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.

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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

 

The New Vitamin D Requirements for the UK

I am not sure how many parents know that the vitamin D requirements for infants and children have changed in the UK….finally. The change followed a review of all the scientific evidence by the Scientific Advisory Committee on Nutrition (SACN) in the UK.

In the past it was thought that sufficient vitamin D was synthesised through the skin exposure of sunlight, but now with public health recommendation to wear protective sunscreen it is recognised that it is no longer  possible. In addition, most children receive very little vitamin D from their diet as the diet on average only contributes only about 10% of requirements and this is based on an optimal diet that contains foods rich in vitamin D or  supplemented with this vitamin.

I am sure you are keen to know what these guidelines are. So here are they are:

  1. All babies under 1 year should receive 8.5 ug-10 ug per day of vitamin D – in particular children that are breastfed from birth should receive these vitamin drops
  2. If your baby is on an infant formula and consumes more than 500 ml per day, it is assumed that you are achieving this amount, as these formulas are highly enriched
  3. All children between 1-4 years should have a daily supplement of 10 ug vitamin D per day

The above recommendations are based on achieving musculoskeletal health and not for any other therapeutic intervention as there continues to be significant debate around levels for prevention of certain diseases. Its important to know that as with any supplementation, too much is also not good, so please do not double the amount suggested and think it will only do good. Vitamin D is not only a fat soluble vitamin, which you can lead to toxicity, but it has a potent effect on the immune system, which may not always be a good thing it taken in excessive amounts.

You will notice, that it is currently difficult to find supplements that contain exactly 10 ug, as most of them contain 7.8-8.5 ug of vitamin D. This is because many supplements are still based on the Department of Health recommendations and the NHS Healthy Start vitamin drops also contain this dose. We are expecting this to change.

So the message from this blog entry is, do get a vitamin D supplement if your child falls within the above category and if in doubt talk to your healthcare professional to assist you.

Health Millet Bars for Toddlers

Ingredients (milk, egg, soya, gluten free)

100g ground nuts (you can grind any nuts you like)*

100g millet flakes

2 tablespoons honey

1 mashed banana

 * this recipe is not suitable for children with multiple nut allergies, but if you have been asked to introduce selective nuts, its ideal and you can only  use the nuts your child tolerates

Method

Mix all together and press with your fingers/spoon in a baking paper lined tray. This recipe is sufficient for pie pan and if you double it you can fill a baking tray.

Bake for 20 min at 180C and cut in 2cmx5 cm squares

Post-traumatic experience leading to feeding difficulties

Today will be my last entry on the causes of feeding difficulties. The last cause is a traumatic experience with food, that on either parent or child’s side causes the avoidance of foods. The most common reason I see for feeding difficulties related to trauma, is following a choking episode on certain foods. It does sometimes happen that with the introduction of lumpier textures, a child gags, becomes quite red in the face and in some cases vomits. Some parents experience this quite traumatic and this can lead to a reluctance to introduce textured foods, which means that it can lead to a delay in the acceptance of texture. If this were to happen to your child there are a few simple steps you can take. First of all, I usually advise parents to do a first aid course just to provide them with the comfort that they will be able to hand a situation like this.

Most importantly, do not give up on texture. Melt-in-the-mouth foods  (like the maize puffs for children) are often a really good first step to get texture into a child after a negative experience. These foods help with feeling texture and chewing (an essential skill), but before a child can choke/gag they melt and become a puree. I have often also suggested the use of a teething net (you place food in this net and your child can chew) for a week or 2 with food, just to get your confidence. Remember, there is a window of opportunity of introducing texture and that is before 10 months of age, after this it can be really difficult and some children become texture hypersensitive.

Children can also have traumatic experiences with food, which often leads to food refusal. Choking can be just as traumatic for a child as a parent. In addition, children that experience allergic reactions to foods often avoid those foods and foods that look the same/have the same texture/taste. It is therefore important when a child has a negative experience with food, to ensure you do not complete avoid the food (outside of a real food allergy of course)/similar foods but to offer food on the table of the high chair in a non threatening way, so that they still see the food is in front of them and get the message, that the food is safe and in their own time they can trial this again.

Most importantly, the reaction of parents to a food-traumatic experience can deter a child from having this food again. So if you see your child is gagging and spitting out foods, although it may be very stressful for you as a parent, try to handle this in a calm manner as a child will try to avoid similar feeding situation like this, which may entail avoiding foods.