Early Years Nutrition Sara Stanner, Science Director Helena Gibson-Moore, Nutrition Scientist From the British Nutrition Foundation
Session 2: Practical Recommendations
Complementary feeding Complementary feeding is a journey where new tastes and textures are introduced over time to help the baby learn to eat and chew, as well as develop a preference for a wide variety of foods Department of Health recommendation: At around six months of age, a variety of complementary foods should be introduced alongside continued breastfeeding (and/or breast milk substitutes, if used) (NHS Choices 2015a) Breast milk or formula milk should still be the main drink for babies up to 12 months (at least 500-600ml formula a day) (NHS Choices 2015b) A cup should be introduced rather than a bottle from about six months. By 12 months, babies should have stopped using bottles with teats (NHS Choices 2015b)
Current recommendations Start4life (2015) http://www.nhs.uk/start4life/solid-foods
Appropriate drinking method? Prolonged bottle use can contribute to poor dental health and may be a risk factor for childhood overweight and obesity (Gooze et al. 2011)
Introduction of solid foods 4 6 months If foods are introduced before 6 months there are certain foods to avoid: - wheat, gluten, nuts, peanuts, peanut products, seeds, citrus fruits and juices, eggs, soya, cows milk, liver, fish, shellfish and soft unpasteurised cheeses Non-wheat cereals such as baby rice mixed with the baby s usual milk or pureed fruit and vegetables can be offered at this stage Advice should be sought from a health professional as to the frequency and timings of introduction of foods (NHS Choices 2015a)
From 6 months Introduction of solid foods To begin with, babies can be offered one feed a day e.g. a non-wheat cereal such as baby rice mixed with the baby s usual milk, mashed or pureed fruit and vegetables Finger-sized pieces of soft/cooked fruit or cooked vegetables can also be offered Once the baby is comfortable taking their first foods, a wider variety of fruit and vegetable purees can be introduced, as well as combinations of different fruit and vegetables. Some foods may need to be offered several times before they are accepted All infants should be supervised while eating The amount and frequency of feeds will gradually be increased, from once a day to twice and then three solid feeds per day, before moving on to different tastes and textures (NHS Choices 2015a)
From around 7 months Introduction of solid foods Introduction of a wider range of foods and textures, and food groups are combined at meal times, in addition to breast or formula milk Amounts offered are also increased, and textures move from smooth purees to mashed and lumpier foods Finger foods can be offered Introduce varied sources of protein, e.g. meat, fish, lentils, beans Foods containing wheat, gluten, seeds, eggs, fish, cow s milk* (in cooking) and full-fat dairy products are included. These foods are introduced one at a time in very small amounts, with a gap of about three days to allow time to spot any reactions that may develop (NHS Choices 2015a)
Introduction of solid foods From around 9 months Babies should be moving towards having 3 meals a day, in addition to healthy snacks and breast or formula milk Lumpier foods (chopped or minced) are introduced to encourage chewing At meal times, two courses can be offered, including a wide range of foods, e.g. a savoury course of meat/fish/pulses and vegetables followed by fruit or yogurt Firmer finger foods can be introduced NHS Choices (2015a)
Introduction of solid foods By 12 months Children should be on 3 meals a day, in addition to healthy snacks (adopting family meals) Full-fat cow s milk can now be introduced as a drink, unless the child has an allergy NHS Choices (2015a)
Foods for babies to avoid: Introduction of solid foods Salt babies under one year of age should have <1g/day, their kidneys cannot cope with much salt Free sugars Honey risk it may contain a bacterium that can cause a serious illness - infant botulism Shark, marlin and swordfish these fish are not suitable for babies because the levels of mercury they may contain can affect nervous system development Raw/undercooked eggs should be cooked until white and yolk are solid Whole nuts will not be given to children under 5 years - risk of choking. Crushed or finely ground nuts and peanuts or other nut butters can be given from 6 months unless there is a history of allergies in the immediate family, or other children at the nursery have a severe nut allergy Low-fat foods fat is an important source of energy (calories) and some vitamins for babies and young children (NHS Choices 2015c)
