of vitamin A, which may be harmful to the baby. Suggested
    amounts are: 2 Portions of fish a week, one of which can be oil rich. Pregnant women
    are advised to avoid swordfish, shark and marlin due to mercury contents and limit tuna
    fish to two tuna steaks (140g when cooked) per week or four medium size cans a week.

•   Dairy products – Daily requirement 3 portions

    These are high in calcium and protein and can be used to increase the protein intake for
    women whose diet is insufficient in meat and fish. Usually no additional calcium is
    required however, for those pregnant adolescents extra calcium may be required as both
    are developing.

    Culturally Asian women may have a high fibre diet which may reduce calcium
    absorption.

    Suggested sources and amounts of calcium:-

       •   150g pot of yoghurt
       •   1/3 Pint of milk or 25g hard cheese.
                                                5
•   Fats and oils

    The major part of energy requirements may be provided by carbohydrates and as such
    help to avoid unnecessary weight gain. Small amounts of unsaturated fats are needed
    for the baby’s brain and eye development.

•   Vitamins and minerals

    Vitamin A foods such as liver products, ie pate should be avoided due to the link
    between high dietary levels of vitamin A and congenital defects. A safer alternative is
    the carotene form of vitamin A found in vegetables.

•   Vitamin B and folic acid

    If mother’s dietary intake of vitamin B is poor this may result in a low birth weight baby.
    Foods containing vitamin B include bread, cereals, eggs, milk, pulses, green vegetables,
    meat and fish.

    Those on a vegan diet where none or few of the listed items are eaten may need vitamin
    B supplement.

    It is widely acknowledged that insufficient folic acid in the diet leads to neural tube
    defects. Folic acid is found in green vegetables especially broccoli and spinach, fortified
    breads and cereals, marmite, oranges, bananas and avocados.                However, the
    Government advises pre-conceptual folic acid supplementation.


•   Vitamin C

    For general good health it is important to have a balanced diet with the inclusion of
    vitamin C. It is essential to include vitamin C both during pre-conception, pregnancy and
    breast feeding to ensure healthy foetal growth and development (page 3) Medline Plus.

    The recommended intake is as follows:-


           Females (15-50 years)                         40 mg/day
           Pregnant Females                              50 mg/day
           Breast Feeding Females (0 – 4 months)         70 mg/day
           Breast Feeding Females (4 months plus)        70mg/day

           This is the US daily recommendation in milligrams.

    Why do you need vitamin C?

    It not only helps the babies growth and development but it is essential for tissue repair,
    wound and bone healing, healthy skin and fights infection. One of the most important
    functions of vitamin C for both mother and baby is the fact that it aids the absorption from
    the gut of iron.

    Vitamin C rich foods include the following:-

           Tomatoes and Tomato Juice
           Potatoes
           Brussel Sprouts (Green Vegetables)
           Cauliflower
                                               6
           Broccoli
           Cabbage
           Orange Juice
           Grapefruit
           Mango.

    Food processing may destroy some vitamins so either fresh or frozen are best.

•   Vitamin D

    Important in enhancing calcium absorption and utilization of calcium during pregnancy.
    A non dietary source is from the sun, dietary sources are from oily fish, eggs and milk.
    Ladies who keep themselves covered up and do not expose themselves to the sun may
    need dietary supplements.

•   Caffeine

    The current advice is to limit caffeine intake to 300 mg a day (high levels can lead to low
    birth weight or even miscarriage).

    300 mgs equates to:-

           •    3 Mugs of instant coffee (100 mg each)
           •    4 Cups of instant coffee (75 mg each)
           •    3 Cups of brewed coffee (10 mg each)
           •    6 Cups of tea (50 mg each)
           •    8 Cans of Cola (up to 40 mg each)
           •    4 Cans of energy drink (up to 80 mg each)
           •    8 Bars of chocolate, weighing 50 mg each.

•   Alcohol intake

    Stop if possible as passed through the placenta and affects the baby. Otherwise limit to
    1 - 2 units of alcohol once or twice a week.

•   Iron

    Iron is needed for the formation of red blood cells for both mother and baby. Ensure the
    diet is balanced in all areas including iron prior to pregnancy. During pregnancy
    increased iron in the diet is not always necessary. However, women who have heavy
    blood loss during periods and low iron stores may need a full blood count to assess iron
    levels.

    Food rich in iron include red meats, kidney, lentils, wholemeal bread, cereals, dark green
    vegetables and dried fruit.

    Iron absorption is enhanced by drinking or eating foods containing vitamin C.

    Avoid drinking tea at meal times.




                                              7
Bibliography and references

BBC News               2005   Low birth weight diabetes link. Available at
                              http://news.bbc.co.uk/2/hi/health/4293509 (accessed
                              November 2005).

Brook                  2005   Preconception and early pregnancy advice. Becher’s
                              Brook (patient information leaflet). Available at
                              http://www.co.uk/patientinformation/preconception
                              (accessed August 2005).

Department of Health   2000   Dietary references for food energy and Nutrients in the
                              United Kingdom.

Ford                   1999   Healthy eating before, during and after pregnancy.
                              Centre for Pregnancy and Nutrition. The University of
                              Sheffield Department of Obstetrics and Gynaecology
                              Centre for Pregnancy Nutrition.

Irving R J et al       2004   Low birth weight predicts higher blood pressure but not
                              dermal capillary density in two populations. Available at
                              http://hyper.ahajournals.org/cgi/contents/abstract/43/3/610
                              (accessed November 2005).

Hopkins J              2005   Researchers identify marker of heart disease in low-birth
                              weight. Available at http://hopkinsnet.jhu.edu/servlet/page
                              (accessed November 2005).

Medline Plus Drug      2005   Ascorbic acid. Available at
Information                   http://www.nlm.nih.gov/medlineplus/druginformation
                              (accessed 2005).

Royal College of       2003   Perconceptual folic acid and food fortification in the P of
Obstetricians and             neural tube defects. Available at http://www.rcog.org.uk.
Gynaecologists

UNICEF                 2004   Maternal nutrition and low birth weight. Available at
                              http://www.unicef.org/nutritionindexlowbirthweight.html
                              (accessed 2005).

Department of Health   2005   Tackling obesity. Available at http://www.dh.gov.uk
                              (accessed 2005)




                                        8
Breast feeding

This policy covers both the Ten Steps to Successful Breastfeeding and the Seven Point Plan
for the Protection, Promotion and Support of Breastfeeding in Community Healthcare
settings. It is therefore suitable for facilities providing both maternity and community
services. Facilities providing only maternity or only community services can easily adapt this
policy by omitting those elements which do not apply. Care should be taken to ensure that
the resulting policy fully covers all the relevant standards.

