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.

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.

Mechanistic feeding as cause for feeding difficulties

I am all for a child having a routine, in particular if this means children get all their nutrients and parents feel relaxed that they have had enough food.

The problem is, when feeding becomes so scheduled that it ignores the natural appetite and satiety of a child. If you were to perform a search on “Dr Google” on feeding schedules for babies, you will find anything from a 3 meal to a 9 meal schedule with breast or bottle feeds in between.

It is important to get to know your child’s appetite and satiety, instead of following a schedule that has been put together without taking your child’s appetite into account. Some children need only 3 meals per day and snacks reduce the meal volume and other actually do better with 3 smaller meals and 3 snacks. What is crucial is to listen to what your child is signalling. Trust your baby, they will signal hunger and satiety and show you when they are hungry.

Evidence has shown that if you “disrespect” the satiety of your child and feed just according to a schedule (i.e. “they must eat at a specific time”), that eating becomes a negative experience. In addition, we do not want to teach our children to override natural satiety as this has bearing on portion sizes in later life.

What I am certainly not saying is to through routine out of the window! Have a routine, but be flexible to adjust this, if your child is never hungry mid-morning for a snack, then do not force it on them. Cut it out and just provide lunch, they will signal if they get hungry in between and then you can bring in a snack. Equally, it may be on days that lunch is not such a successful meal, but dinner is great. This is fine, keep the routine but do not obsess about the success of the meal as most children will make up for poor intake in their next meal. Mechanistic feeding addresses feeding like a machine, which it obviously is not.

Please note: for those children with diagnoses affecting the gastrointestinal tract, hunger and satiety is often affected so the advice above, is for children without any underlying medical diagnoses.

 

When medical conditions cause feeding difficulties

Its been almost 3 months since my last post and I promised to go through the acronym STOMP as causes for feeding difficulties. This week in particular this entry seems important with the publication of a twin study from University College London on Fussy Eating and Neophobia, which has got the media going crazy.

Today’s entry is only about organic or medical causes of feeding difficulties. Those parents that have got children with food allergy, reflux of developmental delay (just to name a couple of medical diagnoses) will know that feeding difficulties are common when a child is not well. The question though is, when is your child’s feeding difficulty possibly a medical condition that has not been diagnosed.

There are a couple of “red flag signs” in regards to feeding difficulties that I would suggest requires a healthcare professional’s attention. These include:

  1. Dysphagia (difficulties in swallowing) – if you see your child has obvious difficulties in swallowing
  2. Coughing and spluttering every time your child has liquids (especially if you child has frequent chest infections)
  3. Gagging every time textured solid foods are given and this causing distress
  4. Apparent pain with feeding – in the young this often exhibits itself as refusing to drink breast milk or from the bottle
  5. Vomiting and diarrhea in association with feeding difficulties
  6. Growth faltering in association with feeding difficulties

If there is an underlying medical cause leading to the feeding difficulty, the problem is unlikely to be resolved without the medical condition being treated. It is therefore important to discuss feeding difficulties with somebody if they exhibit any of the above symptoms.

My next entry will be about mechanistic feeding as cause for feeding difficulties.

 

 

 

Size of a child as trigger of feeding difficulties

I promised last week that I would expand on each trigger of feeding difficulties. I will start with size – or growth of a child, which next to texture transitioning is one of the biggest causes of feeding difficulties.

First of all, it is important to get your child’s growth assessed on a regular basis. I want to define what is growth, because most people just think of weight, but in fact growth encompasses weight, length/height growth and in a child < 2 years of age head circumference. You can not assess how a child is growing only by looking at their weight, because the length of a child gives you important long term information on growth and so does a head circumference in the young. For example if your child’s weight has dropped a centile but the height is continues to grow well, then this is  much less worrying as your child may come from a taller skinnier family and this is genetically normal for your child. So if there is one message that comes out from today’s blog entry, is to get a length/height and head circumference (< 2 years of age) done before you start worrying that your child is not growing.

