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Transcript
Infant Feeding Guideline
0-2 Years
for health professionals
6th Edition, 2013
Introduction
Introduction
The 6th edition of the Infant Feeding Guideline provides
clear, current, evidence based guidelines for healthcare
professionals involved in advising parents and carers of
0-2 year olds regarding infant feeding. We hope you find
this guideline a valuable resource.
The 6th edition of the Infant Feeding Guideline provides
clear, current, evidence based guidelines for healthcare
professionals involved in advising parents and carers of
0-2 year olds regarding infant feeding. We hope you find
this guideline a valuable resource.
We would like to extend our thanks to all health professionals who have contributed to the revised guideline, to
Clare Thornton–Wood for proof reading this document & to
Simon Udal (Simon Udal Designs) for allowing us to use
his original artwork on the front cover.
We would like to extend our thanks to all health professionals who have contributed to the revised guideline, to
Clare Thornton–Wood for proof reading this document & to
Simon Udal (Simon Udal Designs) for allowing us to use
his original artwork on the front cover.
Infant Feeding Guideline Working Party
Infant Feeding Guideline Working Party
Penny Barnard, Team Leader & Specialist Dietitian,
Paediatrics, Western Sussex Hospitals NHS Trust
Penny Barnard, Team Leader & Specialist Dietitian,
Paediatrics, Western Sussex Hospitals NHS Trust
Helen Gane, Specialist Dietitian, Paediatrics, Western
Sussex Hospitals NHS Trust
Helen Gane, Specialist Dietitian, Paediatrics, Western
Sussex Hospitals NHS Trust
1
1
List of Contributing Authors
List of Contributing Authors
Lynette Anear
Oral Health Promoter***
Lynette Anear
Oral Health Promoter***
Penny Barnard
Specialist Dietitian, Paediatrics*
Penny Barnard
Specialist Dietitian, Paediatrics*
Dr Nick Brennan
Consultant Paediatrician*
Dr Nick Brennan
Consultant Paediatrician*
Prof David Candy
Consultant Paediatrician*
Prof David Candy
Consultant Paediatrician*
Lisa Cosgrove
Infant Feeding Advisor*
Lisa Cosgrove
Infant Feeding Advisor*
Odette Dicke
Specialist Dietitian, Paediatrics**
Odette Dicke
Specialist Dietitian, Paediatrics**
Wendy Frost
Specialist Dietitian, Paediatrics**
Wendy Frost
Specialist Dietitian, Paediatrics**
Helen Gane
Specialist Dietitian, Paediatrics*
Helen Gane
Specialist Dietitian, Paediatrics*
Cheryl Geary
Specialist Dietitian, Paediatrics*
Cheryl Geary
Specialist Dietitian, Paediatrics*
Allyson Lucking
Lead Paediatric Speech &
Language Therapist*** (West)
Allyson Lucking
Lead Paediatric Speech &
Language Therapist*** (West)
Abi Mee
Paediatric Pharmacist*
Abi Mee
Paediatric Pharmacist*
Lucy Pope
Specialist Dietitian, Paediatrics*
Lucy Pope
Specialist Dietitian, Paediatrics*
Jackie Smith
Health Improvement Project Manager,
Children's Services***
Jackie Smith
Health Improvement Project Manager,
Children's Services***
Rosy Turner
Children’s Community Nurse,
The Sussex Snowdrop Trust***
Rosy Turner
Children’s Community Nurse,
The Sussex Snowdrop Trust***
*Western Sussex Hospitals NHS Trust, St Richard’s Hospital
*Western Sussex Hospitals NHS Trust, St Richard’s Hospital
**Western Sussex Hospitals NHS Trust, Worthing Hospital
***Sussex Community NHS Trust
***Sussex Community NHS Trust
2
**Western Sussex Hospitals NHS Trust, Worthing Hospital
2
Disclaimer
Disclaimer
The information given in this document is accurate at the
time of going to press. The mentioning of a particular
product, support group or website does not constitute an
endorsement by the Western Sussex Hospitals NHS Trust
or Sussex Community NHS Trust.
The information given in this document is accurate at the
time of going to press. The mentioning of a particular
product, support group or website does not constitute an
endorsement by the Western Sussex Hospitals NHS Trust
or Sussex Community NHS Trust.
The 6th Edition is now the recognised guideline, all prior
editions should be destroyed. These guidelines will be reviewed in Jan 2015.
The 6th Edition is now the recognised guideline, all prior
editions should be destroyed. These guidelines will be reviewed in Jan 2015.
Copyright
Copyright
No part of this publication may be reproduced, stored in a
retrieval system or transmitted in any form or by any
means electronic, mechanical, photocopying, recording or
otherwise, except as permitted by the UK Copyright legislation, without prior permission of the authors.
No part of this publication may be reproduced, stored in a
retrieval system or transmitted in any form or by any
means electronic, mechanical, photocopying, recording or
otherwise, except as permitted by the UK Copyright legislation, without prior permission of the authors.
3
3
4
4
Chapter No.
Page
No.
Chapter No.
Page
No.
1.
Breastfeeding
6
1.
Breastfeeding
6
2.
Bottle Feeding
14
2.
Bottle Feeding
14
3.
Weaning
18
3.
Weaning
18
4.
29
4.
34
5.
Other Infant Formula, Milks and
Drinks
Healthy Start
29
5.
Other Infant Formula, Milks and
Drinks
Healthy Start
6.
Growth
35
6.
Growth
35
7.
Oral Health
41
7.
Oral Health
41
8.
Vegetarian/Vegan Diets
44
8.
Vegetarian/Vegan Diets
44
9.
Food Hypersensitivity
53
9.
Food Hypersensitivity
53
10.
Fussy/Selective Eaters
60
10.
Fussy/Selective Eaters
60
11.
Iron Deficiency
62
11.
Iron Deficiency
62
12.
Common Gut Problems
65
12.
Common Gut Problems
65
(I)
Infantile Colic
65
(I)
Infantile Colic
65
(ii)
Vomiting & Regurgitation
67
(ii)
Vomiting & Regurgitation
67
(iii)
Diarrhoea
68
(iii)
Diarrhoea
68
(iv)
Constipation
71
(iv)
Constipation
71
(v)
Coeliac Disease
73
(v)
Coeliac Disease
73
13.
Paediatric Dysphagia
74
13.
Paediatric Dysphagia
74
14.
Premature Infants
78
14.
Premature Infants
78
15.
Home Enteral Feeding
84
15.
Home Enteral Feeding
84
Appendix 1
Useful Contacts
90
Appendix 1
Useful Contacts
90
Appendix 2
References
92
Appendix 2
References
92
5
5
34
1. Breastfeeding
1. Breastfeeding
All mothers should have the opportunity to make an informed
decision about their choice of feeding method. They should be
encouraged to have skin to skin contact with their baby and to
offer a first breastfeed. They should be provided with suitable
accommodation, with privacy and support, when establishing
breastfeeding. Prolonged postnatal support and consistent
advice is essential, and is proven to increase the incidence
and duration of breastfeeding (De Chareau P & Wyberg B
1977).
All mothers should have the opportunity to make an informed
decision about their choice of feeding method. They should be
encouraged to have skin to skin contact with their baby and to
offer a first breastfeed. They should be provided with suitable
accommodation, with privacy and support, when establishing
breastfeeding. Prolonged postnatal support and consistent
advice is essential, and is proven to increase the incidence
and duration of breastfeeding (De Chareau P & Wyberg B
1977).
The WHO/UNICEF Baby Friendly Initiative, Ten Steps to
Successful Breast-feeding, shown below, illustrates best
practice. The National Institute for Health and Clinical
Excellence (NICE) has published Clinical Guideline 37, 2006,
“Routine postnatal care of women and their babies” (DoH
2006b). It is proposed as the minimum standard for all
maternity units.
The WHO/UNICEF Baby Friendly Initiative, Ten Steps to
Successful Breast-feeding, shown below, illustrates best
practice. The National Institute for Health and Clinical
Excellence (NICE) has published Clinical Guideline 37, 2006,
“Routine postnatal care of women and their babies” (DoH
2006b). It is proposed as the minimum standard for all
maternity units.
Ten Steps to Successful Breastfeeding
Ten Steps to Successful Breastfeeding
Every facility providing maternity services and care for
newborn infants should:
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.
1.
Have a written breastfeeding policy that is routinely
communicated to all health care staff.
2.
Train all health care staff in skills necessary to implement
this policy.
2.
Train all health care staff in skills necessary to implement
this policy.
3.
Inform all pregnant women about the benefits and
management of breastfeeding.
3.
Inform all pregnant women about the benefits and
management of breastfeeding.
4.
Help mothers initiate breastfeeding soon after birth.
4.
Help mothers initiate breastfeeding soon after birth.
6
6
5.
Show mothers how to breastfeed and how to
maintain lactation even if they are separated from
their infants.
5.
Show mothers how to breastfeed and how to
maintain lactation even if they are separated from
their infants.
6.
Give newborn infants no food or drink other than
breast milk, unless medically indicated.
6.
Give newborn infants no food or drink other than
breast milk, unless medically indicated.
7.
Practise “rooming-in” - allow mothers and infants to
remain together 24 hours a day.
7.
Practise “rooming-in” - allow mothers and infants to
remain together 24 hours a day.
8.
Encourage breastfeeding on demand.
8.
Encourage breastfeeding on demand.
9.
Give no artificial teats or dummies (also called
pacifiers or soothers) to breastfeeding infants.
9.
Give no artificial teats or dummies (also called
pacifiers or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support
groups and refer others to them on discharge from
the hospital or clinic.
10. Foster the establishment of breastfeeding support
groups and refer others to them on discharge from
the hospital or clinic.
All babies should be encouraged to be in skin contact with
their mother immediately after birth. All babies will be
encouraged to feed within their first hour of birth and again
at about 6 hours of age. Baby should be offered the breast
when hungry, regardless of the interval of time since the
last feed. Timing the length of each feed should be
avoided. Feeding time will depend on the baby's appetite
and the rate of milk transfer. Mothers should look for signs
of good quality feeding, i.e. correct attachment, good
sucking rhythm and sounds of swallowing. It does not
matter whether the baby wants one breast or both at any
individual feed, provided that he/she is allowed to finish the
feed on the first breast spontaneously before being offered
the other.
All babies should be encouraged to be in skin contact with
their mother immediately after birth. All babies will be
encouraged to feed within their first hour of birth and again
at about 6 hours of age. Baby should be offered the breast
when hungry, regardless of the interval of time since the
last feed. Timing the length of each feed should be
avoided. Feeding time will depend on the baby's appetite
and the rate of milk transfer. Mothers should look for signs
of good quality feeding, i.e. correct attachment, good
sucking rhythm and sounds of swallowing. It does not
matter whether the baby wants one breast or both at any
individual feed, provided that he/she is allowed to finish the
feed on the first breast spontaneously before being offered
the other.
7
7
If the mother feels that she has insufficient milk;

