Download Food and Nutrition Guidelines for Healthy Infants

Food and Nutrition
Guidelines for Healthy
Infants and Toddlers
(Aged 0–2)
A background paper
Draft for consultation
Citation: Ministry of Health. 2007. Food and Nutrition Guidelines for Healthy
Infants and Toddlers (Aged 0–2): A background paper: Draft for consultation.
Wellington: Ministry of Health.
Published in June 2007 by the
Ministry of Health
PO Box 5013, Wellington, New Zealand
ISBN 978-0-478-19148-6 (print)
ISBN 0-478-19149-3 (online)
HP 4395
This document is available on the Ministry of Health webpage:
http://www.moh.govt.nz/foodandnutrition
Contents
Introduction
1
Policy context
Food and nutrition for infants and toddlers
Structure of this background paper
Part 1: The New Zealand Food and Nutrition Guidelines
1.1
1.2
1.3
The New Zealand Food and Nutrition Guideline Statements for Healthy Infants and
Toddlers
Food groups and the nutrients they provide
Nutrient reference values for Australia and New Zealand
Part 2: Dietary Practices and Nutrient Intakes in New Zealand Infants
and Toddlers
2.1
2.2
2.3
2.4
2.5
Sources of data
Breastfeeding rates in New Zealand
Partial and artificial feeding rates in New Zealand
Dietary practices
Nutrient and energy intakes
Part 3: Breastfeeding
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
Background
Importance of breastfeeding
Composition of breast milk
Contraindications to breastfeeding
Support for breastfeeding
Cup feeding
Storing expressed breast milk
Practical advice for breast feeding
Part 4: Formula Feeding
4.1
4.2
4.3
4.4
4.5
4.6
Background
Types of formulae
Changing formulae
Preparing formula
Amount of formula
Practical advice for formula feeding
Part 5: Fluids
5.1
5.2
5.3
5.4
Background
Recommended fluid intakes
Recommended sources of fluid in the diet
Practical advice for fluids
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7
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30
30
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iii
Part 6: Complementary Feeding (Solids) and Joining the Family Diet
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
Age of introduction of complementary feeding
Risks of early introduction of complementary foods (before four months of age)
Risks of late introduction of complementary foods (after six months of age)
The developmental cues that signal readiness for the introduction of complementary
foods
Introducing complementary foods (solids) and progressing to family foods
Feeding the toddler
Practical advice for complementary feeding and joining the family diet
Practical advice for fussy eaters
Part 7: Considerations for Māori Infants and Toddlers and their
Whānau
7.1
7.2
7.3
7.4
Breastfeeding
Dietary practices
Nutritional issues
Traditional Māori foods: Nga tino kai a te Māori
Part 8: Considerations for Pacific and Other Population Groups,
Infants and Toddlers and their Families
8.1
8.2
8.3
35
35
36
37
37
38
45
45
46
48
48
48
49
49
51
Pacific
Fijian Indian
Asian
51
54
55
Part 9: Growth and Energy
58
9.1
9.2
9.3
Growth and rate of growth
Energy
Practical advice for growth and energy
Part 10: Nutrients
10.1
10.2
10.3
10.4
10.5
Protein
Carbohydrate, dietary fibre and prebiotics
Fat
Minerals and trace elements
Vitamins
Part 11: Physical Activity
11.1 Benefits
11.2 Practical advice for physical activity
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Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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64
65
65
67
70
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88
93
93
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Part 12: Other Issues
12.1
12.2
12.3
12.4
12.5
12.6
12.7
12.8
12.9
12.10
12.11
12.12
12.13
Pacifiers
Bottles and teats
Supplements
Food intolerance and food allergies
Colic
Constipation and diarrhoea
Probiotics
Gastric reflux
Vegetarian eating patterns
Overweight and obesity
Infant botulism
Food safety
Food security
94
94
96
97
98
105
105
106
107
108
109
111
111
112
Glossary
115
Abbreviations
121
Appendices
Appendix 1: Summary of the World Health Organization International Code of Marketing of
Breast-milk Substitutes (1981)
Appendix 2: World Health Organization and UNICEF Statement on the 10 Steps to
Successful Breastfeeding (1989)
Appendix 3: Ministry of Health Policy Context for Food and Nutrition Guidelines for Healthy
Infants and Toddlers (Aged 0–2): A background paper
Appendix 4: Reducing Health Inequalities Tools
Appendix 5: Priority Population Health Objectives in the New Zealand Health Strategy (2000)
Appendix 6: Key Population Health Messages Underpinning the Healthy Eating – Healthy
Action Strategic Framework and Implementation Plan
Appendix 7: Sample Meal Plans for Infants and Toddlers
Appendix 8: Nutrient Reference Values for Australia and New Zealand for Infants and
Toddlers
Appendix 9: Composition of Breast Milk and Cows’ Milk-based Formula Available in New
Zealand
Appendix 10: Ministry of Health Definitions of Breastfeeding
Appendix 11: Summary and Strength of Evidence of the Importance of Breastfeeding for
Infants
Appendix 12: Breastfeeding Support Organisations
Appendix 13: Health Education Resources Available from the Ministry of Health to Support
Breastfeeding, Infant Nutrition and Infant Health
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124
125
126
128
129
130
134
136
137
138
139
140
References
142
Submission Booklet
161
Submission Questions
163
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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List of Tables
Table 1:
Table 2:
Table 3:
Table 4:
Table 5:
Table 6:
Table 7:
Table 8:
Table 9:
Table 10:
Table 11:
Definitions of NRV recommendations
Breastfeeding rates (percent) by ethnicity at six weeks, three months and six months,
1997–2006
Mean nutrient intakes for infants from six to 12 months of age from the Dunedin study
Nutrient intake information for one- to four-year-old toddlers
Guidelines for storing expressed breast milk
Developmental cues that signal readiness for introduction of complementary foods
Order for introducing complementary foods and progressing to family foods
The four major food groups: examples of foods and nutrients for infants and toddlers
Estimated energy requirements (EERs) of infants and young children
Classification of the major dietary carbohydrates
Spectrum of iron deficiency
6
8
12
13
22
38
42
44
62
67
75
List of Figures
Figure 1:
vi
Intervention framework to improve health and reduce inequalities
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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Introduction
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2): A
background paper is one of a series of population group-specific background papers.
The population groups are healthy infants and toddlers, children, adolescents, adults,
older people, and pregnant and breastfeeding women.
This background paper has been written to:
•
provide evidence-based, up-to-date policy advice on nutrition and physical activity for
achieving and maintaining the best possible health for infants and toddlers
•
provide reliable, consistent information to use as a basis for programmes and
education to support families and children (for example, technical background for
health education resources for healthy infants and toddlers, District Health Board
programmes)
•
guide and support health practitioners (including dietitians, nutritionists, midwives,
doctors, nurses, primary health care providers, health promoters and teachers) in the
practice of healthy nutrition and to use as a resource for more detailed information if
required
•
provide a basis for preparing policies on protection, promotion and support of
breastfeeding, including compliance with the Baby Friendly Hospital Initiative (BFHI)
and the Baby Friendly Community Initiative (BFCI) for health care facilities
•
identify health inequalities relating to nutrition and physical activity so that education
and support for families and children can be targeted to reduce health inequalities
between population groups.
Policy context
In 2003, the World Health Organization (WHO) and the United Nations Children’s Fund
(UNICEF) jointly released the Global Strategy for Infant and Young Child Feeding to
encourage governments to focus on nutrition and its role in achieving health for this age
group. The strategy also renews global commitment to the BFHI and BFCI, the
International Code of Marketing of Breast-milk Substitutes (see Appendix 1) and the
Innocenti Declaration on the Protection, Promotion and Support of Breast-feeding,
which includes the Ten Steps to Successful Breastfeeding (see Appendix 2). The aim
of the Global Strategy is to improve through optimal feeding the nutritional status,
growth and development, health and thus survival of infants and young children (WHO
2003). This fourth edition of the background paper is part of New Zealand’s response to
the Global Strategy (Stewart 2006).
Food and nutrition guidelines for the New Zealand population are produced in the
context of Ministry of Health policies and strategies. Appendix 3 provides a concise
breakdown of the complete policy context of this paper.
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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He Korowai Oranga: Māori Health Strategy (Minister of Health and Associate Minister of
Health 2002) guides the health and disability sector response towards improving Māori
health. The framework helps ensure interventions, services or programmes are
accessible, effective and appropriate for Māori. He Korowai Oranga promotes a vision
of whānau ora, that is, a vision where whānau are supported to achieve maximum
health and wellbeing. The key pathways identified in achieving whānau ora are:
• whānau, hapu, iwi, community development
• Māori participation
• effective service delivery
• working across sectors.
Therefore, for nutrition activity to be implemented in a meaningful and sustainable way
for Māori, it is important to align outcomes, actions, interventions, programmes or
services with the four pathways framework and in doing so to help give effect to the
vision of whānau ora.
The Government has identified reducing inequalities for different groups of New
Zealanders as a key priority. Inequalities in health exist between socioeconomic
groups, ethnic groups, people living in different geographic areas and between males
and females. People living in the most deprived circumstances have been shown to
have increased exposure to health risks, reduced access to health and disability
services and poorer health outcomes. Health inequalities in New Zealand are greater
between Māori and non-Māori, and also between Pacific peoples and European/others.
Effective action to address inequalities in health must take a balanced approach. The
action must consider the impact of both the social and economic inequalities on health
and the access to and effectiveness of health and disability services. For this reason,
programmes, resources, education and support for families and children should be
planned and evaluated, using the reducing health inequalities tools (see Appendix 4).
The New Zealand Health Strategy (Minister of Health 2000) sets the direction and
priorities for the New Zealand health system (see Appendix 5). Three of these priorities
– improving nutrition, reducing obesity and increasing the level of physical activity – are
addressed in the Healthy Eating – Healthy Action (HEHA) Strategy (Ministry of Health
2003b) and Implementation Plan (Ministry of Health 2004a).
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2): A
background paper provides a policy base for implementing the key messages of HEHA
for this population group (see Appendix 6 for the key population health messages
underpinning HEHA). It also promotes breastfeeding, which contributes positively to
five of the 13 priority population health objectives in the New Zealand Health Strategy:
improving nutrition; reducing obesity; reducing the incidence and impact of cancer;
reducing the incidence and impact of cardiovascular disease; and reducing the
incidence and impact of diabetes.
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Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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Food and nutrition for infants and toddlers
During the first two years of life, infants and toddlers are entirely dependent on their
caregivers for providing them with nourishment. The first two years of life are also a
time of great nutritional change for the child, from a diet consisting entirely of milk (either
breast milk, infant formula or both) to one consisting of a variety of foods. Optimal
nutrition probably has a greater importance during this time of life than during any other
because of its effect on brain growth, development of the nervous system, overall
growth and development, and future health. Breastfeeding is well recognised for its
short-term benefits and for the more recent evidence of long-term benefits for infants
and toddlers (Fewtrell 2004, WHO 2007). These long-term protective effects appear to
be related to the duration and exclusivity of breastfeeding (Riordan 2005).
The influence of the in-utero environment on immediate and later health, especially for
iron status, is very important and is addressed in Food and Nutrition Guidelines for
Healthy Pregnant and Breastfeeding Women: A background paper (Ministry of Health
2006a), which complements this background paper.
While the paper provides recommendations specific to the age of infants, these
recommendations are intended as guidelines only and are based on the rate of
development of the ‘average’ infant. It should be remembered that there is wide
variation in the food and nutrition needs of individual infants and toddlers and in the
rates at which they develop. These recommendations should be applied with this in
mind.
The following definitions are used throughout these guidelines:
• an infant is a child in the first 12 months of life
• a toddler is a child in the second year of life.
Some of the information on nutrients and issues surrounding them are presented
individually, but, where possible, links have been drawn to highlight the holistic nature of
diet and lifestyle. Recommended numbers of servings of food from the four main food
groups have not been given. This is because milk (either breast milk or infant formula)
is the most important energy and nutrient source in the first year of life. Once
complementary foods and family foods are introduced, the emphasis for this age group
is growth and development, and on achieving a varied food intake, including food choice
and texture, and appropriate eating behaviours and patterns. The two three-day meal
plans given in Appendix 7 can be used as a guide to achieving the recommended
nutrient intakes for infants and toddlers given in Appendix 8 (Nutrient Reference Values
for Australia and New Zealand – Infants and Toddlers). The practical advice given in
each section is used as the basis for the related health education resources. These
resources are the primary means of communicating the advice to the public, with this
background paper acting as a source of more detailed information.
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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Structure of this background paper
•
Part 1: The New Zealand Food and Nutrition Guidelines presents the Food and
Nutrition Guideline statements and the background on the use of the Nutrient
Reference Values for Australia and New Zealand (NRVs) (NHMRC 2006).
•
Part 2: Dietary Practices and Nutrient Intakes in New Zealand Infants and
Toddlers discusses the sources of food and nutrient intake data for this paper,
breastfeeding rates, partial and artificial feeding rates, dietary practices, and nutrient
and energy intakes. This section also identifies the dietary practices of concern for
the age groups.
•
Part 3: Breastfeeding discusses the recommendations for duration of exclusive
breastfeeding and continued breastfeeding, the importance of breastfeeding for infant
and maternal health and provides guidelines for storing expressed breast milk.
•
Part 4: Formula Feeding presents advice on the appropriate preparation and use of
formula.
•
Part 5: Fluids discusses the recommended fluid intakes and sources of fluid. The
section gives advice on the use of water, cows’ milk as a drink and fruit juices and
sweet drinks.
•
Part 6: Complementary Feeding (Solids) and Joining the Family Diet discusses
the developmental cues that signal readiness for introduction of complementary
foods and the order for introduction and progression to family foods.
•
Part 7: Considerations for Māori Infants and Toddlers and their Whānau
discusses the specific nutritional issues for Māori and traditional Māori foods and
practices.
•
Part 8: Considerations for Pacific and Other Population Groups, Infants and
Toddlers and their Families discusses the specific nutritional issues for Pacific
peoples and some other ethnic groups.
•
Part 9: Growth and Energy discusses growth rate and assessment of growth and
the recommended energy intakes along with sources of energy in the diet.
•
Part 10: Nutrients considers the role that each of the major nutrients play in health.
The section discusses current and recommended dietary intakes in New Zealand,
identifies sources of various nutrients in the New Zealand diet and summarises the
evidence available on the topics covered. It makes suggestions that can form the
basis for practical advice for feeding healthy infants and toddlers. These suggestions
are intended as a guide only because the nutritional needs of individuals are
dependent on many factors.
•
Part 11: Physical Activity gives background information on the importance of
physical activity for development and refers the reader to SPARC for more
information on SPARC’s Active Movement programme for under fives.
•
Part 12: Other Issues discusses other issues, including food allergies, colic,
constipation and diarrhoea, and food safety.
4
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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Part 1: The New Zealand Food and Nutrition
Guidelines
1.1
The New Zealand Food and Nutrition Guideline Statements for
Healthy Infants and Toddlers
1.
Maintain healthy growth and development of the infant and toddler by providing
appropriate food and physical activity opportunities every day.
2.
Infants should be fed exclusively on breast milk to around six months of age with
continued breastfeeding up to two years or beyond.
3.
If the infant is not breastfed, then an infant formula should be used until one year
of age.
4.
When the infant is ready, appropriate complementary food should be introduced
and breastfeeding continued. The developmental cues should be used to
determine if the infant is ready. The infant will probably be ready at around six
months of age but some infants may be ready sooner. However, infants should
not be given complementary foods before four months of age.
5.
The variety of complementary foods should be increased to ensure an additional
intake of nutrients, especially iron and vitamin C. The infant should be eating
family foods by around one year of age.
6.
For infants, prepare or choose pre-prepared foods with no added fat, salt, sugar or
other sweeteners.
7.
Toddlers should be offered a variety of nutritious foods from each of the major
food groups each day, that is:
• vegetables and fruit
• breads and cereals, preferably wholegrain
• milk and milk products
• lean meat, poultry, seafood, eggs or alternatives.
8.
For toddlers, prepare foods or choose pre-prepared foods, drinks and snacks that:
• have minimal added fat, especially saturated fat
• are low in salt; if using salt, choose iodised salt
• have little added sugar (limit the intake of high-sugar foods).
9.
For toddlers, provide plenty of liquids each day, especially milk and water.
10. Infants and toddlers should not be given alcohol.
11. Purchase, prepare, cook and store food to ensure food safety.
The recommendations for healthy infants and toddlers are based on the New Zealand
Food and Nutrition Guideline Statements for Healthy Adults (see Ministry of Health
2003a).
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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5
1.2
Food groups and the nutrients they provide
The Food and Nutrition Guideline Statements for Healthy Infants and Toddlers refer to
breast milk, infant formula and the four major food groups. See Appendix 9 for the
composition of breast milk and infant formula. Table 8: The four major food groups
gives a description of each of the four major food groups in relation to infants and
toddlers’ requirements and provides a broad indication of the main nutrients supplied by
each food group. Not all of the foods within each group will contain all these nutrients.
Three-day meal plans have also been provided as examples of how to achieve these
guidelines, including the recommended dietary intakes (see Appendix 7).
1.3
Nutrient reference values for Australia and New Zealand
The nutrient reference values (NRVs) are presented as a set of recommendations, with
a range of levels, and include the recommended dietary intake (RDI).1 The NRVs are
defined in the following table.
Table 1:
Definitions of NRV recommendations
EAR (estimated average
requirement)
The median usual intake estimated to meet the requirement of half the
healthy individuals in a life stage/gender group. This value is usually used
for populations.
RDI (recommended
dietary intake)
The average daily dietary intake level sufficient to meet the nutrient
requirements of nearly all healthy individuals (97–98 percent) in a life
stage/gender group.
AI (adequate intake)
Determined when an EAR (and therefore an RDI) for a nutrient cannot be
determined because of limited or inconsistent data. The AI can be used
as a goal for individual intake but is based on experimentally derived
intake levels or approximations of observed mean nutrient intakes by a
group of apparently healthy people maintaining a defined nutritional state.
EER (estimated energy
requirement)
The average dietary energy intake that is predicted to maintain energy
balance in a healthy adult of defined age, gender, weight, height and level
of physical activity, consistent with good health. In children and pregnant
and lactating women, the EER is taken to include the needs associated
with the deposition of tissues or the secretion of milk at rates consistent
with good health.
UL (upper level of
intake)
The highest level of continuing daily nutrient intake likely to pose no
adverse health effects in almost all individuals.
Source: NHMRC 2006
The RDI, AI and UL recommendations have been used in this paper. Readers are
referred to the Nutrient Reference Values for Australia and New Zealand Including
Recommended Dietary Intakes (NHMRC 2006) for detailed information on how the
NRVs were derived.
1
6
The nutrient reference values (NRVs) for Australia and New Zealand (NHMRC 2006) supersede the
1990 Australian Recommended Dietary Intakes (Australian RDIs) (Truswell et al 1990), which had
been used in New Zealand since their adoption in 1991. This background paper for healthy infants
and toddlers uses the NRV values.
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
Draft for consultation
Part 2: Dietary Practices and Nutrient Intakes in New
Zealand Infants and Toddlers
2.1
Sources of data
There are no national data on the dietary practices and nutrient intakes of young New
Zealanders from birth to two years of age. Of the published data, it is difficult to make
generalised assumptions about dietary practice and nutrient intakes. The studies have
used different methods to collect dietary data and have been conducted on regional or
selective population groups. However, there are a number of regional studies and
published papers that enable us to draw some indicative conclusions about dietary
practices and nutrient and energy intakes, and these studies have been referenced in
the text.
2.2
Breastfeeding rates in New Zealand
In New Zealand data, breastfeeding rates have not changed greatly in the eight-year
period from 1997 to 2006. Table 2 shows the breastfeeding percentage rates from
1997 to 2006 with a comparison of the target percentage rates for 2007/08.
Breastfeeding data are collected by Lead Maternity Carers (LMCs) and Well Child
providers. The six-week, three-month and six-month rates reported for New Zealand
are based on data from Plunket. The Plunket data cover approximately 90 percent of all
births. Limitations of these data include incomplete coverage of all births and
population groups.
The data are reported as being exclusive and full because the definitions for both these
terms mean that the infant is likely to be meeting their nutritional requirements and
receiving significant benefits from breast milk.
The definitions of the terms used to describe breastfeeding in Table 2 are as follows:
•
Exclusive: The infant has never, to the mother’s knowledge, had any water, formula
or other liquid or solid food. Only breast milk, from the breast or expressed, and
prescribed2 medicines have been given from birth.
•
Full: The infant has taken breast milk only, and no other liquids or solids except a
minimal amount of water or prescribed medicines, in the past 48 hours.
•
Partial: The infant has taken some breast milk and some infant formula or other solid
food in the past 48 hours.
•
Artificial: The infant has had no breast milk but has had alternative liquid such as
infant formula, with or without solid food, in the past 48 hours (Ministry of Health
2002a).
2
Prescribed as per the Medicines Act 1981.
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Table 2:
Breastfeeding rates (percent) by ethnicity at six weeks, three months and six
months, 1997–2006
Exclusive and full
breastfeeding at six
weeks
Target rate 2007/08
74 percent
Exclusive and full
breastfeeding at
three months
Target rate 2007/08
57 percent
Exclusive and full
breastfeeding at six
months
Target rate 2007/08
27 percent
Year
Māori
Pacific
Asian
New Zealand
European/Other
All
1997
54
54
67
1998
56
60
69
1999
57
56
69
2000
57
57
68
65
2001
55
57
68
65
2002
59
61
68
66
2003
62
62
49
71
67
2004
60
59
55
71
67
2005
58
58
58
71
66
2006
59
57
55
70
66
1997
36
41
53
1998
40
46
53
1999
40
43
56
2000
40
45
56
50
2001
41
43
56
51
2002
47
50
58
55
2003
46
49
49
59
55
2004
47
49
51
60
56
2005
45
48
52
60
56
2006
45
48
53
60
55
1997
12
13
19
1998
14
17
19
1999
13
18
19
2000
13
17
20
18
2001
13
17
21
19
2002
16
20
25
23
2003
16
19
20
26
23
2004
18
20
22
27
24
2005
18
19
23
28
25
2006
17
19
25
29
25
51
Source: Plunket data
In April/May 2005, the sudden infant death syndrome (SIDS) study was carried out to
assess knowledge of SIDS risk factors and infant care practices of 200 mothers with
infants from two age groups (6 to 8 weeks and 3 to 4 months) in Auckland. The
ethnicities of the respondents were: 60 percent European, 4 percent Māori, 10 percent
Pacific (mostly of Sāmoan, Tongan, Niuean or Cook Islands origin), 21 percent other
ethnicity and 4 percent not stated (Hutchison et al 2006).
8
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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The study showed that 97 percent of the infants had been breastfed at some time, while
84 percent in the younger age group and 75 percent in the older group had been
breastfed in the last 24 hours.
Abel et al published the Infant Care Practices study in 2001 (Abel et al 2001). This
qualitative study described and compared the infant care practices and beliefs of
150 Māori, Tongan, Sāmoan, Cook Islands, Niuean and Pākeha (European) primary
caregivers of infants under 12 months residing in Auckland, New Zealand. The study
focused on four factors – source of support and advice; infant feeding; infant sleeping
arrangements and traditional practices and beliefs. Similarities were found across all
ethnic groups in the perceived importance of breastfeeding and in terms of the
difficulties experienced in establishing and maintaining this practice. Breastfeeding was
one of the areas on which there was most consensus among ethnic groups. Most
women were keen to breastfeed because of the perceived physical and emotional
benefits for them and their infant.
All but a few of the 150 participants had attempted to breastfeed. Many had been
successful and had fed for several months or were still feeding at the time of the study.
Factors affecting continued breastfeeding included difficulty in establishment of
breastfeeding; cracked and sore nipples; breast engorgement; and the perception of not
having enough milk. Confusion caused by inadequate and conflicting advice from
professionals and in some cases from relatives presented another barrier to continued
breastfeeding.
2.3
Partial and artificial feeding rates in New Zealand
In 2003, around 9 percent of all infants were artificially (formula) fed by two weeks of
age (Ministry of Health 2006b). In 2005, from Plunket data, the rate of artificial feeding
for all infants was around 18 percent at six weeks, 29 percent at three months and
40 percent at six months, and these rates had not changed between 2003 and 2005.
The rates of artificial feeding for Māori infants were the highest for all ages (25 percent
at six weeks, 37 percent at three months and 49 percent at six months). These rates
were followed by the rates for Pacific infants, then the rates for New Zealand European/
Other and Asian infants, which were similar. The rates for New Zealand European/
Other and Asian infants show a slow downward trend. The rates for 2006 show a
reduction in artificial feeding rates for Māori and New Zealand European/Other, and a
reduction for all infants to 17 percent at three months, and 35 percent at six months.
2.4
Dietary practices
Overall, the literature suggests that many infants in New Zealand are:
•
not breastfed long enough
•
introduced to complementary foods earlier than four months of age (with one of the
main reasons given by mothers for the early introduction of complementary foods
being not having enough breast milk (Heath et al 2002a))
•
introduced to cows’ milk as a drink before one year of age (Simons 1999; Ford et al
1995; Wham 1996; Soh et al 2002; Heath et al 2002b; Grant et al 2003)
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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9
•
consuming foods that are considered inappropriate before one year of age, such as
regular breakfast cereals(for example, muesli, Cornflakes and Cocoa Pops) (Simons
1999), and salted/sweetened snacks (Grant et al 2003).
The literature also suggests that many toddlers are:
• not eating enough vegetables and fruit (Ministry of Health 2001)
• not eating enough meat and alternatives, and milk and milk products (Ministry of
Health 2001).
2.4.1
Introduction of complementary foods
A study of 72 European infants from Dunedin (Simons 1999) found that the median age
that infants began eating complementary foods was five months. Thirty-five percent of
infants consumed solid foods before four months of age. Formula-fed infants received
complementary foods earlier than breastfed infants. There was a different pattern of
nutrient intake for those who were breastfed longer, suggesting differences in both
timing and type of complementary foods.
One study (Tuohy et al 1997) found that Māori and Pacific peoples were more likely
than Europeans to introduce complementary foods before six months of age.
The FSANZ qualitative research (FSANZ 2004) reported that the majority of New
Zealand parents introduced their infants to complementary foods at four months or just
before. New Zealand parents were likely to refer to the target as an age range of four to
six months, although they acknowledged that six rather than four months was
recommended. Across the New Zealand groups, participants were much more familiar
with the physiological cues, such as the tongue extrusion reflex, that indicate a infant’s
readiness for complementary foods than were participants in Australia.
2.4.2
Introduction of cows’ milk as a drink
In the Dunedin study (Simons 1999), 8 percent of infants were given cows’ milk before
six months of age, 25 percent before eight months of age and 50 percent before one
year of age. Exclusive breastfeeder mothers introduced their infants to cows’ milk as a
drink at 10 months of age, formula feeders at 11½ months of age and partial
breastfeeders at nine months of age.
2.4.3
Introduction of cereals
In the Dunedin study (Simons 1999), 65 percent of infants received infant cereals as
their first food, with the remaining 35 percent starting with puréed fruits or vegetables.
Regular breakfast cereals (for example, Weetbix, cooked porridge, muesli, Cornflakes
and Cocoa Pops) were consumed by 42 percent before eight months and by 75 percent
of infants in the first year of life.
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2.4.4
Dietary patterns of toddlers
The pilot for the Children’s Nutrition Survey (CNS) (Ministry of Health 2001) gives some
indication of the dietary patterns of children aged one to four years. The pilot for the
CNS included two age groups: 91 children aged one to four years and 92 children aged
five to 14 years. The information reported here is for the children aged one to four
years. The children were recruited from south and west Auckland, Fielding and
Shannon.
The majority of children consumed a normal mixed diet, including a variety of all foods
(90 percent). Most children ate adequate quantities of cereals. Fifty-three percent ate
less than the recommended number of servings of vegetables (two servings),
26 percent ate less than the recommended servings of fruit (two servings), 20 percent
ate less than the recommended servings of meat and alternatives (one serving) and
16 percent ate less than the recommended servings of milk and milk products (two
servings). Takeaways were consumed by 13 percent of subjects between two and four
times a week.
When asked about the types of foods that they usually consumed, around 72 percent of
children (or their caregivers) said they ate white bread. The next most popular bread
was wholemeal. Standard homogenised milk was drunk by between 70 and 80 percent
of all children, with reduced fat (light blue top) being the next most preferred. Weetbix,
being consumed by around 35 percent of all children, was the most common cereal
eaten, with Cornflakes and Rice Bubbles coming next. Around 90 percent of children
used a fat spread on bread. Butter and margarine blends, and polyunsaturated
margarines were the most popular fat spreads used.
The most disliked foods, listed in order of ranking, were broccoli, pumpkin, tomato,
mushroom, peas, onion and beetroot. The most liked foods were McDonalds, pizza,
chips, ice cream, chocolate, pies, burgers, fish, bananas and lollies. The reasons given
for liking or disliking a food varied, although taste and flavour were most commonly
given as reasons. The foods and the reasons for liking or disliking them were given by
the children.
2.4.5
Intake of dietary supplements
In the CNS pilot (Ministry of Health 2001), only one child took fluoride tablets, while
between 15 and 16 percent of children took vitamin and mineral tablets and around 5 to
6 percent took herbal or food supplements. Using the CNS pilot data, Crowley and Wall
concluded that dietary supplement use was low, with 9.8 percent of children reporting
taking supplements (Crowley and Wall 2004). Of the children taking supplements,
young children and New Zealand European/Others children demonstrated higher levels
of supplement intake. The most commonly consumed supplements were multi-vitamins
and vitamin C alone or in combination with herbals or other vitamins.
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2.5
Nutrient and energy intakes
Table 3 shows the mean daily nutrient intakes of European infants from 6 to 12 months
of age from the Dunedin study (Simons 1999). Table 4 shows nutrient intake
information for one- to four-year-old toddlers (Ministry of Health 2001; Soh et al 2002;
Weber 1997).
These tables, using intake data from regional studies, do not raise concerns about the
nutrient intakes for these population groups. See Part 10 for a more detailed discussion
on specific nutrients and nutritional status.
Table 3:
Mean nutrient intakes for infants from six to 12 months of age from the Dunedin
study
Nutrient
Energy, macronutrients
and dietary fibre
Energy (kJ)
Protein (g)
Carbohydrate
Dietary fibre (g)
Fat (g)
Minerals
Calcium (mg)
Zinc (mg)
Iron (mg)
Magnesium (mg)
Selenium (μg)
Sodium (mg)
Fat-soluble vitamins
Vitamin A (μg RE)
Vitamin D (μg)
Vitamin E (mg α-TE)
Vitamin K (μg)
Water-soluble vitamins
Thiamin (mg)
Riboflavin (mg)
Niacin (mg NE)
Vitamin B6 (mg)
Vitamin B12 (μg)
Folate (μg)
Pantothenic acid (mg)
Biotin (μg)
Vitamin C (mg)
Choline (mg)
Breastfed infants
Non-breastfed infants
6 months
of age
9 months
of age
12 months
of age
6 months
of age
9 months
of age
12 months
of age
3564
17
–
5
27
5364
41
–
10
39
6142
50
–
15
48
5292
41
–
6
25
6411
45
–
14
34
7641
61
–
17
55
1209
3.5
32
125
16
1396
977
6.0
16
216
25
1600
672
3.0
21
128
5
8744
1209
4.1
21
209
11
1888
977
6.7
12
230
26
2315
1290
10
2
1731
19
4
1701
7
4
943
9
3
1858
10
4
1168
4
3
–
–
–
–
–
–
–
–
4
–
–
47
–
5
85
–
–
–
9
–
–
103
–
14
132
–
–
–
16
–
–
154
–
23
162
–
–
–
6
–
–
78
–
9
75
–
–
–
9
–
–
106
–
16
214
–
–
–
19
–
–
178
–
30
131
–
672
2.2
11
56
11
310
Source: Simons 1999
Note: – = not measured.
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The intakes for the breastfed infants include the nutrients from breast milk and
complementary foods. The figures used for breast milk intake in grams per day were
813 g at three months of age, 769 g at six months of age, 646 g at nine months of age
and 448 g at 12 months of age.
Table 4:
Nutrient intake information for one- to four-year-old toddlers
Nutrient
1–4 years of age*
Girls
Boys
Energy, macronutrients and dietary
fibre
Energy (kJ)
Protein (g)
% energy from protein
Carbohydrate
% energy from carbohydrate
Dietary fibre (g)
Fat (g)
% energy from fat
5228
47
–
172
–
11
42
–
4763
43
–
141
–
9
39
–
Minerals
Calcium (mg)
Zinc (mg)
Iron (mg)
Magnesium (mg)
Selenium (μg)
Sodium (mg)
473
6.0
8
–
22
1387
505
7.4
6
–
22
1360
Fat-soluble vitamins
Vitamin A (μg RE)
Vitamin D (μg)
Vitamin E (mg α-TE)
Vitamin K (μg)
Water-soluble vitamins
Thiamin (mg)
Riboflavin (mg)
Niacin (mg NE)
Vitamin B6 (mg)
Vitamin B12 (μg)
Folate (μg )
Pantothenic acid (mg)
Biotin (μg)
Vitamin C (mg)
Choline (mg)
1–2 years of age+
4200
–
14
–
52
–
13–26 months of age#
34
4800
45
–
–
–
–
43
–
704
–
5
–
–
–
–
–
–
–
–
–
–
407
1
4
418
1
4
–
–
–
–
–
–
–
–
–
–
1
1
19
1
3
121
–
–
51
–
1
1
17
1
3
138
–
–
54
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
* Ministry of Health 2001
+ Soh et al 2002
# Weber 1997
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Part 3: Breastfeeding
3.1
Background
Breastfeeding is an unequalled way of providing ideal food for the healthy growth and
development of infants and toddlers. Breast milk is safe, clean and contains antibodies
that help protect the infant against many common childhood illnesses. No matter how
appropriate infant formula may be from a nutritional standpoint, feeding with formula
remains a deviation from the biological norm for virtually all infants when they are not
breastfed or are breastfed only partially.
Breastfeeding forms a unique biological and emotional basis for the health of both
mother and child and plays an important and central role in protecting the health of the
infant and promoting physical, neurological and emotional development both in the short
term and long term (Fewtrell 2004, WHO 2007). These long-term protective effects
appear to be related to the duration and exclusivity of breastfeeding (Riordan 2005).
Breastfeeding is very important in the first six months of life, and its importance
continues into toddlerhood. It is recommended that infants be fed exclusively on breast
milk from birth to around six months of age. After that time, appropriate complementary
foods should be introduced and breastfeeding continued up until two years of age or
beyond (WHO 2003).
Exclusive breastfeeding means that only breast milk, from the breast or expressed, and
prescribed medicines have been given from birth (see Appendix 10 for the Ministry of
Health definitions of breastfeeding). The protective effect of breastfeeding on infant and
maternal health is enhanced with greater exclusivity of breastfeeding (WHO 2002).
Exclusively breast fed infants can meet their fluid requirements with breast milk and do
not need fluids other than breast milk. The provision of water and other fluids reduces
the intake of breast milk, and the infant will be less likely to meet its energy demands.
Exclusive breastfeeding protects the infant from infection by eliminating the exposure to
food or waterborne pathogens and by supplying several compounds which improve the
infant’s ability to resist infection.
After six months of age breast milk alone may not be sufficient for satisfactory growth
and development (Butte et al 2000). Provided that the infant is allowed to breastfeed on
demand, breast milk remains a major source of nutrients throughout the first year of life,
even after complementary foods have been introduced.
Supplementing breastfeeding with formula should be strongly discouraged because this
reduces the breast milk supply by reducing sucking at the breast and diminishing
maternal production of the hormone prolactin (Royal College of Midwives 1991). A
breastfeeding mother who is considering supplementing breast milk with infant formula
to settle an infant should be given advice on settling the infant in other ways. This
should include advice on increasing her supply of breast milk or introducing appropriate
complementary foods if the infant is developmentally ready. See Table 7: Order for
introducing complementary foods and progressing to family foods for a list of
appropriate complementary foods.
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Infants who received infant formula at any time in the first month, irrespective of
quantity, are more than three times more like to cease breastfeeding early, and the use
of a bottle in the first month is associated with more than doubling the probability of
early cessation of breastfeeding (Vogel and Mitchell 1998).
3.2
Importance of breastfeeding
On balance, the published research confirms the importance of breastfeeding and the
increased risks to children of not being breastfed. Positive effects of breastfeeding on
the health of mothers and infants are observed in all settings.
3.2.1
Reasons for breastfeeding
The following is a list of the reasons why breastfeeding is important. See Appendix 11
for a summary of the strength of evidence for the importance of breastfeeding for infants
and the supporting references.
1
Breastfeeding provides optimum nutrition for infants
Breastfeeding meets the full-term infant’s complete nutritional needs for up to the first
six months of life. Provided the infant is allowed to breastfeed on demand, breast milk
can be a major source of nutrients throughout the first and second years of life, after
complementary foods have been introduced. A longer duration of breastfeeding has
been linked to reducing the risk of childhood chronic illness, obesity and improving
cognitive outcomes, although causality has not been established.
