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.

Should my baby have a probiotic?

There is most probably not a week that goes by without parents asking me about probiotics for their baby, either for general health or for specific gastrointestinal conditions. I have just come from the a Gut Microbiome Conference in Paris, so it seems fitting to write about this topic in this blog entry.

So, the bacterial flora constitute 90% of the total number of cells associated with our bodies and only the remaining 10% are human cells. So in fact, we are more bacteria than human! There is not doubt in the scientific community that the microbiota of the gut is part of the answer to our health and also the cause of many illnesses. There are numerous studies indicating an abnormal bacterial flora in children with allergic disease, inflammatory bowel disease and even specific trends in children that are under/overweight have been found. This all sounds very exiting, but here is where the problem lies: your microbiota changes with age, diet, genetic background, antibiotic use in early childhood and environment. So that means, although your baby may have about 40% overlap in bacterial flora with another baby, the rest is unique to them and is determined by the factors mentioned above.  I often have parents that have have had their child’s bacterial flora evaluated at very high cost, that ask me what to give in regards to probiotics, but disappointingly I have tell them that I do not know as I do not know what is “normal” for their child.

In disease (i.e. allergy, reflux, inflammatory bowel disease, irritable bowel disease) they are starting to identify target strains that have specific functions, that is very exiting and many of us working with dietary interventions in children are starting to use these products, BUT I always say to parents that it may not always provide you with this magic symptom relief.

So, what can you do? First of all, the more diverse the diet (in particular with fruit/vegetables and grains) the more diverse the gut bacterial flora and diversity has been linked to health. If you do want to give a probiotic to a healthy baby as a general rule of thumb you would aim for Bifido strains for < 6 months old as this is the predominant strains in a breast fed child and then complementary foods increase Lactobacilli strains increase, so then using these strains may be more useful. Go for a reputable brand, that has actually in what it is supposed to have and if your child has a specific diagnosis, consult your dietitian about what the best strain is to use. An important message to get out, is that strains of probiotic are specific so one may help with one condition but not with another. Another important message is that when your child is on an antibiotic, to choose a probiotic that is resistant to the antibiotic, otherwise the well-meant probiotic will also be killed by the antibiotic.

I leave you with these thoughts and most importantly, that healthy eating also creates a healthy gut.

Food Pouches for Babies and Toddlers

I have been meaning to write about this topic for some time, as I see more and more toddlers just sucking food from commercial food  or refillable pouches.

Undoubtedly, when baby weaning foods  in pouches were introduced many years ago, it revolutionized feeding infants. These pouches were not only better for the environment, but they were lighter, easy to travel with and looked kinda cool. What has suprised many of us working in paediatrics however, is how baby food in pouches has changed the way children are being fed. Suddenly a spoon was not required anymore, because the baby could just suck it directly from the pouch and parents were happy that it did not cause any mess. We now even have companies making refillable pouches and their clever advertising feeds into our aversion with mess.

It seems to be forgotten that there are essential developmental steps that need to occur for a baby/toddler to learn how to eat and allows them to have a normal relationship with food. Sucking, is a reflex a baby gets born with, so this is something that they know how to do, but chewing is something they need to learn and letting a baby/toddler just suck out of a pouch certainly does not help teach them this skill. In addition to this, there are important fine motor skills like holding a spoon and bringing this to the mouth that are important.  Outside of the mechanical side of eating, eating is a sensory experience. When the food is sucked from the pouch, they do not see how the food looks, what it smells like and they just feel the texture. No wonder they then refuse home cooked food when it comes in a plate – because they used to sucking it from a pouch.

Mess is such a crucial part of getting used to foods, accepting flavours, textures and tastes. The most common therapeutic advice we give in children with feeding difficulties is to allow mess, let them play with textures and allow them to explore foods. Letting a child suck from a pouch means, we are side-stepping this very important developmental step and it can actually lead to a feeding difficulty later.

Of course, there are exceptions which I always discuss with parents – you are stuck on a plane, in a car or visiting friends with a white sofa, so in these circumstance by all means allow them to suck from the pouch, but this should not be the norm. Let them explore food in all its colour, texture and taste.


There is sugar and sugar……

Although I constantly get questions about sugar in my clinic, it has become clear to me again with recent questions  I have received, how confusing the whole sugar topic can be for parents and what misinformation there is on the internet. I commonly get comments like “honey/agave is better than sugar”, “I use fruit sugar because that is better” and “there is corn syrup in the hypoallergenic formula so I do not want to give it to my child”.

