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.

 

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When medical conditions cause feeding difficulties

Its been almost 3 months since my last post and I promised to go through the acronym STOMP as causes for feeding difficulties. This week in particular this entry seems important with the publication of a twin study from University College London on Fussy Eating and Neophobia, which has got the media going crazy.

Today’s entry is only about organic or medical causes of feeding difficulties. Those parents that have got children with food allergy, reflux of developmental delay (just to name a couple of medical diagnoses) will know that feeding difficulties are common when a child is not well. The question though is, when is your child’s feeding difficulty possibly a medical condition that has not been diagnosed.

There are a couple of “red flag signs” in regards to feeding difficulties that I would suggest requires a healthcare professional’s attention. These include:

  1. Dysphagia (difficulties in swallowing) – if you see your child has obvious difficulties in swallowing
  2. Coughing and spluttering every time your child has liquids (especially if you child has frequent chest infections)
  3. Gagging every time textured solid foods are given and this causing distress
  4. Apparent pain with feeding – in the young this often exhibits itself as refusing to drink breast milk or from the bottle
  5. Vomiting and diarrhea in association with feeding difficulties
  6. Growth faltering in association with feeding difficulties

If there is an underlying medical cause leading to the feeding difficulty, the problem is unlikely to be resolved without the medical condition being treated. It is therefore important to discuss feeding difficulties with somebody if they exhibit any of the above symptoms.

My next entry will be about mechanistic feeding as cause for feeding difficulties.

 

 

 

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

 

 

The issue about salt in children

The question about salt comes up very frequently from parents I talk to, in particular if babies are above 1 year of age. Before 1 year, everybody has accepted that a “no salt policy” is a good one for baby food, but somehow there is this thinking that something magical happens at the age of one and suddenly salt intake can be totally liberalised. Of course kidneys mature with age and the amount of salt tolerated increases, but the idea behind the guidelines for reducing salt intake is also to raise a new generation of adults that are not as salt dependent as many of us are and therefore become healthier adults.

It is well known in adults that excessive salt intake affects blood pressure, but new research has shown that high salt intake in children may predispose children to high blood pressure, osteoporosis, respiratory illness (i.e. asthma), stomach cancer and obesity. So how much can your child have? The following are recommended intakes for the UK, but other EU countries have similar guidelines.

0-6 month: < 1 g per day

6-12 months: 1 g/day

1-3 years: 2 g/day

4-6 years: 3 g/day

7-10 year: 5 g/day

11 years and above: 6 g/day (adult requirements)

 Simple tips for reducing salt in your toddler’s diet:

  • Do not add salt to food – you can use herbs, spices and garlic/onion to make the food really yummy
  • Be careful of adult type crisp/salty crackers
  • Be careful of sauces/stock – you can find baby stock that does not have salt added and even better make your own
  • Smoked salmon, ham, cheese, bacon and many sausages contain a lot of salt, so best to keep the intake limited of these foods
  • You can also find a lot of salt in bread, snack and even breakfast cereals – food companies in the UK have really improved, but its important to be aware of hidden sources

How to read labels?

Firstly you need to know how to convert salt to sodium and visa versa, as many of the labels use sodium rather than salt.

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Salt = sodium x 2.5 – so if something contains 2.4g of sodium, it means it contains 6 g of salt. Be careful as often sodium is put in mg, so 2400 mg of sodium = 6 g of salt. Let me give you some further examples: if a product per 100 g contains 300 mg of sodium, this is 0.3g sodium x 2.5 = 0.75g of salt or if the product contains 0.2 g of sodium = 0.5g of salt. Hope this makes sense.

Many products now use a traffic light system to indicate salt content and are provided per 100g portion of the specific food.

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  • High is more than 1.5g salt (0.6g sodium) per 100g. These foods may be colour-coded red.
  • Medium is between 0.3 (0.1 sodium) and 1.5 g (0.6 g sodium) salt per 100g. These foods may be colour-coded in amber
  • Low is 0.3g salt (0.1g sodium) or less per 100g. These foods may be colour-coded green.

 

Useful Sites/leaflets

NHS Live Well Salt Guideline

You will see that the UK has published  2017 salt reduction targets for foods like ham, bread and other general products, which should help all of us in the future. You can read them here.