Breastfeeding provides breast milk that is always at the right temperature, readily
available and microbiologically safe; and allows for the infant to self-regulate feeding.
Breast milk:
•
varies in composition during lactation and even during a single feed to meet the
child’s individual and varying appetite and thirst, and hence nutrition and fluid
requirements
•
contains many beneficial bioactive components such as immunoglobulins, probiotics,
prebiotics, enzymes, and hormones that assist in gut maturation, physiological
development and immunity
•
contains optimal ratios of polyunsaturated fatty acids required for retinal and brain
development, along with taurine for fat absorption
•
provides nutrients in a form that is superior to that of infant formulae in terms of
digestibility and bio-availability (for example, protein, calcium and iron).
2
Breastfeeding assists physical and emotional development
Breastfeeding:
• encourages emotional attachment for both mother and infant
• promotes correct development of jaws, teeth and speech patterns
• may have small long-term benefits for child cognitive development and visual acuity.
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3
Breastfeeding decreases the incidence and severity of childhood infectious diseases
Breastfeeding decreases the incidence of:
• otitis media
• acute respiratory infections
• diarrhoea and gastroenteritis, especially in less than optimal environments
• urinary tract infection
• sepsis and meningitis.
4
Breastfeeding is associated with reduced infant mortality and hospitalisation
Breastfeeding is associated with reduced mortality during the first year of life and lower
hospitalisation rates. Breast milk is especially important for low birthweight infants as it
reduces mortality associated with necrotising enterocolitis and offers advantages in
cognitive function. Breastfeeding reduces the risk of sudden infant death syndrome
(SIDS)/sudden unexpected infant death (SUDI).
5
Breastfeeding may reduce the risk of chronic diseases for infants in later life
Breastfeeding may reduce the risk of:
• overweight and obesity
• cardiovascular disease
• high blood pressure
• food allergies in those with a family history of food allergies
• eczema and asthma
• childhood cancers, including childhood acute leukaemia and lymphoma
• coeliac disease in children at increased risk for the disease
• Crohn’s disease and ulcerative colitis
• gastroesophageal reflux
• Type 1 diabetes and Type 2 diabetes.
Note that there are limitations around studies that link breastfeeding to reduced risk of
chronic diseases such as obesity. The evidence is stronger for a link between
breastfeeding and adolescent obesity than childhood obesity. It can be difficult to
demonstrate a causal relationship between breastfeeding and the risk of chronic
disease, in part because of the lack of experimental studies. There are a large number
of potential confounding factors, including infant gestational age, gender, ethnicity and
birth weight, number of siblings, maternal weight or body mass index, maternal
smoking, socioeconomic status, post-infancy diet and physical activity behaviours.
Other factors include variations in the numbers of subjects and statistical power,
differences in the definitions of obesity and exclusivity of breastfeeding and/or formula
feeding, and differences in method.
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6
Breastfeeding may help foster child safety
Breastfeeding may reduce the risk of:
• abuse and neglect
• abandonment
• physical and sexual abuse.
Breastfeeding is also important for the mother’s health because it:
•
provides emotional and physical satisfaction
•
enhances self-esteem in the maternal role (American Dietetic Association 2005)
•
enhances the mother-infant relationship, which is important for healthy child
development
•
may help return the mother to her pre-pregnancy weight (Dewey 2004)
•
helps to protect a mother’s iron status by minimising postpartum maternal blood loss
(Dewey et al 2001; NHMRC 2006)
•
reduces the risk of postpartum haemorrhaging
•
speeds up involution of the uterus after birth (Chua et al 1994; Dewey et al 1993)
•
has a 98 percent contraceptive effect in the first six months after the infant’s birth,
provided the infant is exclusively breastfed on demand and the mother does not
resume menstruation (Guillebaud 1991; Kennedy et al 1989)
•
reduces the risk of premenopausal breast cancer (Byers et al 1985; France 1996;
Zheng et al 2001; Collaborative Group on Hormonal Factors in Breast Cancer 2002)
•
reduces the risk of ovarian cancer (Riman et al 2004; Tung et al 2003)
•
possibly reduces the risk of osteoporosis and hip fracture in later life (Karlsson et al
2005)
•
is environmentally friendly, using only the mother’s natural resources and therefore
producing no manufacturing or consumer waste
•
may inspire healthier choices, such as ceasing smoking, quitting recreational drugs
or improving nutrition
•
requires no preparation before the feed
•
has economic benefits for the household.
3.2.2
Rationale for continued breastfeeding beyond the first year of life
Breastfeeding continues to make an important nutritional and health contribution well
beyond the first year of life (Brown et al 1998). It promotes normal growth and
development, and protects the infant from acute and chronic illnesses.
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17
Breast milk provides energy, essential fatty acids and fat-soluble vitamins. Many of the
anti-microbial constituents of human milk, for example, secretory IgA, are still present in
considerable amounts in the second year of lactation, so breastfeeding continues to
offer some immunological benefits into childhood (Goldman et al 1983; Oddy 2001;
Piovanetti 2001). It has been found that breast milk intake is often desirable during
episodes of diarrhoea and fever when appetite for other foods decreases, and it is
useful in such instances for preventing dehydration and providing essential nutrients for
recovery. Breast milk may provide additional protection for children with allergies.
The reduction in risk of chronic disease in later life appears to be related to the duration
and exclusivity of breastfeeding (Riordan 2005).
Breastfeeding enhances the mother and infant relationship and promotes neurological
development, both of which are important for child development (American Academy of
Pediatrics 1997).As duration of breastfeeding increases, the risk for hip fractures in the
mother decreases in a dose related relationship (Riordan 2005). Sustained
breastfeeding supports weight loss and healthy weight achievement in mothers
(Riordan 2005). A longer duration of breastfeeding is associated with a delay in natural
fertility (Labbok 2001).
3.3
Composition of breast milk
The breast milk produced during the first few days after birth is called colostrum, which
is a milk rich in antibodies. It has a greater proportion of protein, minerals and fatsoluble vitamins but less fat than mature breast milk. From approximately seven to
10 days after birth until two weeks after birth the breast produces transitional milk, which
has higher lactose, fat and energy content than colostrum. The breast then produces
mature milk, in which the water and fat content increases until it reaches a plateau at
about three months (Lawrence and Lawrence 2005).
There can be significant variations in breast milk composition between mothers and
even between samples from the same mother. The fat, carbohydrate, protein, energy,
vitamin, immunoglobulin and mineral levels of breast milk vary throughout lactation as
well as during a feed. It is difficult, therefore, to give the precise nutritional content of
breast milk, although average values of composition for mature breast milk are
available. Appendix 9 offers a breakdown of the composition of breast milk and cow’s
milk (whey) based formula available in New Zealand.
When the infant suckles, they receive foremilk followed by hindmilk. Hindmilk has a
higher protein and fat content than foremilk. It is important, therefore, neither to impose
restrictions on the length of time the infant suckles nor to restrict the infant to only one
breast per feed. If the infant is still hungry after feeding from one breast, then the other
breast should be offered. If only one breast is taken at a feed, then the other breast
should be offered first at the next feed. If both breasts are used during a feed, then the
next feed should start on the breast used last at the previous feed. In this way, both
breasts will receive equal stimulation to produce milk and will be drained equally by the
infant’s sucking, which reduces the risk of engorgement and mastitis (Royal College of
Midwives 1991).
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3.4
Contraindications to breastfeeding
There are very few true contraindications to breastfeeding, but they may include the
following.
3.4.1
Conditions affecting the mother
•
Medications may be passed to the infant through the breast milk to a varying extent,
however, almost all drugs are secreted in breast milk. The infant should be carefully
observed, or in the case of unsafe medications, the infant should not be breastfed.
Drugs that the infant has been exposed to throughout pregnancy, such as medication
for epilepsy, are not likely to add much additional risk when ingested via breast milk.
Practitioners are referred to the Drug Information Centres in the main cities in New
Zealand. Recognised online references such as the Medsafe website
(http://www.medsafe.govt.nz) can be consulted for information on prescribing
medication during breastfeeding.
•
If the mother has temporarily stopped breastfeeding while taking a course of
medicine and wants to reintroduce breastfeeding after the medicine is finished, she
should continue to express breast milk and discard it. If breastfeeding is stopped
suddenly, then there is a risk that the mother may develop mastitis. She will need
careful guidance on how to reduce her breast milk supply to avoid this.
•
Mothers with breast cancer that is detected during pregnancy should not breastfeed
(Lawrence and Lawrence 2005).
•
Mothers with HIV should not breastfeed (Ministry of Health 1999).
•
Mothers with untreated tuberculosis or local infectious lesions affecting breast skin,
such as herpes simplex, should not breastfeed (Croxson et al 1997, American
Academy of Pediatrics 2005)
•
Mothers who are hepatitis B positive can breastfeed provided the infant has had
hepatitis B immunoglobulin immediately after birth and has begun a course of
hepatitis B immunisation.
3.4.2
Conditions affecting the infant
•
Very rare metabolic conditions such as galactosaemia. Galactosaemia is a rare
inherited condition in which the infant is unable to metabolise galactose effectively.
•
Infants with a physical disability, such as a cleft lip, cleft palate or cerebral palsy, may
have difficulty sucking at the breast because they are unable to form an airtight seal
around the breast or have a poor sucking response. However, even if they are
unable to breastfeed, they can still be fed expressed breast milk. Mothers of these
infants may need extra support and assistance to enable them to breastfeed, either
directly or with expressed breast milk.
•
Sick infants in intensive care require an individualised feeding plan, and breast milk
should be used to whatever extent possible. Efforts should be made to sustain
maternal milk production by encouraging the mother to express breast milk and
resume breastfeeding when the infant has recovered. Should re-lactation be
required, the mother is likely to need intensive support from health practitioners.
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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19
•
3.5
Severe dehydration and malnutrition, including infant feeding in emergencies, may
require temporary feeding with infant formula until breast milk production is
re-established.
Support for breastfeeding
Studies on attitudes to breastfeeding indicate that decisions on infant feeding tended to
have been made before birth (Basire et al 1997; Heath et al 2002a). For many women,
breastfeeding was more difficult than anticipated, and most women needed help with
common problems. Those women who enjoyed and were supported in breastfeeding
tended to continue. Many women experienced considerable pressure to breastfeed,
and many felt guilty about bottle feeding (Basire et al 1997). Studies have concluded
that non-judgemental attitudes to infant feeding and support for both breastfeeding and
bottle feeding are essential for successful infant feeding (Basire et al 1997; Ryan 1997).
There is a general need for a more supportive breastfeeding environment in New
Zealand (Essex et al 1995). Support from fathers/partners and employers should be
encouraged to help breastfeeding rates. Such support should include the provision of
areas to express and store breast milk, crèche facilities and flexible working hours.
See Appendix 12 for a list of organisations that provide support for breastfeeding in New
Zealand. The Ministry produces a series of health education resources to support
breastfeeding, infant nutrition and infant health. These resources are listed in
Appendix 13.
The Ministry of Health aims to protect, promote and support breastfeeding in its work,
and the policy context given in Appendix 3 illustrates that work. In response to the
International Code of Marketing of Breast-milk Substitutes (the International Code)
(WHO 1981), the Ministry of Health has developed a code of practice to assist health
workers in applying the International Code in New Zealand (Ministry of Health 1997).
The New Zealand Infant Formula Marketers’ Association has developed a code of
practice for marketing infant formula in New Zealand (NZIFMA 1997).
3.6
Cup feeding
If the mother is temporarily unable to breastfeed, then expressing breast milk is
recommended. Cup feeding is an alternative to the bottle and teat method of feeding
expressed breast milk and other fluids to infants.
Cup feeding has benefits over using a bottle and teat. The infant can pace its own
intake, making breathing easier to control, and swallowing occurs when the infant is
ready (Lang 1994). The cup must be held so that the milk is just touching the infant’s
lips and is not poured into its mouth. Cup feeding fosters early positive body and eye
contact. Another benefit may be that the infant does not have to cope with a nipple or
teat in its mouth. UNICEF promotes cup feeding as a more appropriate infant feeding
method for expressed breast milk than the bottle and teat. However, it remains a
controversial practice for infants who have immature or impaired suck or swallow
co-ordination because of prematurity or other reasons.
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Health practitioners should be able to teach a breastfeeding mother how to feed her
infant expressed breast milk using a cup.
From the second six months of life onwards, an infant may be able to hold a feeding
cup, but the cup must be placed within the infant’s reach, and the caregiver must keep it
filled. Alternatively, a normal cup can be used, but the infant or toddler will need help to
hold the cup when drinking from it.
3.7
Storing expressed breast milk
Hands should be washed before expressing breast milk. Once expressed, breast milk
can be stored in a plastic or glass container with an airtight sealed lid, for example, a
food storage container or bottle. The container should be dated at the time of collection,
and the caregiver should always ensure that the oldest milk is used first (Lawrence and
Lawrence 2005). The milk should be stored in small portions to prevent waste, around
60–120 ml.
Containers and feeding equipment should be sterilised before each use until the infant
is three months old. Sterilising equipment and tablets to make sterilising solution are
available from supermarkets and pharmacies. The manufacturers’ instructions must be
followed carefully.
In the case of refrigerating or freezing breast milk after expressing, each time breast
milk is frozen, it should be stored in a different container rather than being added to
previously frozen breast milk. Adding expressed breast milk to frozen milk can cause
the milk to thaw and then refreeze, which can increase the risk of bacterial growth in the
milk.
Guidelines for storing expressed breast milk (EBM) under different storage conditions
are shown in Table 5. Note these guidelines are for EBM fed to healthy, full-term
infants living in the home and the community.
Thaw frozen breast milk in the refrigerator or by placing the container in warm water
until thawed.
Expressed breast milk should be warmed by placing the cup or bottle containing the
EBM in hot water. The temperature of the EBM should always be tested before the
EBM is given to the infant by shaking a few drops onto the inside of the wrist. The
formula should feel comfortably warm to the touch.
Before feeding, caregivers must always thoroughly shake the bottle containing the
formula then test the temperature as above, before feeding.
Expressed breast milk should not be heated using a microwave oven as this can
destroy some of the immunological components (Sigman et al 1989).
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Table 5:
Guidelines for storing expressed breast milk
Storage conditions
Storage time
Room temperature (< 26ºC)
2 hours
Refrigerated
48 hours
Frozen:
•
Freezer box in refrigerator
2 weeks
•
Separate door fridge/freezer
3 months to 6 months
•
Separate deep freeze
6 months to 12 months
Sources: Hamosh et al 1996; Bjorksten et al 1980; Pardou et al 1994; Lawrence and Lawrence 2005;
American Dietetic Association 2007
3.8
Practical advice for breast feeding
•
Infants should be fed exclusively on breast milk to around six months of age, with
continued breastfeeding up to two years of age or beyond.
•
When the infant is ready, appropriate complementary food should be introduced and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready. The infant will probably be ready at around six months of age but
some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
Supplementing breastfeeding with formula should be strongly discouraged. A
breastfeeding mother who is considering supplementing breast milk with infant
formula to settle an infant should be given advice on settling the infant in other ways.
This should include advice on increasing the mother’s supply of breast milk or
introducing appropriate complementary foods if the infant is developmentally ready
(see Table 7: Order for introducing complementary foods and progressing to family
foods).
•
Breastfeeding advice should include advice not to restrict the length of time the infant
suckles or to restrict the infant to only one breast per feed. If the infant is still hungry
after feeding from one breast, then the other breast should be offered. If only one
breast is taken at a feed, then the other breast should be offered first at the next
feed. If both breasts are used during a feed, then the next feed should start on the
breast used last at the previous feed.
•
If feeding expressed breast milk, try using a cup.
•
When handling and storing expressed breast milk, follow the guidelines in Section
3.7: Storing expressed breast milk.
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Part 4: Formula Feeding
4.1
Background
Infants who are not breastfed must be given a suitable formula and fed safely (WHO
2003). Infants under one year of age should be given only breast milk, infant formula or
water. Other fluids are not necessary or appropriate and are not recommended (see
Part 5: Fluids for a more detailed discussion of recommended fluids).
There are a number of important differences between breast milk and formula. Breast
milk is uniquely superior for feeding infants (American Academy of Pediatrics 2005).
The basic differences include the following:
•
Breast milk varies in composition during lactation and even during a single feed
(Lawrence and Lawrence 2005), whereas formula is of constant composition.
•
The bio-availability of various nutrients, such as iron, protein and calcium, in breast
milk is superior to infant formula even if the levels are the same (having a different
concentration of the ingredient in the formula in part compensates for this superiority
(Lawrence and Lawrence 2005).
•
Breast milk contains different levels of taurine and long-chain polyunsaturated fatty
acids (Lawrence and Lawrence 2005).
•
Many beneficial biologically active components of breast milk, such as
immunoglobulins and prebiotics, which encourage the growth of Bifidobacteria, are
not present in formula (Lawrence and Lawrence 2005).
•
The composition of breast milk serves as a valuable reference for improving formula.
However, breast milk contains living cells, hormones, active enzymes,
immunoglobulins and components with unique molecular structures that cannot be
replicated in infant formula.
•
There is higher risk of infection with formula due to variable sterilisation techniques or
unsafe water sources (Howie et al 1990).
The composition of infant formula and follow-on formula sold in New Zealand must be
consistent with the Australia New Zealand Food Standards Code (FSC) (FSANZ 2002).
The FSC sets compositional and safety standards for infant and follow-on formula so
that the formula is nutritionally adequate to promote growth and development when
used appropriately and so that it is suitable for feeding to healthy infants. The standard
for infant formula requires that the formula meets the complete energy and nutritional
requirements for a healthy full-term infant up to six months of age. After this age, an
infant should also be receiving complementary foods.
Homemade formulae are not recommended because of concerns about their
composition and preparation. The concerns are that they will not meet nutritional
requirements, may have inappropriate ingredients added and may be contaminated, for
example, with bacteria that cause food-borne illness or environmental contaminants,
such as agricultural chemicals and heavy metals.
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While stressing the superior benefits of breastfeeding for both infants and mothers,
health practitioners must give mothers and families who feed their babies infant formula
objective, consistent and accurate advice on the proper use of formula (WHO 1981).
Such information should include the appropriate type of formula, how to prepare the
formula and the equipment, and how to feed the infant.
When advising on formula type and use, the most important considerations are as
follows:
•
The mother should try and maintain some breastfeeding if possible.
•
The formula chosen should be appropriate for the infant’s age.
•
If an infant is thriving on infant formula and complementary foods, then there is
generally no advantage in changing to a follow-on formula. As noted by the World
Health Assembly in 1986, the practice of introducing follow-on formulae, instead of
standard infant formulae, in the second six months of life together with
complementary foods is unnecessary (WHA 1986).
•
Formula should be handled and stored very carefully and made up as close as
possible to feeding time.
•
Cows’ milk-based formula is recommended for routinely feeding a healthy infant who
is not breastfed.
•
Different or more expensive formulae are not necessarily better for the infant unless
specifically recommended by a health practitioner.
•
If there are any concerns about the infant’s health or tolerance to cows’ milk-based
formula, the infant should be assessed by a health practitioner so that the health
concerns can be correctly diagnosed and appropriate action can be taken.
4.2
Types of formula
Some formulae have ingredients added to them, such as long-chain polyunsaturated
fatty acids (see 10.3: Fat); nucleotides; prebiotics (see 10.2.3: Oligosaccharides,
including prebiotics); and probiotics (see 12.7: Probiotics). In general, these ingredients
are found in breast milk and are added to infant formula to make it more like breast milk.
4.2.1
Infant formulae
Infant formulae are designed as breast milk substitutes and have a similar distribution of
energy sources as the average composition of breast milk. From the viewpoint of
providing energy, they can be considered equal to breast milk. Infant formulae have a
higher protein content than breast milk partly to compensate for the infants poorer use
of the protein from infant formulae.
4.2.2
Follow-on formulae
Follow-on formulae are marketed as formulae suitable for infants aged six to 12 months.
Follow-on formulae generally have higher protein, iron and mineral content and a higher
renal solute load than standard infant formulae, although these nutrient levels vary
between products (Wells 1998).
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Follow-on formulae may be useful in preventing and treating iron deficiency (see 10.4.1:
Iron). A health practitioner’s advice should be sought regarding the use of follow-on
formulae for treatment of iron deficiency.
4.2.3
Cows’ milk-based formulae
The protein in cows’ milk-based formula is based on the protein in cows’ milk. Lactose,
corn syrup solids and corn maltodextrin provide carbohydrates. Vegetable oil blends
provide fat.
4.2.4
Soy-based formulae
Soy-based infant formulae differ from cows’ milk-based infant formulae in that the
protein is derived from refined soy protein isolate. Since soy protein lacks sufficient
amounts of the essential amino acid methionine, the formula must be fortified with
methionine, which affects the taste. Soy-based infant formula also contains higher
levels of phytates, aluminium and fluoride than cows’ milk-based formula. The amount
of aluminium and fluoride in soy-based infant formula is controlled by the Food
Standards Code.
Soy-based infant formulae should only be used under the direction of a health
practitioner for management of galactosaemia. There are formulae available in New
Zealand for cows’ milk protein intolerance and lactose intolerance, and these formulae
should be used in preference to soy-based infant formulae. Soy-based infant formulae
may be suitable if a vegetarian formula is required.
Infants with existing hypothyroidism should not be fed a soy-based infant formula or
foods containing soy as a major part of their diet, unless under close medical
supervision and regular monitoring of thyroid function.
Infants fed soy-based infant formulae grow and develop normally and are reported to
have normal metabolic functions (Lasekan et al 1999; Seppo et al 2005). Some
concern has been expressed over the possible physiological effects of phytoestrogens
in soy formulae on the developing endocrine system of infants. There is no clear clinical
or scientific evidence of adverse effects to infants (Tuohy 2003), although there have
been isolated cases of goitre in infants fed soy-based infant formula, which have
resolved on withdrawal of the formula (Ministry of Health 2005b; Chang and Doerge
2000).
4.2.5
Goats’ milk-based infant formulae
Goats’ milk based formulae differ from cows’ milk-based formulae in that the protein is
based on the protein in goats’ milk.
Infants fed goat’s milk-based infant formulae have similar growth rates to those fed
cows’ milk-based infant formulae (Grant et al 2005). The main carbohydrate in goats’
milk-based infant formula is lactose; hence it is not suitable for infants with lactose
intolerance or galactosaemia. It may be suitable for some infants with cows’ milk
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protein intolerance, but as the formulae have similar allergenicity, goats’ milk-based
infant formulae are not always suitable.
4.2.6
Specialised formulae
Specialised formulae are used for infants with allergies, malabsorption syndromes and
metabolic disorders. They should only be used on the recommendation of a dietitian
and/or paediatrician.
The overall nutrient profile of these formulae is similar to other formulae, except that
they have the protein component modified or have specialised ingredients added.
Partially hydrolysed and extensively hydrolysed formulae are available, where the
protein has been broken down into peptides and amino acids. In general, the more
extensive the hydrolysis of the proteins, the less likely the formula is to cause an allergic
response. These formulae are extremely expensive because of the complexity of the
manufacturing process.
4.3
Changing formulae
Formulae are often blamed for a variety of symptoms such as vomiting, spilling, reflux,
crying, diarrhoea or constipation. Many of these symptoms are associated with normal
development, and teaching parents coping strategies is preferable to changing from one
formula to another. If the symptoms persist and are impacting on the health of the
infant, then it is preferable to seek a health practitioner’s advice before changing the
brand of formula or changing to a formula of a different composition.
4.4
Preparing formula
Formulae are available in two forms: powdered or ready-to-use. Ready-to-use formulae
are not commonly available outside hospitals. Powdered formulae are not sterile, even
though it has been manufactured to meet hygiene standards, and may occasionally
contain pathogens that can cause serious illness, for example, Enterobacter sakazakii,
and Salmonella. These bacteria are found throughout the environment and can be, and
have been, located in food, including powdered formulae. Contamination by such
bacteria is not usually associated with illness in healthy full-term infants. However, in
rare cases, such as those involving preterm or immuno-compromised infants in
neonatal units, it can cause serious illness and occasionally be fatal.
Breast milk is best and should be used in preference to formulae. If powdered formulae
are used, several recommended steps have been developed for preparation, storage
and handling of formula to reduce the risk of infection (WHO/FAO 2007). The rationale
for these steps is given in the WHO/FAO guidelines. The recommendations now
include a step to make up formula with hot water as this will kill any E. sakazakii in the
powder.
Cleaning and sterilising feeding and preparation equipment
The equipment used to prepare formula and in feeding must be sterilised before use in
the first three months of an infant’s life to reduce the risk of the infant contracting
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gastroenteritis. Equipment can be sterilised with sterilising solutions, boiling water or a
steam sterilising unit designed for use in a microwave. A dishwasher will not sterilise
equipment.
Sterilising equipment and tablets to make sterilising solutions are available from
supermarkets and pharmacies. Users must follow the manufacturers’ instructions
carefully. Sterilising solutions can be used for 24 hours before needing to be changed.
Feeding equipment can be sterilised in boiling water. The equipment should be
thoroughly washed in warm soapy water after each use and then submerged in boiling
water for five minutes. The hazard (to both the caregivers and young children) of
frequently having boiling water in the vicinity should be weighed against the cost of
using sterilising solutions.
Preparing a feed using powdered infant formula
Before making up any infant formula, parents and caregivers should always wash their
hands. The formula must be made up according to the instructions on the can. The
scoop provided with the can of formula should be used for that formula only. The scoop
has been designed to measure the correct amount of that particular formula to achieve
the correct formula concentration.
The formula should not be diluted or concentrated or have any food, beverage or
medicine added without advice from a health practitioner.
Powdered formulae are made up by mixing formula with hot water. The temperature of
hot water will kill any E. sakazakii in the powder. Care must be taken when handling hot
water and hot formula to avoid burns and scalds.
The water should be boiled for three minutes on the stove. The water should then be
poured into a sterilised container, such as a cup, bottle or jug, and allowed to cool
slightly to no less than 70ºC (the water should be left to stand for no longer than 30
minutes). The correct amount of formula can then be added to the water.
The hot formula must be cooled quickly to feeding temperature by holding the container
under cold running water or by placing the container in a bowl of cold water. Make sure
that the container is tightly sealed to ensure that unsterilised water does not get into the
formula. The temperature of the formula must be checked before feeding to avoid
scalding the infant’s mouth. Shake a few drops of formula on to the inside of the wrist.
The formula should feel comfortably warm to the touch.
Formula should be made up just before a feed. Discard any feed that has not been
consumed within two hours.
Preparing feeds in advance for later use
Prepared formula can be stored in the refrigerator but should only be kept for a
maximum of 24 hours. It is preferable that formula not be frozen, however, formula can
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be frozen for short periods of time (a maximum of six weeks). Any container of frozen
formula should be labelled and dated.
Warming stored feeds
Formula should be warmed gradually by placing the bottle containing the formula in hot
water. The temperature of the formula should always be tested before the bottle is
given to the infant by shaking a few drops on to the inside of the wrist. The formula
should feel comfortably warm to the touch.
Before feeding, caregivers must always thoroughly shake the bottle containing the
formula then test the temperature as above, before feeding.
It is very easy to overheat formula in a microwave. Microwaves can cause variations in
temperature throughout the formula with local ‘hot spots’, and the formula may continue
to heat even after it has been removed from the microwave (hence manufacturers’
recommendations for standing time). This can cause extremely high temperatures,
which may cause scalding (James 1989).
Transporting feeds
If travelling with an infant or toddler, it is important to keep formula stored hygienically.
Caregivers should carry formula as a powder, in measured amounts. Warm formula
should not be carried in a thermos flask.
4.5
Amount of formula
The number of feeds and the amount of formula taken at each feed varies between
infants and over time. An infant’s needs vary with activity, illness and variations in
growth rate. Infants should be fed on demand, as their appetite and thirst will dictate
their needs. Fluid requirements must also be met; healthy babies should generally have
six or more very wet nappies a day. Guidelines for quantities and frequency of feeds
are printed on the formula packets. However, these details are approximations and
should be used only as a guide. See 5.2: Recommended fluid intakes for more
information on adequate intakes for infants.
4.6
Practical advice for formula feeding
•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
•
Wash all equipment in hot soapy water, rinse well in hot water and dry with a clean
tea towel, or wash in a dishwasher.
•
Sterilise all bottles, teats and equipment for infants up to the age of three months;
boil bottles and teats or use an appropriate sterilising solution following the
manufacturer’s directions for use.
•
Wash your hands and dry them with a clean towel before preparing an infant’s
formula or feeding an infant.
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•
Prepare formula in a clean environment with clean hands and prepare exactly to the
instructions on the label.
•
Prepare infant formula as close as possible to feeding time.
•
For more detailed information see Feeding Your Baby Infant Formula Code 1306
(see Appendix 13).
•
For further information about E. sakazakii, refer to the Ministry of Health or New
Zealand Food Safety Authority websites (http://www.moh.govt.nz and
http://www.nzfsa.govt.nz respectively).
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Part 5: Fluids
5.1
Background
A balance between fluid input and output is essential for good health. Fluid is lost
through the urine, faeces, perspiration and breath. Children up to the age of two years
are almost entirely dependent on their caregivers to provide them with fluid.
Fluids are the sole source of nutrients up to around six months of age. Once an infant
has started with the introduction of complementary foods, milk (either breast milk or
formula or both) remains the main source of fluid throughout the first year of life. Other
fluids, preferably water, can be given throughout the day if necessary.
Inadequate fluid intake may contribute to constipation. If an infant becomes constipated
it is worth checking that any formula being used is made up correctly and fluids are
being offered on demand. (See 12.6: Constipation and diarrhoea.)
5.2
Recommended fluid intakes
The adequate intake (AI) for infants from birth to six months of age is 0.7 litres per day
of total fluid (from breast milk or formula). For infants aged seven to 12 months, the AI
is 0.8 litres per day of total fluids. This comprises 0.6 litres (about three cups) per day
of fluids (breast milk, formula, water and other beverages) with the remaining fluid being
obtained from complementary foods.
For toddlers aged one to three years, the recommended AI of total fluids is 1.4 litres per
day, of which 1.0 litres per day (about four cups) is from fluids (breast milk, formula,
water and other beverages).
The child’s appetite and thirst will dictate their fluid requirements. Infants, therefore,
should be fed on demand, and toddlers should be offered fluids frequently. Aim for six
or more very wet nappies a day for infants. In older infants and toddlers, the colour of
urine can be used as an approximate guide to indicate sufficiency of fluid intake – the
urine should be clear to light yellow. Additional fluids will often be required if the infant
or toddler is unwell or the weather is hot.
5.3
Recommended sources of fluid in the diet
The recommended sources of fluid for infants and toddlers are as follows:
• 0–6 months of age
breast milk or infant formula
• 6–12 months of age
breast milk, infant formula or follow-on formula, water
• 1–2 years of age
breast milk, whole (dark blue top) cows’ milk, water.
Parts 3, 4 and 6 also consider the role of fluids in the diet.
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5.3.1
Breast milk
Infants who are healthy and exclusively breastfed on demand are unlikely to suffer from
fluid depletion. Exclusively breastfed infants should be breastfed more often if the
weather is particularly hot or the infant is unwell.
5.3.2
Formula
Formula must be made according to the instructions on the packet (see 4.4: Preparing
formula).
In hot weather or if unwell, a formula fed infant or toddler may need extra fluid, as much
as three or four 150 ml bottles of formula or water per day.
5.3.3
Water
If extra water is needed, infants to three months of age can be given cooled, boiled tap
water. Boil for three minutes on the stove. Cool before giving that water to the infant.
For infants aged three months or older, it is not necessary to boil reticulated (town)
supplies. However, if the water is of poor quality, it should be boiled and cooled for
infants up to six months of age. To check the quality of your water supply, contact your
local public health unit at the District Health Board and enquire about your supply.
Alternatively you can refer to the Register of Community Drinking-Water Supplies in
New Zealand (Ministry of Health 2005a), which provides health professionals and the
general public with a summary of the health risks of all community drinking water
supplies known to the Ministry of Health. All public libraries hold a copy of the register,
and it is available on the Ministry of Health website (http://www.moh.govt.nz).
Water from tanks, bore holes, etc, should still be boiled and then cooled before being
given to any infant up to 18 months of age.
Bore water should be checked for its nitrate concentration (from nitrates leaching from
fertilisers or sewage into underground water sources). Excessive nitrate consumption
can produce methaemoglobinaemia in infants. If water contains an elevated
concentration of nitrate, care must be taken to ensure that the water is not subjected to
prolonged boiling, which will concentrate the nitrate. The alternatives are to use a filter
that filters out nitrate or to use water from a source that has low nitrate levels. You can
contact your local public health unit for advice.
Bottled waters are often bought in the belief that they are ‘pure’ or ‘natural’, but
sometimes they have been found to contain significant amounts of contaminants and
impurities (Hunter and Burge 1987).
Water being used directly from the tap should preferably be taken from the cold tap.
Many New Zealand waters are aggressive (corrosive) and will leach heavy metals from
some pipes and fittings. Running the tap for 10–15 seconds will flush away most of the
corrosion products. If the piping is copper, it may pay to run the tap until the water gets
as cold as it will get (Ministry of Health 2005a).
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5.3.4
Milk as a drink
Infants (under one year of age)
Cows’ milk should not be given as a drink until infants are older than one year of age
(American Academy of Pediatrics 1992). Infants fed cows’ milk before one year of age
are at particular risk of depleting iron stores (American Academy of Paediatrics 2004).
This is not only because the concentration and bio-availability of iron is low but also
because cows’ milk may cause gastrointestinal blood loss (Ziegler et al 1990).
Introducing cows’ milk before the infant reaches the age of 12 months, particularly in the
first six months of life, can contribute to iron deficiency and increase renal solute load
because of the proportions of protein, sodium, potassium and chloride in the milk.
Toddlers (over one year of age)
Amount of milk
It is recommended that toddlers consume no more than 600 ml of milk each day.
Type of milk
Milk is an important food for toddlers as it provides several key nutrients, such as
protein, calcium and riboflavin, some of which are difficult to obtain from other foods in
sufficient quantity. Milk satisfies thirst, and its fat content satisfies appetite as well. The
energy contribution of whole milk is beneficial for toddlers (see also Part 9: Growth and
Energy). Soy drinks that have been calcium fortified are a suitable alternative.
Toddlers may find cows’ milk very palatable, and there can be a tendency to consume
so much that it displaces other foods from the diet. However, milk contains very little
vitamin C, folate and iron, and no dietary fibre. It is, therefore, not a complete food and
should not be treated as such.
Whole (dark blue top) cows’ milk is recommended for toddlers. Reduced-fat milks
should not be used for infants and toddlers because of the low energy content of these
milks at a time when children have high energy requirements (American Academy of
Pediatrics 1992). Reduced-fat milks might be prescribed in special circumstances,
following consultation with a dietitian, who will help to review the child’s diet as a whole.
Milk and milk products should be pasteurised as there is considerable risk of contracting
an infectious disease such as campylobacteriosis or tuberculosis as a result of
consuming unpasteurised milk and milk products.
There is considerable misinformation around suggesting that milk is, for example,
‘mucus-forming’ or that it is responsible for a variety of health problems. Avoiding milk
products on the basis of unfounded claims may have adverse health consequences by
depriving infants and toddlers of essential nutrients. Milk or milk products should only
be excluded from the diet with the expert assistance of a dietitian. Only by a careful
choice of alternatives can nutrient requirements be met to support normal growth and
development.
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Commercial infant foods containing milk
Milk products, aimed at infants, that have been canned or bottled and, therefore, heat
treated to extremely high temperatures, are suitable for infants who are around six
months of age or older.
Toddler milks
Toddler milks are not generally recommended. For toddlers aged one to two years,
whole (dark blue top) cows’ milk as part of a balanced and varied diet is quite suitable.
Toddler milks are cows’ milk-based drinks that are fortified with various minerals and
vitamins, such as iron and vitamin C, and are promoted as alternatives to cows’ milk for
infants over 12 months. The premise is that these vitamin and mineral additions make
toddler milks nutritionally superior to cows’ milk for infants over 12 months.
5.3.5
Fruit juices and sweet drinks
Fruit juices or sweet drinks such as fruit drinks, cordials and soft drinks are not
recommended for infants and toddlers. For infants, other than breast milk or formula,
water is the only fluid that can be given. Toddlers only need milk and water.
Excess consumption of fruit juice by young children has been associated with
gastrointestinal symptoms, failure to thrive, decreased appetite, loose stools and failure
to gain weight (Hoekstra et al 1993; Hourihane and Rolles 1995; Kneepens et al 1989;
Lifshitz et al 1992; Smith and Lifshitz 1994). Flat lemonade is sometimes given to
infants as a remedy for various intestinal disorders, such as diarrhoea or colic. This is
not recommended as the high concentration of the lemonade or fruit juices may
temporarily draw fluid into the intestine and cause further diarrhoea and worsen the
dehydration.
Fruit juice and sweet drink consumption can also affect intake of nutrients such as
calcium by the fact that such drinking displaces milk in the diet (American Academy of
Pediatrics 2001).