Diets for 1 3 year-olds Toddlers/pre-school children are growing and developing quickly An important time to: - ensure they eat well to get all the energy (calories) and nutrients needed - teach them about food and eating, so they get into the habit of consuming a healthy, varied diet, enjoyed with the whole family - create a healthy environment, e.g. encourage, but don t coerce or pressure, ensure availability of healthy foods, provide good role models, encourage responsiveness to satiety signals Evidence suggests that establishing and maintaining healthy eating habits is important. Habits formed in early life are likely to continue into adulthood. Food preferences and food-related experiences during the first 2 years are associated with dietary variety in later childhood (Cribb et al 2013)
Diets for 1 3 years olds: BNF resource Benelam, Gibson-Moore & Stanner 2014. Resource available at: www.nutrition.org.uk
Available at: www.nutrition.org.uk
Good eating habits in this age group Toddlers should have about 6 8 glasses or beakers (~100ml per serving) of fluid a day with meals and at snack times It is best to give only water or milk to drink between meals and to encourage drinks to be consumed from a cup or free-flowing beaker and not from a bottle Fruit juice (150ml) can be consumed occasionally but should be diluted (1 in 10 dilution with water) Sugar-sweetened and fizzy drinks should be avoided and salty foods and those high in free sugars are limited Eating wholegrain cereals and plenty of fruit and vegetables help to ensure that both adults and children are eating enough fibre. 2 5-year-olds: need about 15g of dietary fibre per day (SACN 2015a)
Wholegrains Too much fibre (especially insoluble fibre) in a baby s diet is not advisable as it can fill small tummies, leaving less room for other nutrient-dense foods (NHS Choices 2015d) Insoluble fibre is found mainly in cereal foods such as high-fibre breakfast cereals, wholemeal breads and pasta, brown rice and other wholegrains Giving only wholegrain varieties of these foods to children under 2 years is not advisable. It is best to offer a variety of both wholegrain and white varieties of these foods But from the age of 2 years, more wholegrain products can be introduced (NHS Choices 2015e)
The eatwell plate From age 2 5, children should gradually move to eating the same foods as their family, in the proportions shown on the eatwell plate. Plenty of fruit and vegetables: At least 5 portions of a variety of fruit and veg every day Plenty of potatoes, bread, rice, pasta and other starchy foods: Wholegrain varieties whenever possible and potatoes with their skins on for more fibre Some milk and dairy foods: Lower-fat milk and dairy foods. These are healthier options to help get enough protein and calcium Some meat, fish, eggs, beans and other non-dairy sources of protein: Important sources of proteins, vitamins and minerals A small amount of food and drink high in fat or sugars: Eat fewer sweets, cakes and biscuits, and drink fewer sugary soft drinks (NHS Choices 2015f)
Vitamin supplements: current recommendations Children who don t consume a varied diet may not get enough vitamins A & C It is very difficult to get enough vitamin D through food alone. DH suggests a supplement of 7-8.5 µg of vitamin D per day should be offered (6 months 5 years) Department of Health (DH) advises that, for those not receiving 500ml of formula or more: Children under the age of 5 should take a daily supplement of vitamins A, C and D (in the form of liquid drops) Breastfed infants may need to receive drops containing vitamin D from one month of age, if their mother has not taken vitamin D supplements throughout pregnancy (NHS Choices 2015g) Vitamin drops are available free of charge for low income families through the Healthy Start Scheme (from 6 months 4 years ): 233 micrograms of vitamin A; 20 milligrams of vitamin C; 7.5 micrograms of vitamin D3
SACN report Vitamin D and Health (draft 2015) Risk of poor musculoskeletal health is increased at serum 25(OH)D concentrations below 25nmol/L RNI for vitamin D of 10μg/day proposed for the UK population aged 4 years and over (amount needed for 97.5% of the population to maintain a serum 25(OH)D concentration of 25nmol/L or above when UVB sunshine exposure is minimal), including individuals from minority ethnic groups with darker skin Insufficient data to set RNIs for infants and children aged 0 3 years As a precaution, a Safe Intake of vitamin D is proposed for these ages: 8.5-10μg/d for ages 0 to < 1 year (including exclusively breast fed infants) 10μg/d for ages 1 to < 4 years SACN 2015b