Sugar Free Baby-Toddler Biscuits

One of the most common questions I get from parents is about treats for their baby. The truth is that treats are driven more by us as adults than a need by the child – but by starting them, there is an expectation to continue. For me a treat is a birthday party and special occasions, but not a daily occasion. This brings me to the question about biscuits. In the UK I find a lot of nurseries and schools still provide quite sugary biscuits (and even cakes) as snacks. It is really beyond me, why this can not be changed to just fruit/fresh vegetables. In any case, I therefore set myself a challenge to work on a biscuit recipe that parents could use from 8 months of age. The reason I put 8 months is just to ensure that the baby has got the oral motor skills to manage it, so if your child is one of the more advanced baby lead “weaners”, then this could be consumed earlier, on the other hand, if your child’s oral motor skills are not quite there, then you may need to wait. Also note, this biscuit is NOT supposed to be sweet like the biscuits we eat, it just has the tinge of sweetness from the fruit added.

Ingredients:

  1. 1 cup of flour (you can easily use 1/2 cup of flour + 1/2 cup of nut flour if you are introducing nuts early as per new guidelines – speak to your healthcare professional)
  2. 50 g of butter (I use unsalted butter)
  3. 1/4 of a grated apple – this is where it becomes exiting, I just grated apple using a very fine grate (with the skin), but you could use pear, mashed banana and many other fruit. Depending on the moisture content of the fruit you may need to grate more or sometimes less
  4. 2 Tables spoons of skimmed milk powder
  5. Tip of a knife of vanilla powder – you can replace this with cinnamon or other spices that your toddler may like

 

Method:

  1. Heat oven to 180C
  2. Rub cold butter into flour mixture
  3. Grate in fruit – start with a small amount and feel with your fingers the density of the dough, it needs to end up like a pastry density
  4. Add the vanilla or other spices
  5. Leave in fridge for 30 min
  6. Roll in small finger sized biscuits (so that your to Toddler can hold them)
  7. Bake for 15 min – they keep for a good 2 weeks in a tinIMG_2643

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.

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.

Should a toddler be on a low fat high fibre diet?

This question does come up every now and again in my practice and I do often see young children on low fat yogurts, skimmed milk, very lean meat, only whole grain products and looking very skinny and often iron deficient. Firstly, I want to say that the suggestions I am making today, are for children that grow normally and where overweight and obesity is not a problem.

Fat is the most energy dense source of nutrition in our toddlers’s diets and does not only play an essential role in the development of the cell membranes of the organs (i.e. retina) and the central nervous system, but with a small stomach capacity plays an important role in achieving energy requirements. Do you remember expressing breast milk and being surprised at the thick fat layer when the breast milk separates out?  Well, almost half of the energy from breast milk comes from fat.  The World Health Organization recommends that breast feeding ideally should continue until 2 years of age, meaning also that they have requirements for higher fat until this age.

Of course there is fat, fat and fat. So breast milk is high in essential fatty acids and therefore an ideal source of fat. We also do not want young children to have a diet high in saturated fat (i.e. animal fat), but rather a mixture of different fats – olive oil, rapeseed oil, coconut oil, avocado oil and yes they can have real butter (remember that butter can be high in salt, so check this) as well. Its best though to provide a variety of fat as each type of fat has a different role.

When it comes to protein that often contributes to fat intake – ideally one should aim for 2 portions of oily fish per week, the rest white meat, white fish and pulses and limit red meat to twice per week. When it comes to milk products, in a child that grows normally the recommendation is to have full fat milk and products until 2 year of age and then you can consider changing this to semi-skimmed milk and lower fat milk products. Remember, that fat does not only contribute energy but some of the fat sources contain fat soluble vitamins like vitamin D, E and A and omega-3-fatty acids.

Now what about fibre content of foods. Should you give whole grain rice/pasta and bread from the time you start weaning? The exact amount of fibre young infants require is unclear, but we do know that excessive fibre leads to rapid gut transit time, meaning that the food moves faster through the gut and can reduce the time for absorption. In addition, too much fibre can bind essential vitamins and minerals and reduce the availability for absorption. It is therefore better to have a balanced approach as your toddler should already have 5 portions of fruit/vegetables per day which provides plenty of fibre. I usually suggest providing whole grain (not granary) bread from when they are able to finger feed and they can have Weetabix or other whole grain breakfast cereal from 7-8 months of age (make sure low in salt and sugar), but to wait for whole grain rice/pasta and other similar products until they are one year of age.

It has become a big fashion to add ground up flaxseed and other seeds to toddler meals, but remember flaxseed for example is very very high in fibre, so your child does not get the time to absorb the omega-3-fatty acids, so rather use the oil than the seeds themselves if you want to increase the omega-3-fatty acid intake.

 

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 !