Check that the baby is well attached

Offer each breast twice or more at each feed

Express milk between feeds and offer this back to baby in
a cup or syringe.

Increase the number of feeds over the 24 hour period

Get help & support from their midwife, health visitor or
local support group.
If the mother feels that she has insufficient milk;

Check that the baby is well attached

Offer each breast twice or more at each feed

Express milk between feeds and offer this back to baby in
a cup or syringe.

Increase the number of feeds over the 24 hour period

Get help & support from their midwife, health visitor or
local support group.
Breastfeeding Checklist
Breastfeeding Checklist
If a mother is experiencing any of the following she needs to
seek immediate support from her midwife, health visitor or
breastfeeding adviser.
If a mother is experiencing any of the following she needs to
seek immediate support from her midwife, health visitor or
breastfeeding adviser.
Pain
- Except possibly fleeting at the start of feed
Pain
- Except possibly fleeting at the start of feed
Breasts
- Very full or engorged
Breasts
- Very full or engorged
Nipples
- Damaged, bleeding or pinched
Nipples
- Damaged, bleeding or pinched
Baby
- Not coming off spontaneously
Baby
- Not coming off spontaneously
- Restless or fussy at the breast
- Restless or fussy at the breast
- Not satisfied after feeds
- Not satisfied after feeds
- Taking a long time to feed i.e. regularly more
than 40 minutes
- Taking a long time to feed i.e. regularly more
than 40 minutes
- Feeding frequently i.e. more than 10 feeds in
24 hours
- Feeding frequently i.e. more than 10 feeds in
24 hours
- Feeding infrequently i.e. less than 6 feeds in
24 hours
- Feeding infrequently i.e. less than 6 feeds in
24 hours
- Still passing black stools after 3 days
- Still passing black stools after 3 days
For the first six months breast milk is all that a baby requires
nutritionally to achieve optimum growth, development & health
8
For the first six months breast milk is all that a baby requires
nutritionally to achieve optimum growth, development & health
8
(WHO 2003). WHO recommend that breastfeeding continues
well past the second year. If this is not possible shorter
periods of breastfeeding are still known to be beneficial.
Breastfed babies rarely require extra drinks. Topping up or
complementary feeds should NOT be routinely
recommended, as this hinders the establishment of lactation.
However, if maternal or baby’s health is compromised,
further professional advice may be necessary. Where there
is a family history of atopy or gluten enteropathy, mothers
should be encouraged to breastfeed for six months or longer
(See Chapter 9 Food Hypersensitivity). As with all milks,
good dental hygiene should be practiced (although
prolonged breastfeeding does not obviate the need for dental
hygiene).
(WHO 2003). WHO recommend that breastfeeding continues
well past the second year. If this is not possible shorter
periods of breastfeeding are still known to be beneficial.
Breastfed babies rarely require extra drinks. Topping up or
complementary feeds should NOT be routinely
recommended, as this hinders the establishment of lactation.
However, if maternal or baby’s health is compromised,
further professional advice may be necessary. Where there
is a family history of atopy or gluten enteropathy, mothers
should be encouraged to breastfeed for six months or longer
(See Chapter 9 Food Hypersensitivity). As with all milks,
good dental hygiene should be practiced (although
prolonged breastfeeding does not obviate the need for dental
hygiene).
Maternal Nutrition
Maternal Nutrition
During lactation, the mother requires some additional
calories, protein, vitamins, minerals and fluids. Increased
amounts of a normal balanced diet should satisfy most of
their nutritional requirements. Breast feeding mothers should
take a Vitamin D supplement 10µg/day (DoH 2008). Very
few foods "upset" individual babies. If this is suspected the
mother should avoid the "culprit" foods for a few weeks.
Strict weight reducing diets should be discouraged.
During lactation, the mother requires some additional
calories, protein, vitamins, minerals and fluids. Increased
amounts of a normal balanced diet should satisfy most of
their nutritional requirements. Breast feeding mothers should
take a Vitamin D supplement 10µg/day (DoH 2008). Very
few foods "upset" individual babies. If this is suspected the
mother should avoid the "culprit" foods for a few weeks.
Strict weight reducing diets should be discouraged.
There is no evidence to suggest that micro organisms such
as listeria are transmitted through breast milk. Therefore,
high-risk foods such as pâté and soft cheese are not contraindicated for the breastfeeding mother.
There is no evidence to suggest that micro organisms such
as listeria are transmitted through breast milk. Therefore,
high-risk foods such as pâté and soft cheese are not contraindicated for the breastfeeding mother.
Adequate fluid intake is essential to establish and maintain
lactation. Fluid intake should be increased according to
thirst, but a minimum of 8-10 cups/day is advised. Alcohol
should be kept to a minimum as it passes into breast milk.
Adequate fluid intake is essential to establish and maintain
lactation. Fluid intake should be increased according to
thirst, but a minimum of 8-10 cups/day is advised. Alcohol
should be kept to a minimum as it passes into breast milk.
9
9
Vitamin Supplementation
Vitamin Supplementation
Breastfed infants under six months do not need vitamin
supplementation provided the mother has an adequate
vitamin status during pregnancy. If breastfeeding
continues after 6 months of age as a main drink a
vitamin supplement containing vitamins A, C & D is
required (DoH 1994), see page 28. Infants born preterm
may need vitamin supplements, see chapter 14.
Breastfed infants under six months do not need vitamin
supplementation provided the mother has an adequate
vitamin status during pregnancy. If breastfeeding
continues after 6 months of age as a main drink a
vitamin supplement containing vitamins A, C & D is
required (DoH 1994), see page 28. Infants born preterm
may need vitamin supplements, see chapter 14.
Storing Breast Milk
Storing Breast Milk
PLACE
TIME
PLACE
TIME
Fridge 0-4oC
Up to 5 days
Fridge 0-4oC
Up to 5 days
Freezer compartment of
fridge
Up to 2 weeks
Freezer compartment of
fridge
Up to 2 weeks
Freezer at –18oC
Up to 6 months
Freezer at –18oC
Up to 6 months
Frozen milk should be defrosted in the fridge and not
refrozen once thawed (NICE 2008).
Frozen milk should be defrosted in the fridge and not
refrozen once thawed (NICE 2008).
Special Considerations
Special Considerations

The Department of Health policy (2001) is to advise
HIV infected women not to breastfeed so as to
reduce transmission of HIV to their children.

The Department of Health policy (2001) is to advise
HIV infected women not to breastfeed so as to
reduce transmission of HIV to their children.

Mothers with type 1 diabetes mellitus and type 2
who are treated on insulin should be encouraged to
breastfeed for as long as possible. Insulin will need
to be reduced by at least 10% after the birth.
Women with type 2 diabetes treated with insulin or
Metformin should remain on these while breast
feeding. Regular meals should be encouraged and
extra carbohydrate may be required to minimise
risk of hypoglycaemia.

