Moving on in weaning – a confusing process

Through recent correspondance with parents, it has become apparent to me again, how difficult the progression through weaning can be, as you are bombarded with advice from friends, family members and books. In reality, your baby is an individual and it does not matter what people say or write, a one-fits-all approach just does not work for every baby. That is something that I can reassure every parents, that their child is unique and therefore will require a unique approach.

I like providing parents with a structured way of introducing foods as this way they can keep track of what foods were trialled, how the baby liked the foods and also in my allergic children if there were any reactions. Therefore, I usually suggest starting with  one food, which is then followed by other new food(s). Introduction of weaning food is cumulative, so for example if you have started with carrots and your baby tolerates carrots you then try potato, but you can mix your carrots with the potato. So you are constantly trying  a new food but can mix this with existing foods.

I have provided below an example of a couple of days-weeks:

Start: Carrots

Then: Carrots and potato

Then: Carrots and potato and a pear  (new food)

Then: Carrots, potato and courgette (new food) and pear as a dessert

Now start with 2 meals per day

Then: Potato and courgette (one meal) and another meal of pear and porridge (new food)

Then: Potato, courgette and butternut (new food) and another meal porridge with apple (new food)

As you can see it is an easy process of constantly expanding the foods your child is given and of course repeating foods already trialled to ensure that tastes are accepted. Research has found that some foods (tastes) will need at least 15 introductions before a baby likes the new food, so please do not give up if your baby is not a big fan of a new food and repeat the food many times.

So when do you move from 1-2 -3 meals? I usually suggest going to 2 meals very quickly (when you have introduced 3 or more foods) and when protein are introduced (i.e. meat, chicken, fish, lentils) to move to 3 meals. There is no “rule” that says you have to do this, but I have found this works really well.

Of course what follows on from going up in solid volume is the cutting down of breastfeed/formula. I have in a previous blog entry provided some guidance on routines and milk feeds, but I want to reiterate what I have said before, that responsive feeding is the best feeding method, which means we respond to a child’s appetite and satiety cues. If a child refuses to drink or eat then we stop, if they signal more, then we offer more (please see previous blog entry on portion sizes). This means, that as you go up in volumes of solids, your child would signal which feeds or bottles they are not that keen on and these are the ones you cut out/reduce and adjust your feeding regime around this. It does of course occur that sometimes they love the breast or the bottle too much and would rather take the breast or bottle rather than take solids. If this occurs then it is worth having a chat with your health visitor (in the UK) or dietitian to help you decide which feed should be cut out/reduced to give you maximum benefit with creating appetite for food.

The most important message to come out of this blog entry is that your child is unique and will not always fit into a regime set out by a book/another person. As long as you respond to feeding cues, increase the variety of foods (as explained above), move up in texture and adjust volume of feed/breastfeeding frequency as your child signals, the vast majority of cases babies thrive and do well.

 

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From dirt to probiotics

The most common question I get in my clinic is about which probiotics should be used in children. The answer I give unfortunately can be quite disappointing for some parents because my answer is usually quite vague, unless I know specific research exists related to a specific strain of probiotic and a specific diagnosis.

The gut has millions of bacteria and these are made up of different strains and to make it even more complex, although there is some overlap in bacterial flora in children, the gut microbiota of the individual is quite unique to every child related to whether they were born via C-section/vaginal birth, breast fed or bottle fed, weaning diet and also the environment. So suggesting one strain or even multiple strains for an individual child can be difficult as the microbiota is so specific to an individual. What I can certainly reassure parents is that outside of specific conditions (i.e when a child is immunocompromised for example with cancer) probiotics are fine to use and not harmful, so you will not do any harm if you were to try. We know that a breastfed child will have a flora that is more dominant in bifidobacteria and that this changes with the introduction of solids to more lactobacillus. This of course is a very simplistic explanation as you have lots of other strains that develop.

