Is a sustainable diet suitable for young children?

The discussion about healthy eating, whilst considering the environment is a topic that comes up much more frequent in my consultations. This can be a real challenge when you want to achieve iron requirements, but not eat too much meat, when you want to achieve essential fatty acid intake, but do not want to contribute towards over-fishing and when you are aware that too much fibre (which is common in a plant-based diet) can impact on the availability of many vitamins and minerals.

 

Already in 2017, the British Dietetic Association launched a toolkit for dietitians to help them advise a more sustainable diet and recently, the LANCET, one of the most well-known medical journals, gathered healthcare professionals working in public health to work on a diet that is both healthy (i.e. meeting all requirements) and is good for the environment. According to this publication “Global consumption of fruits, vegetables, nuts and legumes will have to double, and consumption of foods such as red meat and sugar will have to be reduced by more than 50%”. A diet rich in plant-based foods and with fewer animal source foods confers both improved health and environmental benefits.”  ) I have copied below the suggested diet, based on the research by the LANCET, but the problem with these nutritional aims is that to date, they have not been adjusted for children and in particular for babies and toddlers.

Whilst, I can certainly not replace a whole research team, which really is required to answer this question on exact amount, I will try with this blog to provide some general guidance for parents who want to raise their children taking food sustainability into account but not harming their health.

  1. Breast milk and/or formula play an essential part of the diet until your baby is 1 year of age and should not be limited due to environmental concerns.
  2. After 1 year of age full cream milk or plant-based alternative can be considered. According to the planetary diet, cow’s milk/cow’s milk products need to be limited to 250 ml per day, which would not achieve calcium requirements for young children. Whilst calcium enriched plant-based milks provide a similar calcium content, they are generally low in energy, protein (outside of soya-based milk alternatives) and iodine (essential for brain development). Of course, you have other plant-based sources of calcium like broccoli, tahini ect, but the availability for absorption of the body is often quite low due to the fibre content. So it is really difficult to establish exactly how much a baby is in fact absorbing when this nutrient is combined with a lot of fibre. I therefore usually suggest from 1 year of age to aim for 250 ml milk + 1 portion of 30 cheese/100 ml yoghurt to achieve requirements. If you use a plant-based milk, then you need to aim for 300 ml/day or 250 ml + calcium enriched yoghurt (the plant based cheeses are usually enriched with calcium). As a lot of plant-based milks are low in energy and protein (outside of soya) its important to consider how these are replace. In addition, iodine is usually low in plant-based milks and is essential for brain development. It is worth looking at alternatives, including seaweed and in some countries bread is supplemented with iodine (not in the UK).
  3. If I convert the suggested planetary diet meal plan for protein you get the following weekly plan:
    1. Red meat – 1x per week
    2. White meat (poultry) – 2x per week
    3. Fish – 2x per week, of which one portion should be an oily fish
    4. Egg – 1 per week
    5. Legumes (including nuts) – daily
  4. The above schedule of protein would achieve protein and iron (and zinc) requirements in babies/toddlers, but it is worth to consider combining your legumes with a vitamin C rich source (i.e. fruit as dessert or tomato as finger food) to increase the iron absorption. The reason I am not suggesting here cooked vegetables as vitamin C source, is that a lot of the vitamin C is lost during the cooking process.
  5. The planetary diet also suggests reducing saturated fats (i.e. animal fats) and increasing polyunsaturated fats. Its very important to mention here, that babies and toddlers (when growing normally) should not be on a low-fat diet, as they need plenty of fat to sustain energy intake and this nutrient contributes also towards brain development. I therefore suggest to use a combination of olive oil, rapeseed oil and sunflower oil (all contribute different fats) and not to avoid nut butters if not allergic. Palm oil is a saturated fat, but it is essential to assess how this has been sourced. In regards to coconut oil, this is also a saturated fat and can be used, but its also important to establish where this has been sourced and think about the fact that both these fats are not manufactured locally in European countries (i.e. needs to be imported).
  6. The rest of the diet is supposed to be composed of fruit, vegetables and grains. Whole grains I would avoid until 1 year of age and after this age be careful in the amount of wholegrain products, because this can affect the availability of vitamins and minerals by affecting the absorption. For fruit, I would keep to 3 portions of fruit per day (what the child can hold in hand/size of hand) and totally avoid fruit juice.
  7. Avoid sugar, honey and salt definitely until 1 year of age and limit this to a minimum after 1 year of age.

 

I will post guidance on vegan/vegetarian diets in my next blog, as I know this is also a hot topic.