Mothers with type 1 diabetes mellitus and type 2
who are treated on insulin should be encouraged to
breastfeed for as long as possible. Insulin will need
to be reduced by at least 10% after the birth.
Women with type 2 diabetes treated with insulin or
Metformin should remain on these while breast
feeding. Regular meals should be encouraged and
extra carbohydrate may be required to minimise
risk of hypoglycaemia.
10
10
Snacks before feeding, particularly before the night-time
feed may be required, however some mothers may prefer
to adjust insulin levels instead. Careful monitoring of
blood glucose levels will help to determine individual
requirements for insulin and carbohydrate. Treatment
options when breast feeding should ideally be discussed
before the birth of the baby and a review by the diabetes
team encouraged following the birth. Hand expressing
colostrum from 36 weeks gestation is encouraged.
Snacks before feeding, particularly before the night-time
feed may be required, however some mothers may prefer
to adjust insulin levels instead. Careful monitoring of
blood glucose levels will help to determine individual
requirements for insulin and carbohydrate. Treatment
options when breast feeding should ideally be discussed
before the birth of the baby and a review by the diabetes
team encouraged following the birth. Hand expressing
colostrum from 36 weeks gestation is encouraged.
Drugs and Breastfeeding
Drugs and Breastfeeding
Almost all drugs are excreted in breast milk but the
amount may be too small to be harmful to the baby.
Newborn babies and particularly those born prematurely
have immature renal and hepatic function and are
therefore more vulnerable to drug accumulation. Babies
with G6PD deficiency are at risk of haemolytic anaemia
with certain drugs (e.g. dapsone, nalidixic acid and
sulphonamides).
Almost all drugs are excreted in breast milk but the
amount may be too small to be harmful to the baby.
Newborn babies and particularly those born prematurely
have immature renal and hepatic function and are
therefore more vulnerable to drug accumulation. Babies
with G6PD deficiency are at risk of haemolytic anaemia
with certain drugs (e.g. dapsone, nalidixic acid and
sulphonamides).
Most adverse effects are predictable on the basis of
known therapeutic effects of a drug, but idiosyncratic or
allergic reactions can occur very occasionally. Maternal
use of a drug to which an infant is known to be allergic
should be avoided.
Most adverse effects are predictable on the basis of
known therapeutic effects of a drug, but idiosyncratic or
allergic reactions can occur very occasionally. Maternal
use of a drug to which an infant is known to be allergic
should be avoided.
Where a drug is to be used in breastfeeding always
check drug safety in the current British National
Formulary. This will give a quick reference as to whether
the medication is known to be safe. If information is
lacking or there are any concerns, further advice must be
sort. For GP’s please ring the PCT prescribing support
team on 01903 708400 or for midwives and other
hospital staff at St Richard’s Hospital and Worthing
Hospital call 01903 205111 Ext 5471.
Where a drug is to be used in breastfeeding always
check drug safety in the current British National
Formulary. This will give a quick reference as to whether
the medication is known to be safe. If information is
lacking or there are any concerns, further advice must be
sort. For GP’s please ring the PCT prescribing support
team on 01903 708400 or for midwives and other
hospital staff at St Richard’s Hospital and Worthing
Hospital call 01903 205111 Ext 5471.
11
11
Some Drugs to be avoided
Some Drugs to be avoided
This list of drugs to be avoided is by no means
complete. If in any doubt about safety in breast feeding,
consult with other information sources, the prescribing
doctor or pharmacist.
This list of drugs to be avoided is by no means
complete. If in any doubt about safety in breast feeding,
consult with other information sources, the prescribing
doctor or pharmacist.
Drugs to be avoided because of high intrinsic toxicity or
because serious side effects have been documented:
Drugs to be avoided because of high intrinsic toxicity or
because serious side effects have been documented:
-
Amiodarone
Antineoplastic agents
Chloramphenicol
Dapsone
Doxepin
Ergotamine
Gold salts
Iodides (including some cough remedies)
Indomethacin
Lithium
Penicillamine
Oestrogens (high dose)
Radioisotopes
Retinoids
Phenindione
Pseudoephedrine (preliminary data suggests
significant loss in milk production)
Vitamin A and D (high dose)
Tetracyclines
12
-
Amiodarone
Antineoplastic agents
Chloramphenicol
Dapsone
Doxepin
Ergotamine
Gold salts
Iodides (including some cough remedies)
Indomethacin
Lithium
Penicillamine
Oestrogens (high dose)
Radioisotopes
Retinoids
Phenindione
Pseudoephedrine (preliminary data suggests
significant loss in milk production)
Vitamin A and D (high dose)
Tetracyclines
12
Principles of Drug Treatment
Principles of Drug Treatment
There are a number of principles that should be considered in
any situation in which drug therapy is required for the nursing
mother:
There are a number of principles that should be considered in
any situation in which drug therapy is required for the nursing
mother:
-
-
Drug therapy must be necessary.
Suitable alternative drugs should be considered.
The baby's exposure should be minimised.
The state of the baby's health should be carefully
monitored.
Drug therapy must be necessary.
Suitable alternative drugs should be considered.
The baby's exposure should be minimised.
The state of the baby's health should be carefully
monitored.
Guidelines exist for the use of drugs in breast-feeding mothers:
Guidelines exist for the use of drugs in breast-feeding mothers:
a) Unnecessary use of drugs in a breast-feeding mother
should be avoided.
a) Unnecessary use of drugs in a breast-feeding mother
should be avoided.
b) Drugs known to cause serious toxicity in adults should be
avoided. (If there is no alternative discontinue breast
feeding).
b) Drugs known to cause serious toxicity in adults should be
avoided. (If there is no alternative discontinue breast
feeding).
c) For potentially hazardous drugs used in single doses/short
courses, maintain milk production by manual
expression/use of a pump. Discard all expressed milk.
c) For potentially hazardous drugs used in single doses/short
courses, maintain milk production by manual
expression/use of a pump. Discard all expressed milk.
d) Use dosing regimes that present the minimum amount of
drug to the infant:
d) Use dosing regimes that present the minimum amount of
drug to the infant:
- avoid breast feeding at times when drug levels are
highest (usually 1-2 hours after oral administration).
- use drugs with short elimination half-lives.
- use the most appropriate route of administration
(inhalers for bronchodilators and steroids in asthma).
- avoid long-acting preparations which make it difficult to
time feeds to avoid high drug levels.
e)
Infants under 1 year are at most risk of drug effects since
they have a reduced capacity for metabolism/excretion.
13
- avoid breast feeding at times when drug levels are
highest (usually 1-2 hours after oral administration).
- use drugs with short elimination half-lives.
- use the most appropriate route of administration
(inhalers for bronchodilators and steroids in asthma).
- avoid long-acting preparations which make it difficult to
time feeds to avoid high drug levels.
e)
Infants under 1 year are at most risk of drug effects since
they have a reduced capacity for metabolism/excretion.
13
2. Bottle Feeding
2. Bottle Feeding
There are strong advantages to breast-feeding. If this is not
possible, infant formula is the only suitable alternative to
breast milk. The composition of standard infant formulas must
comply with strict criteria set by European Union regulations.
The current Infant Formula & Follow-on Formula (England)
Regulations 2007 can be accessed on the IDFA website:
www.idfa.org.uk.
There are strong advantages to breast-feeding. If this is not
possible, infant formula is the only suitable alternative to
breast milk. The composition of standard infant formulas must
comply with strict criteria set by European Union regulations.
The current Infant Formula & Follow-on Formula (England)
Regulations 2007 can be accessed on the IDFA website:
www.idfa.org.uk.
All parents, after the birth of their infant, should be shown how
to make up an infant formula feed following the
manufacturer's instructions, whether intending to breastfeed
or not. There may be an emergency situation when a breast
feeding mother needs to formula feed her baby. A specific
brand is not recommended but whey based milk should be
the first choice. Mothers should be encouraged not to change
brands or types of infant formula.
All parents, after the birth of their infant, should be shown how
to make up an infant formula feed following the
manufacturer's instructions, whether intending to breastfeed
or not. There may be an emergency situation when a breast
feeding mother needs to formula feed her baby. A specific
brand is not recommended but whey based milk should be
the first choice. Mothers should be encouraged not to change
brands or types of infant formula.
Whey Dominant
Whey:Casein ratio 60:40
Casein Dominant
Whey:Casein Ratio 20:80
Whey Dominant
Whey:Casein ratio 60:40
Casein Dominant
Whey:Casein Ratio 20:80
Aptamil First milk (Milupa)
Aptamil Hungry milk
(Milupa)
Aptamil First milk (Milupa)
Aptamil Hungry milk
(Milupa)
First infant milk from
newborn (Cow & Gate)
Infant Milk for Hungrier
Babies (Cow & Gate)
First infant milk from
newborn (Cow & Gate)
Infant Milk for Hungrier
Babies (Cow & Gate)
Hipp Organic Infant Milk
(Hipp)
Hipp Organic Hungry Infant
Milk
Hipp Organic Infant Milk
(Hipp)
Hipp Organic Hungry Infant
Milk
SMA First Infant Milk
(SMA Nutrition)
SMA Extra Hungry Infant
Milk
(SMA Nutrition)
SMA First Infant Milk
(SMA Nutrition)
SMA Extra Hungry Infant
Milk
(SMA Nutrition)
14
14
The standard formulas are made from skimmed milk
powder with added fats & nutrients. Whey based milks
more closely mimic human milk with their whey:casein
ratio. Casein dominant formulas are often labelled as
stage 2 or second milks, but there is no need for babies
to move from a whey dominant to a casein dominant
formula (Taitz & Scholey, 1989). Whey based formulas
are suitable as a main drink up to & beyond 12 months.
The standard formulas are made from skimmed milk
powder with added fats & nutrients. Whey based milks
more closely mimic human milk with their whey:casein
ratio. Casein dominant formulas are often labelled as
stage 2 or second milks, but there is no need for babies
to move from a whey dominant to a casein dominant
formula (Taitz & Scholey, 1989). Whey based formulas
are suitable as a main drink up to & beyond 12 months.
Additions to Formulae Milk
Additions to Formulae Milk
Standard formula can differ in which novel ingredients
have been added. They can contribute to the normal
growth, development & modify immunity of the infant.
Current research (Fleith & Clandinin, 2005, Koletzko et al
2008) supports the addition of long chain polyunsaturated
fatty acids (LCPs) and these formulae should be
encouraged if bottle feeding. Almost all current formulae
contain nucleotides which has shown a significant impact
on weight gain, decreased risk of diarrhoea and
improvements in some aspects of the immune system
(Gil, 2002). Non digestible food ingredients known as
prebiotics have been shown to be effective in improving
gut flora, with associated health benefits (Boehm et al,
2004). Organic formulae often do not contain LCPs,
nucleotides & prebiotics. For details of pre thickened
formulae see chapter 12, Common Gut Problems page
65.
Standard formula can differ in which novel ingredients
have been added. They can contribute to the normal
growth, development & modify immunity of the infant.
Current research (Fleith & Clandinin, 2005, Koletzko et al
2008) supports the addition of long chain polyunsaturated
fatty acids (LCPs) and these formulae should be
encouraged if bottle feeding. Almost all current formulae
contain nucleotides which has shown a significant impact
on weight gain, decreased risk of diarrhoea and
improvements in some aspects of the immune system
(Gil, 2002). Non digestible food ingredients known as
prebiotics have been shown to be effective in improving
gut flora, with associated health benefits (Boehm et al,
2004). Organic formulae often do not contain LCPs,
nucleotides & prebiotics. For details of pre thickened
formulae see chapter 12, Common Gut Problems page
65.
15
15
Making up Feeds
Making up Feeds
Babies should be offered feeds on demand, correctly
diluted following manufacturer's instructions. The usual
requirements are
Babies should be offered feeds on demand, correctly
diluted following manufacturer's instructions. The usual
requirements are
150ml formula/kg body weight/per day divided
between 4-8 feeds daily.
150ml formula/kg body weight/per day divided
between 4-8 feeds daily.