Giving sweet drinks from an early age may cause the infant to develop a preference for
sweet foods (Beauchamp and Moran 1982).
Fruit juices and sweet drinks all contain sugars, either from the fruit or as added sugars.
Sweet drinks can contribute to tooth decay either from their sugar or acid content (Sorvari
and Rytomaa 1991). An infant should not be left with a bottle of juice or sweet drink, or
milk as a way of settling them because the drink leaves the teeth bathed in sugar.
The use of artificial sweeteners in food and drinks is not recommended because of the
limited amount of data available for their affects on children (American Dietetic
Association 2004).
Some juices and sweet drinks are advertised as containing vitamin C. (See also 10.5.3:
Folate and vitamin C and 12.3: Supplements.)
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5.3.6
Coffee, tea, herbal teas, other caffeine-containing drinks, smart or energy
drinks and alcohol
Coffee, tea, other caffeine-containing drinks, smart or energy drinks, herbal teas and
alcohol are all unsuitable for infants and toddlers. Caffeine, and similar substances, are
found in coffee, tea, cocoa, cola-flavoured drinks or drinks containing guarana or cola
nut. Coffee contains about three or four times as much caffeine as an equal volume of
cola-flavoured drink. Caffeine is a central nervous system stimulant, which can cause
irritability and restlessness.
Tea drinking is not recommended because the tannin content of tea inhibits iron
absorption from the gut (Bothwell et al 1989). The impact of this practice has been
confirmed by a New Zealand study that observed a significant association between tea
drinking in infants and the presence of iron deficiency (Grant et al 2003).
Herbal teas can have adverse effects and are not recommended for infants and toddlers
(Allen et al 1989; Ridker 1989).
Alcoholic drinks are inappropriate for infants and toddlers. In metabolising the alcohol, the
child may become hypoglycaemic. The blood sugar may then fall to such a low level that
the child becomes unconscious and may have a convulsion or suffer brain damage.
5.4
Practical advice for fluids
•
Infants should be fed exclusively on breast milk to around six months of age with
continued breastfeeding up to two years of age or beyond.
•
If the infant is not breastfed, then an infant formula should be used until the infant is
one year of age.
•
When the infant is ready, appropriate complementary food should be introduced and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready. The infant will probably be ready at around six months of age, but
some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
Aim for six or more very wet nappies a day for infants, indicating adequate fluid
intake. In older infants and toddlers, the colour of urine can be used as an
approximate guide, indicating a sufficient fluid intake.
•
Additional fluids may be required if the infant or toddler is unwell or if the weather is
hot.
•
A total of around 500–600 ml of milk per day is sufficient for toddlers.
•
Whole (dark blue top) cows’ milk is recommended for toddlers. Fortified milks are
generally not necessary.
•
Fruit juices or sweet drinks such as fruit drinks, cordials and soft drinks are not
recommended for infants and toddlers. Infants need only milk (breast milk or infant
formula) to drink. Toddlers need only milk and water to drink.
•
Coffee, tea, herbal teas, caffeine-containing beverages, smart or energy drinks,
carbonated beverages and alcohol are not recommended for infants and toddlers.
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Part 6: Complementary Feeding (Solids) and Joining
the Family Diet
6.1
Age of introduction of complementary feeding
Complementary feeding or introduction of solids is defined as the gradual introduction of
solid food and fluids along with the usual milk feed (breast milk or infant formula) to an
infant’s diet. The introduction of complementary foods has been known as weaning,
which comes from the Anglo-Saxon word weanian meaning ‘to accustom’. However,
the word weaning has come to be associated with stopping breastfeeding. For this
reason, the term complementary feeding is preferred. This latter term means that
breastfeeding continues and other foods are introduced to complement or add to the
nutritional intake provided by breast milk, or infant formula if not breastfeeding.
The transition from a largely milk-based diet to milk plus complementary foods is
challenging for infants and parents alike. The food and fluid choices made by the
caregiver are important not only for the infant’s immediate nutrition but also for
developing healthy eating patterns and food preferences that will continue as the infant
grows. Feeding guidance for infants and toddlers should be less structured than it is for
older children and adults because of the varying rates of growth and development that
occur for each child.
In New Zealand, at a population level, it is recommended that infants be fed exclusively
on breast milk to around six months of age, at which time complementary foods can be
introduced with breastfeeding continuing until the child reaches two years of age or
beyond.
If the infant is not breastfed, then an infant formula should be used up to one year of
age.
The introduction of complementary foods should occur when an infant is at the
appropriate stage of development, which will vary between individuals, occurring around
six months of age but not before four months of age (see Table 6: Developmental cues
that signal readiness for introduction of complementary foods).
6.1.1
Nutritional considerations
The nutritional needs of the infant also influence the age at which complementary foods
should be introduced. After about six months of age, breast milk or infant formula alone
cannot meet an infant’s energy requirements (Reilly and Wells 2005). Stores of iron
and zinc are likely to be depleted by six months of age, so the additional energy, iron
and zinc required must be supplied by food. From six months of age onwards, solid
food makes an increasing contribution to nutrient intake.
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Breast milk volume reaches a maximum at about three months of feeding (Whitehead et
al 1986). However, breast milk, or an infant formula, can provide complete nutritional
requirements for most infants for six months. Introduction of complementary foods is a
time of nutritional vulnerability. It is a period of dietary transition just when nutritional
requirements for growth and brain development are high. A nutritionally adequate diet
is essential for achieving optimal growth in the first year of an infant’s life.
The World Health Organization (WHO) Global Strategy for Infant and Young Child
Feeding (WHO 2003) contains a revised recommendation for exclusive breastfeeding –
that exclusive breastfeeding continue to six months of age. This change by WHO
followed a systematic review of the current scientific literature (WHO 2002), the
outcome of which was subjected to a global peer review and technical scrutiny by an
expert consultation (WHO 2001). WHO now recommends that infants should be
exclusively breastfed until six months of age, at which time suitable complementary
foods should be introduced. WHO noted that this recommendation applies to
populations (WHO 2003). However, the WHO review process had a number of
limitations. In particular, the systematic review was based on two small controlled
studies and 17 observational studies of varying quality and geographic location.
Although studies from a number of different settings were included in the review, neither
of the controlled trials was set in a developed country. Hence, only data from
observational studies were considered in relation to developed countries. The expert
consultation also noted the shortcomings of this review by stating that the available data
were insufficient to rule out a number of potential risks, such as growth faltering and
micronutrient deficiencies in some infants (WHO 2001).
6.2
Risks of early introduction of complementary foods (before four
months of age)
There are a number of risks associated with early introduction of complementary foods,
including:
•
increased risk of eczema (Fergusson et al 1990), childhood asthma (Oddy et al
1999), food allergies (Zlotkin et al 1996) and iron deficiency (Oski 1993)
•
respiratory disease (Forsyth et al 1993)
•
increased vulnerability of the gut to infection (Popkin et al 1990)
•
diarrhoea and dehydration (Forsyth et al 1993)
•
impaired absorption of iron from breast milk (Zlotkin et al 1996)
•
increased load on the infant’s kidneys
•
infant malnutrition due to decrease in maternal milk production or inadequate
complementary foods (Zlotkin et al 1996).
Many parents and caregivers in New Zealand feed complementary foods before their
infant is ready or supplement breastfeeding with formula. Reasons given by caregivers
for early introduction include the following:
• the infant is showing a strong interest in food
• the infant is perceived to be unsettled
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•
•
•
•
•
they wish to have the infant sleeping at night
they wish to see the infant progressing to the next stage
they are experiencing peer pressure
they have received family advice
they are interpreting the three-month growth spurt as a need for complementary
foods or formula.
6.3
Risks of late introduction of complementary foods (after six
months of age)
There are a number of risks associated with late introduction of complementary foods,
including:
•
increased risk of iron deficiency (Faldella et al 2003) and wheat allergy (Poole et al
2006)
•
delays in oral motor development (American Dietetic Association 2005)
•
malnutrition, if exclusive breastfeeding becomes inadequate.
6.4
The developmental cues that signal readiness for the
introduction of complementary food
Before introduction of complementary foods can begin, the infant must be physically
and physiologically able to cope.
In the full-term infant, the swallowing reflex is developed by nine to 12 weeks of age.
Before this age, bolus formation, required for controlling swallowing, may not be
achieved. Co-ordination of swallowing movements sufficient to deal with semi-solid
foods is not achieved until four to six months of age (Barness 1990).
While some digestive enzymes are fully developed at birth, pancreatic amylase levels
are low before six months of age (Lebenthal 1985).
A newborn infant has limited renal capacity to conserve fluids and to excrete a solute
load. By four months of age, the renal function has matured considerably.
At about five to six months of age, teeth begin to erupt and feeding behaviour changes
from sucking to biting and chewing. If infants are not encouraged to chew, this ability
may not develop as the child ages. Teaching older infants to chew can be difficult.
There are a number of developmental cues that can be used to recognise readiness for
complementary foods. Table 6: Developmental cues that signal readiness for
introduction of complementary foods summarises these cues. An infant will generally
signal when they are ready for complementary foods, and this will vary from infant to
infant. It may be anywhere from four to six months of age or older. There may be an
increase in the frequency of demand for feeds, or it may become clear that the appetite
is not satisfied after the milk feed has been completed. However, many infants exhibit
fussing and crying behaviour in the first three or four months of life, and this behaviour
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may be misinterpreted as hunger (Walker and Menahem 1994) (see Part 3:
Breastfeeding).
Cues can be hard to interpret objectively. Weight gain was traditionally used, and the
apparent slowing of growth rate compared to standard percentile charts was thought to
be the signal for introducing complementary foods to breastfed infants. However, such
charts are often drawn from data that includes formula-fed infants, in whom
complementary foods have been introduced fairly early. There is no reason to assume
that slower growth rates are in themselves undesirable (see 9.1: Growth and rate of
growth).
Table 6:
Developmental cues that signal readiness for introduction of complementary foods
Weight
Infant’s
cues
When infant:
•
•
Physical
doubles birth
weight
When placed on
stomach, infant
can:
weighs at
least 5 kg.
•
hold head up
•
support
weight on
forearms
•
push up on
arms with
straight
elbows.
Sensory
When infant:
•
•
puts hands
and toys
frequently in
the mouth
What
they
mean
The infant, who is
growing rapidly,
always seems
hungry and may
need extra energy
from
complementary
foods to support
growth and satisfy
hunger.
hold head up
•
keep head
controlled
when tipped
•
sit with less
help
•
reach out for
toy.
The infant is
developing good
control of the
head and trunk,
which support the
mouth skills for
eating.
When hungry or
wants more food,
infant:
•
frequently cries
•
leans forward as
food approaches
explores
fingers,
•
thumbs and
fists with
great interest. •
•
The infant is
seeking important
information about
texture and is
developing an
acceptance of
objects in the
front of the mouth.
Mouth
When infant’s
mouth:
•
opens easily
when spoon
touches lip or
as food
approaches.
reaches for food
or parent’s hand
Tongue:
opens mouth.
•
does not
protrude
•
moves gently
back and forth
as food enters
mouth.
When satisfied or
wants to stop eating,
infant:
When sitting on
parent’s lap infant
can:
•
Meal time
turns head or
body away from
food
When infant’s:
•
mouth
movements
steadily
improve
during the
first week of
spoon
feeding.
Food:
•
loses interest in
food
•
stays in
mouth
•
pushes food or
parent’s hand
away
•
•
closes mouth
can be moved
to back of
mouth and
swallowed
•
looks distressed
or cries.
•
is not
recycled.
The infant knows if
they want to eat and
how much food is
needed.
Learning
The infant has
developed the
type of tongue
pattern necessary
for moving food to
the back of the
mouth and
swallowing.
The infant is
developmentally
ready, both
physically and
emotionally, for
foods in
addition to
breast milk or
formula.
Source: Butte et al 2004
6.5
Introducing complementary foods (solids) and progressing to
family foods
6.5.1
The first food (around six months of age)
Examples of suitable first complementary foods are given in Table 7. The examples
include good sources of iron such as iron-fortified cereals, ready-to-eat cereals that are
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high in iron and age appropriate meats, and it is important that these foods are
introduced.
The first complementary foods need not be bland in taste in order for infants to accept
and enjoy them. Research suggests that flavours infants are exposed to in the womb
and in breast milk, that is, via the mother’s diet, are more readily accepted when
presented as flavours in solid foods (Mennella et al 2001).
The first complementary foods should be introduced in small amounts starting with
about one teaspoon. The quantity should be gradually increased and the texture
thickened. Aim for two tablespoons to half a cup at one meal before increasing the
number of meals.
The first food should be a thin smooth purée. The food should be diluted with
expressed breast milk or infant formula to achieve the right consistency, and breast milk
or formula, rather than water or cows’ milk, should continue to be used to obtain the
right consistency and moisten food until the infant is up to one year of age.
A variety of foods can be introduced gradually as the taste and, more importantly, the
texture is accepted. Table 7 gives the order for introducing complementary foods and
emphasises the progression of variety and texture. New foods should be introduced
one at a time. At first, a new food should only be added every four to five days. The
contributions that foods make to the nutrient content of the diet are shown in Table 8:
The four food groups.
In the case of breads and cereals, start with white or wholemeal bread. Continue to use
wholemeal bread. Wholegrain bread can be given at around one year of age. Ageappropriate infant cereals are recommended to begin with. Wheat breakfast biscuits
contain a moderate level of fibre so can be given from eight months of age. They
should be served once a day only and with breast milk or infant formula, then cows’ milk
after the infant is one year of age.
Cows’ milk should not be given as a drink until the infant is one year of age (see 5.3.4:
Milk as a drink). However, milk products such as custard, yoghurt and cheese can be
introduced when the infant is about eight months of age. Commercial infant foods
containing milk and milk products can be introduced earlier as the heat treatment
denatures some of the proteins and makes the food more easily digested and less
allergenic.
For infants in families that have a history of allergic disease (having conditions such as
hay fever, asthma or eczema), the introduction of certain foods should be delayed (see
12.4: Food intolerance and food allergies).
During the early stages of introducing complementary foods, breast milk or infant
formula remains the most important nutrient source and the complementary foods must
not be given in a way or in amounts that will dramatically reduce milk intake. This can
be achieved at first by giving a milk feed before the complementary foods, which are
then used as a ‘top-up’ at the end. After the infant is eight to nine months of age, offer
complementary foods before the milk feed. Gradually complementary foods will
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displace milk feeds, but breast milk or infant formula should remain a prominent part of
the diet until the infant is at least one year of age.
Cereals and similar foods should never be added to an infant’s feeding bottle as this
can make the feed too concentrated and the infant will not receive sufficient fluids for
proper kidney function.
Attention should be paid to signs of hunger and fullness to avoid both underfeeding and
overfeeding. Signs of hunger can include the infant crying or fussing, while older infants
may move their head toward the spoon, point to the food or open their mouths. Signs of
fullness can include spitting out the food or nipple, a slowed rate of feeding, clenching
the mouth or pushing food away.
Meals are best eaten at the table, away from distractions such as the television or toys.
Parents and caregivers must always supervise an infant or toddler when they are
eating.
Most of the infant’s body systems are maturing and growing rapidly so progress on
introducing complementary foods should be made to ensure nutritional sufficiency and
in keeping with the development of the gut mucosa (Department of Health (UK) 1994).
Infants should progress to eating a variety of foods and foods of different texture and
should be eating family foods by around 1 year of age, assuming that the family food
environment provides a variety of appropriate and adequate foods.
6.5.2
Food rejection
Sometimes food rejection is caused by choosing an inappropriate time for a new food,
such as when the infant is fretful or at the first feed of the day or late at night. It is better
to choose a time to introduce new foods when the infant is relaxed and happy.
Introduce new foods one at a time and repeat exposure to the food at least eight to
15 times before you accept the infant’s rejection of that food (Briefel et al 2004).
Ongoing rejection of a food may mean that the taste or texture is not yet appreciated or
that the infant is intolerant to that food (not necessarily allergic). Even a pleasanttasting food may be rejected in the early phases of food introduction if the texture is
coarse, gritty or fibrous. The food should be introduced again at a later date.
Taste influences food acceptance and preferences at all ages. The introduction of
complementary foods involves learning to recognise and enjoy different tastes as well
as textures. Successful food introduction has to overcome the aversion to new eating
experiences, which is a common reaction in most infants. Foods are chosen or refused
because of sensory stimuli of taste, texture, smell and the appearance of colour, shape
and presentation. An infant’s natural responses may make caregivers think the child
does not like a new taste when it is simply that the child is not familiar with it.
Encouraging as varied a diet as possible is the best means of ensuring an adequate
intake of all nutrients as well as offering an opportunity for the infant to develop personal
preferences and acceptance of a variety of tastes and textures (Mennella and
Beauchamp 1998).
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6.5.3
Preparing food at home
Initially the food needs to be of a thin, smooth purée consistency. This may be
achieved using a food processor, sieve or masher. Many foods, such as banana or
cooked apple, can be prepared simply by pushing them through a domestic sieve with a
wooden spoon. Fibrous components, for example, stringy bits in taro leaves and pele
leaves should be removed before processing. Later food can be mashed with fork.
Take care with food safety (see 12.13: Food safety).
Do not add salt, soya sauce, sugar, honey, cream, butter or margarine, or artificial
sweeteners to infant foods. Even though infant foods may taste bland to adult palates,
the food will be attractive to infants.
6.5.4
Commercial infant foods
All infant foods sold in New Zealand are required to meet the compositional and safety
standards suitable for feeding healthy babies in the Australia New Zealand Food
Standards Code (FSANZ 2002).
Commercial infant foods containing milk products are suitable for infants who are
around six months of age or older, whereas cheese , yoghurt, cottage cheese and
custard should not be given until seven to eight months of age , and milk as drink not
until one year of age. Commercial infant foods containing milk and milk products can be
introduced earlier as the heat treatment denatures some of the proteins and makes the
food more easily digested and less allergenic.
Commercial infant foods can contribute to a mixed diet of family foods and commercial
products. However, they may be more expensive than home prepared foods. They
look, taste and smell different from family foods and so don’t help the infant learn about
the foods the rest of the family eats. When they are used often, the infant may become
so used to them that they are reluctant to change to family foods.
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Table 7:
Order for introducing complementary foods and progressing to family foods
Infant can hold up head; the tongue is used to move food; infant shows signs of chewing movements
(around six months of age).
Introduce new foods one at a time. Start with thin purées and gradually thicken consistency as
tolerated, introduce new flavours.
Suggested foods:
•
iron-fortified infant rice, followed by other age-appropriate infant cereals
•
rice, congee, cassava/tapioca/sago
•
cooked and puréed apple, pear, apricot, peach, plum, melon, mango, pawpaw (all without skins,
pips or seeds)
•
mashed ripe banana, and avocado
•
cooked and puréed potato, kūmara, taro, pumpkin, carrot, kamokamo (marrow), parsnip, yam,
courgette, green bean, broccoli, taro leaf, pele leaf, pūhā, silverbeet, spinach, cauliflower (all
without skins, pips or seeds)
•
cooked and puréed meat (for example, beef, lamb, pork or chicken)
•
cooked and puréed beans, lentils and legumes
•
cooked and mashed egg
•
age-appropriate commercial infant foods.
Infant can sit, is interested in finger foods and is learning to chew and bite; some teeth are present
(around seven to eight months of age).
Serve some food as finger food.
Suggested foods:
•
all types of food listed above
•
continue to cook and purée meat and chicken
•
you can now mash vegetables and fruit (no need to purée)
•
cows’ milk in cooking
•
cheese, yoghurt, cottage cheese, custard
•
infant cereal
•
well-cooked pasta and noodles
•
bread, rēwena bread, steamed plain cake (mantou), steamed dumplings and buns, rusks, crackers,
rice crackers
•
age-appropriate commercial infant foods.
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Infant is interested in extended range of food and varied texture and in self-feeding, with ability to use a
feeding cup and independent eating with some assistance; good chewing and biting with ability to
chew lumps (around eight to 12 months of age).
Offer an increasing variety of foods, presented in different sizes and textures. Discovering, handling
and chewing food assists the development of social skills and promotes the pleasure of eating.
Suggested foods:
•
all types of foods listed above
•
kai moana (seafood, shellfish and seaweed), for example, fish, kina, pipi, kōura (crayfish), pūpū
(periwinkles), parengo (seaweed), pāua, eel
•
soy foods, such as soy milk in cooking, tofu, tempeh, soy yoghurt, soy custard
•
green peas, cabbage, creamed corn and tomatoes (raw or cooked)
•
salad vegetables
•
orange, kiwifruit, pineapple, berry fruit
•
breakfast cereals, for example, porridge, Weetbix, infant muesli
•
peanut butter (smooth)
•
age-appropriate commercial foods.
Infant is using a spoon with varied degree of success; is now able to eat family foods chopped up,
including meat; enjoys many flavours and textures (one year of age and older).
Continue breastfeeding and introduce cows’ milk to drink instead of formula.
Suggested foods:
•
all foods listed above
•
wholegrain breads
•
plain, pasteurised whole milk, soy milks with calcium.
The ages of introduction is provided as guidelines only.
For infants in families that have a history of allergic disease (having conditions such as
hay fever, asthma or eczema), the introduction of certain foods should be delayed (see
12.4: Food intolerance and food allergies).
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Table 8:
The four major food groups: examples of foods and nutrients for infants and toddlers
Food group
Examples
Nutrients provided
Vegetables and fruit
(includes fresh, frozen,
canned and dried)
Vegetables
Potato, kūmara, yam, taro, parsnip,
pumpkin, carrot
Taro leaves, pele leaves, green beans,
pūha, watercress, silverbeet, parengo,
corn, broccoli, spinach, cauliflower,
marrow, cabbage
Salad
Tomato
Carbohydrates
Dietary fibre
Vitamins: especially folate, vitamin A
(yellow and green vegetables), and
vitamin C (dark green vegetables and
most fruit, potatoes)
Minerals: magnesium, potassium
Fruit
Apple, pear, banana, orange, apricot, plum,
peach, melon, mango, pawpaw, avocado,
kiwifruit, pineapple, berry fruit
Fruit salad
Stewed fruit (fresh, frozen or canned)
Dried fruit
Breads and cereals
(includes breakfast
cereals, breads, grains,
rice and pasta),
preferably wholegrain
Bread roll, bun, bread
Muffin, plain cake, rusks
Rēwena bread
Cornflakes, muesli, porridge, Weetbix
Infant cereal, for example, iron-fortified
infant rice
Rice/congee
Cassava/tapioca/sago
Pasta
Plain sweet biscuits
Protein
Carbohydrates
Dietary fibre
Vitamins: all B group (except B12),
E (rich in wheatgerm)
Minerals (particularly in wholegrain
breads and cereals): magnesium,
calcium, iron, zinc and selenium
Milk and milk products
(includes milk, cheese,
yoghurt and ice cream)
and alternatives
Whole (dark blue top) cows’ milk
Yoghurt
Cheese
Calcium-fortified soy milk
Protein
Fats: higher proportion of saturated than
poly- or monounsaturated fats especially
in full fat products
Vitamins: riboflavin, B12, A, D
Minerals: especially calcium, phosphorus,
zinc and iodine
Lean meat, poultry,
seafood, eggs, nuts
and seeds, and
legumes
Cooked meat
Mince or casserole
Egg
Fish and shellfish
Cooked dried beans, peas or lentils
Chicken
Soy foods such as tofu, tempeh, soy
yoghurt, soy custard
Protein
Fats: both visible and marbled in meat
(mostly saturated fat, cholesterol); mostly
unsaturated fats in seafood, nuts and
seeds)
Carbohydrates: mainly legumes (dried
peas and beans)
Vitamins: B12, niacin, thiamin
Minerals: iron, zinc, magnesium, copper,
potassium, phosphorus and selenium
Iodine: particularly in seafood and eggs
Source: Modified from Department of Health (New Zealand) 1991
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6.6
Feeding the toddler
Infants should progress to eating a variety of foods and textures and be eating family
foods by around one year of age, assuming that the family food environment provides a
variety of appropriate and adequate foods. It is important that toddlers be encouraged
to eat and drink small amounts frequently to meet the requirements for growth.
Ongoing breastfeeding will continue to provide benefits to the toddler (see 3.2:
Importance of breastfeeding).
Encouraging as varied a diet as possible is the best means of ensuring an adequate
intake of all nutrients as well as providing an opportunity for the toddler to develop
personal preferences and acceptance of a variety of tastes and textures (Mennella and
Beauchamp 1998).
The family diet should be based on the Food and Nutrition Guidelines (Ministry of
Health 2003a) so that the family food environment provides a variety of appropriate and
adequate foods. Infants and toddlers should not be given fatty or fried foods. However,
the food offered to infants and toddlers, compared to adults’ food, need not be
especially low in fat or high in fibre.
Family meals have an important impact on a child’s dietary intake, psychosocial health
and learning. Family meals can provide the opportunity to communicate, learn, transmit
cultural and ethnic heritage, and develop family rituals. Rituals and routines are
important to young children as they can provide a sense of security (Story et al 2005).
Parents may be concerned if their child does not feed themselves early on, and that the
child’s nutrition will suffer. In the Feeding Infants and Toddlers Study conducted on
more than 3000 infant and toddlers in the USA in 2002, caregivers reported on the ages
that gross motor developmental milestones and fine motor skills required for selffeeding developed, and the food intakes at these ages were compared. Some
differences in nutrient intakes were observed, but these differences disappeared as the
children got older. By 15 to 18 months of age, the feeding skills were comparable for all
children, regardless of whether they self-fed earlier or later than the average (Clarke
et al 2006). Parents and caregivers should encourage children to feed themselves and
offer a variety of nutritious foods.
Many caregivers experience times when their toddler is unusually fussy or picky with
their food. This is a common occurrence and is often associated with toddlers exerting
their independence. Growth rates are slowing at this stage so toddlers need less food
than during their first year.
6.7
Practical advice for complementary feeding and joining the
family diet
•
Maintain healthy growth and development of the infant and toddler by providing
appropriate food and physical activity opportunities every day.
•
Infants should be fed exclusively on breast milk to around six months of age, with
continued breastfeeding up to two years of age or beyond.
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
•
When the infant is ready, appropriate complementary food should be introduced and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready to receive complementary foods. The infant will probably be ready at
around six months of age but some infants may be ready sooner. However, infants
should not be given complementary foods before four months of age.
•
The variety of complementary foods should be increased to ensure an additional
intake of nutrients, especially iron. The infant should be eating family foods by
around the age of one year.
•
For infants, prepare or choose pre-prepared foods with no added fat, salt, sugar or
other sweeteners.
•
Toddlers should be offered a variety of nutritious foods from each of the four major
food groups each day, that is:
– vegetables and fruit
– breads and cereals, preferably wholegrain
– milk and milk products
– lean meat, poultry, seafood, eggs or alternatives.
•
For toddlers, prepare foods or choose pre-prepared foods, drinks and snacks:
– with minimal added fat, especially saturated fat
– that are low in salt; if using salt, choose iodised salt
– with little added sugar; limit intake of high-sugar foods.
•
For toddlers, provide plenty of liquids each day, as milk and water.
•
A total of around 500–600 ml of milk per day is sufficient for toddlers.
•
Whole (dark blue top) cows’ milk is recommended for toddlers. Fortified milks are
generally not necessary.
•
Fruit juices or sweet drinks such as fruit drinks, cordials and soft drinks are not
recommended for toddlers. Toddlers need only milk and water to drink.
•
Coffee, tea, herbal teas, caffeine-containing beverages, smart or energy drinks,
carbonated beverages and alcohol are not recommended for infants and toddlers.
•
Purchase, prepare, cook and store food to ensure food safety.
6.8
•
•
•
•
•
•
•
Practical advice for fussy eaters
Establish a meal-time routine.
Make meal times sociable and sit with the toddler.
Let the toddler select their food from the food provided at the family meal.
Serve small amounts.
Give a choice of healthy foods for meals and snacks.
Too much cows’ milk can dull the toddler’s appetite.
Make food easy to eat – finger foods are good.
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•
•
Involve the toddler in food preparation.
Try different ways of preparing the types of foods that have been refused in the past.
Ignore other people’s comments, particularly if they are making comparisons with
their own children.
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Part 7: Considerations for Māori Infants and Toddlers
and their Whānau
7.1
Breastfeeding
For Māori, breastfeeding is a traditional practice. Breastfeeding is viewed as imperative
to maintaining and sustaining child development and wellbeing. At birth, the natural
bonding between mother and infant may also be enhanced through breastfeeding.
Therefore, active promotion of breastfeeding as a positive option for Māori women
should be supported.
The rate of exclusive and full breastfeeding for Māori infants at six weeks of age in 2005
was 58 percent for Māori, compared to the rate of 66 percent for all ethnicities,
71 percent for New Zealand Europeans, 28 percent for Asian and 58 percent for Pacific
infants. These rates are from Plunket and represent approximately 90 percent of all
births. Limitations of these data include incomplete coverage of all births and
population groups. There has been an increase in the breastfeeding rates for Māori at
all ages, although Māori have not achieved the Ministry of Health’s 2005 breastfeeding
targets of 74 percent at six weeks of age, 57 percent at three months of age and 21
percent at six months of age (Ministry of Health 2002a).
Heath et al published a survey of a self-selected sample of 59 New Zealand Māori
mothers and their infants born in Gisborne between July 1996 and August 1997. The
aim of the survey was to investigate knowledge, attitudes and practices associated with
infant feeding in a New Zealand Māori population. The infants were between three and
eight weeks of age when the mother was interviewed (Heath et al 2000).
Eighty-seven percent of the mothers initiated breastfeeding, with 68 percent exclusively
breastfeeding when the infant was three weeks of age. Factors affecting initiation were:
older mothers were less likely to initiate breastfeeding and those who intended to
breastfeed were more likely to initiate breastfeeding. Factors affecting continued
breastfeeding were: not enough milk (43 percent), embarrassment at breastfeeding in
public (83 percent) and no encouragement to breastfeed (83 percent) (Heath et al 2000).
The Ministry of Health wants to engage with Māori to ensure that any inequalities in
breastfeeding are reduced by introducing programmes to increase breastfeeding.
7.2
Dietary practices
There are very few studies of dietary practices with Māori infants, toddlers and their
whānau. One study (Tuohy et al 1997) showed that Māori were more likely than
Europeans to introduce complementary foods before the infant was six months old.
Anecdotal observations made by health workers are divided on whether parents are
holding off introducing complementary foods and cows’ milk for longer than in the past.
Many parents and caregivers appear to be introducing cows’ milk too early, and some
common reasons given for this are: the infant does not like formula and the cost of
formula.
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Some parents and caregivers are feeding inappropriate drinks in the feeding bottle,
drinks such as Milo, tea, juice, soft drink or Farex.
While some mothers seem more aware of the importance of breastfeeding, younger
Māori mothers seem to be only breastfeeding for two to three months.
Some parents and caregivers seem more aware of appropriate foods and drinks for
toddlers and are giving them a good variety of foods, covering all four food groups, and
water in place of juice, but for toddlers, fruit may be missing from the diet, while high
sugar and fat packaged/convenience foods and takeaways are used commonly.
7.3
Nutritional issues
From the studies conducted on Māori populations about breastfeeding and dietary
practices, the main nutritional issues facing Māori infants and toddlers are: shorter
duration of breastfeeding, higher rate of artificial feeding, more likely introduction to
complementary foods before six months of age and tea drinking.
7.4
Traditional Māori foods: Nga tino kai a te Māori
Kai (food) plays an integral and diverse role in both traditional and contemporary Māori
life. It holds spiritual, social and physical significance for Māori. Kai is a highly prized
taonga (treasure) that is valued for its spiritual origins, for its delicacy, for its numerous
healing properties and for its potential to sustain physical, mental, spiritual and cultural
wellbeing.
The nutritional value in the kai is essential to maintaining good physical health. Infants
and toddlers rely on their mothers, fathers, caregivers and whānau to provide them with
the types of food that will give them a healthy start in life.
The following list gives examples of traditional Māori foods that are suitable for infants
and toddlers. It is always good to check with the family, as use may vary.
7.4.1
Kūmara
Kūmara is a special food that is believed to offer spiritual sustenance not found in other
foods. It can be offered mashed or puréed as a first food for the infant at around six
months of age or as a staple vegetable for older infants and toddlers.
7.4.2
Kamokamo (marrow)
Kamokamo can be mashed or puréed and fed to infants as a first food at around six
months of age, or as a staple vegetable for older infants and toddlers.
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7.4.3
Pūha, watercress
Green leafy vegetables, such as pūhā and watercress, can be offered in a purée after
about six months of age. These foods provide an excellent source of Beta-carotene
(provitamin A) and vitamin C.
7.4.4
Kai moana (seafood)
Traditional seafoods include kina (sea eggs), pipi, kōura (crayfish), pūpū (periwinkles),
parengo (a type of seaweed), pāua and eels. The recommended age for introducing kai
moana is eight to 12 months. Care must be taken to avoid seafood when there is any
possibility of marine biotoxin and food poisoning bacteria, to which infants are
particularly sensitive. Kai moana must only be collected from safe and unpolluted
areas.
7.4.5
Rēwena (bread)
Rēwena bread can make excellent toast fingers for the teething infant and can be
introduced at about seven to eight months of age.
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Part 8: Considerations for Pacific and Other
Population Groups, Infants and Toddlers and their
Families
8.1
Pacific
Pacific peoples as a category encompasses not only the seven largest Pacific
communities in New Zealand (that is, Sāmoans, Cook Islanders, Tongans, Niueans,
Tokelauans, Fijians and Tuvalueans) but also a number of other Pacific groups with
relatively small numbers. There is no one Pacific ethnicity in New Zealand, and Pacific
peoples in New Zealand represent about 22 ethnic groups each with its own culture,
language and traditions. Please note: statistically the Fijian ethnicity does not include
Fiji Indians (Gray 2001).
8.1.1
Breastfeeding
The rate of exclusive and full breastfeeding for Pacific infants at six weeks of age in
2005 was 58 percent, compared to the rate of 66 percent for all ethnicities, 71 percent
for New Zealand Europeans, 58 percent for Asian and 58 percent for Māori infants.
These rates are from Plunket and represent approximately 90 percent of all births.
Limitations of these data include incomplete coverage of all births and population
groups. There has been an increase in the breastfeeding rates for Pacific at all ages,
although Pacific have not achieved the Ministry of Health’s 2005 breastfeeding targets
of 74 percent at six weeks of age, 57 percent at three months of age and 21 percent at
six months of age (Ministry of Health 2002a).
From the data collected for the Pacific Islands Families Study in 2000 of 1376 Pacific
mothers, factors associated significantly with not exclusively breastfeeding at hospital
discharge included: smoking, unemployment prior to pregnancy, years in New Zealand,
not seeing a midwife during pregnancy, caesarean delivery and twin birth status.
Factors significantly associated with cessation (before six weeks of age) of exclusive
breastfeeding (for mothers who initially breastfed exclusively) included: smoking,
employment prior to pregnancy, being in current employment, high number of children,
pacifier use, not receiving a visit from Plunket, infant not discharged at the same time as
the mother, infant not sharing the same room as the parent(s) at night, regular childcare
and having a home visit for the infant from a traditional healer (Butler et al 2004).
Of particular note are the findings for Tongan women who were at greater risk of having
a wide range of feeding problems compared to the other ethnic groups. These findings
are important for demonstrating that the Pacific communities should not be seen as a
homogeneous group. While some beliefs, behaviours and experiences may be
common across groups, many differences exist.
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It has also been noted that there are high Pacific enrolments in primary health
organisations (PHOs), and this presents an opportunity for positive and appropriate
messages on breastfeeding and infant nutrition to be delivered to Pacific peoples. As at
April 2006, 81 PHOs had been established throughout the country. Of these, three are
Pacific-specific PHOs: AuckPAC PHO and Langimalie Clinic Tongan Health Society
Incorporated in the Auckland DHB region and Ta Pasefika Health Trust PHO in the
Counties Manukau DHB region. In 2007, the PHO enrolment figure for Pacific people
was 260,161, which is close to 100 percent when compared to Statistics New Zealand
2006 census figures for Pacific population in New Zealand (265,974) (Ministry of Health
2007).
8.1.2
Dietary practices
One study (Tuohy et al 1997) showed that Pacific peoples were more likely than
Europeans to introduce their infants to complementary foods before six months of age.
The Infant Care Practices Study (Abel et al 2001) reveals some information about
practices for feeding Pacific infants and toddlers. Common early foods for all ethnic
groups were puréed fruit and vegetables and soft cereals. In addition, Sāmoan women
mentioned sua alaisa (a rice soup) and Cook Islands women mentioned pia (arrowroot
starch) and mokomoko (coconut milk). Although some Sāmoan-raised mothers
indicated that, traditionally, caregivers premasticated their infant’s food, none of the
Pacific mothers in the study mentioned doing this themselves. The choice of
complementary foods was an area in which tensions were evident between New
Zealand-raised Sāmoan and Tongan parents and the older generation. The latter
considered fresh fruit and vegetables optimal for the infant and did not condone
prepared foods. There were also differing views about the age at which complementary
foods should be introduced.