Now, why is growth a trigger for feeding difficulties? Usually if somebody tells a parent that their child is not growing it hits a very sensitive nerve that goes to the core of parenting. No parent can be blamed for not taking this personally! The knee-jerk reaction is to immediately start correcting this by feeding more food and increasing the frequency of feeding intervals. It makes sense that more food equals more energy and protein intake which means growth. However, your child may not want to have more and eat more frequently, which then leads to them refusing food, the parents becoming more distressed as they worry about their growth and the more distressed they are the harder they try, the more the child refuses……so you can see a cycle of feeding difficulties starting.

I would like to give some simple tips, but this does not replace professional advice.

  1. Enrich the food that your child is currently eating happily with cheese, cream, pureed lentils and other energy and protein rich foods. Ensure that you give full cream yogurt, provide a spoon of nut butter in the porridge your child is having or make a fruit smoothie with yoghurt and almond butter for example. Gaining weight is not just about energy but protein as well, so adding just oil is not going to do the trick.
  2. Do not increase sweets and chocolates – these are empty calories and do not contribute hugely to catch up growth. Food increases catch up growth which is more balanced and also for the future better for your child.
  3. Ensure that your child has sufficient vitamins and minerals which are co-factors for growth. This means, your body needs them to metabolise the energy they are consuming.
  4. Keep meal times to 30 min and no longer than this!
  5. Offer a manageable portion – this is psychologically important for parent and child
  6. If the can self feed – ensure that they have foods that are higher in energy and protein that they can self fed – cheese strips, falafel, home-made chicken strips, bread sticks and hummus, avocado and oat cakes as snack ect. This is often more successful.
  7. Respect your child’s signals of hunger and satiety – if they signal they are full, stop feeding
  8. Never force feed or feed when they are unhappy and crying

 

What do I need to do if I suspect my child has a cow’s milk allergy?

Last week I wrote a blog on cow’s milk allergy, which I had quite a bit of response on. I thought it is useful to follow this up as promised with a blog entry on what to do if you suspect your child has cow’s milk allergy. First of all, please do NOT remove cow’s milk out of your child’s diet without consulting with your doctor to establish whether there are other causes for the symptoms that your child is exhibiting. If a cow’s milk allergy is suspected an elimination diet of cow’s milk may be recommend to see if the symptoms improve.  This should ideally be done under the supervision of a dietitian. I know that I often get complaints that some of you do not have dietitians in your areas or that there is a long waiting list to see one. It is worth the wait as cow’s milk provides a lot of essential nutrient especially if in the young. The British Dietetic Association has some Fact Sheets that have been put together by the Food Allergy Specialist Group, that provide information, but they do not replace an individualised dietetic appointment.

I wanted to broadly discuss general treatment models for cow’s milk allergy. If you are breastfeeding your baby, please continue breastfeeding and get advice on how to optimally take out cow’s milk out of your diet without compromising your nutritional status and reducing breast milk quality. It is highly likely that a calcium and vitamin D supplement will be required. In some cases your doctor/dietitian may recommend that you remove not only cow’s milk but soya and other food allergens. Again, this should NOT occur unsupervised.

If your child is not on breast milk, but on formula milk you will be recommended a hypoallergenic formula. You get two types, an extensively hydrolysed formula and an amino acid formula. The majority of children with have full symptom improvement on an extensively hydrolysed formula, which is made from short chain peptide (cow’s milk protein chopped up in smaller building blocks) that your child’s body will not recognise as an allergen. In a small number of children an amino acid formula is required. These are formulas that contain amino acids only, the smallest building blocks of protein.

Its important to note that these formulas taste different, smell different and yes, will lead to your child’s stools to look different – dark green in the majority of cases. If they spit up, the smell of this will also be different and it will have a different texture. This is absolutely normal and related to the fact that these milks have smaller pieces of protein or amino acids.

Whilst writing on hypoallergenic formulas, its crucial that parents also understand that any milk from animals on 4 legs (goat, sheep, buffalo, donkey) should be avoided as the protein is very similar and over the counter milks like for example oat, quinoa and coconut milk should only be offered after 1 year of age and ideally after a review by a dietitian. You can though use them in cooking from 6 months of age.