The message that I wanted to get out with this blog post is that you can do a lot of positive with your baby’s gut microbiota with breast feeding (best option) and some formula now also contain prebiotics (food for the good bacteria) and also when solids are introduced to expand the variety to lots of fruit, vegetables and grains, which provide food for bacteria and promote a healthy balance of gut microbiota. In addition to this, is the importance of home-cooked foods, which have also been shown to help with the microbiota, as home-cooked food is not sterile and contains some bacteria, that also helps the microbiota.

I think many of you have heard of the the excessive hygienic conditions we live in, being blamed for the development of allergies. So allowing your child to crawl on a floor, pick things up and put in their mouth (within reason of course) and explore is an important step to helping the gut microbiota develop and improve the immune system. So before you look at a probiotic, think about all the things that you can do at home already that promote not only 1 or 5 bacterial strains in the gut, but millions of strains. If you still then want to try a probiotic for a specific situation, do discuss this with your healthcare professional as there are some strains that have shown to be beneficial for specific symptoms/diagnoses.

….and more on Cow’s Milk Protein Allergy

In spite of a lot of advances in food allergy, the misconceptions amongst parents as well as healthcare professionals continue.  One of the biggest area of confusion is that of non-IgE mediated cow’s milk protein allergy, affecting the gastrointestinal tract. As there are no simple tests (and I mean really NO tests, no matter what the internet says) that can confirm this allergy, it remains an allergy that is based on identifying the symptoms followed by a trial elimination diet and then reintroduction to confirm/disprove the allergy.

I have been involved with an international team to publish the new iMAP guidelines, which provides simple guidelines for healthcare professionals (and parents) for this delayed form of cow’s milk allergy. Allergy UK has been supporting the distribution of these guidelines in the UK and has some useful tools (supported by the UK authors), which can be downloaded from their site.

In addition, Dr. Adam Fox, one of the authors also did a very useful BBC radio interview that many parents may find useful. The section on cow’s milk allergy starts about 7 minutes into the link.

Feeding Routines in the Weaning Infant

I always struggle to answer parent’s questions about feeding routines in babies that are going through the weaning process (when solids are introduced). It would be lovely if there was clear scientific evidence for what exactly to do when solids are introduced but the truth is that there is no clear evidence of what to advise parents, as babies are different sizes, have different growth velocities and different hunger and satiety patterns. I also think that it is really important to take into account other siblings and meal patterns at home, when thinking about a baby’s routine.

The best way to address this question (I think) is to start by thinking what we know in regards to baby’s routines:

  1. In the early stages of weaning the majority of nutrients will come from breast milk or formula and this will remain an important part of the diet until around 1 year of age (give or take)
  2. After 6 months of age babies will need some of the key nutrients to come from food and this includes iron rich foods
  3. The responsive feeding style has been shown to be the most effective in early childhood (see blog on feeding difficulties). To be responsive as a parent around mealtimes, means you listen to their hunger and satiety cues – if they want to stop you stop if they want more you give more (it’s not driven by specific portion sizes)
  4. It is important to broaden the variety of tastes and textures early on, because > 10 months of age it becomes much harder introduce new foods and increase textures

So, when you start weaning, I usually suggest keeping the milk (breast or bottle) routine exactly the same and introduce a midmorning solid. Initially this may just be a couple of teaspoons and you may find that these initial vegetables/fruit do not displace any feeds. It is important to know, that fruit and vegetables do not replace the energy, fat and protein rich breast milk or infant formula. You will soon see whether your child wants to progress faster (i.e. they want bigger portions, they exited about the meal and do really well with new tastes/textures). If your baby is progressing well, you can introduce 2 meals per day quite soon (even if this is within the first week of weaning) and at this stage you may find that they start signalling that they may not want to drink all of their milk. You an follow their lead at that stage and reduce the breast/bottle feed that they are not that interested in.