Lastly, it is important to note that this advice is not suitable for children that are on a restricted diet due to allergies or other conditions and they require individualised advice. If in doubt, speak to your dietitian.

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Sugar in Commercial Baby Food

Many of you would have read in the last week the BBC article on hidden sugars in commercial baby foods in the form of fruit juice or fruit puree. Of course this does not mean, that a baby should not have fruit, but what is acceptable and what not?

This is a pretty simple answer in fact and I will share some simple tips with you today. Baby food should not contain fruit juice, as this is refined sugar and should be avoided. In addition, if a savoury meal contains fruit puree (check the ingredients list for this) and you would not expect this normally in that meal, then that is also a commercial baby food mix you ideally want to avoid. Why ? – well babies are hard wired to prefer sweet food, so if you lace savoury vegetables with fruit, then they will prefer to have all of their bitter tasting vegetables mixed with fruit  and not learn to eat greens. This also goes for recipes that contain fruit. I have noticed grated apple or sweet vegetables in recipes that would not usually have this as an ingredient. Adjust these recipes by replacing the sweet fruit/vegetables with savoury/bitter tasting vegetables.

What about fruit purees? Its useful here to think what would be a normal mealtime balance to give you an idea of allocation for fruit and also some guidance on portions. Ideally you would aim for every meal to have a protein, carbohydrate and fruit/vegetables. This would roughly work out as breakfast cereal with fruit, lunch/dinner with vegetables and either 2 fruit snacks or a small amount of fruit after lunch/dinner.  So about 3 portions per day. The amount of fresh fruit for a baby < 1 year would roughly be the equivalent to 1/3-1/2 (max) of a fresh fruit, outside of really small fruit (like cherries, where you would allow more). So, imagine cooking and pureeing this amount and how much you get. You will find that a pouch of 90-120g would usually be more than that, so it is worth adjusting the amount.

Finally…..mentioned in many previous blog posts! Avoid letting your baby suck the food directly from the pouch. Outside of this not promoting oral motor skills, this feeds into an aversion to self feeding with mess (which is essential for self feeding) and usually this way they consume much more than when they get this either fresh or with fed via spoon.

Keeping your Baby and Toddler Hydrated in this Hot Weather

We have been having exceptionally hot weather in Europe and unlike other years where this may last just for a day or two, this seems to be going on and on.

Babies/Toddlers (as well as elderly) are at higher risk of becoming dehydrated, because of their smaller bodies they have less body fluid reserve and their surface area to volume ratio is higher. Its important therefore to recognise the symptoms of dehydration early, which include:

  • seem drowsy
  • breathe fast
  • have few or no tears when they cry
  • have a soft spot on their head that sinks inwards (sunken fontanelle)
  • have a dry mouth
  • have dark-yellow pee (less wet nappies)
  • have cold and blotchy-looking hands and feet

Firstly it is important to keep them out of the sun and clothe appropriately with light, breathable clothing. Ensure also that your baby is not wrapped up too hot when sleeping.

For breastfed babies < 6 months of age, the ideal is to increase the breastfeeding frequency, which often occurs naturally, as babies signal when they need more fluid. For formula fed babies, they will need more formula as well during hot weather and again, most babies will signal this automatically.

For babies over 6 months of age, cooled boiled water should be offered frequently in hot weather. I often get asked how much they should have, which very much depends on the weight and age of the baby. Most babies > 6 months of age weigh > 5 kg, so that means you are looking at 100 ml/kg of total liquid (that is milk and water) to maintain hydration, during very hot weather this can increase to a total 120-130 ml/kg of water. This is just a rough guide as some children want more than that and some are fine just with 100 ml/kg. It is therefore important to monitor their hydration status.

For toddlers, milk of course is not such a prominent liquid in their diet as for babies. It is therefore really important to ensure that they consume sufficient additional liquid, ideally in the form of water. Fluid requirements are calculated as follows:

  • first 10 kg = 100 ml/kg and for the following 1 kg its 50 ml/kg. So a toddler of 13 kg would require 1150 ml liquid per day.
  • Remember though that food also contains water and contributes to the total fluid intake

I do have children that refuse to drink water and although I am not a fan of fruit juice, in this hot weather its more important to keep them hydrated, so I usually suggest (in cases that refuse to drink plain water) to flavour water with a little bit of fruit juice (1:5 dilution) and/or you can also try fruit ice lollies (blending fruit with water). In addition, offer plenty of juicy fruit (i.e. water melon) and vegetables that contain water (i.e cucumber).

If ant any stage you are worried about your baby or toddlers’ hydration status, please seek professional medical help.

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.

 

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.

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.

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.