My mum wanted to feed [infant] a sua alaisa (rice soup), and I said, “No, not now,
it’s too early”. And she goes, “Se e le meaola fia palangi, oh sa outou laiti”. (“You
act like a Pākehā. When you were young, I used to feed you that.”)
New Zealand-raised, Sāmoan, first-time mother
Although Western health professionals advise that complementary foods not be
introduced until the infant is at least four months old, several Māori, Pacific and young
Pākehā women mentioned that they introduced their infants to complementary foods at
three months of age. A few Pacific caregivers began their infant on complementary
foods as early as six to eight weeks of age. The main reason given for the early
introduction of complementary foods was that the infant would not settle after feeding
and was not sleeping well. Once complementary foods were introduced, this changed,
and it was possible to reduce the frequency of night feeding. Some Cook Islands
participants argued that Pacific babies were hungrier than Pākehā babies so the age
limit advice did not apply to them (Abel et al 2001).
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8.1.3
Nutrition issues
From the studies conducted on Pacific populations on breastfeeding and dietary
practices, the main nutritional issues facing Pacific are: shorter duration of
breastfeeding, more likely to introduce complementary foods before six months of age
and tea drinking.
8.1.4
Traditional Pacific foods
There are some common foods that are either traditionally eaten by Pacific infants and
toddlers or that have been introduced early in Pacific cultures and now find a special
place in Pacific cuisine for children. Not all the foods listed below are eaten by all
Pacific groups because there are some slight differences in usage. For example, sago
is more commonly eaten by Sāmoans and not by Tongans or Cook Island peoples. It is
always good to check with the family as use may vary.
8.1.5
Pacific staple foods
Pacific staple foods are a special group of foods for Pacific peoples, and these foods
are becoming more available and accessible in the highly Pacific populated regions
such as Auckland. The common staples in New Zealand include kūmara, taro, cassava
(tapioca, manioke/a), yam and pumpkin. (Note that the yam referred to here is not the
small pinkish yams available in the supermarket.) These Pacific staples can be cooked
and puréed on their own or boiled together with vegetables and meat and then puréed
together with the cooking water as first foods for infants around six months of age. For
older children, the staples can be mashed together and their consistency and texture
adjusted to suit the child’s developmental cues.
8.1.6
Tropical fruits of the Pacific
Ripe banana, mango and pawpaw are favourite tropical fruits that can be puréed or
mashed for infants and can be given as finger foods for toddlers. Mango and pawpaw
are expensive in New Zealand, but traditionally they have been used as medicine for
infants, toddlers and young children who experience constipation. If possible, offer juice
from the young coconut as a complementary drink to toddlers. The flesh of the young
coconut can also be given to infants and toddlers.
8.1.7
Green leafy vegetables
Taro and pele leaves are common to all Pacific peoples. Pele is sometimes sold at flea
markets around Auckland, although it is more expensive. Many Pacific families also
import these foods from the islands. Taro and pele leaves must be cooked, usually
boiled together with staples and meat, then puréed or mashed and served to infants and
toddlers. It is important to remove the ‘stringy bits’ before offering the vegetables for
consumption. In New Zealand, other substitutes include silverbeet and to a lesser
extent spinach.
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8.1.8
Breads and cereals
Common foods consumed by Pacific infants and toddlers include sago, boiled white rice
mixed with warm milk, and bread or cabin bread soaked in Milo (preferably with no
sugar added). Tea must not be used to soften the bread or cabin bread; freshly brewed
lemon leaves or lemon grass is the recommended fluid for this process.
8.1.9
Lean meat, chicken and fish
Any lean meat such as beef and lamb, chicken and fish can be puréed or mashed for
infants and toddlers to consume.
8.1.10 Foods not recommended as first foods (around six months of age)
Salty meat and fish such as corned beef, povi/pulu masima (salted brisket), tinned fish
and all seafood (shellfish, octopus, etc) except fish should not be used as first foods.
Foods that cause bloating and an upset stomach, including cabbage and beans, should
not be served as first foods.
8.2
Fijian Indian
8.2.1
Breastfeeding
A thesis by Maharaj (1999) described breastfeeding patterns of migrant Fijian-Indian
women in Auckland. The primary research tools were a questionnaire and interview
schedule. The research included 30 Fijian-Indian breastfeeding women aged between
21 and 33 years. Between the 30 women, there were 33 infants, with 32 born in New
Zealand and one in Fiji. The children ranged in age from one month to 3½ years, with a
mean age of 9½ months. All the women had their husbands living with them, and most
had another member of the family living in the household as well.
Breastfeeding appeared to be ceasing at around three months of age and mothers
depended heavily on supplementation, beginning when the infant was around three
weeks of age. Thirty of the 33 infants were supplemented with formula at a mean age
of 3½ weeks, before the introduction of complementary foods. Introduction of
complementary foods was occurring at a mean age of four months. The reasons
offered for ceasing breastfeeding were: insufficient milk, resumption of work, sore
nipples and discomfort, another pregnancy, formula feeding after birth and convenience
of bottle feeding.
In India itself, breastfeeding commonly continues until the infant is one year of age and
beyond but may be supplemented by modified cow, buffalo or goat milks depending on
availability and cost. Complementary foods are infrequently given before the infant is
six months of age and usually not until nine months to one year of age. The infant is
given texture-appropriate versions of the family foods. Food cooked with chilli is not
introduced until the child is at least two years old, but other spices and salt are used.
Migration has affected breastfeeding patterns, with introduction of complementary foods
being brought forward, exclusive breastfeeding rates lowering and supplementation
beginning earlier.
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8.2.2
Dietary practices
Eighty percent of the migrant women taking part in the research fed their infants family
foods as complementary foods, believing that home-made food was more nutritious,
and convenient, and was what they had been raised on. Family foods that were used
as first foods included rice, lentils (dahl), cereals, bananas, pears, and cooked and
puréed potato, pumpkin, carrots and kūmara. Other foods were minced meat, mainly
chicken, spinach, taro, beans, cabbage and fruit. Foods were prepared with less salt
than the food for the family and no spices. Custard and infant rice were given
frequently. Juice was given as a drink to prevent dehydration was and preferred over
water because of higher nutritional value.
In a study of 102 children aged six to 36 months in Fiji (Singh and King 2003), dietary
information was collected through a self-administered questionnaire on: breastfeeding,
use of infant formula or cows’ milk, consumption of snacks, socioeconomic status of
parent, dental visits, addition of sweeteners in milk and frequency of tooth brushing.
The study reported that in the six- to 12-month age group, about 45 percent were
breastfed and 55 percent were using bottles. In the 13- to 24-month age group,
24 percent were breastfed, 67 percent were bottle fed and 9 percent using a cup. In the
25- to 36-month age group, 15 percent were breastfed, 36 percent were bottle fed and
49 percent were using a cup. Breastfeeding was more common among indigenous
Fijians than Indians. About 89 percent of mothers gave snacks to their children. The
most popular snacks were bongos (savoury corn-based snack) and cream crackers
(64 percent), while 25 percent of the children ate or were given fruit as snacks. Homemade infant food was consumed by children and use of processed food was not
common among the sample.
8.3
Asian
8.3.1
Breastfeeding
The rate of exclusive and full breastfeeding for Asian infants at six weeks of age in 2005
was 58 percent, compared to the rate of 66 percent for all ethnicities, 71 percent for
New Zealand Europeans, 58 percent for Māori and 58 percent for Pacific infants. These
rates are from Plunket and not nationally representative. Limitations of these data
include incomplete coverage of all births and population groups. There has been an
increase in the breastfeeding rates for Asian at all ages, although Asians have not
achieved the Ministry’s 2005 breastfeeding targets of 74 percent at six weeks of age,
and 57 percent at three months of age but have achieved over the 21 percent target at
six months of age (Ministry of Health 2002a).
8.3.2
Dietary practices
A cross-sectional survey of 17 healthy preschool (12 to 60 months of age) children born
to Chinese immigrant families living in Dunedin was carried out in 1998 (Soh et al
2000). Three 24-hour diet recalls were collected. The parents were mainly Chinese (82
percent), with 12 percent from Taiwan and 6 percent from other Asian countries.
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The most common foods consumed by the children for breakfast were bread, noodles,
milk and eggs. Unlike European New Zealand children, cold breakfast cereal was not
often consumed. Children who attended preschool facilities that offered meals (n = 8)
were introduced to Western foods, such as sausages, cheese on toast or crackers,
Vegemite sandwiches, cold meats and diluted cordial drinks. These foods were not
eaten in the homes of the survey participants. Rice, vegetables, meat, fruit and eggs
were the most common foods consumed by the children for lunch and dinner. Soup
was often part of the evening meal, and was home-made from chicken or pork bones/
pieces with Chinese herbs and vegetables such as sweet corn, bok choy and carrots.
Common snacks were milk, yoghurt, biscuits, fruit and sweets/chips. The most
common types of fruits and vegetables consumed during February and March were
apples, oranges, bananas, bok choy, green pepper, mushrooms, Chinese cabbage,
eggplant, bean sprouts, carrots, cauliflower, mixed vegetables, broccoli, sweet corn,
potatoes and spring onions.
Less than 40 percent of children were meeting recommendations for vegetables and
fruit consumption, whereas over 75 percent were meeting recommendations for meat
and meat alternatives consumption.
The results from this survey also found that the Yin and Yang philosophy played a role
in eating habits for 71 percent of families. The Yin and Yang philosophy gives rise to
the view that foods have characteristic properties or energies that are released when
the food is metabolised and produce either a heaty condition (feeling hot), or a cooling
condition (feeling cold). Thus foods are chosen to achieve a balance between the
energies of the foods and the energies of the conditions inside and outside the body to
aid good health. Parents reported that when their children were in a heaty condition,
they restricted the consumption of fried foods, chocolates, biscuits and chips and
encouraged the consumption of herbal tea, rice porridge, steamed foods and soups
made from dried Chinese vegetables, Chinese herbs, pork bones and carrots/parsnips.
For children in a cooling condition, they restricted fruits, such as oranges and bananas,
and cold foods, such as ice cream and cold drinks. They reported that children living in
Dunedin tended to be more in a heaty condition than in a cooling one. The mothers
also preferred, in general, to give their children cooked foods instead of cold or raw
foods, such as salads, sandwiches and cold breakfast cereals.
8.3.3
Nutrition issues
From the limited studies conducted on Asian populations in New Zealand about
breastfeeding and dietary practices, the main nutritional issues facing Asian infants and
toddlers in New Zealand are shorter duration of breastfeeding and not meeting the
recommended intakes for vegetables and fruit.
8.3.4
Traditional Chinese foods
The following is a list traditional Chinese foods and customs associated with those
foods (Auckland Regional Public Health Service 2005). It is always good to check with
the family, as use may vary.
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Congee
Congee is made from white rice and water but can be very thin and consequently low in
energy and nutrients. The texture and nutritional value can be increased by thickening
with infant rice. When the infant is about six to seven months of age, cooked meat or
chicken purées or egg yolk can be added to congee to increase variety and nutritional
value.
Noodles
Plain noodles (not instant noodles or flavoured noodles) and steamed plain cake
(mantou) can be introduced when the infant is six or seven months of age.
Soy foods
Tofu and soy custard can be introduced when the infant is eight months of age.
Steamed dumpling and steamed buns
Infants can be offered steamed dumplings and buns with a bland filling. Infant foods do
not need added salt, soya sauce, sugar or honey for flavouring.
Traditional customs and practices
Traditional customs and practices, for example, carrot soup and boiled rice water to
balance ‘heatiness’, may be followed. It is important that these remedies are not used
to replace a meal or milk as this will reduce the energy and nutrient intake.
Finger foods
Appropriate Asian finger food for infants includes such items as plain noodles, steamed
plain cakes or buns, cooked vegetable pieces or soft fruit.
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Part 9: Growth and Energy
9.1
Growth and rate of growth
9.1.1
Background
During infancy and childhood, the focus is on maintaining a rate of growth and
development that is consistent with the expected norms for age, sex and stage of
physiological maturity.
Growth refers to the acquisition of tissue and increase in body size. Development refers
to the increased ability of the body to function physically and intellectually. Physical and
intellectual development proceed at different rates in different individuals.
A positive energy and nutrient balance is critical in achieving and maintaining normal
growth and development. There is increasing evidence of the importance of growth and
nutrition in relation to cognitive development. Cognitive development in infants is
related more to height than to weight.
Growth during infancy influences current and future bone mass (NHMRC 2003; Ministry
of Health 2006a). Dewey (2003) has shown that the height of 12-month-old infants who
were exclusively breastfed to age six months was identical to that of 12-month-old
artificially fed infants, yet they weighed slightly less than the artificially fed infants.
Weight is also a good indicator of acute changes in intakes, while height reflects longterm nutrition. Children are more vulnerable than adults to rapid changes in nutritional
intake. Acute and chronic childhood illnesses impair appetite and may cause a
reduction in food intake to the detriment of growth. Many chronic diseases can also
retard growth, including undiagnosed kidney, heart or metabolic problems. Many
children who are failing to thrive are simply not getting enough food to meet their needs.
This can extend to children who have been placed on very restrictive diet because of
allergies or who are eating the same foods as adults in the family who have been
placed on low-fat diets. Some infants and toddlers may have their food intake
compromised by poverty or culturally restricted diets.
In the period of rapid growth that occurs during infancy, any intentional restriction of
weight gain – through dieting, for example – is usually inappropriate (NHMRC 2003).
9.1.2
Body composition
On average, the full-term infant at birth has about 550 g of body fat, mostly in adipose
(fatty) tissue. This body fat represents about 2000 kJ of energy, that acts as an energy
reserve. The fat also serves to conserve heat by insulating the body. The amount of fat
varies markedly between babies: heavy babies can have over 25 percent of their body
weight as fat.
Pre-term and post-term infants tend to have much less body fat than full-term babies.
This means that they potentially have insufficient energy reserves to meet their
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demands for rapid growth and so may develop hypoglycaemia, with the risk of brain
damage. They may also have problems with heat control. The foetus only stores fat in
substantial amounts from 34 weeks’ gestation, which explains the malnourished
appearance of the pre-term infant. Post-term infants look emaciated probably because
rapidly diminishing placental functions mean that they have to use energy from their fat
stores to remain alive.
9.1.3
Growth rate
Between birth and 18 years of age, a person’s body weight increases about 20-fold.
During infancy the rate of growth is fast and decelerates rapidly over the first year of life
to a slower rate in the second year of life. The rate of increase in weight and length/
height is essentially linear; the rate of increase in weight generally keeps pace with the
rate at which length/height increases.
Exclusive breastfeeding is widely agreed to be the optimal form of infant feeding, hence
other modes of feeding should be measured against exclusive breastfeeding in terms of
growth (American Academy of Pediatrics 2005).
A number of cohort studies have found that infants who have been breastfed for more
than three months have slower growth rates than those who have been formula fed
(Dewey et al 1993). However, there is no health-related significance to this slower
growth rate (Dewey et al 1993). Any temporary faltering of growth may be
misinterpreted and result in concerns over adequacy of breastfeeding.
Rapid weight gain, or upward percentile crossing, during the first two years of life has
been linked to general and central adiposity (fat around the torso) at age five years.
More recently, rapid weight gain during the first week or months of life has been shown
to be associated with an increased risk of excess weight and obesity, on the basis of
body mass index (BMI; in kg/m2), in childhood and in young adulthood (Ekelund et al
2006).
Rapid weight gain in low-birth-weight infants may lead to increased rates of coronary
heart disease, stroke, hypertension, and type 2 diabetes (Barker 2004).
9.1.4
Assessment of growth
Growth is best assessed by measuring weight, length or height and head
circumference. Growth is considered normal when weight and height follow the
percentile line and track along similar percentiles. It is important to note any difference
between the weight and height percentiles. In cases of acute nutritional problems, the
weight percentile is likely to be substantially lower than the height percentile. Where
there are endocrine deficiencies or other long-term diseases, both weight and height will
be substantially depressed. Investigation is appropriate when there are changes in a
child’s growth velocity or there is concern about the child’s growth, health or
development. In general, the more pronounced the change in the growth rate, the
younger the child and/or the more extreme the percentile, the greater the concern.
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Serial measurements indicate growth trends, which reveal more about a child’s nutrition
or health than the position of one measurement on a growth chart. Whenever a new
measurement varies greatly from the previous measurement, the accuracy of the
measurement and recording should be confirmed first.
A child’s percentile indicates the position of the child relative to the reference
population. In the case of premature infants, allowances can be made for their small
size at birth by subtracting the number of weeks of prematurity from the infant’s age
before plotting on a growth chart. After 12 months of age, it is no longer necessary to
allow for prematurity.
An accurate record of growth on a growth chart is one of the most useful assessment
tools for both healthy children and children suffering from disease. The commonly used
growth charts are prepared with a number of percentiles marked, usually ranging from
the 3rd percentile to the 97th percentile, with different charts for boys and girls. There
are three sets of growth charts available for use in New Zealand:
• New Zealand growth charts (1991)
• Centre for Disease Control (CDC) growth charts (2000)
• WHO growth standards (2006).
New Zealand growth charts (1991)
The New Zealand growth charts are based on a 1989 study of 12,311 children aged one
month to five years (Binney et al 1991). The children were from 10 areas – Southland,
Timaru, Christchurch, Wellington, Hutt Valley, Palmerston North, Rotorua, South
Auckland, Auckland and Takapuna. Of the sample, 78.5 percent were European, 9
percent Māori, 6.8 percent Pacific, 5.6 percent Other and 0.1 percent unspecified.
There were no significant differences between those infants who were exclusively
breastfed and the remainder of the sample.
CDC growth charts (2000)
The 2000 CDC growth charts (CDC 2000) represent the revised version of the 1977
growth charts. Most of the data used to construct these charts come from the National
Health and Nutrition Examination Survey (NHANES), which has periodically collected
height and weight and other health information on the American population since the
early 1960s. The 1977 charts had been adopted by the World Health Organization for
international use.
The revised CDC growth charts consist of 16 charts (eight for boys and eight for girls).
These charts represent revisions to the 14 previous charts and the introduction of two
new body mass index-for-age (BMI-for-age) charts for boys and for girls, aged two to
20 years.
The CDC growth charts can be used to assess the growth of exclusively breastfed
infants. However, when interpreting growth patterns, one must take into account that
the mode of infant feeding can influence infant growth. In general, exclusively breastfed
infants tend to gain weight more rapidly in the first two to three months, while from six to
12 months of age, breastfed infants tend to weigh less than formula-fed infants. The
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CDC growth chart reference population includes data for both breastfed and formula-fed
infants, proportional to the distribution of breastfed and formula-fed infants in the
population. During the past two decades, approximately one-half of all infants in the
United States received some breast milk and approximately one-third were breastfed for
three months or more.
WHO growth standards (2006)
WHO have created new growth standards (WHO 2006) for assessing the growth and
development of infants and young children around the world. The standards describe
normal child growth from birth to five years of age under optimal environmental
conditions and can be applied to all children everywhere, regardless of ethnicity,
socioeconomic status and type of feeding. The standards establish the breastfed infant
as the normative model for growth and development.
The data from the WHO Multicentre Growth Reference Study (MGRS), which was
undertaken between 1997 and 2003, were used to generate the new growth standards.
The MGRS collected primary growth data and related information from approximately
8500 children from widely different ethnic backgrounds and cultural settings (Brazil,
Ghana, India, Norway, Oman and the USA). The children included in the study were
raised in environments that minimised constraints to growth, such as poor diets and
infection. In addition, their mothers followed health practices such as breastfeeding
their children and not smoking during and after pregnancy. The MGRS was designed to
provide data that described ‘how children should grow’ and reiterated the fact that child
populations grow similarly across the world’s major regions when their needs for health
and care are met.
Estimates of overweight and undernourishment may change because of differences in
the pattern of growth between the new standards and the old reference, especially
during infancy. The magnitude of the change in the estimates, however, will vary by
age, sex, growth indicator and the underlying nutritional status in the population being
evaluated.
Possible effects of using the new WHO standards compared to the previous
international reference are:
•
lower height for age rates
•
lower weight for length/height rates during infancy (ie, up to about 70 cm length)
•
an increase in underweight rates during the first half of infancy (ie, zero to six months
of age) and a decrease thereafter
•
greater prevalence in overweight that will vary by age, sex and nutritional status of
the index population.
When we compare the New Zealand growth charts with the new WHO growth
standards, there is very little difference between the heights of infants and children for
all ages on the two charts. Likewise, there is very little difference between the weight of
the majority of children on the two charts. However, there would be more marked
differences for children at the lighter and heavier ends of the weight spectrum, who will
be at a higher percentile for weight when assessed using the WHO standards.
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The WHO reference growth charts should be used for New Zealand infants and
toddlers. This is because these growth charts are based on the most recent data, they
indicate how children should grow and they establish the breastfed infant and toddler as
the normative model for growth and development.
9.2
Energy
9.2.1
Background
Food is converted into energy that is used for movement, growth and development, and
metabolic functions, such as breathing, heart contractions, digestion and keeping warm.
Previously measured in calories (cal) and kilocalories (kcal), energy is now measured in
kilojoules (kJ) or megajoules (MJ). A kilocalorie is 4.2 kilojoules.
The young infant uses a considerable amount of energy for growing, most of the rest for
metabolism and relatively little for physical activity. In the first three months of life,
about 35 percent of energy intake is used for growth.
As the child grows, these proportions in energy use change, and the energy used for
growing falls to 5 percent by 12 months and less than 2 percent over the course of the
second year of life (NHMRC 2006). Metabolic needs increase as the child grows, and
the amount of energy used in physical movements increases substantially as the child
learns to roll around, crawl and finally walk.
The estimated energy requirements for infants and toddlers are shown in Table 9.
These energy requirements were estimated using the total energy expenditure (TEE)
and the additional need for growth of 730 kJ per day for infants up to three months of
age, 230 kJ per day for infants from four to six months of age, 90 kJ per day for infants
from seven to 12 months of age and 85 kJ per day for infants one to two years of age
(NHMRC 2006). Physical activity levels were not used in calculating the requirements
of infants.
Four studies comparing breastfed and formula-fed infants have shown higher TEE in
formula-fed infants (Butte et al 1990, 2000; Jiang et al 1998; Davies et al 1990),
averaging an additional 12 percent TEE at three months of age, 7 percent at six months
of age, 6 percent at nine months of age and 3 percent at 12 months. However, no
differences have been seen at 18 and 24 months (Butte 2001).
The child’s appetite and growth are the best guides to adequacy of energy intake.
There may be substantial variation between energy intake in different children.
Between one and two years of age, there is even greater variation in energy needs due
to varying levels of physical activity.
Table 9:
Age
(months)
Estimated energy requirements (EERs) of infants and young children
Reference weight
(kg)
Boys
62
Girls
EER
(kJ/day)
Boys
Girls
EER for breastfed
infants (kJ/day)*
Boys
Girls
EER for formula-fed
infants (kJ/day)*
Boys
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Girls
1
2
3
4
5
6
7
8
9
10
11
12
15
18
21
24
4.4
5.3
6.0
6.7
7.3
7.9
8.4
8.9
9.3
9.7
10.0
10.3
11.1
11.7
12.2
12.7
4.2
4.9
5.5
6.1
6.7
7.2
7.7
8.1
8.5
8.9
9.2
9.5
10.3
11.0
11.6
12.1
2000
2400
2400
2400
2500
2700
2800
3000
3100
3300
3400
3500
3800
4000
4200
4400
1800
2100
2200
2200
2300
2500
2500
2700
2800
3000
3100
3200
3500
3800
4000
4200
1949
2183
2280
2204
2402
2583
2688
2866
3002
3191
3300
3420
–
–
–
–
1739
1940
2062
2037
2218
2369
2441
2576
2711
2874
2971
3078
–
–
–
–
2253
2448
2514
2412
2591
2757
2847
3017
3143
3317
3420
3533
–
–
–
–
2054
2220
2315
2263
2432
2563
2626
2746
3153
3026
3119
3220
–
–
–
–
Sources: NHMRC 2006, * Butte 2005
9.2.2
Sources of energy in the diet
Breast milk provides energy mainly from fat (around 50 percent) and carbohydrate
(around 43 percent) with protein providing around 7 percent. Most of the protein is used
for growth and not as fuel for energy (see 10.1: Protein).
Infant formulae are designed as breast milk substitutes and have a similar distribution of
energy sources as the average composition of breast milk. However, infant formulae
have a higher protein content than breast milk partly to compensate for poorer use of
the protein found in formulae.
In the first year of life, the energy contribution of complementary foods is initially small,
and breast milk or infant formula remains the predominant energy source. Although
infants aged seven to 12 months of age will obtain increasing amounts of energy from
complementary foods, in the first two years of life, most infants and toddlers still obtain
the majority of their energy from milk.
A regional study of Dunedin infants (Simons 1999) found that six-month-old infants
obtained around 80 percent of their energy from milk (either breast milk or infant
formula); nine-month-old infants obtained around 68 percent of their energy from milk
and 12-month-old infants obtained around 65 percent of their energy from milk.
Reduced-fat milks should not be used for infants and toddlers under two years of age
because of the low energy content of these milks at a time when children have high
energy requirements (American Academy of Pediatrics 1992).
The energy density of a food is the amount of energy it contains per unit mass.
Because infants and toddlers have relatively high energy requirements and limited
stomach capacity, they should eat foods that have higher energy density and lower
dietary fibre than adults (see 10.2.4: Recommended carbohydrate, dietary fibre and
prebiotics intakes).
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9.3
Practical advice for growth and energy
•
Maintain healthy growth and development of the infant or toddler by providing
appropriate food and physical activity opportunities every day.
•
Infants should be fed exclusively on breast milk up to around six months of age, with
continued breastfeeding up to two years of age or beyond.
•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
•
When the infant is ready, appropriate complementary food should be introduced and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready. The infant will probably be ready at around six months of age, but
some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
The variety of complementary foods offered to an infant should be increased to
ensure an additional intake of nutrients, especially iron. The infant should be eating
family foods by around one year of age.
•
The child’s appetite and growth and development are the best guides to adequacy of
energy intake. Use appropriate growth charts to monitor growth.
•
There may be substantial variation between energy needs in different children.
•
Between one and two years of age, there is even greater variation in energy needs
between children due to varying levels of physical activity.
•
In the first year of life, the energy contribution of complementary foods is small, and
breast milk or infant formula remains the predominant energy source.
•
After six months of age, the contribution of energy from solid food increases.
However, in the first two years of life, most infants and toddlers still obtain the
majority of their energy from milk.
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Part 10: Nutrients
10.1
Protein
10.1.1 Background
Protein is an essential component of the diet required for infant growth. Unlike fat and
carbohydrate sources, most protein is used for growth and not for energy generation.
However, adequate energy intake is required along with adequate dietary protein intake
to allow protein and amino acids to be used for these functions.
Proteins are made of amino acids. The body can synthesise some amino acids,
whereas the indispensable (formerly known as essential) amino acids must be obtained
from food. Proteins are necessary to build and repair tissue, for synthesising hormones,
enzymes and antibodies, and for many other bodily functions.
10.1.2 Recommended protein intakes
The adequate intake of protein for infants from birth to six months of age is 10 g per
day, and for infants aged seven to 12 months it is 14 g per day (NHMRC 2006). The
recommended dietary intake for toddlers aged one to two years is 14 g per day, or
1.08 g per kilogram body weight. This protein requirement per kilogram of body weight
is the highest for any age group, except for mothers during lactation. Family food that is
shared with a toddler should contain sufficient protein to provide 15 to 25 percent of the
total energy content of the diet.
10.1.3 Sources of protein in the diet
Breast milk and infant formula are the complete source of protein for the infant aged up
to six months, and continue to be the main source of protein until the infant is one year
of age. From six months of age, complementary foods are introduced to the infant’s
diet, which provide some protein. These include meat, poultry, seafood, eggs and
alternatives, and milk products, such as cheese, yoghurt, cottage cheese, custard and
milk in cooking. Milk should not be given as a drink before one year of age.
There are two parts to the protein in breast milk and cows’ milk-based formula. These
are casein and whey and their levels in the protein can be expressed as the
casein:whey ratio. After feeding, whey protein is quickly digested from the stomach,
whereas casein protein forms curds that are more slowly digested, resulting in slower
gastric emptying (Billeaud et al 1990; Fried et al 1992; Tolia et al 1992).
Breast milk is described as whey-dominant, with an average casein:whey ratio of 40:60.
This ratio varies according to stage of lactation – 10:90 in early lactation and 50:50 in
late lactation.
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Infant formulae can be casein-dominant (a casein:whey ratio of 80:20) or wheydominant (a casein:whey ratio of 40:60). Normal-term infants readily digest caseindominant or whey-dominant formula. Both types of formula will ensure normal growth
(Raiha 2002; Turck et al 2006). However, a study of the influence of components of
infant formula on iron, zinc and calcium availability indicated that minerals may be more
available in whey-dominant formulae (Drago and Valencia 2004). The casein:whey
ratio in infant formula influences the types of fats in the blood plasma lipid profile, with
casein raising cholesterol levels in the blood (Weizman et al 1997).
The dominant whey protein in breast milk is L-lactalbumin, and this protein is found in
relatively low levels in formula. The dominant whey protein in formula is betalactoglobulin, and this protein is not found in breast milk (Lien 2003).
Improvements to the protein component of cows’ milk based infant formula are being
investigated. These include reducing the protein content, increasing the proportion of
whey protein, reducing the allergenic component and improving amino acid profiles.
Sources of protein vary in their nutritional value, digestibility, efficiency of use and ratio
of indispensable amino acids. Protein from animal sources – such as meat, poultry,
seafood, eggs and milk, and milk products – tend to be of higher protein quality because
they provide all nine indispensable amino acids. Proteins from plant-based sources
may be limited in at least one indispensable amino acid and are used less efficiently.
Vegetarian diets in New Zealand usually contain adequate protein, but care must be
taken to ensure the vegetarian child’s diet contains adequate protein. Extra care should
be taken with infants over the age of six months and toddlers in families consuming
vegan diets to ensure they eat a range of legumes, nuts (not whole), breads and
cereals, and milk substitutes daily to receive adequate protein.
10.1.4 Practical advice for protein
•
Infants should be fed exclusively on breast milk to around six months of age, with
continued breastfeeding up to two years or beyond.
•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
•
When the infant is ready, appropriate complementary food should be introduced, and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready. The infant will probably be ready at around six months of age, but
some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
The variety of complementary foods should be increased to ensure an additional
intake of nutrients, especially iron. The infant should be eating family foods by
around the age of one year.
•
The toddler over the age of one year should be offered a variety of nutritious foods
from each of the four major food groups each day:
– vegetables and fruit
– breads and cereals, preferably wholegrain
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– milk and milk products
– lean meat, poultry, seafood, eggs, or alternatives.
10.2
Carbohydrate, dietary fibre and prebiotics
10.2.1 Carbohydrates
Carbohydrates can be classified as sugars, oligosaccharides and polysaccharides
(FAO/WHO 1998) as shown in Table 10.
Table 10: Classification of the major dietary carbohydrates
Class
Sub-group
Examples
Sugars
Monosaccharides
Glucose galactose, fructose
Disaccharides
Sucrose, lactose, trehalose
Polyols
Sorbitol, mannitol
Malto-oligosaccharides
Maltodextrins
Other oligosaccharides
Raffinose, stachyose, fructo-oligosaccharides
(FOS), galacto-oligosaccharides (GOS)
Starch
Resistant starch, amylose, amylopectin, modified
starches
Oligosaccharides
Polysaccharides
Non-starch
polysaccharides (NSPs)
Cellulose, hemicellulose, pectins, hydrocolloids
10.2.2 Dietary fibre
Dietary fibre is found in all plant materials. The main sources of dietary fibre are
cereals, legumes, vegetables and fruit. Dietary fibre is generally not digested by normal
digestive processes but is broken down (fermented) by bacteria in the large intestine.
An adequate intake (AI) of dietary fibre is essential for proper gut function and regular
laxation and may also be related to reducing risk for a number of diseases, including
heart disease, certain cancers and diabetes. The definition used for the AI is that
dietary fibre includes non-starch polysaccharides (NSPs), resistant starch and lignin (a
non-carbohydrate) (NHMRC 2006).
Dietary fibre-containing foods have a low energy content relative to their volume.
Infants and toddlers given large amounts of dietary fibre-containing foods may have
their appetite satisfied before their energy requirements have been met (Lifshitz and
Moses 1989).
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Phytates, and to a lesser extent dietary fibre, can bind with and prevent effective
absorption of some minerals including, calcium, copper, iron, magnesium, phosphorus
and zinc (Francis 1986). The nutritional significance of this effect depends on how
much phytate and the minerals it influences are consumed in the diet. Most Western
diets do not contain sufficiently high amounts of phytates for infants and toddlers to be
at risk of mineral deficiencies. However, some sections of the population – such as
vegetarians, vegans and Asian infants and toddlers, whose diets are reliant on grains
and cereals – may consume intakes of phytate and dietary fibre that cause suboptimal
mineral levels. In extreme cases, this could result in rickets (due to inadequate sun
exposure and absence of dietary vitamin D sources) or anaemia (due to inadequate
dietary sources of haem iron, and decreased bio-availability of non-haem iron
secondary to phytates. One New Zealand study showed a negative association
between dietary fibre intake and iron stores in six- to 24-month-old New Zealand
children (Soh et al 2002). Soy-based infant formula contains phytates.
There are limited data on normal intakes of dietary fibre for infants and toddlers. A
New Zealand study looking at nutritional intakes of a group of 53 healthy Auckland
children aged nine to 24 months (Wham 1994) found the mean daily intake of dietary
fibre to be 8 g, with a range between 1 g and 22 g. Girls and boys aged one to four
years in the Children’s Nutrition Survey (CNS) pilot (Ministry of Health 2001) appear to
have a fibre intake (10 g) lower than the AI of 14 g. The CNS pilot also suggested that
many toddlers were not eating enough vegetables and fruit.
10.2.3 Oligosaccharides, including prebiotics
Oligosaccharides are a carbohydrate containing at least three sugar molecules. Many
oligosaccharides occur naturally, such as those in breast milk, which contains a
complex mixture of oligosaccharides that have a demonstrated prebiotic effect (Coppa
et al 2004). The concentration of oligosaccharides in breast milk is around 5 to 19 g/l
(Aggett et al 2003).
Oligosaccharides can also be extracted from plant tissues or synthesised, for example,
fructo-oligosaccharides (FOS) (for example, inulin, chicory), galacto-oligosaccharides
(GOS), lactulose, and lactitol. These extracted or synthesised oligosaccharides are
known as prebiotics (Aggett et al 2003). For a food component to be classified as a
prebiotic, it must be resistant to digestion in the small intestine, be fermented by one or
a limited number of beneficial bacteria in the large intestine and alter the bacteria in the
intestine towards a healthier balance of bacteria (Collins and Gibson 1999).
Naturally occurring oligosaccharides and prebiotics are fermented predominantly by
lactobacilli and bifidobacteria, increasing their growth and activity. Fructooligosaccharides are fermented predominantly by bifidobacteria and increase the
number of faecal bifidobacteria.
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There is a difference in the balance of intestinal bacteria between breastfed and formula
fed infants during the various stages of development following birth (Edwards and
Parrett 2003). Breastfed infants have more bifidobacteria and lactobacilli in their
intestine than formula fed babies (Aggett et al 2003). A bifidus-dominated flora is
considered protective as it may activate the immune system and inhibit invading
pathogens (Gibson and Roberfroid 1995). Formula fed infants have more
Enterobacteriaceae and Bacteroides species. Cows’ milk-based formula contains only
trace amounts of naturally occurring oligosaccharides. Infant formula may be
supplemented with prebiotics. This modification is primarily aimed at altering the
bacteria in the intestine of formula fed infants to more closely resemble those of
breastfed infants. Infants receiving such formula are likely to have softer and more
frequent bowel motions than infants on formulae with no prebiotics (Ghisolfi 2003).
Modulation of the bacteria in the gut may benefit allergic children (Aggett et al 2003).
10.2.4 Recommended carbohydrate, dietary fibre and prebiotics intakes
The AI for carbohydrate for infants from birth to six months of age is 60 g per day and
95 g per day for infants aged seven to 12 months. No AI has been set for infants aged
six to 12 months or toddlers aged one to three years.
Family food, which the toddler shares, should contain sufficient carbohydrates to
contribute between 45 and 65 percent of the total energy intake.
There are no dietary fibre intake recommendations for infants aged between birth and
12 months. An AI of 14 g per day of dietary fibre intake has been set for one- to threeyear-olds (NHMRC 2006).
There are no recommended dietary intakes for prebiotics.
10.2.5 Sources of carbohydrate, dietary fibre and prebiotics in the diet
Breast milk contains around 75 g of carbohydrate per litre, with about 70 g per litre as
lactose, which is digested in the small intestine, and the remainder as oligosaccharides.
Infants who are fed exclusively on breast milk or infant formula do not receive any
dietary fibre. Normal bowel function in infancy is maintained by undigested compounds
including oligosaccharides from milk feeds that, together with gut bacteria, provide the
bulk for normal motions.