Introduce iron rich protein foods soon after 6 months, which then allows you to go onto 3 meals per day. At this stage, your baby should naturally signal that they want to cut down some of their feeds, so you may end up with a routine as below:

Early morning breast feed/bottle

Breakfast

Breastfeed/bottle

Lunch

Breastfeed/bottle – depending on the age of the baby you could cut out either midmorning or mid-afternoon feed and replace with a snack (i.e. yoghurt and fruit)

Dinner

Breastfeed/bottle

I do sometimes have parents that report that their baby eats big volumes and do not want to cut down any breast/bottle feed. If this happens, it is worth to check growth and see whether your baby is moving up excessively in weight gain. If this is the case, I would recommend you talk to a dietitian to see what can be done to prevent early onset overweight/obesity.

What oil/fat to use for my child?

I took a photo this morning of all of my oils in my cupboard and was astonished to see how many different types of oils I have and have been reflecting how confusing this has to be for parents with children.

 

 

When I qualified as a dietitian, saturated fats (i.e butter, animal fats) were bad and we started to use plant fats (i.e. sunflower oil), in fact this was recommended by all international cardiovascular associations as the oil/fat of choice. However a couple of years ago, trans fat were highlighted as a contributing factor in cardiovascular disease, diabetes and even cancers.  This is a type of unsaturated vegetable fat that has a trans configuration (instead of a more common cis configuration) that occurs through an industrial process that adds hydrogen to liquid vegetable oils to make them solid. This occurs in particular with low fat products and also with heating at very high temperature. So, now we have palm oil that is replacing hydrogenated vegetable oil in products and many have switched to coconut oil/fat as fat source.

So first of all, both palm and coconut oil are saturated fats, so they are in the same category nutritionally as animal fat (like butter and like the fat on a piece of steak). I have heard so many times from my parents in clinic that they have been told that coconut oil/fat is an essential fat, which is absolutely not the case. The fact that we should be worried about palm oil, in particular in regards to our environment, I have written about in a previously published article, so this is not one I come across in my clinic a lot. Palm oil a possible health and environmental dilemma – Rosan Meyer Oil seeds Focus March 2017

However, this still leaves parents in a situation where they ask themselves what their child needs. I always like to go back to breast milk, which is just the most wonderful food every for children. The World Health Organisation recommends breast feeding until 2 years of age and breast milk contains around 50% fat. So this is really an important nutrient for children.

Children (and adults) require a mix of saturated (animal based fats and yes also coconut fat/oil), polyunsaturated (these are your rapeseed oils, sunflower oils) and monounsaturated fats (like olive oil). Essential fatty acids, are those that the body can not make themselves and you have to ingest them. These are your omega 3 and 6 fatty acids – omega 9 is not essential as this can be synthesised through other fatty acids. The omega 3 and 6 fatty acids fall under the category of poly unsaturated fatty acids and can be subdivided further in a couple of types of omega 3 and 6 fatty acids. This is also confusing, as many people think that omega 3 for example from rapeseed oil is the same as omega 3 from oily fish, but they are in fact very different type of omega 3 fatty acids and you need both (so one does not replace the other).

So to make it practical, children need fat, and they need them from all categories of different types of fats as they have different physiological roles. If your child has a non-vegetarian diet, its likely that they already have enough saturated fat from meat  and full cream milk products. In regards to the oils that you are using, I would vary between different polyunsaturated ones (sunflower/canola/rapeseed) and olive oil (or avocado oil which also is high in monounsaturated fatty acids) and most importantly not forget about oily fish. In a breast fed child, mothers intake of omega 3 fatty acids influences the content of breast milk. In formula milk fed children, omega 3 fatty acids (and other fats) are highly regulated to ensure children get enough. Otherwise, current UK guidelines is to aim for 2 portions of oily fish per week in children (portion size of their little hand palm) and to avoid shark, marlin and swordfish because of the mercury content. See FSA advice on mercury.

I will write about the pro’s and con’s of frying foods as this covers a totally different emerging area in a future blog.

 

 

Water for babies – how much to give?

With this hot weather in Europe, it is the right time to discuss how much water a baby needs. Per kg of body weight the fluid requirements of a baby is much higher than and adult, but because of their smaller size they can dehydrate much faster than adults (not only with hot weather but also with diarrhoea and/or vomiting). So it is important to provide sufficient liquids.