All UK milks should be made up with one scoop of
milk powder to 30ml of water (water added first).

All UK milks should be made up with one scoop of
milk powder to 30ml of water (water added first).

All feeds should be made up fresh for each feed.

All feeds should be made up fresh for each feed.

Boiled, fresh tap water should be used. Boiled
water should be cooled to no less than 70°C (DOH
& FSA 2006).

Boiled, fresh tap water should be used. Boiled
water should be cooled to no less than 70°C (DOH
& FSA 2006).

Any milk left at the end of a feed should be
discarded.

Any milk left at the end of a feed should be
discarded.

Water that has been artificially softened by a
chemical softener is not recommended for infant
feeding due to its high mineral content. Water
should be taken from the tap that has been left
‘untreated’ (see Chapter 4 Other Infant Formula,
Milks and Drinks).

Water that has been artificially softened by a
chemical softener is not recommended for infant
feeding due to its high mineral content. Water
should be taken from the tap that has been left
‘untreated’ (see Chapter 4 Other Infant Formula,
Milks and Drinks).

Water from water filter jugs should not be used,
because the bacteria and their toxins produced in
the charcoal filter are not necessarily destroyed by
boiling.

Water from water filter jugs should not be used,
because the bacteria and their toxins produced in
the charcoal filter are not necessarily destroyed by
boiling.
16
16

Bottled water should only be used to make up feeds if
reliable tap water is not available. Uncarbonated
bottled water that has a sodium content of less then
200mg per 1000ml such as Evian, Vittel, and
Highland Spring Water should be used. Bottled
water should be treated in the same way as tap water
i.e. boiled before use.

Bottled water should only be used to make up feeds if
reliable tap water is not available. Uncarbonated
bottled water that has a sodium content of less then
200mg per 1000ml such as Evian, Vittel, and
Highland Spring Water should be used. Bottled
water should be treated in the same way as tap water
i.e. boiled before use.

Infant formula should not be warmed in a microwave
oven once it is in the feeding bottle because very hot
fluid at the centre of the bottle may scald the baby.
The milk feed will continue to cook and heat after it is
removed from the microwave.

Infant formula should not be warmed in a microwave
oven once it is in the feeding bottle because very hot
fluid at the centre of the bottle may scald the baby.
The milk feed will continue to cook and heat after it is
removed from the microwave.

No sugar or solids should be added to bottles e.g.
feeds should not be thickened with baby cereals or
rusks etc. This concentrates the feed and can cause
acute thirst in the baby, leading to dehydration.
Adding food to milk in bottles is also known to delay
feeding skills and poses a choking hazard.

No sugar or solids should be added to bottles e.g.
feeds should not be thickened with baby cereals or
rusks etc. This concentrates the feed and can cause
acute thirst in the baby, leading to dehydration.
Adding food to milk in bottles is also known to delay
feeding skills and poses a choking hazard.

Feed thickeners should only be used under medical
supervision and only specialised prescribed
thickening agents such as Carobel, Thick and Easy
or Thixo-D should be used.

Feed thickeners should only be used under medical
supervision and only specialised prescribed
thickening agents such as Carobel, Thick and Easy
or Thixo-D should be used.

All equipment used to feed the infant under 6 months
should be sterilised e.g. breast pump, bottles, teats,
spoons, bowls etc. Salt should not be used to clean
teats. After 6 months it is only necessary to sterilise
bottles and teats.

All equipment used to feed the infant under 6 months
should be sterilised e.g. breast pump, bottles, teats,
spoons, bowls etc. Salt should not be used to clean
teats. After 6 months it is only necessary to sterilise
bottles and teats.
17
17
3. Weaning
3. Weaning
The World Health Organisation (2003) recommends
exclusive breast-feeding for the first 6 months of life. This
advice forms the basis for the current Department of
Health (2004) recommendations which are:
The World Health Organisation (2003) recommends
exclusive breast-feeding for the first 6 months of life. This
advice forms the basis for the current Department of
Health (2004) recommendations which are:

Breast milk is the best form of nutrition for infants.

Breast milk is the best form of nutrition for infants.

Exclusive breast-feeding is recommended for the first
6 months (26 weeks) of an infant’s life.

Exclusive breast-feeding is recommended for the first
6 months (26 weeks) of an infant’s life.

Weaning should preferably be commenced at 6
months (26 weeks), but no earlier than 17 weeks.

Weaning should preferably be commenced at 6
months (26 weeks), but no earlier than 17 weeks.

Breast feeding (and/or breast milk substitutes if used)
should continue beyond the first six months, along
with appropriate types and amounts of solid foods.

Breast feeding (and/or breast milk substitutes if used)
should continue beyond the first six months, along
with appropriate types and amounts of solid foods.
Solids should not be given before 17 weeks because
young babies are at greater risk of developing coeliac
disease & gluten intolerance (Fergusson, 1981). They
should however be taking solids by 6 months because:
 The amounts of energy, protein, iron, zinc, and
vitamins A and D are particularly likely to be
inadequate from milk alone.
Solids should not be given before 17 weeks because
young babies are at greater risk of developing coeliac
disease & gluten intolerance (Fergusson, 1981). They
should however be taking solids by 6 months because:
 The amounts of energy, protein, iron, zinc, and
vitamins A and D are particularly likely to be
inadequate from milk alone.

The infant would need to consume too large a volume
of milk to supply its nutritional needs.

The infant would need to consume too large a volume
of milk to supply its nutritional needs.

The infant needs to be encouraged to develop biting
and chewing behaviour.

The infant needs to be encouraged to develop biting
and chewing behaviour.

Infants in which weaning is delayed beyond 6 months
often find it difficult to accept lumpy foods
(Northstone et al 2001 & Coulthard et al 2009).

Infants in which weaning is delayed beyond 6 months
often find it difficult to accept lumpy foods
(Northstone et al 2001 & Coulthard et al 2009).
18
18
Breast milk or infant formula remains an important source
of nutrition during the first year. Weaning is an educational
process, its aim being to stimulate the infant's appetite and
to encourage the infant to accept a wide variety of foods
by offering different colours, textures and flavours.
Breast milk or infant formula remains an important source
of nutrition during the first year. Weaning is an educational
process, its aim being to stimulate the infant's appetite and
to encourage the infant to accept a wide variety of foods
by offering different colours, textures and flavours.
Parents should be advised that babies go through a learning process from sucking smooth foods, to thicker foods, to
chewing family foods. Infants should be supervised during
all meal times.
Parents should be advised that babies go through a learning process from sucking smooth foods, to thicker foods, to
chewing family foods. Infants should be supervised during
all meal times.
General rules throughout weaning
General rules throughout weaning

Foods should be cooked and served without salt

Foods should be cooked and served without salt

Avoid adding sugar to food where possible

Avoid adding sugar to food where possible

Due to the risk of Salmonella food poisoning all eggs
should be well cooked until the white and yolk are
solid before giving to infants under 1 year. Dishes
which contain raw, uncooked or partially cooked egg
e.g. soft boiled egg, should be avoided until 1 year of
age.

Due to the risk of Salmonella food poisoning all eggs
should be well cooked until the white and yolk are
solid before giving to infants under 1 year. Dishes
which contain raw, uncooked or partially cooked egg
e.g. soft boiled egg, should be avoided until 1 year of
age.

Whole seeds and nuts should not be given before 5
years of age, due to the risk of choking. Nut products
e.g. peanut butter can be given from six months to
non-atopic children.

Whole seeds and nuts should not be given before 5
years of age, due to the risk of choking. Nut products
e.g. peanut butter can be given from six months to
non-atopic children.

Infants with a suspected or proven food allergy or
other allergic disease will need individual assessment
and advice (See Chapter 9 Food Hypersensitivity).

Infants with a suspected or proven food allergy or
other allergic disease will need individual assessment
and advice (See Chapter 9 Food Hypersensitivity).

Babies under 12 months should not consume honey
due to risk of Clostridium botulinum.