Complementary foods are the initial sources of fibre in the infant diet. Cereals,
vegetables, fruit and legumes should be introduced following the order suggested in
Table 7: Order for introducing complementary foods and progressing to family foods.
Age-appropriate infant cereals are recommended as initial sources of carbohydrate.
Wheat breakfast biscuits contain a moderate level of fibre so can be given from eight
months of age. They should be served once a day only and served with breast milk or
infant formula, then cows’ milk after one year of age. Bran-based cereals should not be
given to infants and toddlers. They are too high in dietary fibre and may cause
diarrhoea and affect the bio-availability and absorption of nutrients. Chunky cereals
containing nuts or pieces of dried fruit are not suitable because of the risk of choking.
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In the case of breads and cereals, start with white or wholemeal bread. Continue to use
wholemeal bread. Wholegrain bread can be given at around one year of age.
10.2.6 Practical advice for carbohydrate, dietary fibre and prebiotics
•
Infants should be fed exclusively on breast milk to around six months of age, with
continued breastfeeding up to two years of age or beyond.
•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
•
When the infant is ready, appropriate complementary foods should be introduced and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready. The infant will probably be ready at around six months of age but
some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
The variety of complementary foods should be increased to ensure an additional
intake of nutrients, especially iron. The infant should be eating family foods by
around the age of one year. Whole-grain cereals, green vegetables and legumes
can be introduced over time after the introduction of initially appropriate
complementary foods.
•
For infants, prepare or choose pre-prepared foods that contain no added fat, salt,
sugar or sweeteners.
•
Toddlers should be offered a variety of nutritious foods from each of the major food
groups each day:
– vegetables and fruit
– breads and cereals, preferably wholegrain
– milk and milk products
– lean meat, poultry, seafood, eggs, or alternatives.
•
For toddlers, prepare foods or choose pre-prepared foods, drinks and snacks:
– with minimal added fat, especially saturated fat
– that are low in salt; if using salt, choose iodised salt
– with little added sugar; limit intake of high-sugar foods.
•
For toddlers, provide plenty of liquids each day, especially milk and water.
10.3
Fat
10.3.1 Background
Fat is an essential component of the diet. Dietary fat provides essential substrates for
cell structures and a wide variety of biologically active constituents of the endocrine,
coagulation and immune systems. Fat is a concentrated source of energy. It also
provides the mechanism for absorbing the fat-soluble vitamins A, D, E and K and carries
flavour.
Dietary fat predominantly takes the form of triglycerides, which consist of three fatty
acids and one glycerol unit. Fatty acids can be classified into saturated,
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monounsaturated and polyunsaturated fatty acids. The polyunsaturated fatty acids can
be classified as omega-3 (n-3) and omega-6 (n-6) fatty acids.
There are two polyunsaturated fatty acids that are essential in the diet because they
cannot be synthesised by the body. These are linolenic acid and alpha linolenic acid.
Individuals can use linolenic acid to make the long-chain polyunsaturated fatty acids
(LCPUFAs), arachidonic acid (AA) and gamma linolenic acid (GLA); and use alpha
linolenic acid to make eicosapentanoic acid (EPA), docosahexaenoic acid (DHA) and
docosapentanoic acid (DPA).
Of the many biochemical and immunological differences between breast milk, cows’
milk and infant formula, the differences in composition of the fat are of particular
importance. The differences are in the proportion of polyunsaturated (P),
monounsaturated (M) and saturated (S) fats (summarised as the P:M:S ratio for a milk)
and the differences in the amount of omega-3 (n-3) and omega-6 (n-6) polyunsaturated
fatty acids. Breast milk contains varying amounts of essential fatty acids and LCPUFAs,
depending on maternal intake.
The P:M:S ratio of the milk affects its digestibility. The polyunsaturated fats in breast
milk also aid the absorption of calcium. The type of fat also affects the fat in the infant’s
fat stores and the fat transport vehicles (lipoproteins) in the blood, which may have longterm consequences on the rate of development of cardiovascular disease (Fall et al
1992).
During the past 10 years, the LCPUFAs, DHA and AA have been the focus of much
research. DHA and AA are important components of the phospholipids present in the
retina and the brain (Makrides et al 1995). They are also integral structural components
of all cells in the body. Almost half the high lipid content of the brain is LCPUFA.
Full-term infants fed formula containing no LCPUFAs have lower levels of AA and DHA
in their plasma and erythrocyte phospholipids and lower levels of DHA in their brain
cortical phospholipids compared with breastfed infants. Early research suggests that
infants fed a continuous supply of DHA, from either breast milk or supplemented
formula, may have improved visual functioning (Makrides et al 1995; Carlson et al
1996). However, there is less evidence to support the role of AA in improved visual
functioning (Makrides et al 1995).
It has also been proposed that LCPUFAs may have an affect on the growth of full-term
infants. However, recent research suggests that this is not the case (Makrides et al
2005; Simmer 2001). Importantly, research has demonstrated that AA supplementation
of formula is not required in order for infants to display adequate growth (Makrides et al
2005).
10.3.2 Recommended fat intakes
For infants from birth to six months of age, the AI for total fat is 31 g per day, 4.4 g per
day for n-6 polyunsaturated fats and 0.5 g per day for n-3 polyunsaturated fats.
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For infants aged seven to 12 months, the AI for total fat is 30 g per day, 4.6 g per day
for n-6 polyunsaturated fats and 0.5 g per day for n-3 polyunsaturated fats.
For toddlers aged one to three years, the AI for linoleic acid is 5 g per day, alpha
linolenic acid is 0.5 g per day, and LCPUFAs (DHA+EPA+DPA) is 40 mg per day.
Family food that the toddler shares should contain sufficient fat to contribute between 20
and 35 percent of the toddler’s total energy, with no more than 10 percent of fat being
saturated and trans fats. Omega-6 fatty acids (linoleic) should contribute 4 to 5 percent
and omega-3 (alpha linolenic) 0.4 to 0.5 percent of total energy (NHMRC 2006).
During the first two years of life, the child’s high energy demands for growth and
metabolism have to be met by a diet of greater energy density than for that required in
adulthood. Recommendations for dietary modifications, which aim to reduce total fat
and control the energy intake of the general population, are inappropriate for infants and
toddlers because of the potential adverse effect on their energy balance (Magarey et al
1993). Children on low-fat diets (< 30 percent energy from fat) are at greater risk of
unsatisfactory intakes of fat-soluble vitamins and inadequate energy (Lifshitz 1992).
10.3.3 Sources of fat in the diet
Both breast milk and infant formula provide approximately 50 percent of their energy
from fat (Riordan 2005). The fat content of breast milk is related to maternal size,
pregnancy weight gain and diet. Very low maternal fat intakes have been associated
with lower breast milk fat content, with fat concentration reaching a plateau at a
maternal intake of around 35 g per day, or about 20 percent of energy (Lonnerdal
1986). Although milk with a lower fat concentration has a lower energy concentration,
this does not appear to limit infant energy intake because infants consume more milk if
allowed to breastfeed on demand.
From one to two years of age, the toddler gradually increases the variety of foods in
their diet as they explore differences in taste and texture. The diet changes from one in
which half the energy is derived from fat (particularly milk) to a mixture in which less
than 40 percent of energy is derived from fat. The implication of this change is that
there is a wider range of types of fat in the diet and so the family’s selection of food
becomes of great importance in determining the biochemical influences of fat on serum
lipoproteins and cholesterol. It is recommended that margarine be used as a spread
and in baking to provide a source of polyunsaturated fat. Toddlers up to two years of
age should be given whole (dark blue top) cows’ milk to drink, but reduced fat milk can
be used for baking.
10.3.4 Practical advice for fat
•
Infants should be fed exclusively on breast milk to around six months of age, with
continued breastfeeding up to two years of age or beyond.
•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
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•
When the infant is ready, appropriate complementary food should be introduced and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready. The infant will probably be ready at around six months of age, but
some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
The variety of complementary foods should be increased to ensure an additional
intake of nutrients, especially iron. The infant should be eating family foods by
around one year of age.
•
For infants, prepare or choose pre-prepared foods with no added fat, salt, sugar or
other sweeteners.
•
The toddler over one year of age should be offered a variety of nutritious foods from
each of the major food groups each day:
– vegetables and fruit
– breads and cereals, preferably wholegrain
– milk and milk products
– lean meat, poultry, seafood, eggs, or alternatives.
•
For toddlers, prepare foods or choose pre-prepared foods, drinks and snacks:
– with minimal added fat, especially saturated fat
– that are low in salt; if using salt, choose iodised salt
– with little added sugar; limit intake of high-sugar foods.
•
A total of around 500 to 600 ml of milk per day is sufficient for toddlers.
•
Whole (dark blue top) cows’ milk is recommended for toddlers.
•
Use margarine as a spread, and margarine and reduced fat milk in baking.
10.4
Minerals and trace elements
10.4.1 Iron
Background
Iron is present in haemoglobin as a carrier of oxygen in the blood, the liver, muscle,
tissue and many cell enzymes. Over 60 percent of iron is in haemoglobin and about
25 percent as ferritin iron stores, mainly in the liver (McPhail 2002).
There are two types of iron in the diet: haem and non-haem iron. Haem iron is more
highly bio-available than non-haem iron. Haem iron from meat, poultry and fish is
typically 20 to 30 percent absorbed, and absorption is not significantly affected by other
components of the diet. Non-haem iron from non-animal sources such as plant foods
(vegetables, fruit and cereals), eggs, iron medication and iron fortificants in food is less
bio-available, with absorption of 5 percent or less. The absorption of non-haem iron
from foods of low bio-availability is improved in the presence of beef, lamb, pork,
chicken, liver and fish (Lynch 1997). Non-haem iron absorption is also enhanced by the
presence of vitamin C. Thus, eating fruit and vegetables that contain vitamin C at the
same meal will enhance the absorption of non-haem iron.
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Other promoters of non-haem iron absorption include citric acid, malic acid, tartaric acid
and lactic acid, which are found in fruit and yoghurt.
Absorption of iron varies with physiological requirements, the iron status of the
individual and dietary composition. More iron is absorbed when iron stores are low, and
iron absorption is reduced when iron stores are high. Therefore infants absorb far less
iron in the first six months of life than they do in later infancy when their stores are
depleted.
Iron is present in breast milk in a low concentration (0.2 to 0.7 mg/l), but it is highly bioavailable. About 50 percent of the iron in breast milk is absorbed, compared to
10 percent from cows’ milk-based infant formula (Saarinen et al 1977; Department of
Health (UK) 1994). In breast milk, the lower calcium, phosphorus and protein content,
and the high concentration of lactose, iron-binding protein and lactoferrin, aid
absorption.
Due to the lower bio-availability of iron in infant formulae, those used in New Zealand
are fortified with iron and have a higher iron content (7 to 12 mg/l) than breast milk.
Iron-fortified formulae also have added ascorbic acid, which enhances iron absorption
(Steel et al 1986).
The depletion of iron stores from birth and increased demands of growth indicate that
after six months of age infants are critically dependent on dietary iron supplied from
complementary foods even with continued breastfeeding (Faldella et al 2003; Male et al
2001).
The literature is inconsistent regarding the adequacy of iron stores of exclusively
breastfed infants between four and six months of age (Faldella et al 2003, Thorsdottir
et al 2003; Male et al 2001; Kazal 2002). This is a consequence of variability within and
between the populations studied, and a lack of enough evidence of sufficient quality.
Iron deficiency
Iron deficiency is the most common nutritional deficiency in the world, and one of the
few nutritional deficiency conditions that remains common in the developed world. This
is particularly true for infants aged between six months and two years of age for whom
the consequences of iron-deficiency anaemia (IDA) are more serious than in adults.
Infant feeding practices can play a major role in the prevention of this condition.
Anaemia is the primary sign of severe iron deficiency. The spectrum of IDA can be
characterised in terms of three stages: iron depletion, iron-deficient erythropoiesis and
iron-deficiency anaemia.
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Table 11: Spectrum of iron deficiency
Stage
Definition
Characteristics
1
Iron depletion
Low iron stores based on a fall in serum ferritin from 12 to
20 µg/L; normal haemoglobin
2
Iron-deficient erythropoiesis
Depleted iron stores based on serum ferritin < 12 µg/L;
transferring saturation < 16 percent; normal haemoglobin
3
Iron-deficiency anaemia
Anaemia based on depleted iron stores and low haemoglobin
Source: McPhail 2002
Abnormalities described in the spectrum of iron deficiency have included decreased
immunity, altered intestinal function, abnormal thermogenesis (body heat production)
and decreased red blood cell formation (Gallagher and Ehrenkranz 1995). Sustained
IDA during infancy may be associated with irreversible and detrimental effects on
intellectual and motor performance, including basic learning skills (Holst 1998; Walter et
al 1983, 1989; Lozoff et al 1987, 1991; Grantham-McGregor and Ani 2001; Heath et al
2002b). Children with IDA in infancy are at risk of long-lasting developmental
impairment (Lozoff et al 1991). Iron deficiency may also restrict linear growth (Chwang
et al 1988).
Prevalence of iron deficiency
There are concerns about prevalence of iron deficiency in New Zealand. The
prevalence of iron deficiency and IDA in other Western countries varies widely from
0 to 50 percent (Simons 1999).
The prevalence of the spectrum of iron deficiency in New Zealand has been shown to
be in the range of 18 to 51 percent of children with iron depletion and 5 to 34 percent of
children with IDA (Moyes et al 1990; Dickson and Morison 1992; Poppe 1993;
Crampton et al 1994; Rive et al 1996; Wham 1996; Adams et al 1997; Wilson et al
1999). A study of 323 randomly selected urban South Island six- to 24-month-old
children (Soh et al 2002, 2004) found suboptimal iron status in 29 percent of the infants
and IDA in 10 percent. In a 1997 to 1999 study of 391 hospitalised Auckland children
aged 8 to 24 months (Grant et al 2003), 56 percent had IDA. In a study of 74 healthy
Caucasian infants from predominantly higher socioeconomic groups in Dunedin Simons
1999), the median dietary iron intakes were below estimated requirements at nine and
12 months of age. IDA was present in 7 percent of the infants at each of the age
groups – nine, 12 and 18 months of age (Heath et al 2002b). In a study of an ethnically
stratified, randomly selected group of 416 Auckland children (Grant et al 2007), the
prevalence of iron deficiency was 14 percent. Iron deficiency prevalence varied with
ethnicity (Other 27 percent, Māori 20 percent, Pacific 17 percent, New Zealand
European 7 percent).
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Factors associated with iron deficiency
Infants and toddlers are at risk of becoming iron deficient because of their increased
needs for growth and limited food choices (Dallman et al 1980). They may also be at
risk if born to mothers with certain conditions: low iron status during pregnancy, low
haemoglobin concentration at birth, and perinatal bleeding. They may also be at risk if
they have chronic hypoxia, gain weight quickly or suffer from frequent infections
(Simons 1999). Rates of IDA prevalence in hospitalised children are likely to be higher
than those for healthy children. IDA can be caused by infection, inflammation and
factors affecting health, for example, malabsorption.
Pre-term infants are at particular risk of iron deficiency and require supplementation.
They have lower iron stores at birth because the foetus only stores iron from 34 weeks’
gestation and usually have insufficient body iron to maintain adequate iron status by six
months of age (Dallman 1986).
Infants who are iron deficient are clearly at increased risk of IDA, possibly following
even short periods of stress.
The dietary factors that increase the risk of iron deficiency include:
•
decreased iron intake, which can occur during common infectious or contagious
illnesses, when children are likely to eat poorly; or during an episode of financial need
or family disruption when children may not be adequately fed
•
receiving complementary foods earlier or later than recommended
•
being fed tea frequently
•
a low vitamin C or meat intake once complementary foods are started
•
receiving cows’ milk earlier than recommended
•
drinking too much cows’ milk.
Blood loss from the gut is rare in breastfed infants compared with infants fed cows’ milk
(Ziegler et al 1990). Cows’ milk has a low concentration of iron, and the iron absorption
is poor. Feeding of cows’ milk may cause gastrointestinal blood loss and subsequent
iron deficiency during infancy (Ziegler et al 1990). The calcium, protein and high
phosphate levels in cows’ milk inhibit iron absorption. Whole cows’ milk is not
recommended as a drink until one year of age.
Cows’ milk and cheese may decrease iron availability if they are taken in large amounts;
inhibition is possibly due to the presence of high levels of calcium and phosphorus
(Bothwell et al 1989).
Tannins present in tea are the major inhibitors of food iron absorption (Bothwell et al
1989). In infants, there is a highly significant association between tea drinking and
anaemia. Two older New Zealand studies found tea drinking to be common amongst
iron deficient children, especially those from Māori and Pacific families (Quested et al
1980; Poppe 1993).
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Tea drinking and longer duration of breastfeeding were associated with an increased
risk of iron deficiency in one hospital-based study from Auckland (Grant et al 2003).
Dietary iron bio-availability is also inhibited by phytates, which are present in cereals
(grains and rice) and vegetable proteins such as soy beans, legumes, nuts and wheat
bran. Note that legumes, wholegrains and rice are still useful sources of iron,
particularly for vegetarians and vegans. Infants and toddlers on high-fibre or vegetarian
diets are at greater risk of iron deficiency.
In a study of urban children from the South Island, current consumption of iron-fortified
formula was associated with higher serum ferritin (a measure of iron stores), and
consumption of more than 500 mls per day of cows’ milk was associated with lower
serum ferritin concentrations (Soh et al 2004). In an Auckland study of urban
community living children, there was an increased risk of iron deficiency associated with
low serum vitamin A, increased body mass index (BMI), breastfeeding after six months
of age and not receiving any infant or follow-on formula (Grant et al 2007).
Regional iron intake data (Simons 1999) does not indicate that there is generally a
concern with iron intakes for infants and toddlers.
Overall, the literature suggests that many infants in New Zealand are introduced to
complementary foods earlier than four months of age and introduced to cows’ milk as a
drink before one year of age. These practices put infants and toddlers at risk of iron
deficiency.
Recommended iron intakes
The AI for iron for infants from birth to six months of age is 0.2 mg per day. The AI is
based on the average iron concentration and intake of breast milk. The iron in infant
formula is much less bio-available, so intakes in formula-fed infants need to be
significantly higher.
The RDI for iron for an infant seven to 12 months old is 11 mg per day. The
recommended daily intake (RDI) for toddlers aged one to three years is 9 mg per day.
Absorption is about 18 percent from a mixed western diet including animal foods and
about 10 percent from a vegetarian diet; so vegetarian infants need higher intakes
(NHMRC 2006).
Iron (and zinc) are the only nutrients with sufficient data available to set an RDI for
seven to 12 month old infants. For the other nutrients, the data available for that age
group only allow an AI to be set.
Sources of iron in the diet
Infants should be exclusively breastfed until around six months of age. Breast milk
should be given until at least one year of age since other food sources may not provide
sufficient iron in a bio-available form (Filer 1990). The contribution made by milk (breast
milk or infant formula) in the first year of life is unquestionably a key factor in iron status
in infants (Stevens and Nelson 1995).
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From six months of age, complementary feeding with solid foods from which iron is
easily absorbed should be encouraged. Iron-fortified infant cereals are suitable starter
foods. Most infant cereals are fortified with iron to a level between 10 and 38 mg per
100 g of dry cereal. The iron absorption from infant cereal products varies greatly but
has been estimated at about 3 percent (Truswell et al 1990). At about six months of
age, meat or chicken purées can be added, and as swallowing develops, finely chopped
meats can be introduced. Liver is a good source of iron. However, because it is high in
vitamin A, it should be limited to 10 g (two teaspoons) per week. Dark-green leafy
vegetables, sieved lentils, chickpeas and peas provide a suitable alternative for
vegetarian infants, although the iron is less well absorbed.
Breast milk remains a good source of dietary iron for toddlers.
Infants who are still exclusively breastfed after six months of age and some infants and
toddlers on vegetarian and vegan diets may need supplemental iron, which should be
discussed with a health practitioner (Pizzaro et al 1991).
Practical advice for iron
•
Infants should be fed exclusively on breast milk to around six months of age, with
continued breastfeeding up to two years or beyond.
•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
•
When the infant is ready, appropriate complementary foods should be introduced and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready. The infant will probably be ready at around six months of age but
some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
The variety of complementary foods should be increased to ensure an additional
intake of nutrients, especially iron. Iron-fortified infant cereals are suitable starter
foods and absorption can be enhanced if vitamin C is present. At around six months
of age, meat or chicken purées can be added, and as swallowing skills develop finely
chopped meats can be introduced. Dark-green leafy vegetables, sieved lentils,
chickpeas and peas provide a suitable alternative for vegetarian infants, although the
iron is less well absorbed and should be eaten with a source of vitamin C. The infant
should be eating family foods by around one year of age.
•
Toddlers should be offered a variety of nutritious foods from each of the major food
groups each day:
– vegetables and fruit
– breads and cereals, preferably wholegrain
– milk and milk products
– lean meat, poultry, seafood, eggs, or alternatives.
•
Some infants and toddlers on vegetarian and vegan diets may require an iron
supplement, which should be discussed with a health practitioner.
•
Cows’ milk should not be introduced as a drink until the infant is one year of age.
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•
A total of around 500 to 600 ml of milk per day is sufficient for toddlers.
•
Whole (dark blue top) cows’ milk is recommended for toddlers. Fortified milks, such
as toddler milk, are generally not necessary.
•
Soft drinks, fruit juice or cordial are not recommended.
•
Coffee, tea, herbal teas, caffeine-containing beverages, smart or energy drinks,
carbonated beverages and alcohol are unsuitable for infants and toddlers and are not
recommended.
10.4.2 Zinc
Zinc is essential for many functions, including growth and neurobehavioral
development, immune and sensory function, reproduction, antioxidant protection and
membrane stabilisation (Institute of Medicine 2000). Since protein synthesis is
dependent on a number of essential zinc-containing enzymes, the effects of zinc
deficiency include impaired growth. Infants and toddlers are known to be vulnerable to
nutritional deficiencies in both iron and zinc. The prevalence of zinc deficiency both in
New Zealand and worldwide is unknown because of the difficulty in assessing zinc
status. The prevalence of zinc deficiency is likely to be comparable to that of iron
deficiency in children because dietary patterns associated with iron deficiency also
induce zinc deficiency.
Factors associated with mild zinc deficiency (and iron deficiency) include low birth
weight and prematurity, prolonged exclusive breastfeeding, early introduction and
prolonged excessive use of cows’ milk, poor appetite, high physiological requirements
induced by rapid growth and low intakes of meat combined with high intakes of cereals
unfortified with iron and zinc (Gibson 1997).
Recommended zinc intakes
For infants from birth to six months of age, the AI for zinc is 2.0 mg per day.
The RDI for zinc for infants aged seven to 12 months is 3.0 mg per day, and for toddlers
one to three years it is 3 mg per day.
Sources of zinc in the diet
Infants should be exclusively breastfed until around six months of age.
From six months, complementary feeding with solid foods from which zinc is easily
absorbed should be encouraged, such as meat or chicken purées can be added, and as
swallowing skills develop finely chopped meats can be introduced.
Practical advice for zinc
•
Infants should be fed exclusively on breast milk to around six months of age, with
continued breastfeeding up to two years or beyond.
•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
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•
When the infant is ready, appropriate complementary food should be introduced, and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready. The infant will probably be ready at around six months of age but
some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
The variety of complementary foods should be increased to ensure an additional
intake of nutrients, especially zinc. At around six months of age, meat or chicken
purées can be added, and as swallowing skills develop, finely chopped meats can be
introduced. Dark-green leafy vegetables, sieved lentils, chickpeas and peas provide
a suitable alternative for vegetarian infants. Infants should be eating family foods by
around one year of age.
•
Toddlers should be offered a variety of nutritious foods from each of the major food
groups each day:
– vegetables and fruit
– breads and cereals, preferably wholegrain
– milk and milk products
– lean meat, poultry, seafood, eggs, or alternatives.
10.4.3 Calcium
Background
Calcium is required for the normal development and maintenance of the skeleton. It is
present in the bones and teeth to provide structure and strength. Calcium is essential
for the development of bone, muscle contraction, the transmission of nerve impulses
and blood clotting. It is also an activator for a number of enzymes.
The level of calcium in the body is regulated by the parathyroid hormone, calcitonin, and
metabolically active vitamin D. Vitamin D aids absorption of calcium from the digestive
tract (see 10.5.2: Vitamin D). Certain amino acids and lactose (milk sugar) may
enhance absorption. Fibre, phytates and oxalates present in some cereals and
vegetables may decrease absorption of calcium by forming insoluble salts (Allen 1982).
Phosphorus also influences calcium uptake and combines with calcium to form the rigid
structure of bone. The dietary calcium to phosphate ratio has to be very high (probably
over 1:3) to interfere with calcium availability (Truswell et al 1990).
In children, the failure to deposit sufficient calcium in bone causes rickets, which results
in growth retardation, bowed legs and other skeletal abnormalities. Vitamin D
deficiency is the main cause of rickets not low calcium intakes (see 10.5.2: Vitamin D).
The mean (average) concentration of calcium in breast milk is approximately 260 to
300 mg/l during the first six months of lactation, with no pronounced changes during the
lactation period. The absorption of calcium from breast milk has been estimated at
55 to 60 percent (National Institute of Health 1994b; Lonnerdal 1997; Fomon 1993).
Breast milk from mothers delivering prematurely appears to have a higher concentration
of calcium than milk from women delivering at full term (Demarini and Tsang 1995).
The ratio of calcium to phosphorus in breast milk is approximately 2:1, compared to
approximately 1.2:1 in cows’ milk. The relatively low phosphorus content of breast milk
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may be a factor in the higher absorption of calcium from breast milk than from cows’
milk (and cows’ milk formula). Calcium concentrations in the breast milk of wellnourished women is unaffected by their calcium intake (National Institute of Health
1994a).
The Australia New Zealand Food Standards Code requires that infant formulae sold in
New Zealand contain a minimum of 12 mg of calcium per 100 kJ of formula and a
maximum amount of 33 mg of calcium. The higher concentrations of calcium in infant
formula compared to breast milk are because of the lower bio-availability of calcium in
the formula (Lonnerdal 1997). The calcium to phosphorus ratio in cows’ milk-based
infant formulae ranges from 1.2:1 to 1.9:1. The concentration of calcium in soy-based
formulae is greater than that of milk-based formulae to compensate for the presence of
phytates in the soy protein isolate, which may inhibit calcium absorption.
Recommended calcium intakes
The AI for infants from birth to six months of age is 210 mg per day and infants seven to
12 months, 270 mg per day.
The RDI for toddlers aged one to three years is 500 mg per day.
Sources of calcium in the diet
Breast milk is the optimal source of calcium during the first year of life. There is no
evidence to suggest that calcium intakes greater than those provided by breast milk in
the first six months of life, or breast milk plus complementary foods from six to
12 months, are of any long-term benefit to an infant (Greer et al 2006).
Milk and milk products are the major food sources of calcium and provide many other
essential nutrients such as zinc, riboflavin and vitamin B12. Milk products such as
cheese, yoghurt, cottage cheese, custard and milk puddings are suitable foods to be
introduced at approximately seven to eight months of age.
Whole (dark blue top) cows’ milk is suitable to be introduced to toddlers over one year
of age. Toddlers should be encouraged to consume 500 to 600 ml of whole (dark blue
top) cows’ milk a day. Cheese, yoghurt, cottage cheese, custard and milk puddings can
be used as part of the recommended amount of milk.
Toddlers who do not consume milk or milk products should be encouraged to drink a
calcium-fortified soy milk. Alternative sources of calcium include canned fish with
bones, tofu, nut pastes, green vegetables, and cooked, dried beans (see 12.10:
Vegetarian eating patterns). The use of a calcium supplement should be considered
after consultation with a dietitian and a doctor when there is concern that dietary
calcium requirements have not been met.
Practical advice for calcium
•
•
Breast milk is the optimal source of calcium during the first year of life.
For toddlers, milk and milk products are the major food sources of calcium.
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•
Toddlers should be encouraged to take 500–600 ml of whole (dark blue top) cows’
milk or an equivalent each day. Cheese, yoghurt, cottage cheese, custard and milk
puddings are suitable alternatives.
10.4.4 Iodine
Background
Iodine is a component of the thyroid hormones thyroxine (T4) and its active form
3,5,3’-triiodothyronine (T3). The thyroid hormones play an important role in growth and
development, and in energy production. Iodine deficiency affects growth and
development and reproductive function. In infants, children and adults, iodine
deficiency leads to goitre, hypothyroidism and impaired mental and physical
development (Hetzel et al 1990).
Iodine levels in soil, irrigation and fertilisers affect iodine in food. Most soils in New
Zealand are low in iodine, resulting in low concentrations in locally grown foods. Iodine
is efficiently absorbed from the intestine, but dietary goitrogens (present in vegetables
such as cabbage, cauliflower, broccoli and sweet potatoes) and nitrates may interfere
with the utilisation of absorbed iodine.
Recent nutrition surveys of the New Zealand population suggest that iodine intake is
falling and is below the recommended intake. The decrease in iodine intake has
several explanations. Dairy industry cleaning compounds, called iodophors, which
increased the amount of iodine in milk and milk products, have been replaced by noniodine-containing cleaning products. The use of more ready-to-eat and pre-prepared
foods (in which salt is not iodised) and the recommendation to use less added salt may
have also contributed to a reduced iodine intake.
A recent New Zealand study, set in the South Island (Skeaff et al 2005), found breastfed
infants aged six to 24 months had suboptimal iodine status. The iodine status of infants
is related to the iodine status of the mothers during pregnancy and the iodine content of
the milk the infants are fed.
The iodine content of breast milk correlates with maternal dietary iodine intake. In New
Zealand, Skeaff et al (2005) found that the mean breast milk iodine concentration is
22 µg/l. In countries with iodine deficiency disorders, breast milk iodine concentrations
are typically below 50 µg/l. When iodine intakes are adequate, breast milk iodine
concentrations range between 60 and 150 µg/l (Dorea 2002).
The reported mean iodine concentration of infant formulae in New Zealand is 95 μg/l
(range 30 to 270).
In the CNS pilot, median urinary iodine for the random urine sample was 8.6 μg/dl. This
is in the range of median levels indicating mild iodine deficiency (5.0 to 99 μg/dl),
indicating that New Zealand children aged one to four years are likely to be mildly iodine
deficient (Ministry of Health 2001).
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Recommended iodine intakes
The recommended AI for infants from birth to six months of age is 90 µg/day and for
infants aged seven to 12 months, 110 µg/day.
The RDI for toddlers aged one to three years is 90 µg/day.
Sources of iodine in the diet
Breast milk and infant formulae provide iodine.
Seafood is a rich source of iodine as marine animals and plants concentrate iodine from
seawater. Milk and milk products are a useful source as iodine is secreted into milk.
Other sources of iodine include eggs, some meat and cereals, and sea meal custard.
Kelp tablets are known to be rich sources of iodine, but the iodine content in these
tablets is extremely variable and can be high enough to be toxic.
Practical advice for iodine
•
Offer foods rich in iodine, such as fish and seafood, meat and poultry, eggs, milk and
milk products, and bread. Foods that contain seaweed, such as sushi, sea meal and
alginates (food-thickening agents), also provide a good source of iodine.
•
Iodised salt should be used if salt is used for family cooking and if used at the table.
Rock salt and sea salt have negligible levels of iodine, unless iodised and are not
recommended.
•
The use of iodine supplements is not recommended unless under specialised
nutritional and medical advice.
•
Kelp supplements are not recommended for children.
10.4.5 Selenium
Background
Selenium is involved in a number of roles in the body, including antioxidant functions
and thyroid hormone metabolism (Thomson and Paterson 2003). Selenium is
necessary for normal thyroid function and is a component of the enzyme glutathione
peroxidase, which is an essential part of the body’s antioxidant defence mechanism. An
adequate selenium intake is required to maintain the body’s complex mechanism of
scavenging free radicals that are products of oxidative reactions. The amount of
selenium in food reflects the soil in which the food was grown, and New Zealand soils
are low in selenium.
Regional selenium intake data do not indicate that there is generally a concern with
selenium intakes for infants and toddlers. However there is some concern about the
selenium status of New Zealand infants and toddlers. A recent New Zealand study in
the South Island found that breastfed and formula-fed infants, aged between six and 12
months and toddlers had suboptimal selenium status (McLachlan et al 2004).
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Recommended selenium intakes
For infants from birth to six months of age, the AI level is 12 μg/day, for infants from
seven to 12 months, 15 μg/day and for toddlers aged one to three years, the RDI is
25 μg/day.
Sources of selenium in the diet
Breast milk contains 12 micrograms of selenium.
The concentration of selenium in foods correlates closely with the food’s protein
content. Organ meats, seafood, Brazil nuts, sesame seeds, imported legumes and
baked products made from imported flour are rich sources of selenium. Meat, chicken,
seafood and eggs are good sources of selenium. Cereals are moderately good
sources, but New Zealand-grown fruits and vegetables contain relatively low levels of
selenium so are not good source.
Selenium intakes in New Zealand tend to vary regionally, and the variation is correlated
to selenium concentration in bread and other wheat products. Imported wheat,
especially Australian wheat, is higher in selenium and is used for all bread making in the
north of the North Island, so that region has higher selenium intakes. In the south of the
North Island, about 30 to 35 percent of wheat used is Australian. In the South Island,
usually all wheat is grown locally, accounting for lower selenium intakes there (Thomson
and Paterson 2003).
Estimated selenium intakes appeared to increase between 1987/88 and 1997/98
(Vannoort and Thomson 2005). This was attributed to increased levels of selenium in
wheat products and animal products. Livestock are given selenium supplements to
maintain fertility and prevent disease (Vannoort and Thomson 2005).
Practical advice for selenium
•
Infants should be fed exclusively on breast milk to around six months of age, with
continued breastfeeding up to two years or beyond.
•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
•
Offer good food sources of selenium, such as fish and other seafood, meat and
poultry, eggs, milk and milk products and bread.
•
The use of selenium supplements is not recommended unless under specialised
nutritional and medical advice.
10.4.6 Fluoride and oral health
Background
Fluoride combines with calcium in the body to produce healthy bones and teeth. The
fluoridation of drinking water is the most effective measure for preventing dental caries.
It has a proven beneficial effect on dental health. Recent New Zealand studies have
confirmed the continued beneficial effect of water fluoridation on prevalence and
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severity of dental caries in children (Lee and Dennison 2004; Mackay and Thomson
2005). Children who have been drinking fluoridated water since infancy show the
greatest benefits.
The concentration of fluoride in breast milk is low irrespective of whether the mother
consumes fluoridated or non-fluoridated water (Chowdhury et al 1990). Fluoride
supplementation of the maternal diet during pregnancy and lactation is not necessary
for proper infant dental development.
The New Zealand Drinking Water Standards recommend that water supplies contain 0.7
to 1.0 mg/l of fluoride, which is the optimal level in New Zealand to maximise prevention
of dental caries and to minimise the risk of dental fluorosis (PHC 1995).
Excessive fluoride intake can result in dental fluorosis, which causes mottling of the
teeth. Infants and toddlers are most at risk of fluorosis if they swallow fluoride
toothpaste (Pendrys and Stamm 1990).
Two Hawke’s Bay studies (de Liefde and Herbison 1985, 1989) investigated the
prevalence of fluorosis or diffuse opacity. A diffuse opacity is a change in the
translucency of the enamel, variable in degree and white in colour. The structural
integrity of the tooth enamel is not affected. A diffuse opacities prevalence estimate of
51 percent was reported 1989 and was higher than the 37 percent observed three years
earlier. This led to suggestions that the prevalence of diffuse opacities may have been
increasing at that time.
A study was conducted in New Zealand in 2002 (Mackay and Thomson 2005) to
examine the prevalence, severity and associations of enamel defects and dental caries
in a probability-based sample of nine- and 10-year-old children living in fluoridated
Invercargill City and the non-fluoridated towns of Southland (Gore, Winton and
Queenstown). The estimates obtained suggest that there has been no change in the
prevalence of diffuse enamel opacities within the age group in New Zealand (in direct
contradiction to the 1989 Hawke’s Bay study).
Children who had lived all their lives in a fluoridated area had the highest odds of having
a diffuse opacity. These children also enjoyed the lowest prevalence and severity of
dental caries in their permanent teeth.
Powdered infant formulae available in New Zealand contain negligible amounts of
fluoride. The major source of fluoride in infant formula is from the water used to
reconstitute the powdered formula (provided it is fluoridated water). There is no
evidence that the fluoride derived from water used to reconstitute the formula has any
harmful effects in areas where the fluoride concentration is 1.0 mg/l (PHC 1995).
Infant formulae are regulated under Standard 2.9.1 of the Australia New Zealand Food
Standards Code (FSC). Under this standard, fluoride is not permitted to be added to
infant formula in New Zealand. If a powdered infant formula product contains more than
17 μg of fluoride per 100 kJ formula prior to reconstitution, the product label must
indicate that consumption of the formula has the potential to cause dental fluorosis and
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must recommend that the risk of dental fluorosis be discussed with a medical
practitioner or other health practitioner.