As a rule of thumb during the first 6 months of life, breast milk or formula milk will not only provide all nutrients but all liquids. So the general advice is that the fluid up to 6 months of age, even in hot weather should ideally come from breast milk or formula milk. You may find that they want to breast feed more frequently and demand more formula feed, which is normal  when it is so hot. Of course it is important to keep your baby cool and use current guidance on what to do when the weather is hot (including using sunscreen)  with your baby.

For children > 6 months of age, breast milk/formula volume reduces as it is being displaced by solids (which is normal), so they will need additional fluid and  the demand increases, the hotter the weather. The additional fluid should be in the form of cooled boiled water and fruit juices should be avoided. Of course the question is now to how much should a baby be given when it comes to water? Fluid requirement in theory is driven by the weight of the child; meaning you provide x amount of ml per kg of body weight (< 6 months around 120 ml/kg, > 6 months to 10 kg around 100 ml/kg). This is of course is easier said than done especially if a baby is breastfed, as you have no idea how much fluid your baby is drinking and although its easier to calculate that with bottle feeding, its difficult to establish how much fluid they get from food, as food (i,e, fruit, vegetables) also contain fluid.

So I suggest a pragmatic approach and recommend as a good starting point 20 ml after each meal (not before to avoid displacing food) and then to provide water during the day depending on the temperature (at the same low volumes). You  may find your baby demanding more water and then it is fine to slowly increase the amounts. What I would certainly not recommend is big volumes like 100 ml given all at one go, which may displace breast milk or formula milk.

I also would recommend to give the water in a beaker that is free flow (either spout or open) so that your baby can manage to consume sufficient amounts. Check out for signs of dehydration which include:

  • a sunken soft spot (fontanelle) on their head
  • few or no tears when they cry
  • fewer wet nappies (nappies will feel lighter)
  • being drowsy

Finally, enjoy the summer, this is a wonderful time to enjoy lots of fresh fruits and vegetables.

 

Food Allergen Introductions during Weaning

There seems to be a lot of confusion about when to introduce food allergens in babies’ diets during weaning. I do not blame parents,  as this is a very confusing area and there is a lot of conflicting advice around. I am going to focus today on the general population, not on babies with an atopic background (meaning babies that have eczema, or a strong immediate family history of allergies – asthma, hayfever, eczema) or those with existing food allergies. I will write a blog entry about that particular population later.

Although the main focus has been on peanuts and the introduction of this in babies diets, there are many more allergens to introduce during early childhood including, wheat, egg, cow’s milk, shellfish, soya, sesame and tree nuts. In a previous blog entry, I have debated the age of solid introduction, so will not repeat this in this section. Once you have started with solid introduction, which should not be later than 6 months of age, there is absolutely no evidence to delay any of the allergens. Although it’s pretty easy to introduce milk (yoghurt, cheese) and wheat, a lot of parents get stuck there and do not move on with other allergen introductions as this is either not part of their normal diet (i.e. common feedback about shellfish) or they think it is not appropriate for a child to eat. Egg is a great protein source and as long as its well-cooked, should be introduced as part of your baby’s diet (together with other allergens) soon after weaning is commenced. Nut butters (peanut butter and other tree nut butters) are also very nutritious and you can find sugar and salt free versions from many shops. This can be incorporated in the porridge in the morning, on a toast soldier or many of my children have this on a spoon and lick it off as a snack – again this should be earlier rather than later (soon after weaning has been commence). In regards to soya, most common comment I get is that families do not eat soya products. Well, I would challenge you to start looking at the ingredients of foods! Did you realise that 80% of standard breads in the UK contain soya, so this would be an automatic introduction of soya in a child’s diet if they have bread. Sesame also is an easy one to introduce as the majority of my parents at some point provide hummus, which contains tahini (sesame paste). Lastly the question about shellfish – I know this is not a common one to introduce in children’s diet and can be tricky in regards to sourcing safe and good quality. My advice would be, if you have this in your family’s diet, introduce earlier rather than later.