Babies under 12 months should not consume honey
due to risk of Clostridium botulinum.
19
19
Milk &
Dairy
Products
Starchy
Foods
Stage 1
Stage 2
Minimum 568 ml
(1 pint) breast or
infant formula
568ml (1 pint) breast
milk, infant formula or
follow on formula, daily
Also use milk to mix into
solids.
Cow’s milk
products can be
used (e.g. yoghurt,
custard, cheese
sauce)
Hard cheese (e.g.
Cheddar) can be cubed
or grated & used as
‘finger food’
Use low fibre,
cereals mixed to a
smooth
consistency with
milk.
2-3 Servings Daily
Wheat & oat based
cereal can be used
once 6 months
Milk &
Dairy
Products
Starchy
Foods
Include wheat and oat
based products.
Foods can be a more
solid ‘lumpier’ texture.
Begin to give ‘finger
foods’ (e.g. toast).
Use pureed,
cooked vegetables
& fruit . Do not add
salt or sugar to
food during or after
cooking.
20
Stage 2
Minimum 568 ml
(1 pint) breast or
infant formula
568ml (1 pint) breast
milk, infant formula or
follow on formula, daily
Also use milk to mix into
solids.
Cow’s milk
products can be
used (e.g. yoghurt,
custard, cheese
sauce)
Hard cheese (e.g.
Cheddar) can be cubed
or grated & used as
‘finger food’
Use low fibre,
cereals mixed to a
smooth
consistency with
milk.
2-3 Servings Daily
Wheat & oat based
cereal can be used
once 6 months
Puree starchy
vegetables
Vegetables
& Fruits
Stage 1
Include wheat and oat
based products.
Foods can be a more
solid ‘lumpier’ texture.
Begin to give ‘finger
foods’ (e.g. toast).
Puree starchy
vegetables
Soft fruit & vegetables
(e.g. banana, melon,
tomato) may be used as
‘finger foods’. Cooked
vegetables & fruit can
be a coarser, mashed
texture.
Vegetables
& Fruits
Use pureed,
cooked vegetables
& fruit . Do not add
salt or sugar to
food during or after
cooking.
20
Soft fruit & vegetables
(e.g. banana, melon,
tomato) may be used as
‘finger foods’. Cooked
vegetables & fruit can
be a coarser, mashed
texture.
Stage 3
Milk &
Dairy
Products
Veg &
Fruits
Stage 3
568ml (1pint) milk a day or 3
servings dairy products
(e.g. yoghurt, cheese).
Whole milk can be used as
the main drink after 1 year.
Lower fat milks can be used
in cooking, but not as main
drink. Semi skimmed from 2
years, skimmed from 5
years.
Milk &
Dairy
Products
3 - 4 Servings
Daily
Minimum of 4 Servings
Daily
Starchy
Foods
Encourage some
wholemeal
products
Starchy foods
can be of normal
adult texture.
At least one serving at each
mealtime.
3 - 4 Servings
Daily
Minimum of 5 Servings
Daily
Use lightlycooked or raw
foods.
Chopped or
‘finger food’
texture is
suitable.
Encourage unsweetened
fruit if vegetables are
rejected.
Food can be adult texture
though some fibrous foods
may be difficult (e.g. celery,
radish).
568ml (1 pint)
breast milk or
Infant formula
milk daily
As per stage 1 &
2
Starchy
Foods
After 1 Year
21
568ml (1 pint)
breast milk or
Infant formula
milk daily
As per stage 1 &
2
Veg &
Fruits
After 1 Year
568ml (1pint) milk a day or 3
servings dairy products
(e.g. yoghurt, cheese).
Whole milk can be used as
the main drink after 1 year.
Lower fat milks can be used
in cooking, but not as main
drink. Semi skimmed from 2
years, skimmed from 5
years.
3 - 4 Servings
Daily
Minimum of 4 Servings
Daily
Encourage some
wholemeal
products
Starchy foods
can be of normal
adult texture.
At least one serving at each
mealtime.
3 - 4 Servings
Daily
Minimum of 5 Servings
Daily
Use lightlycooked or raw
foods.
Chopped or
‘finger food’
texture is
suitable.
Encourage unsweetened
fruit if vegetables are
rejected.
Food can be adult texture
though some fibrous foods
may be difficult (e.g. celery,
radish).
21
Meat and
Meat
Alternatives
Occasional
Foods
Stage 1
Stage 2
Use pureed,
cooked meat,
fish & pulses
1 Serving Daily
Minced or chopped meat,
fish or pulses.
Add no salt or
sugar to food
during or after
cooking.
Avoid whole nuts & seeds
Meat and
Meat
Alternatives
Include only well cooked
egg
Stage 1
Stage 2
Use pureed,
cooked meat,
fish & pulses
1 Serving Daily
Minced or chopped meat,
fish or pulses.
Add no salt or
sugar to food
during or after
cooking.
Avoid whole nuts & seeds
Avoid whole nuts
& seeds
Avoid whole nuts
& seeds
Include only well
cooked egg
Include only well
cooked egg
Choose lowersugar desserts;
Avoid honey
Avoid high salt
foods
22
Encourage savoury foods
rather than sweet ones.
Avoid honey
Occasional
Foods
Choose lowersugar desserts;
Avoid honey
Avoid high salt
foods
22
Include only well cooked
egg
Encourage savoury foods
rather than sweet ones.
Avoid honey
Meat & Meat
Alternatives
Stage 3
After 1 Year
Stage 3
After 1 Year
Minimum 1
Serving Daily
from Animal or
vegetable
Sources
Minimum 2 Serving Daily
from Animal or Vegetable
Sources.
Minimum 1
Serving Daily
from Animal or
vegetable
Sources
Minimum 2 Serving Daily
from Animal or Vegetable
Sources.
Avoid whole nuts
& seeds
Encourage lean meat & oily
fish (sardine, herring, mackerel).
Avoid whole nuts
& seeds
Encourage lean meat & oily
fish (sardine, herring, mackerel).
Allow only well
cooked egg
Liver pate can be used after
1 year.
Allow only well
cooked egg
Liver pate can be used after
1 year.
Meat & Meat
Alternatives
Avoid whole nuts & seeds
Occasional
Foods
Try to limit salty
foods.
Limit crisps & savoury
snacks. Give bread, or fruit
if hungry between meals.
23
Avoid whole nuts & seeds
Occasional
Foods
Try to limit salty
foods.
Limit crisps & savoury
snacks. Give bread, or fruit
if hungry between meals.
23
Stage 1 - starting from 4-6 months
Stage 1 - starting from 4-6 months
In the initial stage of weaning the aim is for a baby to get used
to the sensation of food that is not free flowing. Foods suitable
for weaning in the early stages are of smooth consistency such
as:
In the initial stage of weaning the aim is for a baby to get used
to the sensation of food that is not free flowing. Foods suitable
for weaning in the early stages are of smooth consistency such
as:
baby cereal eg rice, sago, maize or cornmeal.
Pureed, freshly cooked rice blended with added liquid to
achieve the correct consistency.
mashed potato blended to a smooth consistency.
pureed vegetables e.g. carrots, parsnips, swede.
custard.
natural full fat yoghurt (unsweetened) and fromage frais.
Stewed pureed fruit e.g. pear and apple.
pureed meat, fish & poultry.
pureed lentils, pulses, beans.
 eggs with whites & yolks fully cooked.
baby cereal eg rice, sago, maize or cornmeal.
Pureed, freshly cooked rice blended with added liquid to
achieve the correct consistency.
mashed potato blended to a smooth consistency.
pureed vegetables e.g. carrots, parsnips, swede.
custard.
natural full fat yoghurt (unsweetened) and fromage frais.
Stewed pureed fruit e.g. pear and apple.
pureed meat, fish & poultry.
pureed lentils, pulses, beans.
 eggs with whites & yolks fully cooked.
It is no longer recommended that infants be introduced to new
foods one at a time. Breast or formula milk will continue to
provide the majority of the baby’s needs at this stage. They will
still need a regular breast feed on demand or formula milk
equivalent to 568ml or 1 pint per day.
It is no longer recommended that infants be introduced to new
foods one at a time. Breast or formula milk will continue to
provide the majority of the baby’s needs at this stage. They will
still need a regular breast feed on demand or formula milk
equivalent to 568ml or 1 pint per day.
Cow’s milk can be used in the preparation of solid foods, such
as custards and sauces and in the form of yoghurt (ordinary and
baby varieties) and to mix with cereals.
Cow’s milk can be used in the preparation of solid foods, such
as custards and sauces and in the form of yoghurt (ordinary and
baby varieties) and to mix with cereals.
24
24
Stage 2 - 7-9 months
Stage 2 - 7-9 months
The amount and variety of foods including meat, fish,
eggs, all cereals and pulses should be increased and the
number of "milk" feeds reduced. Food consistency should
progress from pureed through to minced/mashed to finely
chopped. Family foods can be mashed or blended to a
texture containing some soft lumps, vegetables need to be
cooked until soft and meat will still need to be coarsely
puréed. Babies should be given soft finger foods to help
chewing, especially during teething if able to sit
independently. Start with bite and dissolve foods and then
progress onto bite and easy chew textures.
The amount and variety of foods including meat, fish,
eggs, all cereals and pulses should be increased and the
number of "milk" feeds reduced. Food consistency should
progress from pureed through to minced/mashed to finely
chopped. Family foods can be mashed or blended to a
texture containing some soft lumps, vegetables need to be
cooked until soft and meat will still need to be coarsely
puréed. Babies should be given soft finger foods to help
chewing, especially during teething if able to sit
independently. Start with bite and dissolve foods and then
progress onto bite and easy chew textures.
Suitable foods are:
Suitable foods are:
Bread, toast, rice cakes, savoury biscuits, soft peeled raw
fruits such as banana and pear, and sticks of vegetables,
such as cooked peeled carrots and cooked green beans.
Bread, toast, rice cakes, savoury biscuits, soft peeled raw
fruits such as banana and pear, and sticks of vegetables,
such as cooked peeled carrots and cooked green beans.
Stage 3 - 10-12 months
Stage 3 - 10-12 months
By the age of one year, the infant's diet should be mixed,
varied and integrated into family meals. They should be
encouraged to take lumpy foods of different textures. In
the later stages of weaning, three meals per day are
suggested, with up to three small snacks in between.
Solids should be offered by spoon only until the infant is
able to self-feed.
By the age of one year, the infant's diet should be mixed,
varied and integrated into family meals. They should be
encouraged to take lumpy foods of different textures. In
the later stages of weaning, three meals per day are
suggested, with up to three small snacks in between.
Solids should be offered by spoon only until the infant is
able to self-feed.
Cooked vegetables need only be chopped and some
salad vegetables can be included. Meat may need to be
minced or finely chopped. Finger foods are a preliminary to
full self-feeding. Examples include small cubes of fruit &
vegetables, potato, toast, pasteurised cheese or soft meat
such as thinly sliced ham/chicken.
Cooked vegetables need only be chopped and some
salad vegetables can be included. Meat may need to be
minced or finely chopped. Finger foods are a preliminary to
full self-feeding. Examples include small cubes of fruit &
vegetables, potato, toast, pasteurised cheese or soft meat
such as thinly sliced ham/chicken.
25
25
Baby Led Weaning
Baby Led Weaning
Baby led weaning is defined as the infant taking control of his or her own solid food intake by self-feeding
from the start of the weaning process. Instead of pureed food, the baby is given a range of finger foods
and eventually will self-feed from a spoon (MacDonald
A, 2003). Different textures of food have been shown
to have an impact on food preferences, which can
support the idea that children may become less picky
eaters (Blossfield et al 2007).
Principles of baby led weaning are:

Infants are offered a variety of finger foods at
meal time from the age of six months, preferably
sitting upright in a high chair.

Initially soft fruits are offered with meals; harder
fruits and vegetables are cooked until soft
enough to chew.

Food is offered in baton shaped pieces or in
natural shapes that have a handle (e.g. broccoli)
and it is not cut into bite sized pieces as these
are difficult for the baby to pick up and handle.

Food is free of added salt and sugar.

Initially food may be picked up and played with
only and this process should not be hurried.

It is accepted that many foods may be first rejected but should be offered again.

Infants decide how much they want to eat and
no spoon-fed, puree food top ups are offered at
the end of a meal.

Water is offered with meals, milk feeding is still
baby led and may be given at a separate time
from meal time.
Baby led weaning is defined as the infant taking control of his or her own solid food intake by self-feeding
from the start of the weaning process. Instead of pureed food, the baby is given a range of finger foods
and eventually will self-feed from a spoon (MacDonald
A, 2003). Different textures of food have been shown
to have an impact on food preferences, which can
support the idea that children may become less picky
eaters (Blossfield et al 2007).
Principles of baby led weaning are:

Infants are offered a variety of finger foods at
meal time from the age of six months, preferably
sitting upright in a high chair.

Initially soft fruits are offered with meals; harder
fruits and vegetables are cooked until soft
enough to chew.

Food is offered in baton shaped pieces or in
natural shapes that have a handle (e.g. broccoli)
and it is not cut into bite sized pieces as these
are difficult for the baby to pick up and handle.

Food is free of added salt and sugar.

Initially food may be picked up and played with
only and this process should not be hurried.

It is accepted that many foods may be first rejected but should be offered again.

Infants decide how much they want to eat and
no spoon-fed, puree food top ups are offered at
the end of a meal.

Water is offered with meals, milk feeding is still
baby led and may be given at a separate time
from meal time.
26
26
Limited studies are available regarding the impact and
outcome of baby led weaning. Possible positive outcomes are the promotion of healthy food preferences
that could be protective of obesity and parents have
been shown to be less controlling and more willing to
hand control over to the child when introducing solids
(Blossfield et al, 2007).
Limited studies are available regarding the impact and
outcome of baby led weaning. Possible positive outcomes are the promotion of healthy food preferences
that could be protective of obesity and parents have
been shown to be less controlling and more willing to
hand control over to the child when introducing solids
(Blossfield et al, 2007).
Nutritional adequacy, especially the increased requirements of calories, Iron, vitamin B6 & B12 at 6
months are less likely to be supplied in the required
quantities by a baby starting on baby led weaning. It
may take several weeks or months before an infant
has been established on a full, nutritionally complete
weaning diet.
Nutritional adequacy, especially the increased requirements of calories, Iron, vitamin B6 & B12 at 6
months are less likely to be supplied in the required
quantities by a baby starting on baby led weaning. It
may take several weeks or months before an infant
has been established on a full, nutritionally complete
weaning diet.
It is the view of both the Department of Health and the
Paediatric Group of the British Dietetic Association
that finger foods should be encouraged as soon as
the baby is ready. This can be alongside pureed foods
that improve overall quality of the weaning diet. It
should also be emphasised that no one approach with
regards to weaning will be suitable for all infants with
regards to their individual development and readiness.
It is important to remain flexible whilst discussing the
various options of weaning.
It is the view of both the Department of Health and the
Paediatric Group of the British Dietetic Association
that finger foods should be encouraged as soon as
the baby is ready. This can be alongside pureed foods
that improve overall quality of the weaning diet. It
should also be emphasised that no one approach with
regards to weaning will be suitable for all infants with
regards to their individual development and readiness.
It is important to remain flexible whilst discussing the
various options of weaning.
27
27
Other considerations
Other considerations
Foods given during weaning should be prepared, handled
and stored in a hygienic way. Food should be cooked
thoroughly and served as soon as possible after cooking.
Foods given during weaning should be prepared, handled
and stored in a hygienic way. Food should be cooked
thoroughly and served as soon as possible after cooking.




Left over food should be stored in a refrigerator at the
correct temperature.
Food should not be reheated more than once.
Particular care should be taken when using
microwave ovens to avoid hot spots in foods.


Left over food should be stored in a refrigerator at the
correct temperature.
Food should not be reheated more than once.
Particular care should be taken when using
microwave ovens to avoid hot spots in foods.
Vitamins
Vitamins
The following groups of infants should receive
supplementation of vitamins A, C & D (DOH, 1994):
The following groups of infants should receive
supplementation of vitamins A, C & D (DOH, 1994):







Babies from 6 months of age being breast fed.
Babies from 1 month of age being breast fed where
there is doubt about the mothers nutritional status
during pregnancy.
All infants and children from 6 months to 5 years
unless they are drinking more than 500ml a day of
infant formula.
Infants starting to drink cow’s milk as a main drink.
For pre term infants see chapter 14.