See Appendix 1.




                                              9
Formula Milk

What about formula milk during the first year of life?

It is well known that breast milk is the best drink for babies in the first few months of life and
ideally up to one year of age. The only alternative is infant formula based on cow’s milk.
Two types of formula milk are currently in use: whey-based and casein-based.

Whey based

These are designed to closely resemble human breast milk ie the casein-to-whey ratio
similar to that of human milk (casein 40%, whey 60%). They are suitable from birth.
Examples of whey-based formulas include:-

       Aptamil first                          Milupa Ltd
       Cow and Gate Premium                   Cow and Gate Nutricia Ltd
       Farley’s First Milk                    Farley’s Health Products Ltd
       SMA Gold                               SMA Nutrition.

Casein-based

The casein-to-whey ratio is similar to that of cow’s milk (casein 80%, whey 20%). The
energy content is the same as that of whey-based infant formulas. Casein-based infant
formulas are thought to be suitable for the ‘hungrier’ babies due to the different proportions
of protein, however there is no scientific evidence to support this. Examples include:-

       Aptamil Extra                          Milupa Ltd
       Milumil                                Milupa Ltd
       Cow and Gate Plus                      Cow and Gate Nutricia Ltd
       Farley’s Second Milk                   Farley’s Health Products Ltd
       SMA White                              SMA Nutrition.

Occasionally infants on casein-based milk formula develop constipation - refer to section on
constipation for advice.


Other milks

Follow on formulas

Follow-on-milk formulas have higher levels of iron, calcium and vitamin D than standard
infant formulas. Due to their higher protein and sodium content they are unsuitable for
babies under six months of age. Providing the infant is managing good volumes of milk and
a varied diet there is no real advantage in switching to a follow-on formula. Where there is
concern over the adequacy of iron in the diet follow-on milks should be suggested eg
Forward (Milupa), Step-Up (Cow and Gate), Follow on milk (Farley’s), Progress (SMA).
They can be used beyond one year (up to two years of age) in preference to cow’s milk as a
drink (Department of Health, 1994).

Pre thickened formulas

Pre-thickened formulas are used in the management of infant regurgitation (also known as
mild reflux). They are suitable from birth, nutritionally complete and contain an easily
digestible starch which when mixed with cooled boiled water thickens in the stomach. They
do not thicken on standing and therefore flow through a standard teat.
                                               10
The two pre-thickened formulas available are:-

       SMA Staydown (SMA Nutrition)
       Enfamil AR (Mead Johnson).

For further guidance on the use of these products in the management of mild reflux refer to
page 32.

Soya based infant formulas

Infant soya milk formulas should not be used as a first choice for the management of infants
with proven cow's milk allergy/intolerance, lactose intolerance, galactosemia or
galactokinase deficiency. This is to limit exposure to phytoestrogens while organ systems
are at their most vulnerable as currently the long-term use of soya protein in infancy is not
known. Some infants with atopy may become sensitised to soya protein, this risk being the
greatest in the first six months of life. Therefore the use of soya in allergic infants or in
infants at high risk of developing allergy is not recommended before six months of age (Host
et al, 1999).

There is a clinical need for feeding soya-based infant formulas in some groups eg infants
with cows milk intolerance who refuse extensively hydrolysed formulas however they should
be referred to a dietician for appropriate advice, monitoring and to ensure adequate nutrition.
Examples available on prescription include:-

       Farley's Soya Formula         Heinz
       Infasoy                       Cow and Gate
       Wysoy                         SMA Nutrition
       Prosobee                      Mead Johnson.

Soya milks have a high sugar content which can contribute to tooth decay and therefore
ideally should be offered at mealtimes. However individual circumstances such as infants
with faltering growth need to be addressed on an individual basis ie some may need
additional milk as a snack between meals to promote growth.

Hydrolysed protein infant formulas

These formulas are nutritionally complete hypoallergenic formulae, containing extensively
hydrolysed proteins, for infants and children who have cows milk protein and/or disaccharide
intolerance with related symptoms such as colic, eczema, diarrhoea. They are used in
allergy prevention for infants at risk of developing atopic disease. Examples include:-

       Nutramigen 1 and 2     (Mead Johnson)
       Pepti Junior           (Cow and Gate)
       Pepdite                (SHS international).
       Pepti                  (Cow and Gate).

Before recommending the use of this product the infant should be referred to their GP and a
dietitian. Hydrolysed formulas are available on prescription.




                                              11
Cow’s milk

Cow's milk is not suitable as a main drink for infants under 12 months due to its poor iron
content and high sodium content. However whole cow's milk can be used as an ingredient
in complementary foods, eg to moisten mashed potato from six months onwards.

Sheep and Goats milk

These aren't suitable as drinks for babies under a year old as they don't contain enough iron
and other nutrients. Providing they are pasteurised they can be used after one year of age.

References

Department of Health       Weaning and the weaning diet. Report of the working group on
                           the Weaning Diet of the Committee on Medical Aspects of Food
                           Policy. Report on health and social subjects, No 45. HMSO,
                           London 1994.

Host A, Koletzko B,        Dietary products used in infants for treatment and prevention of
Dreoborg S et al (1999)    food allergy. Joint Statement of the European Society for
                           Paediatric Allergology and Clinical Immunology 9ESPACI)
                           Committee on Hypoallergenic Formulas and the European
                           Society for Paediatric Gastroenterology, Hepatology and Nutrition
                           (ESPAGHAN) Committee on Nutrition. Archives of Diseases in
                           Childhood, 81:80-4.




                                             12
Drinks in the first year of life

Water

Milk (breast or infant formula) should be the main source of liquid in an infants diet. Water is
the next best alternative and can be given in addition to milk but should not be offered
instead. Fully breastfed babies do not need water until they start eating complementary
foods however bottle fed infants may need additional water. Infants under six months of age
should be offered cooled boiled water (from a tap). Most bottled mineral waters have
mineral contents unsuitable for making up infant formula feeds or used as a drink. However
there are some bottled waters that are suitable which have lower sodium contents. Bottled
water is not sterile and therefore needs to be boiled as advised above. Softened water is not
suitable as it contains increased sodium levels.

Fruit juice/herbal drinks

Baby fruit juices are damaging to infant’s teeth when given in a bottle or cup between meals
as they are acidic and contain natural sugars. They will also reduce an infant’s appetite for
milk. If given they should be used sparingly and are better served with meals and preferably
from a CUP after the age of 6 months (Department of Health, 1994). They should not be
given at bedtime (Department of Health, 1994).