I want to start by being clear that free sugars should be avoided and in excess are definitely bad for your baby (and for you). The current recommendations in the UK suggest that a diet should contain less than 5% of free sugars. I have put a link in here of the report for you to read….you will need to have some time and possibly a glass of wine to read through it.

So lets start with the basics. Dietary carbohydrates include both starches and sugars and are ultimately ALL converted to glucose which is the primary energy source for adults and children. They are divided into 4 groups, but I am going to stick to only mono- and disaccharides, which are the ones that cause most confusion. Monosaccharides are single sugar molecules and include glucose, fructose and galactose. Disaccharides have 2 linked sugar molecules and include sucrose (glucose + fructose), lactose (glucose + galactose) and maltose (glucose + glucose). Foods that contain these sugars include:

Fructose = fruits, honey and agave nectar

Lactose = breast milk and formula milk

Sucrose – table sugar and all those sweets/chocolates and sugary drinks

Free sugar is defined by the World Health Organization as all mono- and disaccharides added to foods by the manufacturer, cook, or consumer, plus sugars naturally present in honey, syrups, and fruit juices. So honey is a free sugar, so adding this to any of your child’s foods still means they have free sugars and similarly giving fruit juice also means you are giving a free sugar. Best therefore to stick to water or milk for drinks and plain fruit.

Now what about breast milk and infant formulas. Breast milk contains lactose, this is a sweet dissaccharide that consists of glucose and galactose. Formulas also have lactose in a similar amount as breast milk.  I recently read on a popular forum that some parents believe that some formulas are higher in free sugars than others. First of all the majority of sugar formula is lactose, which is the same as in breast milk.  As mentioned in a previous blog post, the formula ingredients are strictly controlled by the EU so they have to adhere to this. In some of the European Countries you may find flavoured Growing Up milks (please note these are NOT infant formula, but milks for older children). Of course these will have additional sugar and should be avoided, however standard infant formula will have a similar amount of lactose than breast milk.

Finally what about glucose corn syrup. Parents of allergic infants will notice that the majority of hypoallergenic formulas have glucose corn syrup as carbohydrate source. This sugar contains mainly glucose but also maltose. Depending on the method used to hydrolyse the starch and the extent to which the hydrolysis reaction has been allowed to proceed, different grades of glucose syrup are produced, which have different characteristics and uses….and different tastes. You will note that these hypoallergenic formulas are not sweet like syrup (on the contrary they taste bitter), but actually provide a similar amount of glucose/maltose to lactose in breast milk. This is therefore an essential ingredient that provides the majority of energy in the feed.

I will in future also write about oligo and polysaccharides, but I think for a start this is enough about sugars.


My first blog…..

Its been some time that I have been meaning to blog about common themes in regard to paediatric nutrition, but I was waiting for the elusive 36 hour day to fit blogging into my schedule….never mind that I  am not blessed, when it comes to the technical aspect of setting up a site. I have now realised that the 36 hour day is not going to happen and unless I make time for this, it is never going to become a reality. Surprisingly, with a little bit of help from my husband, I have also been able to master the basics of the blogging site.

As you will see from  “about the author”, I am a paediatric dietitian and hope to demystify paediatric nutrition for you. I will try as far as I can to keep my blog as evidence based as possible, but make this information practical for daily use.

So what should I write my first blog about? Of course it should be mind-blowing and make you want to follow my blog. I therefore thought a good start would be to discuss good resources, because I may not always blog exactly on the topic that you are struggling with at that stage, but knowing where you can find the information is important. “Dr. Google” is a wonderful tool to use for all questions, but sadly has no medical degree, so you need to be smart in choosing the right information. The amount of tears I have had in my clinic about parents thinking their child will suffer long term problems, because of misinformation from the internet! Don’t get me wrong, the internet is a wonderful tool, its just important to know what information is trust worthy. I will therefore try to provide you with some international  and UK specific sites (I work in the UK) that you can use.

As a healthcare professional, I will always go to pubmed to provide me with the latest peer reviewed (meaning no article is published here unless reviewed by peers specialising in the field that check the information) information. This may be useful to you, but remember for the majority of publication you can only access the abstract and the medical terms used may be a bit overwhelming. Otherwise, I suggest using the NHS or the Food Standard Agency for general information on infant feeding. For specific infant and toddler feeding information, the Infant and Toddler Forum, which I am part of is really good and the British Dietetic Association has Diet sheets on healthy eating, calcium intake and food allergy in their list of public fact sheets.  As we go through topics related to childhood nutrition, I will be providing more specific sites that you can access for further reading, but for the time being I think this is enough to digest for a first blog.