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.

 

Advertisements

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.

 

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.

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.

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…….

The wonders of breast milk

Okay, so your baby is born and the obviously choice of feed is breast milk. I cannot say how amazing breast milk is! It has the right balance of energy, protein and vitamins and minerals, the baby’s stomach digests it much easier and also flavours of what you consume (i.e. garlic) are transferred through your breast milk, starting the journey of oral taste perception. You will often find that a breast fed baby is much more open for stronger flavours, including onion/garlic and herbs and spices, especially if mum likes those types of foods and consumed it during breast feeding. As your baby grows older, breast milk also does not remain the same; non-nutritive factors (antibodies, enzymes, good bacteria) adjust to your child’s needs, making it perfect.

I often get the question to how mum’s diet influences the breast milk and the answer is HUGELY. As already mentioned, flavours get transferred but the nutritional content can also be influenced by the mother’s diet. For example the nutritional status of the mother appears to influence fat concentration and thus the energy content of breast milk as well as its fatty acid composition (i.e. omega-3-fatty acids from oily fish) and immunological properties. So it is really important that a breast feeding mum also has a healthy diet. Here is a great article to read when you have time on breast milk properties and dietary influences.

How long should you continue to breast? Instead of me saying 2 years, which is recommend by the World Health Organization I usually say, that every day of breast feeding is a bonus, because breast milk is the “liquid gold” of nutrition. So it is important not to feel guilty if you do not manage to breast feed as long as recommended, because any breast milk your child gets is great! That also means, if you are not able to exclusively breast feed, to not just stop, because you think breast feeding is “all or nothing”.  Any amount you can provide your baby with is amazing!

If you are one the mums where breast feeding comes easy and you manage to breast feed until 6 month you have done an amazing job, if until 1 year of age, my goodness this even better and if you last longer, good on you! Remember, though, too much breast milk, meaning too frequent breast feeding in the older child can also become a problem. A child is supposed to have solids from 6 months of age, as they do not only need to develop oral motor skills but also contribute to essential nutrient, in particular vitamin D, Vitamin C, iron and vitamin A that are not sufficient in breast milk alone after 6 months. Too much breast milk, can displace solids and children can develop an iron deficiency or vitamin D deficiency. It is therefore important to ensure that your child receives a balanced diet and breast milk after 6 months of age. All breast fed babies from six month of age should take a daily supplement containing vitamin D, in the form of vitamin drops. This helps them to meet the requirement set for this age group of 7-8.5 micrograms of vitamin D per day. If you did not take a vitamin D supplement during pregnancy it is better that your baby is supplemented from 1 month of age.

So the message throughout my blog will always be that breast milk remains the best source of nutrition, BUT we have to acknowledge that not everybody can breast feed and I also want to ensure that mums get advice on formula feeding in subsequent blog entries.