Last tip, once you have introduced an allergen successfully, do keep it in your child’s diet on a regular basis, to ensure that tolerance is maintained.

Cooking for my baby and toddler – practical tips

I have decided this week to write about cooking, reheating, boiling and not boiling water  for your baby/toddler as it is still question that many parents have.

I think the most common question I get is whether to boil/steam foods and if they are older whether its okay to roast. There are no specific guidelines on the cooking methods for children and as this mainly depends on whether you are using the baby led weaning approach (see my previous blog entry under Introduction of Solids) or whether you are introducing solids in the more traditional way (i.e. puree and then lumpy). Of course with cooking, you will loose some of the heat sensitive vitamins, but its important initially to have a texture that is suitable for your child. In particular in the initial phases of weaning, vitamins and minerals will come mainly from breast milk or formula, so cooking the vegetables for example really softly (i.e. very long) to a manageable texture is not going to lead to vitamin deficiencies. As a side, energy/protein/carbohydrate and fat content does not change with heating and most minerals (i.e. calcium) are heat stable.

In regards to equipment, I find steamers really useful and of course a good hand-blender. There are many baby steamers that have integrated blenders. I have tried a couple and find most okay, but when you want to prepare bigger volumes for freezing for example, I find their container size quite small. So before you go an buy something special, think about the future and whether you envisage cooking fresh each day (then smaller container makes sense) or making larger batches. When it comes to the texture, if its too thick you can either  add your breast milk, formula or the cooking water to thin it to a texture tolerated by your baby. However, if you are planning to freeze these in batches, its better to not add your breast milk/or formula to the foods you are freezing but rather do this fresh after reheating.

Okay, so now to cooking and reheating. Firstly the cooked food should be cooled as quickly as possible and then frozen  and then place this into the fridge or freezer. Foods kept in the fridge, should be eaten within 2 days. Foods that are frozen should ideally be defrosted first (for example take out and place in fridge) and then reheat to piping hot and let it cool down to a temperature tolerated by your baby. I get a lot of questions about using the microwave. Reheating in the microwave is not ideal, as it often creates heat pockets and areas that are not properly heated. If you want to use the microwave, then stir the food whilst heating so that you make sure that all areas are properly heated through. Foods that have been reheated and not eaten should not be reheated/used again.

More information on this is on this NHS website.

In regards to water; in the UK we follow the WHO guidelines for mixing of formula, which is to mix formulas with cooled boiled water that is about 70C. You reach this temperature after boiling the kettle and letting it stand for about 30 min (see this site for more information). Fully breastfed babies do not need any water until they’ve started eating solid foods. Bottle-fed babies may need some extra water in hot weather. For babies under six months, use water from the mains tap in the kitchen, boil this water and then cool as per guidelines above regarding temperature. Water for babies over six months doesn’t need to be boiled, however if your child is immunocompromised (has an illness/diagnosis effecting their health) then you may be advised by your healthcare professional to boil until 1 year of age. Bottles and teats need to continue to be sterilised until a baby is 12 months of age.

Bottled water is not recommended for making up formula feeds as it may contain too much salt (sodium) or sulphate. It does however happen when travelling that tap water is not safe and you do not have a choice. If this is the case, its best to have a discussion with your healthcare professional to discuss which bottled water has low sodium and also how to establish what is high/low sodium as your healthcare professional may not know the names of bottled waters outside of UK/EU. This website may be useful for you.

 

Should my baby have a probiotic?

There is most probably not a week that goes by without parents asking me about probiotics for their baby, either for general health or for specific gastrointestinal conditions. I have just come from the a Gut Microbiome Conference in Paris, so it seems fitting to write about this topic in this blog entry.