Babies from 6 months of age being breast fed.
Babies from 1 month of age being breast fed where
there is doubt about the mothers nutritional status
during pregnancy.
All infants and children from 6 months to 5 years
unless they are drinking more than 500ml a day of
infant formula.
Infants starting to drink cow’s milk as a main drink.
For pre term infants see chapter 14.
Vitamins A, C & D should be continued until 5 years of
age. Other vitamin preparations or nutritional supplements
should not be used unless under medical supervision.
Vitamins A, C & D should be continued until 5 years of
age. Other vitamin preparations or nutritional supplements
should not be used unless under medical supervision.
28
28
4. Other Infant Formula, Milks and Drinks
4. Other Infant Formula, Milks and Drinks
Follow-on formula
Follow-on formula
Standard follow-on formulas are suitable from six months of
age. They are higher in some nutrients including iron. Iron
stores laid down before birth are becoming depleted by six
months but, a nutritious weaning diet can provide the extra
nutrients required so changing to a follow-on formula is not
necessary. Growing-up formula milks are also available
which are suitable from 10 months to 3 years depending on
the manufacturer. These are not necessary for infants on a
nutritious weaning diet. Similarly, “Good Night” milks are not
advised.
Standard follow-on formulas are suitable from six months of
age. They are higher in some nutrients including iron. Iron
stores laid down before birth are becoming depleted by six
months but, a nutritious weaning diet can provide the extra
nutrients required so changing to a follow-on formula is not
necessary. Growing-up formula milks are also available
which are suitable from 10 months to 3 years depending on
the manufacturer. These are not necessary for infants on a
nutritious weaning diet. Similarly, “Good Night” milks are not
advised.
Name
Manufacturer
Name
Manufacturer
Follow-on milk for babies 6
months +
Cow & Gate
Follow-on milk for babies 6
months +
Cow & Gate
“Good Night” milk
Cow & Gate
“Good Night” milk
Cow & Gate
SMA Follow-on milk
SMA Nutrition
SMA Follow-on milk
SMA Nutrition
Aptamil Follow-on
Milupa
Aptamil Follow-on
Milupa
Hipp Organic Follow-on milk
Hipp
Hipp Organic Follow-on milk
Hipp
Hipp Organic “Good Night” Milk
Drink
Hipp
Hipp Organic “Good Night” Milk
Drink
Hipp
29
29
Goat’s Formula
Goat’s Formula
Goat’s infant formula is no longer available for sale in the
UK as sufficient evidence to support its use as a source of
protein has not been presented to the European Food
Safety Authority (DOH, 2006a).
Goat’s infant formula is no longer available for sale in the
UK as sufficient evidence to support its use as a source of
protein has not been presented to the European Food
Safety Authority (DOH, 2006a).
Goat’s & Sheep’s milk
Goat’s & Sheep’s milk
Non formula goat’s milk and sheep’s milk should not be
used in infants under 12 months due to their low vitamin
content and uncontrolled production. Both sheep and
goats milk have high solute loads and both contain
lactose. Goat’s milk is low in vitamins A and D, iron, and
folic acid. Sheep’s milk is low in iron, vitamin D and folate.
Both goat’s and sheep’s milk may be used after 1 year of
age, but they must be boiled or pasteurised. Supplements
of vitamins A and D, iron, and folic acid will also be
required for children having these milks. These milks
should not be used in allergy management.
Non formula goat’s milk and sheep’s milk should not be
used in infants under 12 months due to their low vitamin
content and uncontrolled production. Both sheep and
goats milk have high solute loads and both contain
lactose. Goat’s milk is low in vitamins A and D, iron, and
folic acid. Sheep’s milk is low in iron, vitamin D and folate.
Both goat’s and sheep’s milk may be used after 1 year of
age, but they must be boiled or pasteurised. Supplements
of vitamins A and D, iron, and folic acid will also be
required for children having these milks. These milks
should not be used in allergy management.
Soya Formula and Soya milk
Soya Formula and Soya milk
Soya Infant formula is not advised for infants under 6
months of age. It should only be used over 6 months of
age if there is a medically proven case of food
hypersensitivity e.g. lactose intolerance or cow’s milk
protein allergy (see chapter 9, Food Hypersensitivity). It
may also be the formula of choice for parents wishing their
child to follow a vegan diet or where there is a clinical need
i.e. for the treatment of Galactosaemia. Soya Infant
formulas available are Infasoy (Cow & Gate) & SMA
Wysoy (SMA Nutrition).
Soya Infant formula is not advised for infants under 6
months of age. It should only be used over 6 months of
age if there is a medically proven case of food
hypersensitivity e.g. lactose intolerance or cow’s milk
protein allergy (see chapter 9, Food Hypersensitivity). It
may also be the formula of choice for parents wishing their
child to follow a vegan diet or where there is a clinical need
i.e. for the treatment of Galactosaemia. Soya Infant
formulas available are Infasoy (Cow & Gate) & SMA
Wysoy (SMA Nutrition).
Any infant who takes less than 300mls of soya infant
formula per day should be considered for dietetic referral
for nutritional assessment. Non-formula, off-the-shelf soya
milk is available in most supermarkets & health food
Any infant who takes less than 300mls of soya infant
formula per day should be considered for dietetic referral
for nutritional assessment. Non-formula, off-the-shelf soya
milk is available in most supermarkets & health food
30
30
shops. They are suitable for children over two years of age
as a main drink. Calcium enriched versions should be
encouraged. They should not be used during weaning, as
they can be deficient in energy, vitamins and calcium. Alpro
‘one plus’ is available for use from 1 year.
shops. They are suitable for children over two years of age
as a main drink. Calcium enriched versions should be
encouraged. They should not be used during weaning, as
they can be deficient in energy, vitamins and calcium. Alpro
‘one plus’ is available for use from 1 year.
Good feeding practices should be encouraged at all times to
reduce the risk of tooth decay (See chapter 7 Oral Health).
Good feeding practices should be encouraged at all times to
reduce the risk of tooth decay (See chapter 7 Oral Health).
Cow’s Milk
Cow’s Milk
Whole pasteurised cow’s milk should not be used as the
sole source of nutrition due to its low iron content. It is
recommended that whole pasteurised cows milk as a main
drink is given only after the age of 1 year. During stage 1
weaning it can be introduced as part of the diet e.g. yoghurt,
milk based sauces and as puddings etc, but not as a main
drink. From one until five years of age, 568ml (1 pint) of
pasteurised full fat cows milk daily should be encouraged.
This is inclusive of milk used on cereals and that used in
custard, yoghurt and sauces etc.
Whole pasteurised cow’s milk should not be used as the
sole source of nutrition due to its low iron content. It is
recommended that whole pasteurised cows milk as a main
drink is given only after the age of 1 year. During stage 1
weaning it can be introduced as part of the diet e.g. yoghurt,
milk based sauces and as puddings etc, but not as a main
drink. From one until five years of age, 568ml (1 pint) of
pasteurised full fat cows milk daily should be encouraged.
This is inclusive of milk used on cereals and that used in
custard, yoghurt and sauces etc.
Semi-skimmed cows milk is not suitable as a drink before
the age of two years but thereafter it may be introduced
gradually if:
Semi-skimmed cows milk is not suitable as a drink before
the age of two years but thereafter it may be introduced
gradually if:

The child's energy and nutrient intake is adequate.

The child's energy and nutrient intake is adequate.

Growth remains satisfactory.

Growth remains satisfactory.
Skimmed milk should only be given after the age of five
years. Skimmed and semi-skimmed milk have a lower
energy and vitamin A content.
Skimmed milk should only be given after the age of five
years. Skimmed and semi-skimmed milk have a lower
energy and vitamin A content.
Raw, untreated milk must be boiled. Ordinary pasteurised
milk does not need to be boiled.
Raw, untreated milk must be boiled. Ordinary pasteurised
milk does not need to be boiled.
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31
Water
Water

Tap water from the first tap on the mains supply
(usually the cold tap in the kitchen) should be used.
Run the tap first if water comes from lead pipes. Seek
advice regarding private supplies of water from the
environmental health officer.

Tap water from the first tap on the mains supply
(usually the cold tap in the kitchen) should be used.
Run the tap first if water comes from lead pipes. Seek
advice regarding private supplies of water from the
environmental health officer.

Infants under 6 months of age do not normally require drinks in addition to breast or formula milk. If
additional fluids are needed boiled and cooled tap
water should be offered. After 6 months of age tap
water no longer needs to be boiled unless it is being
used to make an infant formula.

Infants under 6 months of age do not normally require drinks in addition to breast or formula milk. If
additional fluids are needed boiled and cooled tap
water should be offered. After 6 months of age tap
water no longer needs to be boiled unless it is being
used to make an infant formula.

Water from water filter jugs should not be used because boiling does not necessarily destroy the
bacteria and their toxins which maybe produced in
the charcoal filter.

Water from water filter jugs should not be used because boiling does not necessarily destroy the
bacteria and their toxins which maybe produced in
the charcoal filter.

Softened and some bottled waters whose label includes the word "natural mineral water" should not be
used due to their higher mineral content and solute
loads. Carbonated water is also not suitable.

Softened and some bottled waters whose label includes the word "natural mineral water" should not be
used due to their higher mineral content and solute
loads. Carbonated water is also not suitable.
 If travelling abroad boiled, cooled bottled still water
with a low mineral content should be advised. Aim for
water with a sodium (Na) content less than
200mg/l. Alternatively ready to use infant milks available in cartons that are pre-mixed could be used.
32
 If travelling abroad boiled, cooled bottled still water
with a low mineral content should be advised. Aim for
water with a sodium (Na) content less than
200mg/l. Alternatively ready to use infant milks available in cartons that are pre-mixed could be used.
32
Juice
Juice

Fruit juices, "baby" fruit juices, soft drinks, carbonated
drinks and milk drinks containing sugar should never
be given in a bottle or a (non spill) valved feeder cup.

Fruit juices, "baby" fruit juices, soft drinks, carbonated
drinks and milk drinks containing sugar should never
be given in a bottle or a (non spill) valved feeder cup.

Drinks formulated specifically for infants usually contain less additives than adult drinks, but may contain
relatively high concentrations of sugars which can
contribute to dental caries. Drinks containing fruit
also contain acid which, when frequently consumed,
can contribute towards enamel erosion.

Drinks formulated specifically for infants usually contain less additives than adult drinks, but may contain
relatively high concentrations of sugars which can
contribute to dental caries. Drinks containing fruit
also contain acid which, when frequently consumed,
can contribute towards enamel erosion.

To lower the risk of dental caries and enamel erosion
if fruit juice or "baby" fruit juice is offered, it should be
well diluted e.g. 1:12 - 1 part juice to 12 parts water.
It should be given sparingly and only given at mealtimes. It should never be served in a bottle or a (non
spill) valved feeder cup.

To lower the risk of dental caries and enamel erosion
if fruit juice or "baby" fruit juice is offered, it should be
well diluted e.g. 1:12 - 1 part juice to 12 parts water.
It should be given sparingly and only given at mealtimes. It should never be served in a bottle or a (non
spill) valved feeder cup.

Drinks that contain artificial sweeteners are not intended for babies and children. Frequent consumption of artificially sweetened drinks by children could
result in excessive intakes and may also result in diarrhoea.

