There is sugar and sugar……

Although I constantly get questions about sugar in my clinic, it has become clear to me again with recent questions  I have received, how confusing the whole sugar topic can be for parents and what misinformation there is on the internet. I commonly get comments like “honey/agave is better than sugar”, “I use fruit sugar because that is better” and “there is corn syrup in the hypoallergenic formula so I do not want to give it to my child”.

I want to start by being clear that free sugars should be avoided and in excess are definitely bad for your baby (and for you). The current recommendations in the UK suggest that a diet should contain less than 5% of free sugars. I have put a link in here of the report for you to read….you will need to have some time and possibly a glass of wine to read through it.

So lets start with the basics. Dietary carbohydrates include both starches and sugars and are ultimately ALL converted to glucose which is the primary energy source for adults and children. They are divided into 4 groups, but I am going to stick to only mono- and disaccharides, which are the ones that cause most confusion. Monosaccharides are single sugar molecules and include glucose, fructose and galactose. Disaccharides have 2 linked sugar molecules and include sucrose (glucose + fructose), lactose (glucose + galactose) and maltose (glucose + glucose). Foods that contain these sugars include:

Fructose = fruits, honey and agave nectar

Lactose = breast milk and formula milk

Sucrose – table sugar and all those sweets/chocolates and sugary drinks

Free sugar is defined by the World Health Organization as all mono- and disaccharides added to foods by the manufacturer, cook, or consumer, plus sugars naturally present in honey, syrups, and fruit juices. So honey is a free sugar, so adding this to any of your child’s foods still means they have free sugars and similarly giving fruit juice also means you are giving a free sugar. Best therefore to stick to water or milk for drinks and plain fruit.

Now what about breast milk and infant formulas. Breast milk contains lactose, this is a sweet dissaccharide that consists of glucose and galactose. Formulas also have lactose in a similar amount as breast milk.  I recently read on a popular forum that some parents believe that some formulas are higher in free sugars than others. First of all the majority of sugar formula is lactose, which is the same as in breast milk.  As mentioned in a previous blog post, the formula ingredients are strictly controlled by the EU so they have to adhere to this. In some of the European Countries you may find flavoured Growing Up milks (please note these are NOT infant formula, but milks for older children). Of course these will have additional sugar and should be avoided, however standard infant formula will have a similar amount of lactose than breast milk.

Finally what about glucose corn syrup. Parents of allergic infants will notice that the majority of hypoallergenic formulas have glucose corn syrup as carbohydrate source. This sugar contains mainly glucose but also maltose. Depending on the method used to hydrolyse the starch and the extent to which the hydrolysis reaction has been allowed to proceed, different grades of glucose syrup are produced, which have different characteristics and uses….and different tastes. You will note that these hypoallergenic formulas are not sweet like syrup (on the contrary they taste bitter), but actually provide a similar amount of glucose/maltose to lactose in breast milk. This is therefore an essential ingredient that provides the majority of energy in the feed.

I will in future also write about oligo and polysaccharides, but I think for a start this is enough about sugars.


How do I get in the nutrients?

I wrote on Sunday about portion sizes in infants between 6-12 months and ratios of protein to carbs and vegetables/fruit. I often get also questions about ensuring that my child “gets everything they need” from food. Food intake is of course more than just achieving energy, protein and fat intake but also making sure your baby has sufficient vitamins and minerals. Without these your child can not achieve optimal growth and development (including brain, muscle, eye and others), in addition the immune system requires vitamins and minerals to function. When you plan a meal, think about the variety of colours of the foods you are giving – sounds mad, but it is easy and works. Fruit and vegetables of different colours tend to have different vitamins and minerals and complement each other. Red and white meat and white and pink fish also have differences in their nutrient content. For example, lamb with potato and carrots and spinach – here you have some protein rich in iron, a carbohydrate source and vegetable sources rich in vitamin A, iron, folic acid and vitamin C. Compare this to a meal of chicken, with potato and sweet corn and cauliflower – you do have a protein source that has iron and a carbohydrate source, but you do not have a vegetable source high in vitamin A (yellow/orange or dark green) for example. If you replace the cauliflower with broccoli you will make this meal much more nutritious….and also more colourful. Another example is pasta with peas and salmon – 3 colours and each provides totally different vitamins and minerals. Remember that 60% of eating occurs through the eyes. So its important to ensure that your baby is exposed to different colours of foods (including textures and temperatures) to develop their acceptance of different variety of foods in the future. Now what about fruit? Banana is a favourite for all mothers, as it is convenient and you can puree, mash or give it as pieces. I think it is a great fruit to always have as a back-up. You can use a banana as one portion of fruit per day, but you do not want to give three portions of bananas as fruit/day, because this would provide you with exactly the same nutrients. So again looking at colours you can vary the nutrient content easily – banana, mango and apple – 3 different fruit, different colours and different vitamins and minerals. Below is a photo of a baby bowl with different colours of foods at the ratios previously discussed.