So, the bacterial flora constitute 90% of the total number of cells associated with our bodies and only the remaining 10% are human cells. So in fact, we are more bacteria than human! There is not doubt in the scientific community that the microbiota of the gut is part of the answer to our health and also the cause of many illnesses. There are numerous studies indicating an abnormal bacterial flora in children with allergic disease, inflammatory bowel disease and even specific trends in children that are under/overweight have been found. This all sounds very exiting, but here is where the problem lies: your microbiota changes with age, diet, genetic background, antibiotic use in early childhood and environment. So that means, although your baby may have about 40% overlap in bacterial flora with another baby, the rest is unique to them and is determined by the factors mentioned above.  I often have parents that have have had their child’s bacterial flora evaluated at very high cost, that ask me what to give in regards to probiotics, but disappointingly I have tell them that I do not know as I do not know what is “normal” for their child.

In disease (i.e. allergy, reflux, inflammatory bowel disease, irritable bowel disease) they are starting to identify target strains that have specific functions, that is very exiting and many of us working with dietary interventions in children are starting to use these products, BUT I always say to parents that it may not always provide you with this magic symptom relief.

So, what can you do? First of all, the more diverse the diet (in particular with fruit/vegetables and grains) the more diverse the gut bacterial flora and diversity has been linked to health. If you do want to give a probiotic to a healthy baby as a general rule of thumb you would aim for Bifido strains for < 6 months old as this is the predominant strains in a breast fed child and then complementary foods increase Lactobacilli strains increase, so then using these strains may be more useful. Go for a reputable brand, that has actually in what it is supposed to have and if your child has a specific diagnosis, consult your dietitian about what the best strain is to use. An important message to get out, is that strains of probiotic are specific so one may help with one condition but not with another. Another important message is that when your child is on an antibiotic, to choose a probiotic that is resistant to the antibiotic, otherwise the well-meant probiotic will also be killed by the antibiotic.

I leave you with these thoughts and most importantly, that healthy eating also creates a healthy gut.

Is rice safe for my baby?

Over the weekend my inbox was filled with e-mails by worried parents over the safety of rice in their baby’s diet. It did not take me long to figure out why this happened, as BBC online had an article on the safety of rice in children featuring Prof. Meharg, who is well known in the field of arsenic research, in particular related to arsenic in rice.

So what is the concern. Arsenic exists in soil and small amounts can get into food, though in general these levels are so low that they are not a cause for concern. However rice is different from other crops, as it is grown under flooded conditions. This makes the arsenic in the soil more readily available so that more can be absorbed into the rice grains.

Already in 2008 the Food Standard Agency (see FSA policy on rice and arsenic) has put in place guidelines for the use of rice milk, which should not be used < 4.5 years of age. In 2015 the EU put in place legislation on maximum limits of inorganic arsenic in rice and rice products and these legal limits have been applied since 2016. The FSA did a survey of infant foods in 2016 and we are awaiting there results.

Prof. Meharg, assessed many brands of baby rice, rice crackers and rice cereals from the UK (between 2014 and March 2016) and found that in some the inorganic arsenic was higher than the recommended levels and in particular this was found in products that contained whole rice (arsenic is mainly concentrated at the surface of the whole grain) and were often associated with organic rice products. One has to take into account that legal limits were only implemented since 2016, so this study may have included products prior to these limits being implemented. Similar data exists from the USA.

I am sure though you want to know what to do now with rice in your baby’s diet? Unfortunately no official body has  yet come out with any guidelines (outside of rice milk guidelines that were published by the FSA a couple of years ago) on general rice consumption for children, so what I am going to provide you in this blog entry is my own opinion on what to do (based on the data that we have) and also some of the practical advice from Prof. Meharg in the BBC article. We hopefully will get more official guidance, as soon as the FSA has their data published.

  1. Do not use rice milk as alternative 4.5 years of age
  2. Keep rice intake in children to max 2-3x per week and if used soak in a lot of water ideally overnight (throw water away) or if not time for soaking cook using a lot of water (5:1 ratio) – this significantly reduces the arsenic content
  3. Try using other baby cereals than baby rice – millet, quinoa, oat ect
  4. Be aware the whole grain rice may have more inorganic arsenic