Fruit juice should not be given until six months of age at which they can be recommended to
infants who refuse to eat vitamin C containing foods or to infants fed a vegetarian diet who
need vitamin C to help absorption of iron from their diet. Fruit juice should be well diluted
and given in a feeding cup at mealtimes only. (1:10 parts).

Squashes/fizzy drinks/flavoured milks

These are not suitable for young babies as they contain sugars. Filling up on these can
cause babies to have a poor appetite for milk and complementary foods, poor weight gain
and loose stools.

Fizzy drinks whether diet or otherwise provide little nutrition and some such as cola contain
stimulants such as caffeine. Sugar-free can also be too acidic and therefore their usage
should be limited.

All should be limited to meal times only.

Tea and coffee

These are not suitable for infants or young children.

References

Department of Health        Weaning and the weaning diet. Report of the working group on
                            the Weaning Diet of the Committee on Medical Aspects of Food
                            Policy. Report on health and social subjects, No 45. HMSO,
                            London, 1994.
Health Education            Nutrition and oral health ; guidelines for pres schools
Authority




                                              13
Premature and low birth weight infants

Low birth weight and preterm infants have special nutritional needs in the period following
discharge from the neonatal unit. Additional requirements for energy, protein, long chain
polyunsaturated fatty acids, iron, calcium and selenium have all been documented. This is
because infants lay down their stores of these nutrients predominantly in the last trimester of
pregnancy.

Medical complications together with sub-optimal digestion, absorption and metabolism of
nutrients lead to a poor intake in the preterm infant who already has limited stores of
nutrients. Some have ongoing medical problems which cause increased nutritional
requirements (eg Chronic Lung Disease) but a decreased nutritional intake (eg chewing and
swallowing difficulties).


What to feed?

All mothers should be encouraged to demand breast-feed their infants wherever possible
once discharged from hospital. For preterm infants who are not breastfed there are nutrient
enriched post-discharge formulas available such as Nutriprem 2 (Cow and Gate) and
Premcare (Heinz). These are available on prescription until 6 months corrected age. After
six months parents can change to follow-on milks (due to higher iron content) or a term
formula which can be used until 14-18 months of age.

Infants who are breastfed will need vitamin D and iron supplements. When infant formula or
breast milk is changed to cows milk at 14-18 months infants should be started on children’s
vitamin drops as per DH guidelines (COMA, 1994).

References

Department of Health       Weaning and the weaning diet. Report of the working group on
                           the Weaning Diet of the Committee on Medical Aspects of Food
                           Policy. Report on health and social subjects, No 45. HMSO,
                           London, 1994.




                                              14
Complimentary Feeding

Weaning is defined in the Committee on the Medical Aspects of Food Policy (COMA) report
Weaning and the Weaning diet as:-

       "the process of expanding the diet to include foods other than breast milk and infant
       formula" (DoH, 1994).

At international level the term 'complementary feeding' is becoming increasingly popular to
define the process of introducing foods and liquids alongside breast milk when breast milk
can no longer fulfil an infants nutritional needs. 'Complementary feeding' emphasises the
recommendation that mothers should continue to breast feed after the introduction of
complementary foods and other liquids throughout the first year of life.

For the purpose of this policy “complementary feeding” and “solid feeding” have been used.

Mothers who are unable to, or choose not to, follow these recommendations should be
supported to optimise their infants' nutrition.


Why introduce complementary foods?

By the age of six months an infants dietary needs cannot be met from breast milk alone; the
volume of milk required to meet an infant’s nutritional needs will exceed a mother’s
lactational capacity and the baby's ability to consume sufficient volumes of milk. The
introduction of complementary foods enables the infant to meet their changing nutritional
requirements during a period of rapid growth and development. The following nutrients need
to be obtained from other dietary sources:-

       •   Energy
       •   Protein
       •   Iron
       •   Vitamin A and D
       •   Zinc
       •   Copper.

The introduction of complementary foods is also important for the development of babies’
ability to bite and chew.


Developmental readiness

In 2001 the World Health Organisation (WHO) completed a systematic review on the
Optimal Duration of Exclusive Breastfeeding and concluded that exclusive breastfeeding for
six months confers several benefits on the infant and the mother. The Department of Health
(DOH) endorsed these new recommendations and issued a statement (12/05/03):-

       “Breastfeeding is the best form of nutrition for infants. Exclusive breastfeeding is
       recommended for the first six months (26 weeks) of life as it provides all the nutrients
       a baby needs'. Breastfeeding and/or breast milk substitutes, if used, should continue
       beyond the first six months along with appropriate type and amounts of
       complementary foods".

In infants who are mixed fed on breast and infant formula milk or solely fed on infant formula
milk should also be advised to delay the introduction of complementary foods until six
months of age.
                                             15
On a population basis there are no adverse effects of exclusive breastfeeding for six months
on infant growth providing the mother is well nourished (Fleischer, 2000). Therefore
breastfeeding mothers may need appropriate nutritional advice (and supplementation where
necessary) to ensure their breast milk provides adequate nutrition to their infant.
There are some circumstances where infants can experience a faltering in their growth or
develop nutritional deficiencies when exclusively breastfed for six months (Butte et al 2002;
Lanigan et al 2001). For example infant iron reserves at birth play an important role in
determining the risk of anaemia as the iron content of human milk is low. Normal birth
weight infants whose mothers pre-natal iron levels were good usually have adequate iron
stores. However low birth weight infants or infants whose mothers had pre-natal iron
deficiency are at a greater risk and therefore will need medicinal iron drops form 2-3 months
of age (UNICEF/WHO, 1999). Other micronutrients such as zinc, vitamin A, D, B6 and B12
may also become depleted before six months.

Health professionals need to manage infants individually and consider their individual
developmental and nutritional needs before giving advice on introducing complementary
foods so insufficient growth and other adverse outcomes can be addressed or prevented.

Some parents will choose to give complementary foods earlier than six months (Fewtrell et
al 2003; Foote & Marriott, 2003). They should be encouraged to view four months (17
weeks) as the earliest age at which complementary foods can be introduced. The COMA
'Weaning and the Weaning Diet' can be used for guidance on appropriate types and
amounts of first foods (COMA, 1994).

Current recommendations from the DOH, 2004 are:-

       •   Breast milk is the best form of nutrition for infants; it provides all the nutrients a
           baby needs

       •   Exclusive breastfeeding is recommended for the first six months of an infant's life

       •   Six months is the recommended age for the introduction of complementary foods
           for both breast and formula fed infants

       •   Breastfeeding (and/or breast milk substitutes, if used) should continue beyond
           the first six months along with appropriate types and amounts of complementary
           foods.