Infant feeding survey found: Supplement use 7% of babies were being given vitamin drops at stage 1 of the survey (around 6 weeks) 14% at stage 3, around 8 10 months Uptake of Healthy Start (HS) vitamins low 1 in 10 eligible beneficiaries for free vitamins reported taking HS vitamins for either themselves or their children (Jessiman et al 2013) poor access to vitamins, low awareness of their availability, and or the need for vitamin supplementation, and lack of motivation NICE report on Vitamin D: increasing supplement use in at risk groups (2014) has identified a strategies to improve uptake and awareness, including the need for health professionals to recommend vitamin D supplements at all opportunities
Free vitamin supplements for all children? Facts Behind the Headlines Do we need free vitamins for all babies and young children in the UK? Nutrition Bulletin 39:187-194 - Evidence shows current feeding practices and lifestyle habits are failing to achieve the daily vitamin D requirements of some infants and children - Extremely low intakes among children aged 12 35 months - Lack of awareness in at risk groups - Need for better dissemination of government advice (Alderton 2014)
Summary: Practical Recommendations Parents must be given appropriate advice to follow existing guidance on appropriate types/amounts of foods to give at each stage of complementary feeding to ensure that all infants are fed safely and receive a nutritionally adequate diet Feeding practices associated with obesity risk include: early (before 4 months) introduction of solid foods prolonged bottle use DH recommends that all children aged 6 months 5 years are given a supplement with vitamins A, C and D, such as Healthy Start Vitamins, unless they are drinking 500ml of formula/day This is especially important when they are learning to eat a variety of foods and if they are fussy eaters Health visitors may advise mothers who did not take vitamin D supplements throughout pregnancy, to give vitamin D drops from 1 mth Raising awareness of the need for vitamin supplementation is important, particularly for vitamin D
Thank you! www.nutrition.org.uk www.foodafactoflife.org.uk
References Alderton S (2014) Do we need free vitamins for all babies and young children in the UK? Nutrition Bulletin 39: 187-194 Benelam B, Gibson-Moore H & Stanner S (2015) Healthy eating for 1 3 year-olds: A food-based guide. Nutrition Bulletin. 40 (2): 107 117 British Nutrition Foundation (BNF) (2013) 5532 a day resource http://www.nutrition.org.uk/healthyliving/toddlers/5532.html Cribb VL, Northstone K, Hopkins D, Emmett PM (2013) Sources of vitamin A in the diets of pre-school children in the Avon Longitudinal Study of Parents and Children (ALSPAC). Nutrients. 15;5(5):1609-21. Gooze RA, Anderson SE & Whitaker RC (2011) Prolonged bottle use and obesity at 5.5 years of age in US children. J Pediatr 159(3) :431-6 Jessi man T, Cameron A, Wiggins M et al. (2013) A qualitative study of uptake of free vitamins in England. Archives of Disease in Childhood 98: 587 91. NICE (2014) Vitamin D: increasing supplement use in at risk groups. https://www.nice.org.uk/guidance/ph56 NHS Choices (2015a) Your baby s first solid foods http://www.nhs.uk/conditions/pregnancy-and-baby/pages/solid-foodsweaning.aspx NHS Choices (2015b) Drinks and cups for babies and toddlers http://www.nhs.uk/conditions/pregnancy-and-baby/pages/drinks-andcups-children.aspx NHS Choices (2015c) Foods to avoid giving your baby http://www.nhs.uk/conditions/pregnancy-and-baby/pages/foods-to-avoidbaby.aspx NHS Choices (2015d) Toddler food: common questions. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/baby-foodquestions.aspx NHS Choices (2015e) What to feed young children. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/understanding-foodgroups.aspx NHS Choices (2015f) The eatwell plate. http://www.nhs.uk/livewell/goodfood/pages/eatwell-plate.aspx NHS Choices (2015g) Vitamins for children. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/vitamins-for-children.aspx SACN (2015a) Carbohydrates and Health. https://www.gov.uk/government/publications/sacn-carbohydrates-and-health-report SACN (2015b) Vitamin D and Health draft report. https://www.gov.uk/government/consultations/consultation-on-draft-sacnvitamin-d-and-health-report Start4life (2015) The 3 signs your baby is ready for solid food http://www.nhs.uk/start4life/solid-foods