Recommended fluoride intakes
The AI for fluoride for infants from birth to six months of age is 0.01 mg per day and for
infants aged seven to 12 months, 0.50 mg per day. For toddlers aged one to three
years, the AI is 0.7 mg per day. The upper level of intake (UL) for fluoride for infants
from birth to six months of age is 0.7 mg per day, for infants aged seven to 12 months,
0.9 mg per day, and for toddlers aged one to three years is 1.3 mg per day.
Sources of fluoride in the diet
For infants, the main source of fluoride is breast milk or infant formula.
For toddlers, the main source of fluoride is fluoridated water. For those who live in
areas without fluoridated water, fluoride toothpaste is the main source of fluoride.
Dietary sources of fluoride include fish and chicken. Although tea contains significant
amounts of fluoride, it is not recommended for infants and toddlers because it inhibits
the absorption of iron from the diet.
Practical advice for fluoride and oral health
•
Fluoride toothpaste should be used by all children from the time their first tooth erupts.
•
A smear of toothpaste should be used on each occasion, and to avoid ingestion, an
adult should supervise tooth brushing.
•
Avoid leaving a bottle with a sleeping infant or using one as a pacifier. Avoid nighttime and long-term use of infant bottles containing liquids other than water.
•
Do not dip pacifiers or bottle teats in sugar or honey.
10.4.7 Sodium
Salt is sodium chloride. Sodium is an important component of extracellular fluid. The
physiological roles of sodium include maintaining the acid base balance, energy transfer
mechanisms, the uptake of nutrients and fluid balance within and outside cells
(Department of Health (UK) 1991). High sodium intake (principally from salt) is
associated with high blood pressure, an important risk factor for cardiovascular disease,
particularly stroke. There is strong evidence of a dose-response relationship between
sodium intake and blood pressure (Ministry of Health 2003a).
Salt should not be added to food for infants and the use of salty foods should be limited.
This is because the infant’s gut and organs are immature and not able to cope with salt,
especially the kidneys, which have limited capacity to conserve fluids and to excrete
salt. Excess sodium in the diet can increase calcium excretion. Studies suggest that
high sodium intake in infancy may be related to high blood pressure in later life
(Geleijnse et al 1997).
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In a study conducted on a group of children in Dunedin, infants aged six to 12 months
had dietary sodium intakes that were higher than the AI of 170 mg per day. Nonbreastfed infants had higher sodium intakes than breastfed infants (Simons 1999).
Toddlers aged one and four years had dietary sodium intakes of around 1400 mg per
day, which is higher than the UL of 1000 mg per day.
In an Auckland study, infants were consuming foods that are considered inappropriate
before one year of age, such as salted/sweetened snacks (Grant et al 2003). Many
toddlers have been found to be not eating enough vegetables and fruit (Simons 1999).
Offering more vegetables and fruit could improve the nutritional quality of the diet and
reduce the sodium intake.
Recommended sodium intakes
The AI for sodium for infants from birth to six months of age is 120 mg per day
(5.2 mmol) and for infants aged seven to 12 months, 170 mg per day (7.4 mmol). For
toddlers aged one to three years, the AI is 200 to 400 mg per day (9 to 17 mmol).
No UL has been established for infants. The UL for toddlers aged one to three years is
1000 mg sodium (43 mmol) per day.
Sources of sodium in the diet
The practice of adding salt to infant and toddler food is not recommended.
Sodium is often added during food processing, with up to 85 percent of the average
daily sodium intake for adults coming from processed and manufactured foods (Godlee
1996; Engstrom et al 1997; Young and Swinburn 2002). The amount of sodium in
commercially prepared infant foods is controlled by the FSC (FSANZ 2004).
The two three-day sample meal plans (Appendix 7) use low-salt margarine to ensure
the UL is not exceeded.
Practical advice for sodium
•
•
For infants, prepare or choose pre-prepared foods with no added salt.
For toddlers, prepare foods or choose pre-prepared foods, drinks and snacks that are
low in salt; if using salt, choose iodised salt.
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10.5
Vitamins
10.5.1 Vitamin A
Background
Vitamin A is involved in vision, reproduction, gene expression, embryonic development,
growth, immune function, integrity of the epithelium and bone remodelling.
The term vitamin A includes retinol (preformed vitamin A) from animal sources and
pro-vitamin A carotenoids (precursors of retinol) in oils, vegetables and fruit.
Carotenoids are pigments in plants. There are over 600 carotenoids, but only a small
number have vitamin A activity, and beta-carotene is the most active. Dietary vitamin A
is expressed as retinol equivalents (REs), where 1 RE is equivalent to:
• 1 µg of all-trans retinol
• 6 µg of all-trans beta-carotene
• 12 µg of α-carotene, B-cryptoxanthin and other provitamin A carotenoids.
Absorption of beta-carotene is increased with chopping, puréeing and cooking and by
the addition of a small amount of fat (American Dietetic Association 2003).
Vitamin A deficiency is unusual in New Zealand infants and toddlers but well recognised
in developing countries. An Auckland study on a random sample of 416 children aged
six to 23 months (Grant at al 2007) found low vitamin A status in 9 percent of the
children.
Excess vitamin A intake as retinol can cause hypervitaminosis in infants, which may
cause anorexia and vomiting, and dry itchy skin. Vitamin A intake as beta-carotene,
and other provitamin A carotenoids, is of low toxicity for infants and toddlers and does
not cause adverse effects, although high intakes may cause a yellowing of the skin
(NHMRC 2006).
Sources of vitamin A as retinol include butter and margarine, whole (dark blue top) milk
and milk products, oily fish, liver and egg yolk. Sources of carotenoids include dark
green leafy vegetables, and yellow, red and orange vegetables and fruit.
Practical advice for vitamin A
•
Infants and toddlers should be offered a wide variety of vegetables and fruit, including
dark-green leafy vegetables (spinach, silverbeet or pūhā) and yellow, red and
orange-coloured vegetables and fruit (carrots, pumpkin, kūmara, tomatoes, apricots,
tamarillos).
•
Liver should not be offered more than once a week, and no more than a 10 g (two
teaspoons) serving.
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10.5.2 Vitamin D
The main function of vitamin D is to maintain serum calcium and phosphorus
concentrations within the range that optimises bone health, by affecting the absorption
of these minerals from the small intestine, their mobilisation from bone and calcium
re-absorption by the kidney. Vitamin D circulates in the blood as 25-hydroxy-vitamin D
and is converted in the kidneys to the biologically active form, 1.25-dihydroxy vitamin D.
Vitamin D is synthesised in the skin, hence dietary requirements depend on exposure to
sunlight. Infants and children who are regularly exposed to sunlight are much less
dependent on dietary sources of vitamin D. During the daylight saving months, when
ultraviolet radiation (UVR) levels are high or extreme, most infants and toddlers should
be able to achieve adequate vitamin D levels through incidental outdoor ultraviolet (UV)
exposure outside peak UV times, that is, before 11 am or after 4 pm. During winter,
particularly in southern New Zealand, where UVR levels are dramatically lower,
vitamin D status may drop below adequate levels. Additional measures to achieve
adequate vitamin D status may be required, particularly for those at risk of vitamin D
deficiency (see Sources of vitamin D below). Summer levels of vitamin D influence
winter levels of vitamin D because the body stores of vitamin D decline in winter
(Sunsmart Partnership 2005).
The time to achieve adequate vitamin D levels depends on skin type. Skin types 1–3
are fair-skinned, burn more easily and need less time for adequate vitamin D synthesis.
Skin types 4–6 are darker-skinned, burn less easily and need more time for adequate
vitamin D synthesis because the pigment in the skin reduces UV absorption. This may
have implications for the vitamin D status of Māori, Asian and Pacific communities,
especially those living further south. People with skin types 1–3 may only need five
minutes of exposure outside peak times (to the face, hands and forearms), while people
with skin types 4–6 will need more time, for example, up to 20 minutes (Sunsmart
Partnership 2005).
Vitamin D deficiency in an infant results in inadequate mineralisation or demineralisation
of the skeleton. Rickets occur in New Zealand and in Auckland were found to be more
common among children of Indian ethnicity (Blok et al 2000). Vitamin D deficiency is
not usually dietary in origin but due to insufficient sunlight exposure.
There is increasing evidence that New Zealanders have less than optimal vitamin D
status (NHMRC 2006), and there is concern about the vitamin D status of New Zealand
infants and toddlers.
There are no data on the vitamin D status of exclusively breastfed babies in New
Zealand. In a study of 353 six- to 24-month-olds living in Auckland (Grant et al 2007),
low vitamin D status was present in 46 (10 percent) of the children. Low vitamin D
status was associated with enrolment in the study during winter, being of Pacific or
Māori ethnicity and not having any infant or follow-on formula.
Analysis of the Children’s Nutrition Survey (CNS) pilot showed that approximately onethird of New Zealand children aged five to 14 had levels of 25-hydroxyvitamin D that
were insufficient (less than 37.5 nmol/l)(Ministry of Health 2003c). Pacific children had
the highest levels of insufficiency followed by Māori and New Zealand European.
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While infants appear to have adequate intakes, girls and boys aged one to four years in
the CNS pilot (Ministry of Health 2001) appear to have a vitamin D intake (1 mcg) lower
than the AI of 5 μg. Note that sun exposure is the main source of vitamin D.
Infants and toddlers at risk of vitamin D deficiency include babies of vitamin D deficient
mothers, infant and toddlers who are not exposed to sunlight, infants and children with
darker skin types and those who have their skin covered by clothing for religious or
cultural reasons (Sunsmart Partnership 2005). Low socioeconomic status and low
educational levels have also been identified as risk factors (Hollis and Wagner 2004).
Those pregnant and breastfeeding women and children at risk of vitamin D deficiency
are more dependent on dietary vitamin D supplements (see Sources of vitamin D
below).
Recommended vitamin D intakes
The AI for vitamin D for infants and toddlers up to three years of age is 5 μg per day.
Sources of vitamin D
In New Zealand the main and important source of vitamin D is from exposure to
sunlight. Adequate vitamin D status is unlikely to be achieved through food sources
alone in New Zealand where foods are not fortified, except some margarines.
Deliberate exposure at peak UV times is not recommended as this increases the risk of
skin cancer, eye damage, and photo aging. During the daylight saving months, when
UVR levels are high or extreme, most people should be able to achieve adequate
vitamin D levels through incidental outdoor UV exposure outside peak UV times, that is,
before 11 am or after 4 pm. The ultraviolet index (UVI) is a measure of the intensity of
UVR in our environment. The higher the number, the greater the risk of skin and eye
damaging exposure to UVR. When the UVI is low (1 or 2), no sun protection is
required. When the UVI is higher than or equal to 3, sensible sun protection behaviour
is warranted. When it is 6 and above sun protection is essential. The UVR intensity
can reach levels as high as 14 or 15 during the New Zealand summer. It is important to
encourage parents and caregivers to provide sun protection, including providing a broad
brimmed sunhat, sun protective clothing, for example sleeves and a collar, a broad
spectrum, SPF 30+ sunscreen and sunglasses that meet the Australian/New Zealand
standard.
Good food sources of vitamin D include oily fish (such as canned tuna, sardines,
herrings, mackerel, eel, warehou and salmon), vitamin D-fortified margarine, eggs, fish
oils and liver. Infants and toddlers with risk factors for vitamin D deficiency may need a
5 μg tablet of vitamin D per day.
Practical advice for vitamin D
•
There is no evidence at present to support the routine use of vitamin D supplements
for breastfed babies in New Zealand.
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•
Infants need to have appropriate exposure to sunlight (outside of the peak UVR
times).
•
During the daylight saving months, before 11 am and after 4 pm, expose face and
arms to 5 to 20 minutes of UVR per day (not through glass). The amount of time
depends on skin type.
•
During the daylight saving months, between 11 am and 4 pm, provide sun protection,
including shade, a wide brimmed hat (with a minimum 7 cm brim), sun protective
clothing (for example, a top with sleeves, collar and made of a fabric with a tight
weave), sunglasses that meet the Australian/New Zealand standard and a broad
spectrum SPF 30+ sunscreen.
•
Outside the daylight saving month, make sure you spend some time in the sun to
ensure adequate vitamin D synthesis.
•
Health practitioners should identify infants and toddlers at risk of vitamin D deficiency.
•
Parents and caregivers of at risk infants and toddlers should be advised that oily fish,
eggs and vitamin D-fortified margarine are rich sources of vitamin D. Infants and
toddlers with risk factors for vitamin D deficiency may need a 5 μg tablet of vitamin D
per day under supervision of the health practitioner.
10.5.3 Folate and vitamin C
These vitamins are present in substantial amounts in various fresh fruit and vegetables.
Both vitamin C and folate are easily destroyed by heating (Moser and Bendich 1991).
Therefore, these vitamins are lost from fruit and vegetables during the cooking process.
The main problem with insufficient intake tends to occur when the range of vegetables
and fruit is severely restricted, as is the case for families on low incomes. Infants aged
one to four years in the CNS pilot appear to have had a folate intake (130 μg) (Ministry
of Health 2001).
Supplements should only be given following a full assessment by a dietitian and if it is
considered that dietary modification will be sufficient on its own.
10.5.4 Practical advice for vitamins
•
Infants should be fed exclusively on breast milk to around six months of age, with
continued breastfeeding up to two years of age or beyond.
•
If the infant is not breastfed, then an infant formula should be used until one year of
age.
•
When the infant is ready, appropriate complementary foods should be introduced,
and breastfeeding continued. The developmental cues should be used to determine
if the infant is ready. The infant will probably be ready at around six months of age
but some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
The variety of complementary foods should be increased to ensure an additional
intake of nutrients, especially iron. The infant should be eating family foods by
around one year of age.
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•
Toddlers should be offered a variety of nutritious foods from each of the major food
groups each day:
– vegetables and fruit
– breads and cereals, preferably wholegrain
– milk and milk products
– lean meat, poultry, seafood, eggs or alternatives.
•
See section 10.5.1 for practical advice on vitamin A.
•
See section 10.5.2 for practical advice on vitamin D.
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Part 11: Physical Activity
Physical activity is just as important for infants and toddlers as it is for older children.
Sport and Recreation New Zealand (SPARC) has developed the Active Movement
programme, which provides a guide for activity for under-fives. The resources for the
Active Movement programme suggest ways of encouraging physical activity in infants
and toddlers to help their bodies to develop, encourage them to learn and to develop
their confidence.
Ideas for physical activities include tummy time (infant spending time lying on their
tummy), rolling and crawling through to walking, running and jumping activities, balance,
upper body development, catching, throwing and kicking. More information and
resources from the Active Movement programme for under-fives is available from
SPARC’s website (http://www.sparc.org.nz).
11.1
Benefits
The health benefits of being physically active and eating well are becoming recognised
as important to public health promotion and the prevention of illness. There is clear
evidence that increasing regular physical activity in populations can result in health
benefits particularly in:
• maintaining a healthy weight
• preventing cardiovascular disease
• preventing and controlling diabetes
• preventing some cancers
• preventing and controlling injury
• promoting positive mental health.
Research indicates that children who develop the key movement skills and experience
the joy of moving, gain physical confidence and competence and will participate in
physical activity and enjoy the many benefits an active life provides. The extra incentive
for assisting infants to become confident and competent movers is that these children
are more likely to lead physically active lifestyles in the future. Early childhood research
reveals that an opportunity in the early years to create active learning and moving
dispositions enhances the future likelihood of the child maintaining an active lifestyle
throughout their lifespan.
Physical activity can help infants and toddlers develop balance and movement.
11.2
Practical advice for physical activity
•
Maintain healthy growth and development of the infant and toddler by providing
appropriate food and physical activity opportunities every day.
•
Refer to SPARC’s website (http://www.sparc.org.nz) for more information and access
to resources from SPARC’s Active Movement programme for under-fives.
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Part 12: Other Issues
12.1
Pacifiers
12.1.1 Use of pacifiers
In an Auckland SIDS study (Hutchison et al 2006), a pacifier was usually used on
31 percent of infants. This rate was similar to the 32 percent seen in the Auckland
control group of the New Zealand Cot Death Study (Mitchell et al 1992) and the
37 percent in a 1996 study of pacifier use in two- to three-month-old Auckland infants
(Vogel et at 1999, 2001). Reported UK, European and Canadian rates are much higher
at 50 to 66 percent.
In the Auckland SIDS study (Hutchison et al 2006), almost all mothers who used a
pacifier with their infants reported using it to settle the infant. Two mothers reported
using a pacifier specifically for SIDS prevention. Most mothers had no concerns about
using a pacifier, although 21 percent were concerned about the infant becoming
dependent. Small numbers reported concerns about misshapen teeth, the infant losing
the pacifier in the night and safety. For those mothers who did not use a pacifier with
their infants, the main reasons given were that the infant didn’t need it (33 percent), the
infant wouldn’t take it (27 percent), the mother feared dependency (16 percent) and the
mother didn’t like pacifiers (13 percent). Smaller numbers were concerned about the
effects on teeth or mouth shape, choking, hygiene, colic and hindrances to
breastfeeding. Concerns expressed about pacifiers in this survey were similar to those
previously reported, ie, dependency and hygiene. However, the main reasons were that
the mothers felt the infant did not need a pacifier or would not take one.
12.1.2 Concerns about the use of pacifiers
Concerns have been raised about the use of pacifiers. These concerns have focused
on breastfeeding, otitis media and other infections, and dental malocclusion
(misalignment of teeth and/or incorrect relation between the top and bottom teeth).
Research regarding the effect of pacifiers on breastfeeding is conflicting. However, a
number of studies have shown an association between pacifier use and decreased
duration of breastfeeding (Howard et al 1999, 2003; Victoria et al 1997). A recently
published review article (Mitchell et al 2006) noted that observational studies have
shown a clear relationship between frequent or continuous pacifier use and a reduction
in breastfeeding.
Pacifier use has been associated with a significantly higher risk of infections. There is a
1.2- to two-fold increased risk of otitis media associated with pacifier use.
Although some dental malocclusions, notably cross bite, have more commonly been
found among pacifier users than non-users, the differences generally disappear after
cessation.
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12.1.3 The role of pacifiers in reducing the risk of SUDI/SIDS
SUDI is defined as a sudden and unexpected infant death. The term SUDI is now often
used instead of sudden infant death syndrome (SIDS) because coroners prefer to use
the term ‘undetermined’ for a death previously considered to be SIDS. SUDI and SIDS
are both used in this document to indicate the transitional nature of the terminology.
In 1979, Cozzi et al postulated that pacifiers might protect against SUDI/SIDS (Cozzi
et al 1979). Mitchell et al first reported support for this hypothesis in 1993 (Mitchell et al
1993). Since then, there have been other studies that have supported this observation,
although evidence is lacking for a biological underlying mechanism and, outside this
field, pacifier use has mainly been associated with detrimental effects (Mitchell et al
2006).
A recent meta analysis to identify whether pacifiers reduce the risk of SUDI/SIDS
showed a strong correlation between giving an infant a pacifier when placing them to
sleep and reducing their risk of dying from SUDI/SIDS (Hauck et al 2005). The results
indicate that the effect is strongest when the pacifier is given at the infant’s night sleep.
The pacifier results were all part of larger studies examining potential risk and protective
factors. A California study (Li and Willinger 2006) that interviewed the mothers of
185 infants who were victims of SUDI/SIDS and 312 randomly selected controls,
identified that, after adjusting for known risk factors, the use of a pacifier during sleep
was associated with a 90 percent reduced risk of SIDS, compared with infants who did
not use a pacifier. The study also claimed some evidence that use of a pacifier may
reduce the impact of other risk factors, especially those related to other adverse sleep
conditions.
The mechanism by which pacifiers might reduce the risk of SUDI/SIDS is unknown, but
several hypotheses are postulated. These include avoidance of the prone position,
protection of the oropharyngeal airway, reduction of the gastro-oesophageal reflux
through non-nutritive sucking and lowering the arousal threshold.
Additional research is needed to understand the factors that may influence the use and
non-use of pacifiers, including parenting behaviours and infant factors. Ongoing
monitoring of rates of SUDI/SIDS using population-based infant mortality statistics, as
well as pacifier usage in these infants, will be needed to help evaluate the impact of this
practice. At this stage, the Ministry of Health and the Child and Youth Mortality Review
Committee do not recommend pacifier use in infants, although it seems appropriate to
stop actively discouraging pacifier use.
Any possible reduction in SUDI/SIDS needs to be balanced against the established
risks, especially the reduction of breastfeeding duration, with the attendant reduction in
health benefits to the infant. In New Zealand, the Ministry of Health expects every
facility providing maternity services and care for newborn infants to become ‘baby
friendly’, which means that they should practise the Ten Steps to Successful
Breastfeeding (see Appendix 2: World Health Organization and UNICEF Statement on
the Ten Steps to Successful Breastfeeding (1989)), including Step 9, regarding use of
pacifiers.
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12.1.4 Practical advice for pacifiers
•
The routine use of pacifiers is not recommended.
•
If an infant is already being bottle fed, it is reasonable to consider the use of pacifiers,
especially if risk factors for SUDI/SIDS are present.
•
Mothers breastfeeding their infants should consider the benefits of breastfeeding and
the risks of pacifier use.
•
If breastfeeding mothers wish to use pacifiers, it is best to wait until breastfeeding is
well established.
•
It is important that all pacifiers are:
– kept clean and regularly checked for cracks or loose parts
– sterilised frequently
– are not sweetened with honey or other sweeteners
– not shared.
12.2
Bottles and teats
Infant feeding bottles come in glass, plastic (polyethylene) and polycarbonate. Plastic
and polycarbonate bottles are more difficult to clean but are more robust than glass.
Wide-necked bottles are easy to fill and clean and the teat can be easily stored inside
when not in use.
Teats are available in latex, which is soft and needs to be replaced often, and silicone,
which is firmer and longer lasting. Teats come with varying numbers of holes: the more
holes the faster the milk flows. One-hole teats encourage vigorous sucking and should
be used with newborns. Milk should drip out of teats rapidly but not flow out. Children
with cleft lips or palates or co-ordination problems may need special teats if they are
bottle-fed.
Research suggests that non-ventilated and under-ventilated bottles lead to pressure
changes in the infant’s oral cavity, which may lead to pressure changes in the middle
ear and potentially predisposition to middle ear infections (Brown and Magnuson 2000).
Infants should not be placed lying down with a bottle propped up so that they can
continue to feed without an adult being present. An infant left alone might choke if the
fluid goes down the airway rather than the oesophagus. Fluid can also enter the middle
ear of infants fed with a bottle propped up, causing inflammation. If the infant has teeth
and falls asleep before the contents of the bottle are finished, the teeth will continue to
be bathed in carbohydrate-containing fluid long after feeding has finished. This can
lead to so-called nursing bottle caries, in which the teeth decay and may require
extraction (Swartz et al 1993; Ripa 1988).
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12.2.1 Practical advice for bottles and teats
•
Fully-ventilated bottles that more closely resemble the mechanism of breastfeeding
should be utilised when bottle feeding.
•
The use of propped bottles to feed an unattended infant is not recommended.
•
Bottle feeding of any drinks containing sugar, for example, soft drinks, cordials and
fruit juice is not recommended as such beverages are highly cariogenic (cause tooth
decay) due to the sugar content.
12.3
Supplements
Full-term infants fed breast milk or infant formulae do not require supplements of
vitamins, minerals or other nutrients. There is no evidence to support the use of vitamin
supplements for breastfed babies in New Zealand.
A mother with a very poor diet can have relatively low levels of iodine, some B vitamins
and vitamin C in her breast milk (Fomon and McCormick 1993), but even in extreme
cases, it would normally be better to give the vitamin supplements to the mother rather
than to the infant.
In New Zealand, there is no evidence to suggest that there is any need or benefit from
giving nutritional supplements to infants and toddlers who are adequately fed. Those
who do develop vitamin deficiency have usually had a diet inadequate in quality or
quantity. In these cases, a change in diet is the correct course of action.
Parents are sometimes encouraged by advertising or word of mouth to provide
supplements of vitamins for infants and toddlers in the belief that this may help to
prevent infections or to ‘strengthen’ the immune system. There is no evidence that their
use offers any benefits where the child is receiving appropriate food choices.
Dietary supplements for infants, including herbal supplements, should only be used on
the recommendation and with directions of a medical practitioner or dietitian.
12.3.1 Special indications for supplements
There are some situations where it may be necessary to give specialised feeding
advice. These include a pre-term birth, a breastfed pre-term infant, an infant is born to
a growing and/or malnourished mother, there has been delayed or inappropriate
introduction of complementary foods, the caregiver is nutritionally uninformed, the infant
is diagnosed with iron deficiency or there are concerns with the infant’s vitamin D status
(Cockburn 1998).
For iron deficiency, iron supplements must be used with caution because of the danger
of poisoning should a child consume a large quantity. If swallowed in excess, iron can
cause life-threatening acute poisoning. An excessive iron intake overwhelms the iron
control systems in the body leading to high free-iron levels. These act as pro-oxidants
and greatly enhance the risk of infections. Liquid iron preparations have a tendency to
stain teeth, and all chemical forms of iron can be irritating to the gut.
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Infants who are breastfed for extended periods or whose mothers have vitamin D
deficiency or who are not exposed to sunlight are at increased risk of vitamin D
deficiency. These infants require supplementation. Young children who are not
exposed to sunlight may also be at risk of vitamin D deficiency and may require
supplementation (see 10.5.2: Vitamin D).
If supplements are recommended, they should be given in liquid form and not in tablet
or capsule form as the infant or toddler may inhale them and choke. Only preparations
specifically designated to use with infants and toddlers should be taken, and they must
be given in the correct dosage, Supplements should not contain sugar. Any
supplements should be securely stored in containers with child-resistant closures.
Great care must be taken to ensure that infants and toddlers do not have access to any
medicines as they may mistake tablets for sweets.
12.3.2 Practical advice for supplements
•
Infants and toddlers generally do not require supplements.
•
Seek recommendations and directions of a medical practitioner or dietitian if there
are any concerns about the infant or toddler’s nutrition intake, status or health.
•
Infants and toddlers may require iron supplements under certain circumstances, such
as when the infant is pre-term, has been diagnosed with iron deficiency or has been
exclusively breastfed for a prolonged period.
•
Vitamin D supplements may be required by infants of vitamin D deficient mothers,
and toddlers at risk of vitamin D deficiency (see 10.5.2: Vitamin D).
•
Breastfeeding by vegan mothers can result in vitamin B12 deficiency in the infant. In
such instances, the mother may require supplementation. Infants and toddlers of
vegan mothers may also require Vitamin B12 supplements.
12.4
Food intolerance and food allergies
12.4.1 Food intolerance
A food intolerance is a reproducible reaction to a food, without accompanying antibody
production, as the reaction is not mediated by the immune system. The most common
causes include an enzyme deficiency (for example, lactose intolerance caused by
lactase deficiency), a histamine-releasing effect (for example, sensitivity to shellfish), or
the release of substances produced by the fermentation of food residues in the bowel
(Royal College of Physicians and British Nutrition Foundation 1984).
Most lactose intolerance in children is secondary, usually to an intestinal infection.
During such an infection, breastfed infants can usually continue to tolerate breast milk
despite its high lactose content. However, formulae containing lactose may pose a
temporary problem. In some severe cases, a temporary change to a lactose-free
formula may be required, but only under medical supervision (Chandra and Haemmed
1992).
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12.4.2 Food aversion
Food aversion is not the same as food intolerance. Food aversion is an adverse
reaction caused by the emotion associated with a particular food or foods rather than
the food itself and does not occur when the food is given in an unrecognisable form.
Food aversion may be influenced by parental behaviour and attitudes (Egger 1991).
12.4.3 Food allergies
A food allergy is an abnormal response of the immune system in some people to a food
allergen, almost always a protein. The immune system recognises the food allergen as
‘foreign’ or ‘dangerous’ and reacts. This allergic reaction often involves elevated levels
of total and allergen-specific IgE in the serum with subsequent effects in different parts
of the body. Common signs and symptoms of an allergic reaction include:
•
respiratory: nasal congestion and runny nose, sneezing, coughing, wheezing
•
skin: swelling of the lips, mouth, tongue, face and/or throat; itching; redness or
rashes (for example, hives, eczema), allergic conjunctivitis
•
gastrointestinal: intestinal cramps, diarrhoea, nausea, vomiting, colic, bloating
•
systemic: anaphylactic shock.
Prevalence of food allergies
Food allergies occur in around 6 percent of children under three years of age and
decrease in prevalence over the first decade of life (Wang and Sampson 2006). It is
estimated that 80 to 90 percent of infants outgrow their allergies by three years of age
(British Nutrition Foundation 2001).
There is an association between eczema and food allergies. Approximately one-third of
infants with eczema also have a food allergy. There is also a correlation between the
presence of a food allergy and the severity of eczema. This is confirmed by research
that has demonstrated a pathway between the IgE antibody response and the
development of eczema lesions (Burks 2003). Food is only one of the many possible
causes of the condition. Other causes include exposure to aeroallergens (animal hair
and dust, dust mites, moulds), irritants (tobacco smoke) and viral infections.
It is estimated that around 2 percent to 8 percent of respiratory reactions are foodinduced (James 2003), which is probably much less than that perceived by the public.
Common food allergens
As mentioned, a food allergen is almost always a protein. If a person has a food allergy
is present, the allergen will cause a reaction each time it is eaten. Common food
allergens in Western populations include: cows’ milk, eggs, peanuts, soy, fish and
shellfish, tree nuts (Sampson 2003), and wheat (Taylor et al 1999). Tree nuts include
almonds, Brazil nuts, hazel nuts, pecans and walnuts.
The allergens that must be declared on food labels in Australia and New Zealand
(FSANZ 2002) are:
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•
•
•
•
•
•
•
milk and milk products
egg and egg products
peanuts and soy and their products
cereals containing gluten and gluten products (wheat, oats, barley and rye)
fish and fish products (including shellfish)
crustacean and crustacea products (crab, prawn, crayfish)
tree nuts and sesame seeds and their products.
Labels must also declare the presence of sulphites above a certain level. Sulphites can
cause an intolerance reaction in some people.
Cows’ milk and milk products
Cows’ milk is the most common food allergen for infants and toddlers. It is estimated
that between 1 and 3 percent of infants have an allergy to cows’ milk protein, with a
much lower incidence in older children (Host et al 1995). Almost all infants who have a
cows’ milk allergy grow out of the allergy. It is estimated that over 70 percent of infants
with cows’ milk allergy will outgrow their allergy (Zeiger 2003).
If a cows’ milk protein allergy is present, milk and milk products must be avoided. Heat
treatment of cows’ milk denatures some of the offending proteins, which may reduce
their allergenicity. Cows’ milk-based infant formulae are slightly less allergenic than
their product of origin due to the heat process undertaken during manufacturing.
It is important to note that soy and goats’ milk protein are also potentially allergenic:
25 percent of infants with cows’ milk protein allergy have an allergic response to soy,
and 50 percent have an allergic response to goats’ milk.
Eggs
Cooked egg yolk has traditionally been used as an early food, probably because of its
reputation as a good source of iron. However, eggs, particularly egg white, contain a
number of proteins known to cause allergic reactions.
Peanuts
Peanuts, including peanut butter, are remarkable for their ability to cause especially
severe allergic reactions. A peanut allergy rarely resolves with age and is potentially
the most immediate and life threatening allergy (Wood 2003). Symptoms for a peanut
allergy can be mild to severe, including anaphylaxis and death.
Soy (see also 4.2: Types of formula)
A soy allergy probably has a similar prevalence to a cows’ milk protein allergy, that is,
2 percent of children. Of those children, 10 to 15 percent will have an IgE mediated
allergy, and the remainder will have non-IgE mediated gastrointestinal symptoms
(Zeiger et al 1999).
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Wheat
A wheat allergy is a reaction to one of the proteins in wheat (for example, gluten,
globulin, gliadin or albumin) although the specific protein at fault is often not known,
hence the general term ‘wheat allergy’.
Coeliac disease
Coeliac disease overlaps somewhat with wheat allergy. It is a disease of
hypersensitivity specifically to gluten, which is found in wheat and also rye, oats and
barley, causing damage to the mucosa of the small intestine. Coeliac disease is usually
recognised after nine months of age and is characterised by failure to gain weight and
chronic diarrhoea. A gluten-free diet is very restrictive and should not be started unless
a diagnosis of coeliac disease has been confirmed by intestinal biopsy (Walker-Smith et
al 1990).
12.4.4 Prevention of food allergies
Any infant and toddler can potentially have an allergic reaction to food. There appears
to be a strong inherited predisposition, which increases the likelihood of a child having
an allergy, including a food allergy. Children born into allergic families are more likely to
have an allergy (50 to 80 percent) compared with those with no family history of allergy
(20 percent). The risk appears to be higher if both parents have an allergy (60 to
80 percent), and if the mother rather than the father has an allergy (Prescott and Tang
2004).
It is not possible to alter an inherited predisposition to a food allergy. It may, however,
be possible to reduce the likelihood of the predisposition developing into a food allergy
(primary prevention) or to reduce the severity of allergic reactions if an allergy does
become established (secondary prevention). It may also be possible to reduce the
symptoms or consequences of allergic reactions to food, in particular by delaying their
onset. Delaying the onset of allergic reactions means the infant or toddler is more
physiologically developed before they experience a reaction. This may result in the
reaction being less severe; the infant or toddler being able to cope with the reactions
better; the reaction being easier to treat; or the child growing out of the allergy.
Maternal avoidance of common food allergens during pregnancy and breastfeeding
Studies on maternal avoidance of common food allergens during pregnancy and
breastfeeding generally have not shown a reduced risk of allergic disease (Kramer and
Kakuma 2003). Therefore, in general, maternal avoidance of common food allergens
during pregnancy and breastfeeding is not recommended (Prescott and Tang 2004).
The exception is that pregnant women in families with a history of allergic disease (such
as hay fever, asthma or eczema) are advised to avoid peanuts and peanut products
during pregnancy and breastfeeding to assist in preventing the development of a peanut
allergy in their infants (Medsafe 2000; Zeiger 2003).
If women do choose to avoid common food allergens, it would be prudent to consult a
registered dietitian to assure that all forms of the foods within their diet have been
identified (that is, to allow complete elimination of the allergen and also to confirm that
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the diet is nutritionally adequate to prevent potentially adverse effects on the nutritional
status of the mother and/or the infant).
Breastfeeding
Breast milk offers the ideal nourishment for all newborns in terms of nutritional,
immunological and physiological factors – reason enough to recommend exclusive
breastfeeding for around six months (Zeiger 2003). Breastfeeding has a role in primary
prevention as it probably reduces the risk of developing a food allergy (see
Appendix 11: Summary and Strength of Evidence of the Importance of Breastfeeding for
Infants). Breastfeeding may be particularly important for infants in families that
experience atopic disease (such as hay fever, asthma or eczema). However it is
unclear as to the precise role breastfeeding does play in the prevention of allergic
disease. Whilst some studies show breastfeeding may prevent, reduce or delay
development of the disease, others have shown an increased risk of allergic disease
development (in children whose mothers had asthma) (Zeiger 2003).
Formula feeding
Infants in families with a history of allergic disease (having conditions such as hay fever,
asthma or eczema) who are not breastfed should be fed a protein hydrolysate formula
(Prescott and Tang 2005).
Delayed introduction of complementary foods to around six months of age
Delaying the introduction of complementary foods until around six months of age may
delay the onset of the symptoms or consequences of a food allergy, so infants should
be fed exclusively on breast milk (no complementary foods) until around six months of
age.
Delayed introduction of common food allergens
For most infants, there is insufficient evidence that delaying the introduction of common
food allergens has a role in preventing a food allergy.
For infants in families that have a history of allergic disease, introduction of common
food allergens should be delayed as long as practical, that is, later than around six
months. In the case of the following items, the delay should be even longer:
• cows’ milk and milk products until one year of age
• egg until two years of age
• peanuts, tree nuts, fish and shellfish until three years of age (American Academy of
Pediatrics 2000).
No infant under one year of age should be given cows’ milk as a drink. For most infants
(for example, those without a family history of allergy), milk products and milk in
cooking, can be given at seven to eight months of age (see Table 7: Order for
introducing complementary foods and progressing to family foods). For infants in
families that have a history of allergic disease, commercial infant foods containing small
amounts of milk and milk products can be given at the appropriate age with careful
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observation for any allergic reaction. If there is no allergic reaction, then small amounts
of milk products and milk in cooking could be trialled.
12.4.5 Diagnosis and management of food allergies
Infants with food allergies have a greater risk of developing not only further food
allergies but also inhalant allergies. Hence early diagnosis of infants with food allergies
and implementation of a management plan is of real benefit in reducing the possible
development of further food allergies, asthma and hay fever (Wood 2003).
Diagnosis
Diagnosis can be difficult in infants and toddlers. Health practitioners need to rely on
parental observation and interpretation of an infant or toddler’s reactions, which can be
influenced by the parents’ own attitudes and interpretation.
Misdiagnosis of a food allergy is common. After the introduction of complementary
foods, normal changes, such as the character or frequency of an infant’s bowel motions,
may be incorrectly identified as abnormal and due to a food allergy. Common childhood
complaints, such as colic and skin rashes, can also be wrongly attributed to a food
allergy.