Parents need to be supported and given appropriate advice to optimise their infant's nutrition
regardless of their feeding decisions (breastfeeding or bottle feeding; early or late
introduction of complementary foods).


Early introduction of complementary foods

Introduction too early is undesirable because:-

       •   Early introduction of complementary foods can reduce the absorption of nutrients
           eg iron and zinc from breast milk (COMA, 1994)

       •   Increased risk of infections and development of allergies due to greater gut
           permeability

       •   Immature kidneys may not be able to cope with the increased renal solute load of
           solids

                                              16
       •   Energy dense foods could contribute to obesity later in life.


Late introduction of complementary foods

Late introduction may cause:-

       •   Increased difficulty in introducing complementary foods and increased risk of
           feeding difficulties (Northstone et al, 2001)

       •   Delayed tongue rolling/chewing can contribute to delayed speech development.

There is concern that introduction of complementary foods later than six months will give rise
to feeding difficulties and ability to chew. The historical "window of opportunity" theory
appears to have arisen from an old paper by Illingsworth and Lister, 1946 which presented
case studies of children who remained on a liquid diet for six to twelve months. However
some of these children had developmental delays or disabilities.

How should complementary foods be introduced?

Due to the physiological development of the infant at six months onwards the introduction of
complementary foods can be progressed more quickly. Therefore the consistency and
variety can be increased as the child gets older to accustom the infant to a range of tastes
and textures.

Infants from six months old can eat pureed or semi-solid foods, by eight months most can
eat finger foods and by 12 months most can eat the same types of food as the rest of the
family. Initially most babies can manage semi-solid foods until the ability for 'munching' (up
and down mandibular movements) or chewing appears. The conventional practice of
moving from liquids to pureed to solids is not supported by data (Stevenson & Allaire, 1991).
Transitional feeding is not given much attention by other cultures who wean babies straight
onto more solid foods.

Suitable first foods include:-

       •   Baby rice mixed with expressed breast milk or infant formula milk
       •   Home cooked vegetables (potato, sweet potato, carrots, broccoli) - can be fresh
           or frozen but avoid tinned due to salt content
       •   Stewed fruit - apple, plum, apricot (remove fibres, skins), banana, ripe avocado.
           Citrus fruits can also be included.
       •   Meat/fish.
       •   Pulses eg lentils, beans.
       •   Well cooked eggs (>10 minutes).
       •   Cheese.
       •   Natural yoghurt, fromage frais.
       •   Rusks.

Human milk is known to be a poor source of iron. However the iron in breast milk is in an
easily digested form and thus absorption rates are good. Foods rich in absorbable iron (red
meat, eggs) or pulses and fortified cereals (combined with a vitamin C source) for vegetarian
infants should be encouraged to prevent the development of iron deficiency and anaemia.
Infants fed infant formula milk are not at such a risk as formula milk is fortified with iron.

Mothers who decide to introduce their babies to complementary foods earlier than the
recommended age of six months should be advised to avoid the following until six months.

                                              17
The introduction of complementary foods should be a more gradual process and consist
mainly of pureed foods:-

      Foods to avoid before six months                            Reason

   Eggs                                         May cause allergic reaction

   Fish and Shellfish                           May cause allergic reaction

   Wheat based foods which contain gluten       May cause allergic reaction

   Citrus fruits                                May cause allergic reaction
   Nuts including ground nuts and nut           Risk of choking and may cause allergic
   spreads                                      reaction.


Six months and beyond

Despite increased variety of food being offered certain foods should still be avoided:-

           Foods to avoid six months
                                                                  Reason
                  and beyond

                                                Infants’ kidneys are immature and
                                                therefore unable to readily excrete large
   Salt                                         amounts of salt. Parents should be
                                                advised to avoid adding salt to meals or
                                                during the cooking process.
                                                Convenience foods not specifically
   Foods high in salt including cheese,
                                                designed for infants eg soups and
   bacon, sausages, tinned meats, smoked
                                                sauces are naturally high in salt and
   foods, crisps, butter
                                                therefore their use should be limited.
                                                Sugar should not be given between
                                                meals. Only add a small amount of
                                                sugar to sweeten sour foods such as
   Sugar                                        cooking apples. Frequent use of sugar
                                                will encourage a sweet tooth and can
                                                lead to tooth decay when first teeth come
                                                through.
                                                Infants should not be given honey until
                                                they have had their first birthday as it can
                                                contain a type of bacteria that produces
   Honey
                                                toxins in the babies intestines which can
                                                cause infant botulism.         Honey also
                                                contributes to tooth decay.
                                                Whilst these might be part of the family's
                                                normal diet be aware these may irritate
                                                the gastrointestinal tract. Some mild
   Chillies and spices
                                                spices can be used in dishes eg dahl.
                                                Other flavouring alternatives include
                                                herbs, onion and garlic.



                                              18
Finger foods

Infants often are ready to try finger foods when they start using their fingers to put toys etc
into their mouth. It is important to reassure mothers that some infants can take finger foods
readily even if they are not managing lumpy foods. Allowing infants to feed themselves can
help develop their chewing and hand co-ordination skills.

Suitable foods to try include:-

       •   Ripe peeled soft fruits such as banana, pear, peach etc
       •   Cooked soft vegetables such as carrots, parsnip
       •   Fingers of buttered toast
       •   Slices of cheese
       •   Well cooked pasta shapes.


Meal frequency

Initially infants can be offered one meal per day, gradually increasing to 2 - 3 meals per day
at about 6 - 8 months and 3 - 4 meals per day at 9 - 12 months with additional snacks.


Food refusal and lumps

All babies will reject food at some time for many reasons including tiredness, the infant isn’t
hungry, food is too hot or bitter. They may refuse it the first time as they are suspicious of it,
not because they do not like it. The following lists some practical advice to offer parents:-

       •   Offer new food in small amounts every few days over a period of a few weeks

       •   Family meal times are an important time for learning about eating, infants may try
           new foods if other people around them are enjoying their food

       •   Give the child plenty of encouragement and praise for trying new foods

       •   Keep meal times to a maximum of thirty minutes

       •   Do not force a child to like a new food, this will actually make feeding more
           difficult.

