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.

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.

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.


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.


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…….