The only certain method of establishing a firm diagnosis as to whether the infant or
toddler has a food allergy is withdraw the suspected food and then reintroduce the food,
preferably under double-blind conditions (neither the child and their parents nor the
observer know whether the food contains the ingredient suspected of causing the
problem). This should only be done in co-operation with a dietitian to ensure that all the
suspected food is removed from the diet and that the infant or toddler is still receiving a
nutritionally adequate diet.
An allergic reaction always involves antibody formation, which can usually be
demonstrated by skin testing or by a radio allergosorbent test (RAST) of the blood.
However, studies have shown that a positive test correlates with a reaction in less than
half of cases. This means that there are a number of false positive results indicating
hypersensitivity, and there may also be false negative tests when a true food allergy is
actually present. It is recommended that in order to diagnose a food allergy, an
appropriate diagnostic elimination diet and controlled food challenge be carried out
(Sicherer et al 2003).
The symptoms of the food allergy may occur immediate (within minutes) or may be
delayed (many hours later). Diagnosis of a food allergy when the symptoms appear
immediately is easier because the symptoms correlate closely with eating the offending
food. Diagnosis when the appearance of symptoms is delayed is more difficult because
the infant may have been involved in a lot of potential allergy causing events in the
intervening hours since the food was eaten.
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Management
A food allergy is managed by avoiding the food allergen and ensuring that the infant has
a nutritionally adequate diet. A food allergy should be managed jointly by a dietitian, the
referring doctor and the family. Dietitians have a key role in assessing nutritional
requirements and in regularly reviewing the diet and checking compliance (Wham et al
1989). The doctor and dietitian should monitor the diet to avoid unnecessary food
restriction and to monitor growth. Children may outgrow food allergies or intolerances,
and they should be tested regularly to ensure that dietary modifications are not
prolonged unnecessarily.
The Australia New Zealand Food Standards Code (FSANZ 2002) contains provisions
relating to the labelling of foods with warning statements. These provisions require that
all common food allergens (see 12.4.3: Food allergies above) are clearly highlighted on
the label if they are present in that product as an ingredient, food additive or a
processing aid. In this manner, consumers can make informed decisions about food
purchases for infants and toddlers who are in their care and have food allergies.
The Manufactured Food Database (MFD) provides information on manufactured foods
that are free of common food allergens. The database is available on
http://www.mfd.co.nz
12.4.6 Practical advice for food intolerance and food allergies
•
In general, maternal avoidance of common food allergens during pregnancy and
breastfeeding is not recommended.
•
Pregnant women in families that have a history of allergic disease (for example, hay
fever, asthma or eczema) are advised to avoid consuming peanuts and peanut
products during pregnancy and breastfeeding.
•
If a woman chooses to avoid common food allergens during pregnancy and
breastfeeding, she should consult with a dietitian to ensure that her nutritional needs
are being met and to help identify all hidden sources of the food allergen in her diet.
•
Infants should be fed exclusively on breast milk to around six months of age.
•
For most infants, there is insufficient evidence that delaying the introduction of
common food allergens has a role in preventing food allergies.
•
For infants in families that have a history of allergic disease, introduction of common
food allergens should be delayed as follows:
– cows’ milk and milk products until one year of age
– egg until two years of age
– peanuts, tree nuts, fish and shellfish until three years of age.
•
Food allergies should be managed jointly by a dietitian, the referring doctor and the
family.
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12.5
Colic
Colic can be described as episodic inconsolable crying in an otherwise healthy infant.
The crying often begins with the infant going red in the face, pulling up the knees or
arching the back, with a tight stomach, windy sounds and explosive bowel motions.
Colic will usually begin in the first three weeks of life and can continue for 12 to 16
weeks. It is not known what causes colic. There are a number of treatments
recommended that may work for some infants but not others. Cuddling, rocking and
massaging are common ways of soothing infants with colic.
Parental counselling is an effective intervention for managing the stress associated with
colic (Taubman 1988). Some other methods include making changes in infant feeding
practices, such as eliminating cows’ milk protein, although breastfed infants are also
known to get colic. It is recommended that any changes to infant feeding should only
be made under the direction of a doctor or dietitian (Lucassen et al 1998). See also
Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding Women: A
background paper (Ministry of Health 2006a).
Ensure that any dietary modification or pharmacological intervention is safe and does
not result in nutritional deficiencies. The first step to take with colic is to seek the advice
of a health practitioner.
12.6
Constipation and diarrhoea
Constipation and diarrhoea are a common cause of concern for parents and caregivers.
Defining constipation and diarrhoea depends on what is normal or usual for the infant
and what is considered a change in bowel habits. Normality in bowel habits for infants
can vary greatly. Straining to pass a stool is not uncommon or necessarily abnormal.
Thus it is important to educate parents about the wide variation in normal bowel
function.
12.6.1 Constipation
Definition of constipation in children
Stool frequency reduces progressively in early childhood, from more than four stools a
day to one to two a day by four years of age, by which age 98 percent of children are
toilet trained. Constipation is typically characterised by infrequent bowel motions, large
hard stools, and difficult or painful defecation (Rubin and Dale 2006).
Constipation is considered a change in bowel habits to harder, less frequent stools, and
diarrhoea is a change to looser, more frequent stools. Infants who are exclusively
breastfed on demand commonly have soft motions whereas infants who are formula fed
often have firmer motions.
Causes of constipation
For 90 to 95 percent of children with constipation, the problem is functional. A family
history of constipation may be present. Case-control studies have shown an
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association between low dietary fibre and constipation and with lower energy and
nutrient intake (Rubin and Dale 2006).
Most children with constipation are developmentally normal. Psychosocial factors are
often suspected, and some studies have reported higher levels of behavioural disorders
in children with constipation, with or without incontinence, though it remains unclear
whether these precede the problem or are a maintaining factor. Chronic constipation
can lead to progressive faecal retention, distension of the rectum and loss of sensory
and motor function (Rubin and Dale 2006).
An infant or toddler who is not getting sufficient fluids will become dehydrated. The
urine will become darker and stronger smelling as it becomes more concentrated. More
fluid will be extracted from the intestine, resulting in hard, pellet-like motions.
Constipation may occur in infants as they move from breast milk to infant formula or
change infant formula. If the formula-fed infant becomes constipated, it is worth
checking that the formula is made up correctly and is being offered on demand. If the
formula is made too concentrated (that is, if more powder is used than is
recommended), the infant may be getting insufficient fluids for adequate kidney
excretory function. For infants eating complementary foods, increasing fruit intake may
help, as well as increasing intake of water.
Medical advice should be sought if constipation persists for more than a week.
12.6.2 Diarrhoea
The main danger from diarrhoea is dehydration, especially in infants under six months
of age. All breastfed babies should continue to receive breast milk, with extra feeds
offered. Formula-fed infants should continue to receive formula. Any changes to the
feeding of the infant should be under the direction of a doctor or dietitian.
Offering small drinks of cool fluids every 10 minutes will help ensure the toddler remains
hydrated. The optimal treatment for diarrhoea is rehydration through the use of oral
rehydration and electrolyte solutions and early reintroduction of feeding.
Medical advice should be sought if diarrhoea continues for more than 24 to 48 hours.
12.7
Probiotics
Probiotics are defined as live bacteria that when administered in adequate amounts
confer a health benefit on the host (FAO/WHO Working Group 2002). The benefit
occurs because the intestinal bacteria balance is improved (Collins and Gibson 1999).
Breast milk contains up to 109 bacteria per litre in healthy mothers (Mackie et al 1999).
Probiotics can be added to food. The bacteria are isolated, purified, characterised,
evaluated and ultimately used therapeutically. The doses required to confer health
benefits are estimated between 106 and 109 colony-forming units per day (Saavedra
2001). Probiotics are in a variety of fermented dairy products such as buttermilk,
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cheese and yoghurt as well as in some dietary supplement powders, capsules or
tablets. Some infant formulae contain probiotics.
The most common probiotics are lactic acid-producing bacteria such as bifidobacteriae
and the lactobacilli. They produce short-chain fatty acids as well as acetate and lactate
as a result of carbohydrate fermentation and are responsible for increasing the acidity of
the gut, which is a desirable effect. Lactobacilli also produce compounds that inhibit
growth of harmful bacteria.
Since the 1980s there has been interest in the effect of probiotics on the intestinal
bacteria and resulting health of infants. Recent research suggests that infant formula
containing certain strains of probiotics may reduce the severity and/or occurrence of
diarrhoea (Weizman et al 2005). There has also been a suggestion that probiotics may
possibly have a role in preventing and managing allergic and inflammatory diseases
(Salminen et al 2005), but more research is needed to confirm this.
Recently, oral probiotics have been shown to reduce the incidence and severity of
necrotizing enterocolitis in very low birth weight infants; no sepsis has been caused by
the probiotics and there is even a reduced overall incidence of neonatal sepsis.
However, probiotics alone do not completely eliminate necrotizing enterocolitis, as it is a
disease with many factors.
Saavedra et al (2004) reported on tolerance and safety after long-term consumption of
infant formulae containing live probiotic bacteria. They concluded that long-term
consumption of formulae supplemented with probiotics was well tolerated and safe.
Use of the formulae resulted in adequate growth, a significant reduction in colic or
irritability and a significantly lower frequency of antibiotic use compared to the placebo
group. Therefore, probiotics seem to have a generally advantageous and safe profile
but should be used with caution in immunocompromised infants.
The benefits of probiotics seem to outweigh the potential danger of infection causing
sepsis. Anecdotal reports of sepsis do exist, however, and these reports have raised
the need to proceed cautiously with using probiotics.
12.8
Gastric reflux
Spilling after feeds occurs in some infants. In most cases, it is harmless, although it can
worry parents and caregivers. No treatment is required, apart from careful handling
after feeds, if:
• spilling is infrequent (not every feed)
• there are only small amounts of undigested milk in the spill
• the infant is thriving.
Gastro-oesophageal reflux involves more frequent spills, and in larger amounts, of
undigested milk. If the infant is very unsettled or is failing to thrive, medical assistance
should be sought.
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There are thickeners available that can be added to expressed breast milk or fed from a
teaspoon prior to breastfeeding or between changing from one breast to another.
A number of formula companies now produce special formula thickened to assist
gastro-oesophageal reflux. These products are considered suitable from birth and may
help the problem.
12.9
Vegetarian eating patterns
Vegetarian food patterns are increasingly common in New Zealand. It is important to
establish what parents mean if they describe themselves as vegetarian as there are
different types of vegetarianism. Vegetarians can vary from excluding only red meat
(semi-vegetarians); all meat, including fish (lacto-ovovegetarians); eggs and meat
(lacto-vegetarians) or all animal products (total vegetarians or vegans).
The infant should continue to receive either breast milk or infant formula for at least the
first year of life. Infant formulae that contain no animal products are available.
A vegetarian diet for an infant is similar to any other in the first weeks of introducing
complementary foods, as suitable first foods are the same, that is, infant cereals,
vegetables and fruit. As the introduction of complementary foods progresses, there is a
potential risk of the infant receiving insufficient amounts of energy, iron, zinc and
protein. Table 8: The four food groups shows where these and other nutrients can be
found in infant foods.
Legumes are good sources of protein, iron, zinc and soluble fibre. Cereals and darkgreen leafy vegetables can help to supply protein, iron and some B vitamins. Red and
orange vegetables and fruit, and dark-green leafy vegetables provide energy, fibre and
vitamins.
A vegan diet is highly restrictive and carries considerable risk of nutritional deficiency,
especially for energy, protein and vitamin B12. Infants of vegan mothers may be born
with a vitamin B12 deficiency because the amount of vitamin B12 stored by the foetus is
related to the mother’s intake of the vitamin during pregnancy. Breastfed infants of
vegans are also likely to receive vitamin B12 deficient breast milk (Specker 1994). It is
important, therefore, that the mother consumes vitamin B12 in her diet during
pregnancy and breastfeeding and she may need supplements (Ministry of Health
2006a). Special care must be taken to ensure that these infants and toddlers receive
complementary foods containing vitamin B12, such as soy milk and textured vegetable
protein, and supplements may be required (British Paediatric Association 1988).
Families should be strongly encouraged to seek advice from a dietitian to ensure that
their vegan child receives a nutritionally adequate diet with sufficient energy, protein and
other nutrients.
For vegan infants and toddlers, cereals, pulses and vegetables should be sieved and
whole grain cereals replaced by foods with low fibre content (Dagnelie et al 1990).
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12.10.1 Practical advice for vegetarian eating patterns
•
Infants should be fed exclusively on breast milk to around six months of age with
continued breastfeeding up to two years or beyond. Vegetarian mothers should be
advised to breastfeed their infants for as long as possible – two years or more.
Vegan mothers may require a vitamin B12 supplement.
•
If the infant is not breastfed, then an infant formula should be used until one year of
age. For vegan infants who are not breastfed or are partially breastfed, use of a
commercial soy-based infant formula during the first two years of life is
recommended.
•
When the infant is ready, appropriate complementary food should be introduced, and
breastfeeding continued. The developmental cues should be used to determine if the
infant is ready. The infant will probably be ready at around six months of age but
some infants may be ready sooner. However, infants should not be given
complementary foods before four months of age.
•
The variety of complementary foods should be increased to ensure an additional
intake of nutrients, especially energy, protein iron and vitamin B12. The infant should
be eating family foods by around the age of one year.
•
For infants, prepare or choose pre-prepared foods that have no added fat, salt or
sugar.
•
Toddlers should be offered a variety of nutritious foods from each of the major food
groups each day:
– vegetables and fruit
– breads and cereals, preferably wholegrain
– milk and milk products
– lean meat, poultry, seafood, eggs or alternatives (as appropriate for the family food
choices).
•
For toddlers, prepare foods or choose pre-prepared foods, drinks and snacks:
– with minimal added fat, especially saturated fat
– that are low in salt; if using salt, choose iodised salt
– with little added sugar; limit intake of high-sugar foods.
•
For toddlers, provide plenty of liquids each day, especially whole (dark blue top)
cows’ milk, or calcium fortified soy milk, and water.
12.10 Overweight and obesity
In recent years, there have been rapid increases in the occurrence of childhood
overweight and obesity. This is of public health concern as there are significant health
problems associated with child obesity, notwithstanding the psychological issues
resulting from the social stigma of obesity. Additionally the probability of obesity and
associated diseases in adulthood is substantially greater for the obese child (American
Academy of Pediatrics 2003).
There is some evidence that breastfeeding probably reduces the risk of obesity in later
childhood and adulthood (see Appendix 11: Summary and Strength of Evidence of the
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Importance of Breastfeeding for Infants). Studies of maternal control of feeding in
toddlers, have shown that mothers who breastfed their infants through the first year of
life are less likely to impose control on meals in the second year of life. It has been
suggested that breastfed infants are exposed to a widely varying sensory experience
through breast milk, as compared to static formula feeds, and hence are more accepting
when complementary foods are introduced.
This may explain the lesser degree of control and encouragement implemented by
mothers who have breastfed (Fisher et al 2000). However, recent research
investigating the association between breastfeeding, introduction of complementary
foods and later obesity is conflicting (Burdette et al 2006; Ong et al 2006).
It is recognised that genetics are involved in causing obesity, however, the rapid
increase in obesity in recent years cannot be explained by genetics, and environmental
factors must be considered. Although considerable research has been undertaken in
relation to child obesity, information relating to behaviours in infants and toddlers is
more limited. Nevertheless, some key areas relating to obesity risk in children have
emerged, such as parenting practices, fatness in parents and dieting history (Birch and
Fisher 1998).
It is important to recognise the impact of the family’s diet on that of the child (Greer et al
2006). Parents create their children’s eating environment through their choice of an
infant feeding method, by the foods they make available, by their modelling of
behaviours, by the media exposure the child has in the home and also the way they
interact with the child at mealtimes. Hence there are associations between parent’s fat
intake, the child’s fat intake and the child’s degree of body fat (Birch and Fisher 1998).
Studies have also shown that preschool children will consume more food when served
consistently with larger portions. This effect is particularly pronounced in children who
had poor satiety responses. The researchers found that allowing children to self-select
their own portion sizes circumvented this problem (Fisher et al 2003).
In addition, studies show that parental directives encouraging or restricting intakes of
various foods can have adverse consequences. That is, children may prefer foods that
parents deem to be ‘bad’ and as a result restrict, and the converse may apply to socalled ‘good’ foods. Studies have also shown that children have an innate ability to
regulate their energy intake, and attempts by parents to control the energy intake of
children may again have the opposite effect (Birch and Fisher 1998). Recent research
has provided longitudinal evidence of this effect in five-year-old girls (Birch et al 2003).
In this study, mothers’ restrictive feeding practices on their five-year-old daughters were
associated with increased episodes of the girls eating in the absence of hunger in later
years, a behaviour prevalent in overweight adults.
Physical activity is important for normal growth and development, and regular fun
activity should be part of the infant’s and toddler’s life. Physical activity and dietary
practices set during the first two years of life form the framework of future practices so
should be modelled and encouraged by parents and caregivers.
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12.11 Infant botulism
The risk of infant botulism occurring is very small. Infant botulism occurs in infants
under one year of age (Midura 1996), and is caused by the toxin produced when
ingested spores of Clostridium botulinum germinate in the intestinal tract. Unlike older
children and adults, the gut flora of infants under one year of age is unable to prevent
colonisation by Clostridium botulinum. While most bacteria responsible for foodborne
illness are usually destroyed by the cooking process, Clostridium botulinum spores
survive standard cooking temperatures.
Approximately 90 percent of the reported cases of infant botulism occur in the USA,
where the average annual incidence is less than three per 1,000,000 live births (ACMSF
2005). The Ministry of Health is not aware of any reported cases of infant botulism in
New Zealand.
Ninety-nine percent of cases in the USA occur in children less than one year old, with
94 percent occurring before six months of age (ACMSF 2005). All of the six cases of
infant botulism confirmed in the United Kingdom since 1978 occurred in children under
the age of six months. In Europe, 93 percent of cases occurred in infants under six
months of age. Previous reports cited that 98 percent of the incidence of infant botulism
occurs in infants under six months of age (Arnon et al 1981).
Infant botulism is associated with the ingestion of spores, so the presence of spores in
infant foods is a key consideration (ACMSF 2005). For breastfed infants, the greatest
risk occurs when complementary foods are introduced, for formula fed infants, the
greatest risk is in the first few weeks of life when formula is introduced (ACMSF 2005).
Honey has been associated with cases of infant botulism in the USA, Japan, Argentina,
Italy and Denmark but not in the six cases of infant botulism confirmed in the United
Kingdom since 1978 (ACMSF 2005). In the USA, the ingestion of honey was suspected
in up to 15 percent of cases (Shapiro et al 1998). Clostridium botulinum spores have
been found in up to 20 percent of honey samples worldwide, but no formal studies on
the presence of Clostridium botulinum in honey have been undertaken in New Zealand.
The risk of contracting infant botulism from honey is extremely small.
As a general recommendation, honey should not be given to infants younger than one
year of age. This is to ensure consistency with the New Zealand recommendation not
to add sugar or sweeteners to food for infants and because internationally honey is not
recommended before one year of age.
12.12 Food safety
Food is easily contaminated and needs to be handled with care to prevent illness in
infants and toddlers. Appropriate food handling and preparation should reduce the risk
of infants contracting serious food-borne illnesses, such as salmonellosis and
campylobacteriosis. For general information on food safety, please refer to the New
Zealand Food Safety Authority.
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12.13.1 Practical advice for food safety
•
Sterilise all bottles, teats and equipment for infants up to the age of three months:
boil bottles and teats or use an appropriate sterilising solution following the
manufacturer’s directions for use.
•
Wash hands and use a clean towel before preparing an infant’s food or feeding an
infant.
•
Wash all babies’ utensils in hot soapy water, rinse well in hot water and dry with a
clean tea towel or in a dishwasher.
•
Only take out of the refrigerator/freezer sufficient food to feed the infant at one feed
time.
•
Avoid leaving any infant food sitting at room temperature for any length of time.
•
Throw out any food the infant has not eaten at the end of the meal, as it may be
harmful to the infant to reuse food where there has been an opportunity for harmful
bacteria to grow on that food.
•
Most commercial infant foods and home-prepared infant foods can be kept in a
covered container in the refrigerator for up to 48 hours. Read and follow any
instructions on the packaging.
•
See Part 4: Formula Feeding for advice on preparing and storing formula. For further
information about Enterobacter sakazakii refer to the Ministry of Health or New
Zealand Food Safety Authority websites.
12.13 Food security
Food security is an internationally recognised term that encompasses the ready
availability of nutritionally adequate and safe foods and the assured ability to acquire
personally acceptable foods in a socially acceptable way (Ministry of Health 2003c).
12.13.1 Health consequences of food insecurity
The highest rates of illness and premature death are generally experienced by those
less financially secure (National Health Committee 1998). Low socioeconomic and
income groups are food insecure more often and frequently have a higher risk for
chronic diseases. As food security status worsens, diet quality declines (Cristofar and
Basiotis 1992) and eating patterns become more disordered (Kendall et al 1995).
12.13.2 Impact of food insecurity on population groups
Māori and Pacific households are disproportionately represented in the two lowest
income quintiles (Statistics New Zealand 1999). Māori and Pacific households were
among those that experienced the greatest income reductions between 1991 and 1993
(National Health Committee 1998). In a New Zealand study of households on
government benefits, 70 percent of mothers said they restricted their own meal size to
feed their children, and the study indicated these women were getting insufficient
energy, iron and calcium. Single-parent households were among those that
experienced the greatest income reductions between 1991 and 1993 (National Health
Committee 1998). A significant number of homes where the sole parent was female
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were in the lowest income groups (Statistics New Zealand 1998, 1999). In addition, a
child of a female sole parent was more likely to be in the low-income households and so
was at higher nutritional risk (Statistics New Zealand 1999).
12.13.3 Impact of food insecurity on children
In the CNS02, food security was reported on behalf of the children by the adult
members of the household. The children in the CNS02 were aged five to 14. The
CNS02 reported on food security using the eight statements about access to food, the
responses to which provide a nationwide assessment of food poverty in New Zealand
(Ministry of Health 2003c).
Around 20 percent of households experienced food insecurity sometimes or often based
on the responses to five of the eight statements: they could afford to eat properly, they
run out of food; they eat less because of lack of money; they experience stress because
of not having enough money for food; and they experience stress because of not having
the food they want for social occasions. In around one-third of all households, the
variety of foods they were able to eat was limited sometimes or often.
Larger households, households in higher NZDep01 quintiles, and households with
Māori and Pacific children were more likely to be in the group households experiencing
food insecurity. These households were also more likely to experience food insecurity
sometimes or often based on their responses to the other three statements: they rely on
others for food and/or money for the household when they didn’t have enough money;
and they make use of special food grants and foodbanks.
Data on food security was collected in the CNS pilot (Ministry of Health 2001). Children
among the higher income groups had much less influence over buying decisions than
those children in lower income groups. This applied to each item in the range of foods
inquired into in this question, with limited variation between food types. This may be
because for families operating on tight budgets, it was imperative that children ate the
food that was purchased.
Fourteen of the 17 participants in the income band ($10,000–$20,000), and four of the
five participants in the income band <$10,000 said that they had had insufficient income
sometimes to buy food.
When there was insufficient food, the major source of assistance were relatives for all
income groups. The next most common response was ‘other’, mostly friends. Six of all
the responses used foodbanks.
Of the 121 respondents who answered the question about feeling hungry, 15
(12 percent) reported that they had felt hungry in the last week or month because of
shortage of food at home.
If the children were hungry and away from home they were mostly given pies and fast
foods for example burgers, fried chicken, fish and chips.
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12.13.4 Impact of household socioeconomic status on food security and food
choice
Although nutrient intakes are less than optimal among people with lower incomes, these
families have been found to obtain more nutrients for the amount of money spent than
people with higher incomes. The limited food budget means that they need to obtain
more energy per dollar spent, which may result in purchasing foods high in fat and
sugar. The NNS97 found that people in lower income areas were less likely to obtain
the recommended servings of vegetables and fruit. Households in these areas – as
with all households – were making choices based on a wide range of needs.
Before giving advice about food to mothers and families, health practitioners should be
aware of and sensitive to the fact that inadequate diet may be a result of an inadequate
income rather than ignorance or lack of education (Parnell et al 2001).
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Glossary
Adequate Intake (AI)
Where an estimated average requirement (and therefore a recommended
dietary intake) for the nutrient cannot be determined because of inconsistent
data, an AI is determined. The AI can be used as a goal for individual intake
but is based on experimentally derived intake levels or approximations of
observed mean nutrient intakes by a group of apparently healthy people
maintaining a defined nutritional state.
Alpha-linolenic acid
An omega-3 fatty acid with 18 carbon atoms; found in soybean, canola,
flaxseed, walnut oils, nuts and seeds.
Amylase
An enzyme involved in food digestion that breaks down amylose (a form of
starch).
Anaemia
Reduction of the haemoglobin below normal for age and sex. A diagnosis of
iron deficiency anaemia is made when anaemia is accompanied by
laboratory evidence of iron deficiency, such as low serum ferritin.
Anaphylaxis
Once an antigen has stimulated an allergic response, the next encounter with
that antigen may result in either anaphylaxis (a hypersensitive harmful
reaction) or prophylaxis (a protective response giving immunity).
Antigen
A substance, usually a protein, that can stimulate the production of antibodies
and react specifically with those antibodies. An antigen may be a bacterium,
pollen grain, etc. Each antigen requires a different antibody to neutralise it.
Antigenicity
The strength or potency of an antigen.
Atopy
The genetic tendency to develop the classic allergic diseases – eczema
(atopic dermatitis), hay fever (allergic rhinitis) and asthma. Atopy involves
the capacity to produce IgE in response to common environmental proteins,
such as house dust mites, grass pollen and food allergens. The diagnosis of
atopy is not based on one single distinctive clinical feature or laboratory test
but on results from a combination of patient/family history and clinical
findings.
Arachadonic acid
An omega-6 fatty acid with 20 carbon atoms; found in egg yolk, and meats
(particularly organ meats).
Basal metabolic rate
(BMR)
The amount of energy required to sustain basic essential processes for
keeping the body alive, healthy and growing, such as heart, lungs, nervous
system and kidneys. It is measured when an individual is at rest in a warm
environment, is in the post-absorptive state (that is, they have not eaten for at
least 12 hours) and is disease free.
Bio-availability
The degree to which a drug, medication or other substances (for example,
iron) becomes available for use by the body after administration.
Casein
Milk proteins are divided into two groups: casein (curd) and whey proteins.
Casein is the predominant phosphoprotein in milk, precipitated by acids and
rennet.
Children’s Nutrition
Survey (CNS)
A cross-sectional population survey of New Zealand children aged five to
14 years.
Codex Alimentarius
Commission
The joint body, comprising the Food and Agriculture Organization and the
World Health Organization, developed for setting international food
standards.
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Colostrum
The first milk secreted from the breasts after childbirth. It contains a large
amount of protein and immunising factors for the newborn.
Contraindication
A sign, symptom or condition suggesting that a certain line of treatment
should be discontinued or avoided.
Diabetes mellitus
Diagnosed when levels of glucose are abnormally elevated in the blood. It is
usually caused either by a lack of insulin or by the body’s inability to use
insulin efficiently. The two most common types of diabetes mellitus are type
1 (T1DM) and type 2 (T2DM).
Dietary folate
equivalents (DFEs)
Recommended folate intake is expressed as a dietary folate equivalent to
account for differences in the bio-availability of food folate and synthetic folic
acid. 1 µg of DFEs equals:
•
•
•
1 µg of folate from food
0.5 µg of a folic acid tablet taken on an empty stomach
0.6 µg of folic acid from fortified food/as a tablet taken with meals
(NHMRC 2006).
Docosahexaenoic acid
(DHA)
An omega-3 fatty acid with 22 carbon atoms; found in fish (especially tuna
and bluefish).
Eicosapentanoic acid
(EPA)
An omega-3 fatty acid with 20 carbon atoms; found in fish (especially tuna
and bluefish).
Essential amino acids
See indispensable amino acids.
Estimated average
requirement (EAR)
The median usual intake estimated to meet the requirement of half the
healthy individuals in a life stage/gender group. This value is usually used for
assessing adequacy of intakes of certain populations.
Exclusive
breastfeeding
The infant takes only breast milk and no additional food, water or other fluids
with the exception of medicines prescribed under the Medicines Act 1981.
Fatty acids (FAs)
A component of fat that is an even-numbered chain of carbon atoms with
hydrogens attached, a methyl group at one end and a carboxyl group at the
other. Fatty acids are classified as short (less than 8 carbons), medium (8–
12 carbons) or long (14 or more carbons) chains. Some fatty acids are
essential.
Folate
Generic term for the various forms of folate found in food. Involved in the
metabolism of nucleic and amino acids, and hence the synthesis of DNA,
RNA and proteins.
Folic acid
A synthetic form of folate, found in supplements and fortified foods and
beverages. It is more bio-available and stable than folate in food.
Food security
Access to adequate, safe, affordable and acceptable food.
Fully breastfeeding
The infant has taken breast milk only, and no other liquids or complementary
foods except a minimal amount of water or prescribed medicines, in the past
48 hours.
Galactosaemia
A rare inherited condition in which the infant is unable to metabolise
galactose to glucose.
Gamma linolenic acid
(GLA)
An omega-6 fatty acid with 18 carbon atoms; found in evening primrose and
blackcurrant oils.
Gastroenteritis
Inflammation of the lining of the stomach and the intestine. The cause is
usually a bacterial or viral infection or food poisoning, resulting in vomiting or
diarrhoea.
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Glutathione peroxidise
An antioxidant enzyme.
Goitre
An enlargement of the thyroid gland, forming a protuberance on the side or
front part of the neck. It results from an iodine deficiency.
Glycaemic index (GI)
The rise in blood glucose after a portion of carbohydrate-containing food is
eaten compared with the rise in blood glucose after a standard food (usually
white bread or glucose) is eaten. GI is normally expressed as a percentage.
Haem
The iron-holding part of the haemoglobin protein. About 40 percent of the
iron in meat, fish and poultry is haem iron; the other 60 percent is non-haem
iron.
Haemoglobin
The protein carrying oxygen in the red blood cells.
Hyperthyroidism
Excessive activity of the thyroid gland, characterised by high metabolic rate,
heat intolerance and weight loss.
Hypoglycaemia
A deficiency of sugar in the blood.
Immunoglobulins
A group of globulins capable of reacting specifically as antibodies (eg, IgA,
IgG, IgM).
Indispensable amino
acids
Formerly known as essential amino acids. Nine amino acids required for
protein synthesis that cannot be synthesised by the body and must be
obtained through the diet. These amino acids are histidine, isoleucine,
leucine, lysine, methionine, phenylalanine, threonine, tryptophan and valine.
Insulin
A polypeptide hormone that regulates carbohydrate metabolism. Apart from
being the primary effector in carbohydrate homeostasis, it also takes part in
the metabolism of fat, triglycerides and proteins. It has anabolic properties.
Insulin resistance
Decreased sensitivity of target cells (muscle and fat cells) to insulin.
Lactoferrin
A factor in breast milk that binds iron and prevents bacteria from metabolising
iron. It assists antibodies to resist certain infectious diseases.
Long-chain
polyunsaturated fatty
acids (LCPUFAs)
Longer-chain fatty acids that are derived from the essential fatty acids and
are precursors to hormone-like eicosanoid compounds, prostaglandins and
leukotrienes. These fatty acids occur in food and can be made from the
essential fatty acids.
Low density lipoprotein
(LDL)
A class and range of lipoprotein particles, varying somewhat in size and
content, which carry cholesterol in the blood and around the body, for use by
various cells. LDL is commonly referred to as ‘bad’ cholesterol because of
the link between high LDL levels and cardiovascular disease.
Metabolism
The uptake and digestion of food, and the disposal of waste products in living
organisms.
Methionine
An essential amino acid containing sulphur.
New Zealand Total
Diet Survey (NZTDS)
A survey examining contaminants and nutrients in some commonly eaten
New Zealand foods.
NNS97 (New Zealand
National Nutrition
Survey 1997)
A cross-sectional survey of adult New Zealanders aged 15 years and older.
Niacin equivalents
(NEs)
Nicotinic acid, nicotinamide and the contribution to niacin obtained by
conversion from dietary L-Tryptophan. The relative contribution of tryptophan
is estimated as follows:
•
60 mg of L-tryptophan = 1 mg of niacin = 1 mg of niacin equivalents.
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Non-starch
polysaccharide (NSP)
Included in the definition of dietary fibre. Two types – insoluble and soluble.
Most plant foods contain varying proportions of both. Good sources of
insoluble NSP include wheat, corn, rice, vegetables and pulses. Good
sources of soluble NSP include peas, oats, dried beans, lentils, barley, pasta
and fruit.
Nucleotides
The structural units of RNA, DNA and several cofactors – CoA, FAD, FMN,
NAD and NADP. In the cell, they play important roles in energy production,
metabolism and signalling.
Nutrient reference
values (NRVs)
A set of recommendations, including recommended dietary intakes (RDIs),
for intakes of nutrients.
NZDep96
An index of deprivation based on an individual’s residential address. The
index is based on eight dimensions of deprivation: income, access to a car,
living space, home ownership, employment, qualifications, support and
access to a telephone (Salmond et al 1998).
In the National Nutritional Survey 1997 (NNS97), quartile I is defined as
individuals living in the least deprived areas and quartile IV as individuals
living in the most deprived areas. When reported by Statistics New Zealand,
quintiles rather than quartiles are used.
Omega-3
Polyunsaturated fatty acids found in oily fish and in vegetable oils, nuts and
seeds. Omega-3 fatty acids are classed as essential fatty acids. Common
omega-3 fatty acids in the body are linolenic, eicosapentaenoic acid and
docosahexaenoic acid.
Omega-6
Polyunsaturated fatty acids found in vegetable oils, green leafy vegetables
and nuts and seeds. Omega-6 fatty acids are classed as essential fatty
acids. Common omega-6 fatty acids in the body are linoleic acid, the
shortest omega-6 fatty acid, and arachidonic acid.
Phytates
The principal storage form of phosphorus in many plant tissues, especially
grains, bran, legumes, seeds and nuts. They bind with minerals such as iron,
calcium and zinc and make the minerals unavailable for absorption.
Phytoestrogen
A compound with oestrogen activity, naturally occurring in plants.
Polyunsaturated fatty
acids (PUFAs)
Unsaturated fatty acids whose carbon chain has more than one double or
triple valence bond per molecule; found chiefly in fish and corn, soybean and
safflower oils. Human milk contains not only C18 essential fatty acids but also
very long-chain (C20 and longer) polyunsaturated fatty acids. These nutrients
are structurally essential for normal brain and eye development.
Prophylactic
A medicine that protects or defends against infection and disease.
Protein hydrolysate
formulae
Similar in composition to cows’ milk- and soy-based formulae. Milk protein,
either casein or whey protein, is heat treated and enzymatically hydrolysed.
The resulting hydrolysate, consisting of free amino acids and peptides of
varying length, is then fortified with amino acids to compensate for those
amino acids lost in the manufacturing process. In general, the more
extensive the hydrolysis, the more reduced the allergenicity and the greater
the price.
Recommended dietary
intake (RDI)
The average daily dietary intake level that is sufficient to meet the nutrient
requirements of nearly all (97 to 98 percent) healthy individuals in a particular
life stage and gender group.
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Retinol equivalents
(RE)
The recommendation for vitamin A intake is expressed as micrograms (mcg)
of retinol equivalents (RE). Retinol activity equivalents account for the fact
that the body converts only a portion of beta-carotene to retinol. One µg RE
equals 1 µg of retinol or 6 µg of beta-carotene.
Rickets
The result of vitamin D deficiency or malabsorption, which occurs mainly in
children.
Saturated fat
A fatty acid in which there are no double bonds between the carbon atoms of
the fatty acid chain. Saturated fats tend to be solid at room temperature.
Diets high in saturated fat correlate in some studies with an increased
incidence of atherosclerosis and coronary heart disease. Dehydrogenation
converts saturated fats to unsaturated fats, while hydrogenation
accomplishes the reverse.
Socioeconomic status
Social position, measured by an ordinal scale, indicating an individual’s (or a
family’s or household’s) relative position in the social hierarchy, based on
criteria such as income level, occupational class or educational attainment.
Taurine
An important component of bile acids, present in human milk in relatively high
levels. Infants fed on low-taurine formula tend to conjugate bile acids with
glycine rather than taurine. This may result in less efficient fat absorption.
Total energy
expenditure (TEE)
Encompasses basal metabolic rate, thermoregulation, synthetic cost of
growth and physical activity.
Triglycerides (TG) (or
triacylglycerols)
Fat molecules composed of one glycerol and three fatty acids.
Type 1 diabetes
mellitus (T1DM)
Previously known as IDDM (insulin dependent diabetes mellitus), T1DM is
caused by the destruction of insulin-producing cells, resulting in insulin
deficiency.