Introducing lumps can be difficult but should not be put off otherwise it will be harder to
introduce these foods. Lumps ideally should be offered to all infants by 9 months of age.
Practical advice to offer parents include:-

       •   Thicken pureed foods to the maximum infants can manage before introducing
           lumps

       •   Offer soft but small lumps eg ripe mashed banana or partly liquidised soft home
           cooked foods

       •   Allow infants to play with food as this helps them learn about new foods and more
           readily accept them

       •   Lumpy cereals such as puffed rice with milk can be difficult for the infant as they
           have to control the lumps and the runny liquid at the same time

                                               19
         •   Reassure parents that gagging and coughing are normal with infants starting
             lumps. Encourage them to remain calm.


References

Butte NF et al                 Nutrient adequacy of exclusive breastfeeding for the term
                               infant during the first six months of life. WHO, Geneva, 2002

Department of Health           Draft clarification document on Infant Feeding:Questions and
                               answers for health professionals. Department of Health.
                               London. 2004

Fewtrell M S, Lucas A,         Factors associated with weaning in full-term and pre-term
Morgan T B                     infants. Archives of Disease in Childhood: Fetus and
                               Neonates. 2003:88, F296-F301

Fleishcer Michaelson K,        Feeding and nutrition of infants and young children.
Weaver L, Branca F et al       Copenhagen: WHO Regional Publication, European Series
                               No. 87, 2000

Foot K D, Marriott L D         Weaning of infants. Archives of Disease in Childhood. 2003;
                               88, 488-492

Hamlyn B, Brooker S,           Infant Feeding Survey 2000. BMRB International.         2002.
Oleinikova K, Wands S          London. The Stationery Office.

Illingsworth R S, Lister J     The critical or sensitive periods, with reference to certain
                               feeding problems in infants and children.        Journal of
                               Paediatrics 1964;45, 839-848

Lanigan J A, Bishop J A,       Systematic review concerning the age of introduction of
Kimber A C et al               complementary foods to the healthy full-term infant. European
                               Journal of Clinical Nutrition. 2001;55, 309-320

Northstone K, Emmett P,        The effect of age on introduction to lumpy foods eaten and
Nethersole F and the           reported feeding difficulties at 6 and 15 months. Journal of
ALSPAC Study Team              Human Nutrition and Dietetics. 2001;14, 43-54

Oski F                         Iron Deficiency in Infancy and Childhood.      New England
                               Journal of Medicine. 1993;329, 190-193

Stevenson R D, Allaire J H     The development of normal feeding and swallowing. (Review)
                               (22 refs). Paediatric Clinics of North America. 1991;38(6),
                               1439-1453

Wellstart                      Reviews of the Relevant Literature Concerning Infant GI,
                               Immunologic, Oral Motor and Maternal Reproductive and
                               Lactational Development. April 2001. Eds, A J Naylor, A L
                               Morrow

World Health Organisation      Infant and Young Child Nutrition. Global stategy on infant and
(WHO)                          young child feedings. WHO 55th World Health Assembly, 16
                               April 2002.


                                             20
Nutrition in faltering growth

It should be noted that the following is not in line with current healthy eating guidance
regarding low salt and sugar intake however the over riding priority is weight gain
therefore the foods should be seen as a short term measure under the supervision of
a health professional.

High energy advice

Children with faltering growth or who have high energy requirements due to illness can
benefit from a diet high in energy (calories) to aid growth and weight gain. The calorific
content of their diet can be increased by two ways:-

       •   Eating more and choosing energy dense foods eg having puddings or sweet
           desserts once or twice a day

       •   Fortifying food with calories.


Energy dense foods

Children often have small appetites and therefore little and often should be encouraged eg
three small meals and three snacks per day rather than three large meals. The following
ideas for suitable snack choices (eg after school or at bedtime), nourishing drinks and
energy dense light meal ideas should be included in the diet.

Sweet snacks

       •   Breakfast cereal with full cream milk
       •   Pot of full fat yoghurt, fromage frais, full fat custard, rice pudding, crème caramel,
           trifle, milk jelly
       •   Ice cream
       •   Dried fruit, stewed fruit with sugar, tinned fruit in syrup
       •   Malt loaf, toast, crumpets, muffins, brioche, croissants, teacakes or scotch
           pancakes with margarine
       •   Cakes such as flapjacks, fairy cakes, fruit pies, chocolate crispier cakes
       •   Biscuits eg hobnobs, shortcakes, garibaldi, chocolate coated biscuits
       •   Chocolate coated raisins and nuts (whole nuts not to be given to children under
           five years of age)
       •   Chocolate bars.

Savoury snacks

       •   Mini babybel, cheese triangles, cheesestring
       •   Savoury biscuits with margarine and cheese triangles or cubes of hard cheese
       •   Toast with peanut butter, hummous, cheese or scrambled egg
       •   Mini sausage rolls, pork pies, samosas, scotch eggs, quiche, pepperami
       •   Potato wedges with dips eg sour cream, cream cheese
       •   Garlic bread, naan bread
       •   Cheese, egg mayonnaise, tuna mayonnaise sandwiches
       •   Crisps
       •   Nuts (do not give whole nuts to children under five years of age)
       •   Cup of soup with added cream/cheese.


                                              21
Nourishing drinks

       •   Full fat milk
       •   Milkshakes with added full fat yoghurt, ice cream and/or fruit such as bananas
       •   Malted drinks such as ovaltine or horlicks made with full fat milk
       •   Hot chocolate with whipped cream
       •   Fresh fruit juice.

Nourishing light meals

       •   Toast with baked beans and cheese, ravioli, macaroni cheese, fried egg and
           bacon
       •   Sausages with baked beans and fried potatoes or bread
       •   Fried fish fingers, chicken in breadcrumbs with chips/ fried potatoes and peas
       •   Jacket potato with margarine/butter and cheese, cheese and coleslaw, egg or
           tuna mayonnaise, baked beans or chilli with cheese
       •   Pasta with cheese or cream sauce eg macaroni cheese
       •   Corned beef hash
       •   Cauliflower cheese
       •   Sandwiches with two fillings eg cheese and coleslaw, egg and bacon.

Food fortification

Children who have poor appetites may find it difficult to increase their intake at mealtimes or
have additional snacks and therefore food fortification involves increasing the energy content
of the food and drink children currently eat.

The following are ideas which can be suggested to parents/carers to increase the energy
content of meals:-

       •   To potatoes and vegetables add: grated cheese, cream, eggs, margarine, oil,
           milk based sauces (using full cream milk), mayonnaise

       •   To milk based sauces add: double cream, cheese, evaporated milk

       •   To breakfast cereals add: full fat milk, evaporated milk, full fat yoghurt, honey,
           sugar, dried fruit, chopped nuts

       •   To soup add: double cream, cheese, margarine, dried milk powder, croutons,
           dumplings, pasta

       •   To puddings add: double cream, evaporated/condensed milk, ice cream,
           yoghurt, honey, jam, custard, chopped nuts, dried fruit

       •   Encourage milk/fruit juice as drinks instead of water or ordinary squash

       •   Fry foods in sunflower/olive oil rather than grilling, steaming, poaching or baking.



