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.

Health Millet Bars for Toddlers

Ingredients (milk, egg, soya, gluten free)

100g ground nuts (you can grind any nuts you like)*

100g millet flakes

2 tablespoons honey

1 mashed banana

 * this recipe is not suitable for children with multiple nut allergies, but if you have been asked to introduce selective nuts, its ideal and you can only  use the nuts your child tolerates

Method

Mix all together and press with your fingers/spoon in a baking paper lined tray. This recipe is sufficient for pie pan and if you double it you can fill a baking tray.

Bake for 20 min at 180C and cut in 2cmx5 cm squares

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

 

Feeding difficulties in Children

Every week I see children with feeding difficulties of varying degree in my clinic. What I can tell parents is that it is common, you are not abnormal and that it is very difficult dealing with a child that does not want to eat. I do want to focus a couple of blog entries over the next weeks on this topic, as I think there are some simple tips that may help and most importantly its you as parents want to know when do you need to see a healthcare professional.

Lets start with what are feeding difficulties.Generally if a child has one (or a combination) of the below they are classified as having feeding difficulties

  • extended mealtimes (if they take > 30 min)
  • sealing of the mouth/pushing food away
  • gagging on solids
  • spitting food out – every meal and all foods
  • dream feeding – so refusing to feed from the bottle if awake and only taking it whilst asleep

There is a lovely acronym summarising all triggers for developing feeding difficulties and it is called “STOMP”.

S – Size: the natural response to a child not achieving optimal growth is to try harder, to feed more, increase volume or frequency of foods and all of this leads to an increase in stress in mealtimes and as a result feeding becomes something your child (and you) want to avoid.

T – Transitioning: transitioning from breast to bottle, from puree to textured foods can can also lead to problems. For example the first time you provide some lumpier textures your child gags (which normally looks like they are choking but is not that bad), you get a fright and as a result do not move on with textures. If textured foods are not introduced by 10 months of age, it becomes very difficult as a critical window of opportunity has been missed.

O – Organic disease: there are many medical reasons why a child does not want to feed. That may be related to an anatomical problem with swallow/stomach, reflux or food allergies. It is therefore important to ensure that medical causes are ruled out. I will in a future blog highlight exactly the medical “red flag sign” that should not be ignored with feeding difficulties.

M- mechanistic feeding: the most common question from parents is that they want an exact schedule (including timing) for when their child should have a bottle, when they should have a snack and meal. So meal times become “mechanistic” rather than responsive to your child’s needs. Feeding a child or lets say trying to feed a child when they are not hungry but just according to the clock may also feed into the development of a feeding difficulty.

P – post traumatic: this can happen for example with a severe allergic reaction. For example your child had some egg, started swelling up in the mouth, was rushed to the emergency room and as a result is not only refusing egg but any foods that have a texture like egg. Another example is chocking (and I mean really choking) on food, which is very frightening for parents and the child and can put children off having pieces in future because they are scared of choking.

I will write next week on who size can impact on feeding difficulties and what you can do

 

 

Cow’s milk allergy – does my child have this?

There seems to be a lot of confusion on this topic so I have been meaning to write a blog entry for some time on cow’s milk allergy. I have finally found some time to write this on a flight back from Athens after a Gastroenterology Congress.

Although many parents believe their child has a cow’s milk allergy, only about 2-4% have a real allergy – meaning that the cow’s milk allergy was proven through a double blind challenge where the child received milk without the parents or the medical staff knowing and developed symptoms. I am actually not surprised that there is such a difference between believing a child has a cow’s milk allergy and real cow’s milk allergy because some of the symptoms of this allergy overlap with normal childhood tummy complaints like colic, loose/harder stools and spitting up of milk which usually settles with time as the tummy becomes more mature. So, it is not always an easy diagnosis to pick up even for us as healthcare professionals.

First some basics and unfortunately this is a bit technical but essential to help you understand. You get two types of cow’s milk allergy: Immunoglobulin E (IgE) mediated, which is the immediate type allergy, where a baby consumes the milk/milk products and usually within 2 hours has symptoms that include skin rashes, hives, acute vomiting and in severe but rare, cases swelling and closing of the throat, and compromised breathing called anaphylaxis.  This usually is an easier allergy to identify. The other type of allergy is a non-IgE mediated cow’s milk allergy which is a delayed type allergy and the symptoms typically occur after 2 hours and can take up to a couple of days to occur after the consumption of cow’s milk/cow’s milk products. The delayed type cow’s milk allergy usually affect the stomach and bowels and you can get diarrhoea (with or without blood), severe constipation, abdominal pain, vomiting and/or eczema. This allergy is really hard to diagnose as it relies on symptoms only!

Its important to familiarise yourself with the terminology, in particular there seems confusion about the delayed type cow’s milk allergy, which often is inappropriately called a “lactose intolerance” or a “cow’s milk protein intolerance”.  A food allergy means the reaction is mediated by the immune system, whereas with a food intolerance this is not the case. This is important as the treatment is different between for example lactose intolerance and cow’s milk protein allergy. A non-IgE mediated cow’s milk allergy is treated with a total elimination diet of cow’s milk in all forms due to an allergy to the protein, whereas lactose intolerance is just an intolerance to lactose the carbohydrate in cow’s milk and is treated with a low lactose diet and a lactose free milk, where only the carbohydrate “lactose” is removed. However all lactose free milks, yoghurts, cheese still contain the cow’s milk protein, so is not suitable for a child with a cow’s milk protein allergy.

The diagnosis of an IgE-mediated cow’s milk allergy is based on an allergy focused history that your doctor/dietitian takes and tests including skin prick tests and specific IgE blood tests help with confirming this diagnosis. Unfortunately, with the delayed type non-IgE mediated cow’s milk allergy there is no reliable blood test or skin test to help with the diagnosis. The diagnosis is reliant on following an elimination diet of cow’s milk for about 4 weeks with subsequent symptom improvement followed up by a reintroduction with the reappearance of symptoms.  Do not be fooled by any alternative tests on the market for “intolerances” (i.e. Vega testing, York test or IgG4 testing and lots more).

It is really important that the diagnosis of cow’s milk allergy is made by a healthcare professional that understands allergy and that you do not just cut out cow’s milk out of your child’s diet as this is a nutrient that is essential for growth. There are many guidelines available to help with the diagnosis In the UK we have the NICE guidelines and also MAP guidelines, which are really good.  I will post a blog of specialists feeds next week.

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 !

 

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.

 

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!

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.

 

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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