Type 2 diabetes
mellitus (T2DM)
Previously known as NIDDM: non-insulin-dependent diabetes. Of unknown
cause but associated with a combination of insulin resistance and a relative
insulin deficit. The major risk factors for T2DM are obesity, increasing age,
physical inactivity and nutritional factors such as a high intake of saturated
fatty acids. Can usually be controlled by diet and physical activity, along with
oral hypoglycaemic agents and (increasingly) insulin to control blood glucose
levels.
Unsaturated fat
A fat or fatty acid in which there is one or more double bonds between carbon
atoms of the fatty acid chain. Such fat molecules are monounsaturated if
each contains one double bond, and polyunsaturated if each contains more
than one.
Upper level of intake
(UL)
The highest average daily nutrient intake level likely to pose no adverse
health effects to almost all individuals in the general population. As intake
increases above the UL, the potential risk of adverse effects increases.
Whey
Milk proteins are divided into two groups: casein (curd) and whey proteins.
Whey is the liquid remaining after cows’ milk has been coagulated with
rennet and strained; it is a by-product of the manufacture of cheese or
casein. Whey proteins mainly consist of α-lactalbumin and β-lactoglobulin.
Whey:casein ratio
Cows’ milk has a higher proportion of casein to whey proteins (80:20) than
human milk (40:60) in addition to its higher total protein. Human and cows’
milk proteins have different amino acid composition.
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Wholegrain
The intact grain or the dehulled, ground, cracked, milled, cracked or flaked
grain where the proportion of endosperm, germ and bran are typical of the
proportion of the whole cereal. Includes wholemeal.
Wholemeal
A product containing milled endosperm, germ and bran in proportions typical
of the whole cereal.
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Abbreviations
α-TE
µg
AA
AI
BMI
BMR
cm
CNS
DFE
DHA
DNA
DPA
EAR
EER
EPA
FA
FAO
FOS
FSANZ
FSC
g
GI
GLA
GOS
HIV
IDA
kcal
kg
kJ
LC
LCPUFA
LDL
LMC
m
M
MFD
mg
mJ
n-3
n-6
alpha-tocopherol equivalent
microgram
arachidonic acid
adequate intake
body mass index
basal metabolic rate
centimetre
National Children’s Nutrition Survey
dietary folate equivalent
docosahexaenoic acid
deoxyribonucleic acid
docosapentanoic acid
estimated average requirement
estimated energy requirement
eicosapentanoic acid
fatty acid
Food and Agriculture Organization
fructo-oligosaccharides
Food Standards Australia New Zealand
Australia New Zealand Food Standards Code
gram
glycaemic index
gamma linolenic acid
galacto oligasaccharide
human immunodeficiency virus
iron-deficiency anaemia
kilocalories
kilogram
kilojoules
long chain
long-chain polyunsaturated fatty acids
low density lipoprotein
Lead Maternity Carer
metre
monounsaturated
Manufactured Food Database
milligram
megajoule
omega 3 fatty acid
omega 6 fatty acid
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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121
NE
NHC
NHMRC
NNS97
NRV
NSP
NZFSA
NZTDS
PHC
PUFA
RAST
RDI
RE
RNA
SPARC
SPF
T3
T4
TE
TEE
UK
UL
UNICEF
UNU
UV
UVI
UVR
WHO
122
niacin equivalent
National Health Committee
National Health and Medical Research Council of Australia
National Nutrition Survey 1997
nutrient reference value
non-starch polysaccharide
New Zealand Food Safety Authority
New Zealand Total Diet Survey
Public Health Commission
polyunsaturated fatty acids
radio allergosorbent test
recommended dietary intake
retinol equivalent
ribonucleic acid
Sport and Recreation New Zealand
sun protection factor
3,5,3’-triiodothyronine
thyroxine
total energy
total energy expenditure
United Kingdom
upper limit of intake
United Nations Children’s Education Fund
United Nations University
ultraviolet
ultraviolet index
ultraviolet radiation
World Health Organization
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
Draft for consultation
Appendix 1: Summary of the World Health
Organization International Code of Marketing of
Breast-milk Substitutes (1981)
The aim of the International Code of Marketing of Breast-milk Substitutes (Article 1) is to
contribute to the provision of safe and adequate nutrition for infants, by protecting and
promoting breastfeeding and by ensuring the proper use of breast milk substitutes when
these are necessary, on the basis of adequate information and through appropriate
marketing and distribution.
A summary of the Code is as follows.
1.
Products should not be advertised or otherwise promoted to the public.
2.
Mothers and pregnant women and their families should not be given samples of
products.
3.
Health care providers should not be given free or subsidised supplies of products
and must not promote products.
4.
People responsible for marketing products should not try to contact mothers or
pregnant women or their families.
5.
The labels on products should not use words or pictures, including pictures of
infants, to idealise the use of products.
6.
Health workers should not be given gifts.
7.
Health workers should not be given samples of products, except for professional
evaluation or research at the institution level.
8.
Material for health workers should contain only scientific and factual information
and must not imply or create a belief that bottle-feeding is equivalent or superior to
breastfeeding.
9.
All informational and educational materials for pregnant women and mothers,
including labels, should explain the benefits and superiority of breastfeeding, the
social and financial implications of its use and the health hazards of the
unnecessary or improper use of formula.
10. All products should be of a high quality and take account of the climate and
storage conditions of the country where they are used.
Context
In 1981, the World Health Assembly adopted the WHO International Code of Marketing
of Breast-milk Substitutes that recommended as a basis for action various requirements
and restrictions in relation to marketing and distributing breast milk substitutes. The
New Zealand Government adopted the Code in its entirety in 1983 through consensus
and discussion rather than through regulation.
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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123
Appendix 2: World Health Organization and UNICEF
Statement on the 10 Steps to Successful
Breastfeeding (1989)
The Baby Friendly Hospital Initiative (BFHI) is an initiative designed by the World Health
Organization and UNICEF in 1991 to encourage hospital facilities to follow the 10 Steps
to Successful Breastfeeding. BFHI is implemented in New Zealand by the New Zealand
Breastfeeding Authority (NZBA).
The 10 steps to successful breastfeeding
Every facility providing maternity services and care for newborn infants should:
1.
have a written breastfeeding policy that is routinely communicated to all health
care staff
2.
train all health care staff in the skills necessary to implement this policy
3.
inform all pregnant women about the benefits and management of breastfeeding
4.
help mothers initiate breastfeeding within half an hour of birth
5.
show mothers how to breastfeed and how to maintain lactation even if they should
be separated from their infants
6.
give newborn infants no food or drink other than breast milk, unless medically
indicated
7.
practise rooming-in, that is, allowing mothers and infants to remain together –
24 hours a day
8.
encourage breastfeeding on demand
9.
give no artificial teats or pacifiers (also called soothers) to breastfeeding infants
10. foster the establishment of breastfeeding support groups and refer mothers to
such services on discharge from the hospital or clinic.
Source: WHO 1989
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Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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Appendix 3: Ministry of Health Policy Context for Food
and Nutrition Guidelines for Healthy Infants and
Toddlers (Aged 0–2): A background paper
Maternity
Service
Providers
(Section 88
Maternity
Notice)
Breastfeeding
advocacy and
support
programmes
Baby Friendly
Hospital Initiative and
Baby Friendly
Community Initiative
The Code in
New Zealand (see
Appendix 1)
The New
Zealand
Health
Strategy
and
the New
Zealand
Disability
Strategy
He Korowai
Oranga: M? ori
Health Strategy
Food and Nutrition
Guidelines for
Healthy Infants and
Toddlers (aged 0–2)
Breastfeeding: A Guide
to
Action
Well Child –
Tamariki Ora
National
Schedule
Handbook
and Well Child
Framework
DHB
pregnancy
and
parenting
programmes
Food and
nutrition
guidelines for:
• healthy
pregnant
and
breastfeeding
women
• healthy infants
and toddlers
The Pacific Health
and Disability
Action Plan
Primary Health Care
Strategy
Reducing inequalities –
intervention framework
and HEAT tool
Healthy Eating –
Healthy Action:
strategy and
implementation
plan
All documents associated with these areas are available on the Ministry of Health
website, http://www.moh.govt.nz, or from Wickliffe, PO Box 932, Dunedin, telephone
(03) 479 0979, or (04) 496 2277 email: [email protected]
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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125
Appendix 4: Reducing Health Inequalities Tools
Health Equity Assessment Tool (HEAT) for tackling inequalities in
health
The following questions have been developed to help you consider how particular
inequalities in health have come about and where the effective intervention points are to
tackle them. The questions should be used in conjunction with the Ministry of Health’s
reducing inequalities intervention framework for reducing health inequalities.
1.
What health issue is the policy/programme trying to address?
2.
What inequalities exist in this health area?
3.
Who is most advantaged and how?
4.
How did the inequality occur? (What are the mechanisms by which this inequality
was created, is maintained or was increased?)
5.
What are the determinants of this inequality?
6.
How will you address the Treaty of Waitangi in the context of the New Zealand
Public Health and Disability Act 2000?
7.
Where/how will you intervene to tackle this issue? Use the Ministry of Health
intervention framework for reducing health inequalities (Ministry of Health 2002b)
to guide your thinking.
8.
How could this intervention affect health inequalities?
9.
Who will benefit most?
10. What are possible unintended consequences?
11. What will you do to make sure the intervention does reduce/eliminate inequalities?
12. How will you know if inequalities have been reduced/eliminated?
Source: Public Health Consultancy and Te Rōpu Rangahau Hauora a Eru Pōmare Wellington School of
Medicine and Health Sciences 2004
126
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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Figure 1: Intervention framework to improve health and reduce inequalities
1. Structural
Social, economic, cultural and historical factors
fundamentally determine health. These include:
• economic and social policies in other sections
– macroeconomic policies (eg, taxation)
– education
– labour market (eg, occupation, income)
– housing
• power relationships (eg, stratification,
discrimination, racism)
• Treaty of Waitangi – governance, Māori as a
Crown partner
2. Intermediary pathways
The impact of social, economic, cultural and
historical factors on health status is mediated
by various factors including:
• behaviour/lifestyle
• environmental – physical and psychosocial
• access to material resources
• control – internal, empowerment
4. Impacts
The impact of disability and illness on
socioeconomic position can be minimised
through:
• income support, eg, sickness benefit,
invalids benefit, ACC
• antidiscrimination legislation
• deinstitiutionalisation/community support
• respite care/care support
3. Health and disability services
Specifically, health and disability services can:
• improve access – distribution, availability, acceptability,
affordability
• improve pathways through care for all groups
• take a population health approach by:
– identifying population health needs
– matching services to identified population health needs
– health education
Interventions at each level may:
• apply nationally, regionally and locally
• take population and individual approaches
Source: Ministry of Health 2004b
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Appendix 5: Priority Population Health Objectives in
the New Zealand Health Strategy (2000)
The 13 population health objectives listed in the New Zealand Health Strategy are to:
1.
reduce smoking
2.
improve nutrition
3.
reduce obesity
4.
increase the level of physical activity
5.
reduce the rate of suicides attempts
6.
minimise harm caused by alcohol and illicit and other drug use to both individuals
and the community
7.
reduce the incidence and impact of cancer
8.
reduce the incidence and impact of cardiovascular disease
9.
reduce the incidence and impact of diabetes
10. improve oral health
11. reduce violence in interpersonal relationships, families, schools and communities
12. improve the health status of people with severe mental illness
13. ensure access to appropriate child health care services, including well child and
family health care and immunisation.
Source: Minister of Health 2000
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Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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Appendix 6: Key Population Health Messages
Underpinning the Healthy Eating – Healthy Action
Strategic Framework and Implementation Plan
1.
Eat a variety of nutritional foods.
2.
Eat less fatty, salty, sugary foods.
3.
Eat more vegetables and fruits.
4.
Fully breastfeed infants for at least six months.
5.
Be active every day for at least 30 minutes in as many ways as possible.
6.
Add some vigorous exercise for extra benefits and fitness.
7.
Aim to maintain a healthy weight throughout life.
8.
Promote and foster the development of environments that support a healthy
lifestyle.
Source: Ministry of Health 2003b
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129
Appendix 7: Sample Meal Plans for Infants and
Toddlers
The following meal plans were analysed using Foodworks Professional Edition 2005.
Infants, 9 to 12 months of age: three-day meal plan
Day 1
Day 2
Day 3
Infant rice, fortified (5 tbsp)
Infant muesli, fortified (4 tbsp)
Infant cereal, fortified (3 tbsp)
Apple, stewed (3 tbsp)
Fruit salad, canned (3 tbsp)
Breast milk or formula to mix
Pears, stewed or canned
(3 tbsp)
Milk, breast or formula (150 ml)
Breast milk or formula to mix
Breakfast
Milk, breast or formula (150 ml)
Milk, breast or formula (100 ml)
Mid-morning
Rice crackers (3)
Raisins (1 tbsp)
Lightly toasted bread, plain
(¼ slice)
Milk breast or formula (150 ml)
Margarine, low salt (0.5 tsp)
Cooked carrot sticks (2 tbsp)
Avocado (2 tsp)
Milk breast or formula (150 ml)
Cheese on toast (½ slice)
Cheese, Edam (1 tbsp)
Milk breast or formula (150 ml)
Lunch
Brown bread (½ slice)
White bread (1 slice)
Soft pasta spirals (¼ cup)
Margarine, low salt (0.5 tsp)
Margarine, low salt (1 tsp)
Ripe banana (¼)
Soft cooked diced chicken
(3 tbsp)
Vegemite (1 tsp)
Cooked carrot sticks (2 tbsp)
Cheese, Edam, grated
(2-cm cube)
Ripe banana (¼)
Cubes of melon (4 tbsp)
Milk, breast or formula (100 ml)
Soft fruit (¼ cup)
Milk, breast or formula (100 ml)
Milk, breast or formula (100 ml)
Mid-afternoon
Banana custard (3 tbsp)
Fruit yoghurt (¼ cup)
Biscuit, plain (1)
Cracker (1)
Peaches, canned (3 tbsp)
Soft pear pieces (¼)
Weetbix, crushed (3 tbsp)
Milk, breast or formula (100 ml)
Cooked mashed fish (¼ cup)
Tomato and meat sauce (4 tbsp)
Chicken casserole with
vegetables (50 g)
Mashed or chopped broccoli
and carrot (1 tbsp)
Carrot, mashed or soft pieces
(1 tbsp)
Mixed vegetables (1 tbsp)
Milk, breast or formula
(100 to 200 ml)
Milk, breast or formula
(100 to 200 ml)
Dinner
Spaghetti noodles (2 tbsp)
Potato wedges (2 small)
Supper
Milk, breast or formula
(100 to 200 ml)
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Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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Summary of the nutritional analysis of the three-day meal plan for infants,
9 to 12 months: average per day
Energy (kJ)
3118
Carbohydrate (g)
99.5 (53.7 percent of total energy)
Protein (g)
23.3 (12.5 percent of total energy)
Total fat (g)
28.7 (33.7 percent of total energy)
Fibre (g) (Englyst)
8.3
Saturated fat (g)
11.7 (14.2 percent of total energy)
Calcium (mg)
322.4
Iron (mg)
11.4
Sodium (mg)
602.4
Zinc (mg)
3.6
Selenium (μ)
18.8
Vitamin C (mg)
80.0
Total vitamin A equivalents (μg)
776
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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131
Toddlers, 1 to 2 years of age: three-day meal plan
Day 1
Day 2
Day 3
Weetbix (1½ biscuits)
Rice cereal (½ cup)
Weetbix (1½ biscuits)
Banana (¼)
Milk (100 ml)
Milk (¼ cup)
Milk (¼ cup)
Wholegrain toast (0.5 slice)
Strawberries (4)
Margarine, low salt (1 tsp)
Jam (1 tsp)
Banana (½) or tinned fruit in
natural juice
Water cracker with smooth
peanut butter (4)
Plain crackers (4)
Malt biscuit (2)
Cream cheese (1 tbsp)
Apple, chopped (½ cup)
Carrot sticks (3 tbsp)
Banana (½)
Juice, unsweetened (¼ cup)
Raisins (3 tbsp)
Juice (¼ cup)
Water (¼ cup)
Juice, unsweetened (¼ cup)
Water (¼ cup)
Breakfast
Mid-morning
Water (¼ cup)
Lunch
Wholegrain bread (½ slice)
Wholegrain bread (1 slice)
Macaroni cheese (30 g)
Egg, mashed (1/3)
Ham (2 tbsp)
Wholegrain roll (1/3)
Lettuce (2 leaves)
Margarine (½ tsp)
Margarine, low salt (1 tsp)
Mayonnaise, red fat (1 tsp)
Carrot sticks (3 tbsp)
Peas (1 tbsp)
Margarine, low salt (1 tsp)
Celery sticks (3 tbsp)
Milk (¼ cup)
Cucumber sticks
Orange (½)
Milk (¼ cup)
Milk (100 ml)
Mid-afternoon
Fruit yoghurt (1/3 cup)
Dried apricots (4 halves)
White bread toasted (¼)
Weetbix, crushed (½ cup)
Cheese cubes (2)
Jam (1 tbsp)
Juice, unsweetened (¼ cup)
diluted with ¼ cup water
Bread sticks (2)
Yoghurt (50 g)
Milk (100 ml)
Juice unsweetened (¼ cup)
diluted with ¼ cup water
Lamb chop (1 small)
Tomato and meat sauce (3 tbsp)
Fish, pie with mashed potato
(½ cup)
Peas (2 tbsp)
Green beans (3 tbsp)
Parsnip and carrot mash
(5 tbsp)
Broccoli (3 tbsp)
Carrot (3 tbsp)
Broccoli (3 tbsp)
Dinner
Spaghetti (¼ cup)
Peas (3 tbsp)
Water (¼ cup)
Supper
Apples, stewed (3 tbsp)
Peaches, canned (1/3 cup)
Fruit yoghurt (1/3 cup)
Wheatgerm (2 tbsp)
Milk (½ cup)
Plums, stewed (3 tbsp)
Milk (½ cup)
132
Milk (½ cup)
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
Draft for consultation
Summary of the nutritional analysis of the three-day meal plan for toddlers
1 to 2 years of age: average per day
Energy (kJ)
3899
Carbohydrate (g)
127.3 (55 percent of total energy)
Protein (g)
36.4 (15.7 percent of total energy)
Total fat (g)
31.3 (29.3 percent of total energy)
Fibre (g) (Englyst)
14.2
Saturated fat (g)
13.1 (12.7 percent of total energy)
Calcium (mg)
621
Iron (mg)
10.3
Sodium (mg)
853
Zinc (mg)
4.9
Selenium (μ)
20.1
Vitamin C (mg)
95.3
Total vitamin A equivalents (μg)
969.5
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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133
Appendix 8: Nutrient Reference Values for Australia
and New Zealand for Infants and Toddlers
Nutrient
Infants aged
0–6 months
AI
Infants aged
7–12 months
AI
Toddlers aged
1–3 years
RDI
Energy, macronutrients and dietary fibre
Energy (kJ)
Protein (g)
Carbohydrate (g)
Dietary fibre (g)
Fat (g)
Linoleic acid (g)
Alpha-linolenic acid (g)
LC omega-3 fatty acids (mg) (DHA, EPA, DPA)
See Table 9
10
60
–
31
4.4
0.5
–
See Table 9
14
95
–
30
4.6
0.5
–
See Table 9
14
–
14 (AI)
–
5 (AI)
0.5 (AI)
40 (AI)
Minerals
Calcium (mg)
Zinc (mg)
Iron (mg)
Magnesium (mg)
Iodine (μg)
Selenium (μg)
Copper (mg)
Fluoride mg
Sodium mg
210
2.0
0.2
30
90
12
0.20
0.01
120
270
3.0 (RDI)
11 (RDI)
75
110
15
0.22
0.05
170
500
3
9
80
90
25
0.7 (AI)
0.7 (AI)
200–400 (AI)
250 as retinol
5
4
430
5
5
300
5 (AI)
5 (AI)
2.0
2.5
25 (AI)
0.2
0.3
2
0.1
0.4
65
1.7
5
25
125
700
700
0.3
0.4
4
0.3
0.5
80
2.2
6
30
150
800
600
0.5
0.5
6
0.5
0.9
150
3.5 (AI)
8 (AI)
35
200 (AI)
1400 (AI)
1000 (AI)
Fat-soluble vitamins
Vitamin A (μg RE)
Vitamin D (μg)
Vitamin E (mg α-TE)
Vitamin K (μg)
Water-soluble vitamins
Thiamin (mg)
Riboflavin (mg)
Niacin (mg NE)
Vitamin B6 (mg)
Vitamin B12 (μg)
Folate (μg DFEs)
Pantothenic acid (mg)
Biotin (μg)
Vitamin C (mg)
Choline (mg)
TOTAL water ml
From fluids only ml
Source: NHMRC 2006.
Notes:
1. Assumes minimal sun exposure.
2. Does not include additional supplemental folic acid required to prevent neural tube defects; see 10.5.3 Folate and
vitamin C, 12.3 Supplements and Glossary (Folate and Folic Acid).
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TE = total energy; AI = adequate intake; LC = long chain; RE = retinol equivalent; α-TE = alpha-tocopherol
equivalents; NE = niacin equivalents; DFE = dietary folate equivalents; – = not established.
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Appendix 9: Composition of Breast Milk and Cows’
Milk-based Formula Available in New Zealand
Composition per litre
Nutrients
Mature human
milk*
Whey dominant infant
formula
Follow-on formula
Energy, macronutrients and dietary fibre
Energy (kcal)
720
655–680
648–680
Protein (g)
14
14.5–15
21–22
Carbohydrate (g)
72
70–72
66–80
Fat (g)
43
36–38
Fat source
N/A
Vegetable and soy lecithin;
blend of five vegetable oils
30–37
Vegetable and animal fat; soy
lecithin; blend of five vegetable oils
Minerals
Calcium (mg)
345
420–550
700–780
Zinc (mg)
3.1
4–5
4–8
Iron (mg)
0.7
7.7–8
10
Magnesium (mg)
31
46–100
64–73
Iodine (µg)
70
50–60
58–60
Selenium (µg)
20
not added
not added
Copper (µg)
400
440–470
440–480
Sodium (mmol)
6.8
6.5–8.3
8.3–9.6
Potassium (mmol)
15.5
14.3–20
17–22.5
Phosphorus (mg)
156
280–360
450–580
Chloride (mg)
439
400–460
410–640
Manganese (µg)
271
46–100
42–100
Vitamin A (µg)
605
600–1000
600–830
Vitamin D (µg)
0.4
9.3–10
9.3–11
Vitamin E (mg)
3.5
7.8–10
7.2–9.5
Vitamin K (mg)
2.9
30–55
30–55
Thiamin (µg) B1
200
430–670
400–670
Riboflavin (µg) B2
300
570–1000
830–1600
Niacin (mg)
7.2
2.5–7
2.6–7
Pyridoxine (µg) B6
100
250–420
390–420
Vitamin B12 (µg)
0.1
1.3–2.2
1.3–2.6
Fat-soluble vitamins
Water-soluble vitamins
Folic acid (µg)
52
40–54
40–75
Pantothenic acid (mg)
2.6
2.1–6.5
2.1–5.2
Biotin (µg)
73
11–15
15–25
Vitamin C (mg)
41.8
55–69
55–65
Choline (mg)
90
50–120
50–120
Taurine (mg)
40
37.6–50
37.6–50
Carnitine (mg)
20
6.5–20
7
Inositol (mg)
N/A
27–120
N/A
Casein: Whey Ratio
40:60
40:60
40:60–80:20
Renal solute load (m0sm/L)
not added
not added
117–134.4
Other
*
Human milk data from FoodWorks Professional Edition, Version 3.02, Build 540, 1998–2003, Xyris Software, New Zealand.
Formula data from Cormack 2007, based on the range of composition of formulae in the categories.
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Appendix 10: Ministry of Health Definitions of
Breastfeeding
The following are the standard breastfeeding definitions for New Zealand adopted by
the Ministry of Health in 1999 (Ministry of Health 2002a).
•
Exclusive: The infant has never, to the mother’s knowledge, had any water, formula
or other liquid or solid food. Only breast milk, from the breast or expressed, and
prescribed3 medicines have been given from birth.
•
Full: The infant has taken breast milk only, and no other liquids or solids except a
minimal amount of water or prescribed medicines, in the past 48 hours.
•
Partial: The infant has taken some breast milk and some infant formula or other solid
food in the past 48 hours.
•
Artificial: The infant has had no breast milk but has had alternative liquid such as
infant formula, with or without solid food, in the past 48 hours.
3
Prescribed as per the Medicines Act 1981.
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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137
Appendix 11: Summary and Strength of Evidence of
the Importance of Breastfeeding for Infants
Strength of evidence
Protective effects
Convincing
•
Protects against infectious diseases such as gastroenteritis (Kramer et al
2001; Lopez-Alarcom et al 1997; Howie et al 1990) and respiratory
infections (Howie et al 1990; Wilson et al 1998; Galton et al 2003)
•
Meets the full-term infant’s complete nutritional and fluid needs for up to
the first six months of life (Butte et al 2002; Lawrence and Lawrence
2005)
•
Otitis media (Duncan et al 1993; Aniansson et al 1994)
•
Bacteraemia, bacterial meningitis (Hylander et al 1998), urinary tract
infections (Marild et al 2004 ) and necrotising enterocolitis (Lucas and
Cole 1990; Beeby and Jeffery 1992; American Academy of Pediatrics
2005)
•
Infant mortality (American Dietetic Association 2005)
•
Hospitalisation (McVeagh 2006)
•
Food allergy in those with a family history of food allergy (Vanderplus
1998; Kramer and Kakuma 2003; Van Odijk et al 2003; Sears et al 2002;
Kemp and Kakakios 2004); allergies and atopic disease (Zeiger 2003;
Siltanen et al 2003)
•
Asthma (Gdalevich et al 2001) and eczema (Dell and To 2001)
•
Malocclusions or malalignment of teeth (American Dietetic Association
2005)
•
Sudden infant death syndrome (SIDS) (Mitchell, Scragg et al 1991; Ford
et al 1995; McVea et al 2000)
•
Obesity in later childhood and adulthood (Armstrong and Reilly 2002;
Arenz et al 2004; Grummer-Strawn and Mei 2004; McMillen et al 2005;
Harder et al 2005; Owen et al 2005; Dewey 2003; Burdette et al 2006) ,
allows the infant to self-regulate their feeding (Dewey and Lonnerdal
1986)
•
Type 1 diabetes (Gerstein 1994; Mayer et al 1988; Vintanen et al 1991;
Couper 2001)
•
Type 2 diabetes (Pettit et al 1997; Owen et al 2006)
•
Crohn’s disease, ulcerative colitis, (Klement et al 2004) and other chronic
digestive diseases (American Academy of Pediatrics 1997); coeliac
disease (Nash 2003; Norris et al 2005)
•
Gastroesophageal reflux (Heacock et al 1996)
•
Cardiovascular disease (Owen et al 2002) and high blood pressure
(Wilson et al 1998)
•
Cognitive development (Drane and Logemann 2000; Horwood et al 2001)
•
Visual development (Makrides et al 1995; Carlson et al 1996; Horwood
et al 2001)
•
Childhood cancer and lymphoma (Bener et al 2001)
•
Abuse and neglect (Klinger 2002)
•
Abandonment (Lvoff et al 2000; Buranasin 1991)
•
Physical and sexual abuse (Acheson 1995)
Probable (probably
reduces the risk)
Possible (possibly
reduces the risk)
138
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Draft for consultation
Appendix 12: Breastfeeding Support Organisations
Provider
Contact
Community health worker
Telephone the local hospital.
Midwife
Look in the yellow pages telephone directory, under ‘Midwives’ or in
the white pages telephone directory, under the front section, ‘Hospitals
and other health service providers’ or under ‘M’ for midwife.
Phone 0800-MUM2BE (686 223).
La Leche League New
Zealand
A nationwide voluntary organisation that offers mother-to-mother
information and support and breastfeeding resources for parents and
health practitioners.
National Office, PO Box 1270, Wellington
Phone/Fax: 04 471 0690
Email: [email protected]
Website: http://www.lalecheleague.org.nz
Lactation consultants
Telephone the local hospital.
Medical practitioner
Listed at the front of the white pages telephone directory under
‘Registered Medical Practitioners and Medical Centres’.
New mothers’ support
groups
Refer to the Plunket nurse, practice nurse or general practitioner for
further details.
Parents Centre
A nationwide voluntary organisation that offers education in birthing
and parenting, support to parents and aims to improve community
attitudes and facilities. Many parents centres offer breastfeeding
support. There are 62 centres in New Zealand. For local support refer
to the local white pages telephone directory under ‘P’.
Plunket nurse
National Office, PO Box 5474, Wellington.
Practice nurse
Telephone your general practitioner (GP).
Well Child nurse
For local assistance, refer to the local white pages telephone directory
or call Healthline: 0800 611 116.
Public Health nurse
Telephone the local public health service.
Te Kōhanga Reo
Listed in the local telephone directory.
Tipu Ora
Listed in the telephone directory.
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
Draft for consultation
139
Appendix 13: Health Education Resources Available
from the Ministry of Health to Support Breastfeeding,
Infant Nutrition and Infant Health
Resources can be ordered from your local authorised provider or can be accessed and
printed from the Ministry’s health education website http://www.healthed.govt.nz.
Information on health and disability policy advice and research can be found on the
Ministry of Health’s main website http://www.moh.govt.nz.
9015
Breastfeeding: You Can Do It
9003
Fast Free Food for Babies (A2 poster)
9011
Fast Free Food for Babies (postcard)
9059
Breastmilk: Food for Life (A3 breastfeeding poster for Pacific women)
1521
Eating for Healthy Babies and Toddlers: from birth to two years old/Te Kai
Totika mo te Hunga Kohungahunga
6014
Starting Solids (A4 pad of 25 leaflets)
1405
Food Allergy (information about food allergies and allergic reactions to food)
1306
Feeding Your Baby Infant Formula (a booklet for use by health professionals
in advising parents and caregivers who have decided to partially or
completely formula feed a baby)
9060
Soy-based Infant Formula (A5 leaflet with information for parents about
soy-based milk alternatives)
7012
Well Child/Tamariki Ora Health Book (parent information and health
immunisation record book for 0- to 5-year-olds)
7027
Useful Information Children 0–5 (key messages in Sāmoan – mainly for use
with the Well Child book (7012))
7028
Useful Information Children 0–5 (key messages in Tongan – mainly for use
with the Well Child book (7012))
7029
Useful Information Children 0–5 (key messages in Niuean – mainly for use
with the Well Child book (7012))
7030
Useful Information Children 0–5 (key messages in Tokelauan – mainly for
use with the Well Child book (7012))
7031
Useful Information Children 0–5 (key messages in Cook Islands Māori –
mainly for use with the Well Child book (7012))
4934
Oranga Niho Oranga Kata (A4 pad of 25 leaflets with tamariki dental health
information for parents and caregivers)
7016
Fluoride Gives You Better Teeth for Life (A2 poster)
9038
Baby Teeth Are Important (A5 pad of 25 leaflets with information for parents
of preschool children on early dental care)
4147
Folic Acid and Spina Bifida (protection in pregnancy)
140
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
Draft for consultation
4160
When You Drink So Does Your Baby (information on alcohol and pregnancy)
1231
Changing Smoking in Pregnancy (information about how smoking affects
babies and the benefits of stopping or reducing smoking during pregnancy)
8018
I’ll Give Him a Choice (a poster promoting the smokefree choice, showing a
young mother making her smokefree choice for her baby)
1119
Break Free (a magazine-style resource for teenagers about quitting smoking)
8035
E Te Whānau Awhi Mai/My Baby Will Be Māori and Smokefree (a fold-out
stand-up card that warns of the effects of smoking on unborn infant)
9007
Avoiding Listeria (listeria information for vulnerable people, including
pregnant women)
1420
Your Pregnancy/Tō Haputanga (a guide to being pregnant, giving birth, the
first few weeks, and the roles and responsibilities of Lead Maternity Carers
(LMCs))
6002
Eating for Healthy Pregnant Women/Nga Kai Totika ma te Wahine Hapu
6003
Eating for Healthy Breastfeeding Women/Nga Kai Totika ma te Ukaipo
1230
Eating for Healthy Teenagers: A Teenager’s Guide to Healthy Eating
9024
Food for Health/Kai Pai mo te Hauora (A2 poster)
9028
Food for Health (English)
9029
Food for Health/Kai Pai mō te Hauora (Māori)
9030
Food for Health (Sāmoan)
9031
Food for Health (Tongan)
9032
Food for Health (Niuean)
9033
Food for Health (Fijian)
9034
Food for Health (Cook Islands Māori)
9035
Food for Health (Tokelauan)
1332
Servings per Day: How Much Do We Need? (A2 poster showing serving
sizes from the four main food groups)
1333
Everyday Eating for Health (basic nutrition messages for low-literacy adults)
1440
Oranga Kai – Healthy Eating for Adult Māori (basic nutrition advice for adult
Māori)
1518
Eating for Healthy Adult New Zealanders/Te Kai Totika mo te Hunga Pakeke
o Aotearoa
1519
Eating for Healthy Vegetarians/Te Kai Totika mo te Hunga Pukuwhenua
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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141
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breastfeeding. Acta Paediatrica 88: 1320–6.
Vogel AM, Hutchison BL, Mitchell EA. 2001. The impact of pacifier use on breastfeeding: a
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Submission Booklet
Submissions close at 5 pm on Tuesday 4 September 2007.
You do not have to answer all the questions or provide personal information if you do
not want to.
When commenting on the document, where appropriate, support your comments with
evidence.
This submission was completed by:
Address:
(name)
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(town/city)
Email:
Organisation:
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Position:
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Are you submitting this as:
(Tick one box only in this section)
an individual (not on behalf of an organisation)
on behalf of a group or organisation
other (please specify) ........................................................................................................
Please indicate which sector(s) your submission represents
(You may tick as many boxes as apply)
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Māori
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Education/training
Non-government agency
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Health sector (public)
Industry
Other (please specify) .......................................................................................................
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Please return only one copy of your submission no later than 5 pm on
Tuesday 4 September by post to:
Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
A background paper
Submissions
Ministry of Health
PO Box 5013
WELLINGTON
Email: [email protected]
All submissions will be acknowledged by the Ministry of Health, and a summary of
submissions will be sent to all those who request a copy. The summary will include the
names of all those who made a submission. In the case of those who withhold
permission to release personal details, the name of the organisation will be given if
supplied.
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Your submission may be requested under the Official Information Act 1982. If this
happens, the Ministry of Health will release your submission to the person who
requested it. However, if you are an individual as opposed to an organisation, the
Ministry will remove your personal details from the submission if you check the following
box.
I do not give permission for my personal details to be released to persons
under the Official Information Act 1982.
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Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2):
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Submission Questions
There are nine questions in total.
Question 1
In this background paper, we have included chapters on topics such as breastfeeding,
formula feeding, fluids, complementary feeding, physical activity, allergies, etc (see
Table of Contents).
Do you agree with the inclusion of all of these chapters in the background paper?
Yes, all of them
No
What do you want removed? Please justify/include evidence/suggest an alternative.
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Question 2
Are there any issues relevant to the nutritional status of healthy infants and toddlers that
have been omitted from this background paper that you would have included?
Yes, there are omissions
No, there are no omissions
Please list omissions and justify/include evidence for inclusion of new chapters.
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Question 3
This background paper proposes changes to existing policy. These include the policy on:
•
the duration for exclusive breastfeeding and the age for introduction of
complementary foods
•
the use of the new WHO growth charts.
Do the sections and advice on these policy areas in this background paper raise any
issues or concerns?
Yes
No
Please justify/include evidence/suggest an alternative.
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Question 4
This background paper revises the existing policy on the preparation of formula
(page 26). The revision is based on guidelines from WHO/FAO to reduce the risk of
infection with E. sakazakii and Salmonella.
Does the policy revision in this background paper raise any issues or concerns?
Yes
No
Please justify/include evidence/suggest an alternative.
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Question 5
Several sections in the background paper have been significantly revised. These
include the sections on:
• the importance of breastfeeding
• fluids
• complementary feeding
• pacifiers
• allergy.
Do these sections and advice in this background paper raise any issues or concerns?
Yes
No
Please justify/include evidence/suggest an alternative.
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Question 6
Some new sections in the background paper have been added. These include sections
on:
• dietary practices and nutrient intakes
• risks of late introduction of complementary foods
• considerations for Māori infants and toddlers
• considerations for Pacific and other population groups, infant and toddlers
• prebiotics
• probiotics
• overweight and obesity
• food security.
Do these sections and advice in this background paper raise any issues or concerns?
Yes
No
Please justify/include evidence/suggest an alternative.
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Question 7
In this background paper, we have included practical advice at the end of most sections.
Do you find the practical advice generally useful?
Yes, the practical advice is generally useful
No, the practical advice is not generally useful
Please suggest any improvements that could be made to the practical advice.
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Question 8
The target audience for the background paper is health practitioners, including
dietitians, doctors, nurses, well child providers, primary health care providers, health
promoters, nutritionists and teachers in the practice of healthy nutrition.
Is this background paper at an appropriate technical level for the target audience?
Yes
No
Please explain what needs to be changed.
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Question 9
Do you have any other issues or comments?
Yes
No
Please comment.
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Thank you.
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