Encouraging a poor eater

       •   Make meal times fun by involving the child when preparing and cooking food eg
           involving children in adding pizza toppings to bought pizza bases

                                              22
•   Use a variety of different colours and textures to make food look more appealing

•   Ensure there are no distractions in the room when the child is eating eg turn
    television off, clear away toys and sit the child at the table

•   Encourage children to eat and offer praise when they do eat something. Try not
    to give attention or comment when children do not eat but praise when they do.

•   Offer small portions to avoid ‘over-facing’ children, they can always be offered
    second helpings.

•   Ensure other people are also eating with the child as children are more likely to
    eat if others around them are eating.




                                       23
Nutrition guidelines for children aged one to five years

Once an infant has reached one year he or she will hopefully be enjoying a variety of food
tastes, involved in family meals and developing their own eating habits and food
preferences. Healthy eating habits established now will hopefully be continued on through to
adulthood.

There are many reasons why children’s diets need special attention: the stomach is small so
children are not able to eat large quantities; young children are usually very active and
although appetite can vary significantly the range of foods a young child will eat is often
limited. Therefore the few foods children will eat need to contain a good variety of nutrients.
The easiest way to ensure children are eating a balanced diet is to provide regular meals
and snacks consisting of a wide variety of foods from the four main food groups every day.


The balance of good health

The food groups are:-

1    Fruit and vegetables

     Aim for 4 - 5 servings per day
     These can be included as snacks
     Offer fresh, frozen, canned or dried

2    Breads, other cereals and potatoes

     Aim for a serving with each meal
     Choose wholegrain/wholemeal varieties at some mealtimes
     These can be offered as snacks eg cereal as suppertime snack
     Encourage vitamin and iron enriched breakfast cereals

3    Milk and Dairy foods

     Aim for 3 servings per day
     Children need one pint of milk per day or the equivalent (eg 1/3pt milk + 1oz cheese +
     pot of yoghurt/fromage frais)
     Offer full fat dairy products, semi skimmed milk can be introduced after the age of 2
     and skimmed milk after the age of five providing the child is growing and gaining
     weight adequately

4    Meat, fish and alternatives

     Aim for minimum 2 servings per day
     Encourage children to try a variety including beef, chicken, pork, fish, eggs, baked
     beans, lentils and nuts (whole nuts should not be given to children under the age of
     five due to risk of choking)

5    Foods containing fat and sugar

     This food group includes foods such as crisps, pastry, sweets, fizzy drinks etc. These
     foods provide little nutrition other than calories and therefore their intake should be
     limited to treats or for special occasions. Healthier alternatives to offer children will be
     discussed later.



                                              24
What is a serving?

This depends on the age of the child and the stage they have reached. Parents can be
encouraged to give a little of a food and wait for the child to reach (and ask) for more, rather
than offer too much. Parents need to be reassured that children may not eat a full portion at
every mealtime.


Specific nutrients for consideration

Energy

It is important that under five’s get enough energy (calories) for growth and development.
Children under five should not adopt the adult healthy eating guidelines of low fat and high
carbohydrate. Such a diet may satisfy a child’s appetite thus children may be unable to
consume sufficient food to provide all the nutrients they need.

Carbohydrate

       •   The term carbohydrate covers both starch (main component of cereals, pulses
           and root vegetables) and sugars. Sugars can be broken down into 3 different
           types:-

       •   Intrinsic sugars (these are contained in the cell walls of fruit and vegetables)

       •   Milk sugars (these are found in milk and milk products)

       •   Non-milk extrinsic (NME) sugars (these include table sugar, sugar added to
           recipes and honey).

Parents should be advised to reduce the intake of NME sugars as these sugars contribute to
tooth decay. Such sugars also provide calories but few other nutrients. If children receive a
large proportion of their calorie intake from sugary drinks and foods it may be difficult for
them to obtain all the nutrients they need each day. Excess intake of NME sugars in many
children can contribute to obesity.

If children have sugary drinks or foods these should be given at mealtimes rather than
snacks.

Fibre (non starch polysaccharides)

Fibre is important in children's diets to prevent constipation. However because of the bulk of
non starch polysaccharide rich foods if eaten in excess may prevent children from eating
enough to satisfy their nutrient and energy requirements. Fibre can also impair the
availability of certain nutrients such as iron.

Good sources of fibre include fruit, vegetables, wholemeal bread, breakfast cereals, oats,
baked beans and lentils.

Increasing children’s intake of fibre without an increase in their fluid intake will result in a
child becoming constipated.




                                              25
Fat

The current advice for adults and children over five years is to consume a diet in which fat
provides 35% of the total energy. The fat intake of children under 2 years of age should not
be restricted as they need energy and nutrient dense foods ie foods that contain a lot of
nutrients and energy in a small volume.

Iron

Iron intake has been shown to be lower in children under five years of age and therefore
children should be offered a diet high in iron-rich foods such as red meat, liver, poultry, eggs,
dark green leafy vegetables, baked beans and fortified breakfast cereals.

Encouraging a vitamin C source at mealtimes will enhance iron absorption eg having a glass
of orange juice, fruit or green vegetables at mealtimes. Tea limits the absorption of iron and
therefore children should not be given cups of tea with their meals.

Vitamin C

Children like adults need vitamin C to produce and maintain collagen, the foundation
material for bones, teeth and skin. It is also important in wound healing. Encourage foods in
the diet which contain vitamin C eg fruit and fruit juices, potatoes, tomatoes, dark green
vegetables and other vegetables and fruits.

It is recommended that children up to the age of five years receive vitamin drops containing
vitamin A, C and D. This is the responsibility of the parents however health professionals
may wish to remind parents.

Vitamin D

Vitamin D helps the body to absorb calcium present in food. Sunlight acts on the skin to
produce vitamin D which is then stored in the body. Infants and children between the ages
of six months and three years are particularly vulnerable to vitamin D deficiency due to rapid
bone growth and limited exposure to ultraviolet radiation.

Good dietary sources of vitamin D include oily fish (eg sardines), eggs, liver, fortified
breakfast cereals and margarine. However it is impossible for young children to obtain
satisfactory vitamin D intakes from diet alone and therefore it is recommended that children
up to five years of age receive supplementary vitamin D in vitamin drops (Department of
Health, 1994).