I would like to finish off this blog entry by saying that what I have written above does not replace professional advice cow’s milk allergy and nutritional management. Advice is ideally tailored for the individual.

Baby Led Weaning (BLW) – When to use?

There is almost not a week going by without parents asking me about the BLW approach. For those of you that do not know this approach it was developed by Jill Rapley, a UK qualified health visitor that suggested starting with soft pieces of food from 6 months of age – meaning you jump the whole puree phase and babies just start by feeding themselves. She has published several books and has a website as well.

Initially it was seen as a craze from us as healthcare professionals, but since then this method of weaning has been studied by a couple eminent researchers. The studies have found that the majority of babies can feed themselves from 6 months of age using this approach and thrive, they learn how to regulate their own appetite better, have a preference for healthier foods and have a lower BMI  (Body Mass Index) when they are older . There are however babies where this approach may not be appropriate, in particular those children with developmental delay, with faltering growth and other medical problems where food needs manipulation due to a medical reason. In these cases it is better to consult a dietitian or if you are in the UK your health visitor to establish if this method is safe and would sustain growth and development.

Key to using BLW is to start it only at 6 months of age and really to follow your baby with introductions. It is amazing how quickly they learn to eat soft fruit and vegetables and I have plenty of babies who eat meat happily without any teeth. You will find plenty of You Tube videos if you are a “non-believer” of babies from 6 months of age chomping on chicken legs and other more complex foods.

The advantage for me in using this approach for children with no underlying medical conditions is that you get less feeding difficulties as the baby has to regulate their own appetite and will therefore eat what they want to eat, instead of you as parents feeling they need to eat a specific portion. Although this method is pretty new, it is possibly also that we may have less obesity using an approach where babies control their own appetite. Of course you still need to offer a balanced meal and for this I suggest that you look at my previous blog entries to help you out. Happy feeding !

 

Tastes, textures and colours during weaning

Eating for us and for babies is a sensory experience, which is often forgotten. I frequently hear that a food is rejected because of the taste, but it could actually be the texture, the temperature, the colour of the food and also the environment that leads to rejection. It is therefore important to take this into account when you feed your baby.

There is a “window of opportunity” when babies are more open to new tastes and textures, which is usually from (5)6-10 months. During this period, they will be open to trial new foods. It is therefore important when you start with weaning foods, to constantly introduce new foods and from 6 months on start introducing texture. Try to also change the temperature, that your baby is used to eating foods that are hot or cold. This may become very  useful, for those days when you are out and about and can not heat the food up to the perfect temperature. Most babies will prefer sweet foods; as such you should not be disheartened if they do not like your green bean and broccoli mixture the first time you give it to them. It is important to repeat these foods and repeat them a lot…..it takes at least 15 x before some rejected foods are accepted.

When it comes to textures, whether you follow the baby led weaning approach or the traditional approach, texture is important and by 10 months ideally children should have a good variety of foods they can feed themselves by hand. Of course you are not expecting them to spoon feed at this age! Finger feeding is a messy affair, but good to let them explore and mess as this is not only a way for them to discover textures but also to enjoy the meal and feel independent.

Remember that babies look at colour as well and often choose their foods on how they look. “Mush” may therefore not always be as attractive as the food on your plate (which they may try to grab), which is colourful and plated out separately. So if they reject their mix, do try finger foods separately.

Finally, it’s a myth that babies like bland food.  Of course that does not mean you are going to add salt to the food, but there is no reason for you to not use garlic, onion, basil, rosemary and all kinds of exiting herbs and spices. I often get parents that are surprised that their child likds olives or enjoyed some curry from their plate, but this is normal, depending on the mother’s diet they would have been exposed to flavours in the womb and through breast milk. Therefore, be adventurous and add herbs and spices that are normally part of your diet to their food.

Most importantly, let your baby enjoy meal times!

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.

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