What is a “portion of food” for a baby

Now the topic of food portions in young babies (6 months – 1 year) is very close to my heart, as I think most tears in my practice have been cried about my “baby not eating enough”. What is enough for a baby when it comes to food? Is it what the food companies put in a jar/pouch? Is it what as a parent you feel is enough for your child? I can tell you certainly that what is in a jar/pouch is not a portion, so do not worry if your child does not finish this. Also, what you are dishing up in most cases will also not be a right portion for your baby – because this is highly influenced by  your own eating habits (we measure our babies portion to what we would eat). It is a myth that for babies < 1 year of age you have a “magical portion size” for all foods, as sometimes a 6 month old baby can be 6 kg and sometimes 4 kg, surely you would not expect them to eat the same?

So what is a portion? Firstly between 6-12 months you are introducing solids and then expanding the variety, whilst milk intake slowly reduces as solid volume goes up. In the initial phase its all about tastes and textures and really ensuring that your child gets exposed to a wide variety of different flavours. Of course as the variety of foods increase, the nutritional contributions of weaning foods also increases. In the vast majority of babies, they have very good appetite and satiety control and generally when they signal hunger they will eat and they will stop when they are not hungry. The ideal feeding style for parents is therefore “responsive feeding” – which means you are listening to your child’s cues and respond with portions sizes according to their hunger. Other feeding styles include indulgent, controlling and neglectful feeding, which all have a negative impact on your baby’s feeding – I will discuss these further when we get to feeding difficulties. Hand in hand with a responsive feeding style goes growth monitoring, if your child grows well, you can be assured that you are getting sufficient energy and protein in, if weight gain is excessive, then they are getting too much. When you have introduced a good variety of foods into your baby’s diet you can start looking at proportions – 1/5 protein, 2/5 carbs and 2/5 vegetables. This will ensure that you have sufficient non-protein energy for the protein to be used for growth and development.

Of course there are always exceptions when it comes to a appetite and satiety. In a small number of young children there can be a disregulation of appetite and satiety where professional help is required. On the other hand when your child is unwell, their food intake is altered and  you need to respect that, because as adults when we are unwell we also do not want to eat. Can you imagine somebody sitting in front of you when you have the flu and forcing food down you?!! There are also medical diagnoses that affect appetite and satiety, including non-IgE mediated gastrointestinal food allergies (which I will discuss in another blog entry) and other gastrointestinal diseases. If your baby’s growth drops down centiles you definitely need to speak to a healthcare professional.

Now, for toddlers > 1 year of age there are some portion sizes,  which the Infant and Toddler Forum have published and they regularly tweet photos of portion sizes which help put your portions into perspective. Again, a big boy may eat more than recommended portion sizes whereas a petite girl may eat less, so looking at the portions is a great guide, but also take your child’s appetite and satiety into account.  I will write more on older children and food intake in future blog entries, as behaviour does set in when they are older so eating can often be a difficult.

Free from biscuit recipe

I had to develop a recipe recently for one of my children with multiple food allergies that needed a snack in between meals that has sugar for quick energy and protein to sustain them. I wanted to share it, as I think some of my readers may find it useful. It is milk, egg, soya and gluten free and suitable from 1 year of age.


1 cup almond flour

4 heaped Tbs of gluten free flour (if your child is not gluten allergic, you can use normal flour)

2 1/2 heaped Tbs millet flakes (which gives it a slight crunch)

1 heaped Tbs sugar (I used sugar instead of honey, as this is faster sugar release in children that get drops in their sugar levels)

1/2 large banana pureed

50 g cold dairy free spread

Vanilla essence 20160207_094508



Mix above ingredients together and let rest for 1-2 hours in fridge

Roll out between 2 wax/parchment papers, which makes it easy and not sticky

Use a round cooking cutter and place on baking tray and bake in preheated oven of 180 C for 12-15 min (depending on the shape of your biscuit)




Mixing infant formulas safely

I had promised I would write something about formula mixing, which seems so easy, I often get asked…”and can I use mineral water” and “do I need to sterilize the bottle after 1 year of age”? So I do think there are still questions to be answered.