Salt

High salt intakes have a direct impact on children’s health and therefore in May 2003 the
Scientific Advisory Committee on Nutrition (SACN) made recommendations on the maximum
amount of salt babies and children should have in their diet:-

       0-6 months      less than 1g salt per day
       7-12 months     maximum 1g salt per day
       1-3 years       maximum 2g salt per day
       4-6 years       maximum 3g salt per day.

According to the British Nutrition Foundation (1994) manufactured foods contribute 65 – 70%
of our total sodium intake.



                                               26
The following foods are high in salt and therefore should be limited:-

       •   Processed foods including ready meals, soup

       •   Tinned foods such as baked beans (choose those stated “no added salt”)

       •   Salty snacks such as crisps, nuts, savoury cheese crackers

       •   Butter, bacon, cheese and smoked foods.

Parents can be advised to avoid adding salt to the cooking process and at the table.


References

British Nutrition Foundation   Salt in the Diet. Briefing Paper. 1994

Gregory J R, Collins D L,      National Diet and Nutrition Survey Children Aged 1.5 – 4.5
Davies P S W, Hughes J M,      years. Report of the Diet and Nutrition Survey, Volume One.
Clarke P L                     HMSO. London. 1995

Scientific Advisory             Salt and Health. London. The Stationery Office. 2003
Committee on Nutrition




                                              27
Menu planning

The following points are useful in helping parents to plan menus:-

       •   Children need to eat regularly and therefore can be offered something every
           three hours

       •   All children ideally should eat breakfast, either at home or in childcare if available

       •   Some children may eat slowly and therefore allow enough time to eat

       •   A main meal should include a food from each of the following groups:-

                  -   Bread, cereals or potatoes
                  -   Fruit and vegetables
                  -   Meat, fish and alternatives (beans, lentils)
                  -   Dairy foods

       •   Combining colours can make the food look attractive.          Three or four defined
           areas of colour look good on a plate.

       •   A combination of different textures increases appeal, eg crisp, crunchy, chewy,
           smooth and soft foods.


Lunch boxes

Many children take a packed lunch to nursery or school. To ensure a balanced diet include
at least one item from each of the four food groups, eg:-

       •   Chicken and salad sandwich (bread, meat and vegetables)
       •   Yoghurt (dairy)
       •   Banana (fruit)
       •   Drink such as water, milk.

Sandwiches

Include a variety of breads such as wholemeal or high fibre white bread, rolls, pitta bread,
chapatti, bagels, plain muffins, or Mediterranean breads such as ciabatta, French bread.
Vary sandwich fillings, eg:-

       •   Lean cooked meats, sausage with lettuce/tomato
       •   Tinned tuna and cucumber/sweet corn
       •   Tinned salmon with cream cheese
       •   Smooth peanut butter +/- banana
       •   Hard boiled egg mashed with cress and salad cream
       •   Grated cheese and pickle
       •   Cheese triangle with tomato
                                               28
         •   Creamed cheese with chopped grapes, dried apricots
         •   Mashed sardines with tomato
         •   Cheese and marmite sandwiches.

Wrap sandwiches individually or use easily opened containers.

Use biscuit cutters to cut out the bread to make sandwiches more interesting.

Alternatives to sandwiches

         •   Quiche
         •   Pizza
         •   Samosas
         •   Pasta salads-use different colour pasta and shapes.         Mix with colourful
             vegetables such as carrot, sweet corn, dried fruit and then cubes of cheese or
             meat. Mix with salad cream.
         •   Tubs of finger foods eg cubes of cheese and pineapple
         •   Crackers/mini bread sticks and miniature cheeses
         •   Cheese scones with filling
         •   Left over family food such as meatballs or chicken pieces.

Healthy snacks

There are many interesting and appealing alternatives to fatty and sugary foods such as :-

         •   Fromage frais or yoghurt or cartons of milk
         •   Greek yoghurt
         •   Cheese or fruit scones, carrot cake
         •   Teacake, fruit loaf/bread, malt loaf
         •   Plain biscuits such as digestives, oat biscuits, fig roll
         •   Fruit – tinned in juice or fresh
         •   Fresh vegetables eg carrot or cucumber sticks, cherry tomatoes
         •   Individual pots of rice pudding or custard
         •   Individual cheeses or cubes of cheese.

Drinks

Many drinks are unsafe for children’s teeth due to the acid and sugar content. Even sugar
free, no added sugars and tooth kind drinks can damage teeth and therefore ideally these
should be restricted to meal times only. Suitable drinks include:-

         •   Milk, milk and fruit smoothies
         •   Water
         •   Diet or No Added Sugar squash/ fizzy drinks.

                                                  29
Feeding vegetarian and vegan infants and young children

It is widely recognised by the British Medical Association that a vegetarian diet can provide
all the nutrients needed for growing infants.

Eating patterns of vegetarians vary. Lacto-ovo vegetarians diets are based on grains, nuts,
seeds, vegetables, fruit, legumes, dairy products and eggs. They do not eat meat, fish or
fowl. Total vegetarians or vegans eat similar diets but exclude eggs, dairy products and
animal products. Even in these patterns there is considerable variation in the extent to
which different animal products are avoided.

Important nutrients

Iron

Iron rich sources to incorporate into the diet after six months of age include: prune juice,
pureed apricots, refined lentils, fortified breakfast cereals, well mashed beans and green
vegetables eg spinach. Many of the plant sources of iron are also high in fibre, which can
inhibit iron absorption and therefore cereals high in fibre should be limited. Vegetarian and
vegan babies unless they are consuming an adequate intake of the above foods will need an
iron supplement from six months of age.

Vitamin C aids the absorption of iron from plant foods. Vitamin C is found in frozen, fresh or
juiced fruit and vegetables.

Calcium

Breast or formula milk provides all the calcium an infant needs initially. Fortified cow's or
soya milk, cheese, green vegetables, bread, beans, ground almonds, nut butters and tofu
are all good sources of calcium which can be included in the later stages of weaning and
throughout childhood.

Infant soya milks can be given until 2 years of age minimum and if dietary intake is poor
these can be continued until five years of age.

Protein

Protein must be balanced to provide the right balance of amino acids. Combining foods
such as breakfast cereal with milk, or bread with beans will provide the right balance. Good
sources of protein include:-

       •   Lentils
       •   Pulses
       •   Seeds such as sunflower or pumpkin
       •   Tofu, tempeh, textured vegetable protein, veggie-burgers
       •   Cows or soya milk, yogurts.
       •   Nuts and nut butters, eg tahini paste.

Wholegrain bread, potatoes, pasta and corn also contribute to protein intake.




                                             30
Energy

Babies and young children on vegetarian diets should not receive too many foods that are
bulky as this will fill them up. Encourage concentrated energy foods in the diet such as
avocado, cheese or smooth nut butters and offer frequent meals and snacks to help them
meet their energy needs.

Vitamin B12

Vitamin B12 is mainly found in animal derived foods. Very young babies will get their vitamin
B12 from formula or breast milk. Vegetarian babies and young children should obtain
enough of this vitamin from dairy foods and eggs. Vegans will need vitamin B12 from
fortified foods such as some fortified soya milk, low salt yeast extract or veggie burgers. If
intake sub-optimal a non-animal derived supplement will be necessary. Solely breast-fed
vegan infants will need a supplement if mums diet is not supplemented.

Vitamin D

Vitamin D is found mainly in animal products and some fortified breakfast cereals and can be
made by the action of sunlight on the skin. Both vegetarian and vegan infants and young
children will likely need a vitamin D supplement.




                                             31
Nutritional related problems

Constipation

Defined as infrequent or difficulty in passing stools and the stools may be hard but this is not
always the case (Babu 2002).

Some parents may verbalise this as their child being lazy but this not usually the case.

Cause

        •   Inadequate fluid intake
        •   Excess milk intake
        •   Family history
        •   Fear of passing hard stool, which can hurt
        •   Difficulty during potty toilet training
        •   Psychological difficulty eg concerns about school toilet, too busy to go to the
            toilet, changes in home circumstances
        •   Rarely but occasionally due to a physical/neurological condition such as
            hypothyroidism, high calcium or Hirschsprungs disease.

Advice

With regard to a baby ensure that there was no past history of delayed meconium passage.

In a toddler being over enthusiastic and pushing potty/toilet training can in fact put the child
off and result in them holding on and resisting defecation.

The use of diluted orange juice, or sugar and water should not be given. Extra fluid (but not
milk) ie cooled boiled water 1 - 2 oz/24 hours can be suggested for younger babies. Older
babies (6/12>) and children should be encourage to drink more water and to consume more
fruit and vegetables. Laxatives can be prescribed by nurse prescribers but they are advised
to discuss this with the doctor first. They would possibly need laxatives for four to six
months (Babu 2002).

The usual softener is Lactulose, however, owing to its sugar content it is best given at the
beginning of a meal or drink in guidance of tooth decay prevention.

Wind and Colic

Several factors can contribute to wind, firstly teat hole size, a hole which is too small causes
the baby to suck so hard that they also take in air. A teat hole size which is too big might
cause the baby to gulp and take in too much air. If this swallowed air becomes trapped the
baby might feel discomfort. Parents might need to be shown how to effectively wind their
baby effectively (Lucas and St. James-Roberts 1988, Journal of Family Health Care 2003).

Colic

Usually starting at three weeks of life until 3 - 4 months of age. Whilst colic is acknowledged
by Health Professionals its causes are uncertain. Some feel that it is a type of stomach
cramp due to spasm of the gut, and others think that there are insufficient enzymes to break
down the fats in the milk (Lucas and St. James-Roberts 1988, Puntis 2002).

                                                  32
The symptoms of colic appear to be inconsolable crying, usually the same time every day,
often during the evening and early night, drawing up of the legs towards the stomach.

Relief of Colic

Colic may be difficult or impossible to relieve and only relieves as the baby grows and
develops. There is no proven medical evidence that any of the suggestions below work but
here are some ways to try to relieve colic:-

       •   Positioning, holding the baby in such a way that puts gentle pressure and warmth
           on its stomach, ie face down over your lap or holding the stomach with your
           hands

       •   Use of baby massage

       •   Cooled boiled water.

       •   Use of anti-colic drops Infacol or Dentanox drops.

       •   Use of milk where the fats have been broken down such as Cow and Gate
           Omneo-Comfort which contains hydrolysed fats. The parents need to be warned
           that the consistency of the babies faecal stools may become looser and more
           offensive.

       •   If the baby is breast-fed reducing the mother’s dietary dairy intake.

       •   Use of Colief drops.

Remember there are many ways to relieve colic but no evidence that they are effective.

Reflux (or Posseting)

The medical term used to describe when the stomach contents escape from the stomach
into the oesophagus often flowing back up to the mouth causing sickness (Puntis 2002,
Journal of Family Health Care 2003).

Causes

Weak/poor functioning of the oesophageal sphincter, the ring of muscle which guards the
upper stomach so allowing regurgitation of food and acid. The reason why this muscle is
weak is not fully understood but, as babies grow, it becomes stronger and the vomiting
stops.

How serious is reflux

Most young babies (about 65%) regurgitate some milk, especially with and after meals Even
though this usually resolves spontaneously between 10 - 12 months many parents find it
unacceptable. Babies generally do not come to any harm. Less than 10% have
complications.

Reflux only becomes problematic when the child shows complications (ie weight loss,
irritability, aspiration etc) (Babu 2002, Journal of Family Health Care 2003).




                                              33
Symptoms

Regurgitation, vomiting, failure to thrive, frequent chest infections, cough, wheeze, stridor,
apnoea (especially in premature babies).

Medicines used to treat reflux

Gaviscon is used to thicken. It is not usually given under one year of age but is fine used
under medical supervision.

Diagnosis

Is usually based after clinical examination and most children do not need a test as
confirmation.   However with complicated gastro-oesophageal reflux ie weight loss,
aspiration, apnoea, chest infection etc would require referral to a paediatrician.

Treatment

Babies should be positioned upright when feeding with careful handling. Frequent winding
and have smaller feeds more often.

After feeding advise parents to position the baby with the head of the cot raised by
approximately 30°. Compensatory feeds may be required to replace those lost through
vomiting.

Feeds can be thickened to help it remain in the stomach such as Carobel Thick and Easy.
Parents need to be warned that Carobel may cause changes in bowel patterns or diarrhoea.
Pre-thickened milks such as Enfamil AR or Staydown.

Thick and Easy is usually given to babies who vomit and fail to thrive.

Enfamil/AR (Mead Johnson)

This is a casein based pre-thickened formula for mild reflux and positing, available over the
counter and on prescription. On contact via the stomach acids, the milk thickens and
therefore may help to reduce episodes of regurgitation and positing in babies.

Staydown (SMA)

This is a gelatinised corn (maize) starch designed to treat mild to moderate reflux, not to be
used in conjunction with feed thickeners.




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