I am going to start with the basics, which to make sure your hands are clean. In addition to that it is important to read the instructions on the tin on how to mix the formulas as there may be some differences between formulas. I know, this seems logical, but the amount of times I have had parents telling me, they add extra water because it makes the bottle last longer at night or they add and extra scoop here and there because they think their baby needs more. Diluting and concentration should ONLY occur under guidance by a healthcare professional to establish if this is safe to do and required. So as a rule of thumb, in the UK you mix 1 scoop per 30 m/1 oz water for formulas. This does not mean you “tap” or “scrape”  the scoop against the tin to level it off,  but do this with a dry flat knife. The feeding equipment needs to be sterilized and you do this until your baby is 1 year of age. Bottles that are not properly cleaned can lead to thrush or diarrhoea and/or vomiting because of bug contamination. Official guidance can be found here.

There seems to be also confusion about the temperature of the water for mixing feeds. Currently the guidelines indicate for tap water to be used, which is then boiled, left to cool for no more than 30 min, so that the temperature is around 70C when the powder is added. It does sometimes happen that you do not have a safe tap water supply when you are traveling or taking a long haul flight. If you  do use bottled water, then it is important to check the label to make sure the water contains:

•less than 200 milligrams (mg) a litre of sodium (also written as Na)
•no more than 250mg a litre of sulphate (also written as SO or SO4)

In future I will write more about  specialist formulas, like those suitable for children with food allergies, as these are different to standard formulas.



What about infant formula milk

The topic of infant formula milk is often seen as a taboo topic for healthcare professionals due to the drive to improve breast feeding rates. Of course as a dietitian I think breast milk is the most wonderful “feed” available for babies and as far as possible this should be supported. The truth is though, that in spite of best efforts many mums are just not successful with breast feeding for numerous reasons. I get the impression from the mothers that I see in clinic, that they are made to feel guilty about this which is a shame.
Firstly, people think that the UNICEF Baby Friendly Initiative only includes guidelines on how to breast feed successfully and what hospitals need to do to achieve this status, but in 2014 further guidance was brought out by the UK UNICEF Baby Friendly Initiative which included the following points:
1. Mothers who give other feeds in conjunction with breast feeding are enabled to do so as safely as possible and with least possible disruption to breast feeding
2. Mothers who formula feed are enabled to do so as safely as possible
3. Mothers who bottle feed are encouraged to hold their baby close during feeds and offer the majority of the feeds the their baby themselves to help enhance the mother-baby-relationship
Nutritionally it is absolutely fine to combine breast and bottle feeding and for me as a dietitian it is crucial that parents get the correct information on how to make formula feed choices and how to prepare these formulas. First I would like to give some more information on formulas that are currently available. In the EU, the ingredients of formulas are strictly regulated for protein, energy, vitamins and mineral content, which need to be within ranges that are provided by the EU Directive. This means, that in general formulas will have a very similar content. All feeds by law also need to contain LCP – meaning long chain phospholipids (essential fatty acids) but there may be some slight differences in regard to prebiotic contents and some micronutrients.
In general you can divide feeds into 2 categories: whey or casein dominant. Whey protein is the main protein in breast milk, so first infant formulas (< 6 months or usually have the name followed by 1 or first) are whey dominant. This protein empties the stomach like a liquid and does not curdle. Now in theory you can continue on these formulas until your child is 1 year of age, because your breast milk remains the same protein throughout.
Then you get casein dominant formulas – these are also called formulas for “hungrier babies” or follow on formulas (number 2 or the tin says follow-up/growing up). These formulas should not be used < 6 months of age. Casein, is another cow’s milk protein, that curdles and it empties the stomach like a solid. That means it may keep your child more satisfied, not because of more calories in the feed, but because the protein remains in the stomach longer. This feed may in some cases make the stools much harder, so you should not be surprised if this happens. As mentioned before, in theory there is no reason why you need to change to this formula. The only aspect that I think make it worth-while in certain situations is when more iron and vitamins are required. Follow-on formulas outside of their different protein, have more iron and vitamin D in particular. There is some low level evidence that it may help with iron status in populations where iron intake is lower (i.e. vegans).
Infant formula milk is recommended as main drink for babies up to 1 year of age, because the introduction of cow’s milk before this age has been linked to the development of iron deficiency anaemia. You can from 6 months use cow’s milk for cooking, but please do not replace your formula until 1 year of age, when your child should have a nutritionally complete diet. I know there are now toddler formulas available that go up to 3 years of age. I rarely use these formulas in my practice as there is very limited evidence that they provide any benefit in a child where food intake is good.
I think this is enough for today’s blog entry, but will write next week on mixing of feeds and feed volumes…….