Drinks that contain artificial sweeteners are not intended for babies and children. Frequent consumption of artificially sweetened drinks by children could
result in excessive intakes and may also result in diarrhoea.
Herbal drinks & Tea
Herbal drinks & Tea



All herbal drinks and herbal teas should be discouraged due to their high sugar content and because
the pharmacology of these drinks is unknown.
It is also advised that tea is not given as a main drink
for infants and young children. Tannin in tea may interfere with the absorption of iron and other minerals,
thereby compromising iron status.
33

All herbal drinks and herbal teas should be discouraged due to their high sugar content and because
the pharmacology of these drinks is unknown.
It is also advised that tea is not given as a main drink
for infants and young children. Tannin in tea may interfere with the absorption of iron and other minerals,
thereby compromising iron status.
33
5. Healthy Start
5. Healthy Start
Who Qualifies?
Women at least 10 weeks pregnant and children under 4
in a family who are:

Receiving Income support, or

Income based Jobseeker’s Allowance, or

Income-related Employment and Support Allowance,
or

Child Tax Credit run-on

AND has an annual family income of £16,190 or less
(2011/12) or

Under 18 years of age
Who Qualifies?
Women at least 10 weeks pregnant and children under 4
in a family who are:

Receiving Income support, or

Income based Jobseeker’s Allowance, or

Income-related Employment and Support Allowance,
or

Child Tax Credit run-on

AND has an annual family income of £16,190 or less
(2011/12) or

Under 18 years of age
What do Healthy Start beneficiaries receive?

Pregnant women & children aged 1-3 years get one
voucher a week

Babies under the age of one get two vouchers a
week
Each voucher is worth £3.10 and can be spent on cow’s
milk, fresh or frozen fruit and vegetables, or infant formula
milk in a wide variety of local shops and supermarkets and
with milkmen that have registered to take part in the
scheme. Every eight weeks, beneficiaries also receive
green vitamin coupons which they can swap for Healthy
Start vitamins in their local area. The coupons are either
for Healthy Start women’s tablets or Healthy Start
children’s drops.
What do Healthy Start beneficiaries receive?

Pregnant women & children aged 1-3 years get one
voucher a week

Babies under the age of one get two vouchers a
week
Each voucher is worth £3.10 and can be spent on cow’s
milk, fresh or frozen fruit and vegetables, or infant formula
milk in a wide variety of local shops and supermarkets and
with milkmen that have registered to take part in the
scheme. Every eight weeks, beneficiaries also receive
green vitamin coupons which they can swap for Healthy
Start vitamins in their local area. The coupons are either
for Healthy Start women’s tablets or Healthy Start
children’s drops.
Where are vitamins available?
Vitamins are available in all Children and Family Centres,
Midwife and Health Visitor clinics and some Health
Centres (currently: Burgess Hill Clinic, Durrington,
Lancing, Littlehampton, Nightingale Primary Care Centre
and Shoreham).
To apply use form HS01 available from the above, call the
Healthy Start Helpline 0845 607 6823 or go online to http://
www.healthystart.nhs.uk/
Where are vitamins available?
Vitamins are available in all Children and Family Centres,
Midwife and Health Visitor clinics and some Health
Centres (currently: Burgess Hill Clinic, Durrington,
Lancing, Littlehampton, Nightingale Primary Care Centre
and Shoreham).
To apply use form HS01 available from the above, call the
Healthy Start Helpline 0845 607 6823 or go online to http://
www.healthystart.nhs.uk/
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34
6. Growth
6. Growth
Accurate and regular measurement of infant growth is an
important part of assessing the general health and development of the child.
Accurate and regular measurement of infant growth is an
important part of assessing the general health and development of the child.
Weight measurement is the principle indicator of good
health and nutrition in the child’s first year of life (Child
Growth Foundation/Stanhope A, 2000).
Weight measurement is the principle indicator of good
health and nutrition in the child’s first year of life (Child
Growth Foundation/Stanhope A, 2000).
Potential benefits of growth monitoring include:
Identification of chronic disorders
Reassurance to parents/carers
Monitoring the health of the nation’s children and
supporting future research (Hall & Voss 2000).
Potential benefits of growth monitoring include:
Identification of chronic disorders
Reassurance to parents/carers
Monitoring the health of the nation’s children and
supporting future research (Hall & Voss 2000).
All health professionals involved in monitoring infant
growth should receive training in measurement
technique and interpretation of growth charts (Hall
& Elliman 2006).
All health professionals involved in monitoring infant
growth should receive training in measurement
technique and interpretation of growth charts (Hall
& Elliman 2006).
Weight is also used for calculating infant feed volumes.
Weight is also used for calculating infant feed volumes.
Which Scales?
Only Class III digital portable scales with a weighing pan
should be used (RCPCH, 2009). Weighing scales must
be calibrated for accuracy by the regular user at least annually. Ideally serial measurements should be on the
same scales.
Which Scales?
Only Class III digital portable scales with a weighing pan
should be used (RCPCH, 2009). Weighing scales must
be calibrated for accuracy by the regular user at least annually. Ideally serial measurements should be on the
same scales.
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35
How Often Should an Infant’s Growth be
monitored?
How Often Should an Infant’s Growth be
monitored?
The Royal College of Paediatricians & Child Health
(RCPCH) standards for growth monitoring (2009) are as follows:
The Royal College of Paediatricians & Child Health
(RCPCH) standards for growth monitoring (2009) are as follows:
Weight

At birth & during the first week as part of a feeding assessment & thereafter if needed.

Once feeding is established babies should be weighed
at 8,12 & 16 weeks & at 1 year at the time of routine
immunisations.
Weight

At birth & during the first week as part of a feeding assessment & thereafter if needed.

Once feeding is established babies should be weighed
at 8,12 & 16 weeks & at 1 year at the time of routine
immunisations.
Length & Head circumference should be measured:

If there is a concern about a child’s weight gain, growth
or general health.

If the weight is below the 0.4th centile or above the
99.6th centile.

If there is rapid weight gain.
Length & Head circumference should be measured:

If there is a concern about a child’s weight gain, growth
or general health.

If the weight is below the 0.4th centile or above the
99.6th centile.

If there is rapid weight gain.
Head Circumference should also be measured:

Around birth.

At the 8 week check.

If there are concerns about a child’s head growth.
Head Circumference should also be measured:

Around birth.

At the 8 week check.

If there are concerns about a child’s head growth.
If there is any concern about growth measurements they
should be double checked and taken more frequently. This
may also be requested by another health care professional
(eg Paediatrician, Paediatric Dietitian).
If there is any concern about growth measurements they
should be double checked and taken more frequently. This
may also be requested by another health care professional
(eg Paediatrician, Paediatric Dietitian).
However measurements should not be taken too often as
this can cause unnecessary parental (and health professional) anxiety.
However measurements should not be taken too often as
this can cause unnecessary parental (and health professional) anxiety.
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36
How to Measure Infant Growth
How to Measure Infant Growth
Measurements (weight, supine length & head circumference) should be taken following the standardised instructions on growth charts. Children should have supine
lengths taken on a length board or mat until 2 years of
age.
Measurements (weight, supine length & head circumference) should be taken following the standardised instructions on growth charts. Children should have supine
lengths taken on a length board or mat until 2 years of
age.
Infants & children under 2 should be weighed naked
(RCPCH, 2009) unless there are special circumstances eg
a dressing, splint or plaster. The state of dress should be
recorded. Ensure the room is warm (Hall D & Elliman)
2006.
Infants & children under 2 should be weighed naked
(RCPCH, 2009) unless there are special circumstances eg
a dressing, splint or plaster. The state of dress should be
recorded. Ensure the room is warm (Hall D & Elliman)
2006.
Which Chart?
Which Chart?




All babies should be plotted on UK WHO Growth
charts.
Babies born before 32 weeks gestation should be
plotted on a UK WHO Neonatal & Infant Close Monitoring (NICN) growth chart.
Children over 4 years should be plotted on the UK90
growth & BMI chart.


All babies should be plotted on UK WHO Growth
charts.
Babies born before 32 weeks gestation should be
plotted on a UK WHO Neonatal & Infant Close Monitoring (NICN) growth chart.
Children over 4 years should be plotted on the UK90
growth & BMI chart.
The UK WHO charts describe optimal rather then average
growth and are based on healthy breast fed babies. For
more information go to www.growthcharts.rcpch.ac.uk.
The UK WHO charts describe optimal rather then average
growth and are based on healthy breast fed babies. For
more information go to www.growthcharts.rcpch.ac.uk.
Plotting Infant Growth
Plotting Infant Growth
For all infants born after 37 completed gestation, plot from
the estimated delivery date (EDD). Measurements should
be recorded in kg (and imperial measurements if desired)
alongside the infants age in weeks if under 12 months and
For all infants born after 37 completed gestation, plot from
the estimated delivery date (EDD). Measurements should
be recorded in kg (and imperial measurements if desired)
alongside the infants age in weeks if under 12 months and
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37
calendar months thereafter. Ensure entry is signed and
dated, with the location of the weight recorded (eg Health
visitor, hospital, ward).
calendar months thereafter. Ensure entry is signed and
dated, with the location of the weight recorded (eg Health
visitor, hospital, ward).
Correcting for prematurity
Correcting for prematurity
It is vital that infant growth is accurately corrected for prematurity. For infants born at less than 36 weeks 6 days
completed gestation, draw a vertical line at the appropriate
week on the growth chart and plot measurements from this
line.
It is vital that infant growth is accurately corrected for prematurity. For infants born at less than 36 weeks 6 days
completed gestation, draw a vertical line at the appropriate
week on the growth chart and plot measurements from this
line.




Infants born 32-36 weeks correct for up to 12 months
Infants born before 32 weeks correct up to 2 years
(RCPCH, 2009)
Infants born 32-36 weeks correct for up to 12 months
Infants born before 32 weeks correct up to 2 years
(RCPCH, 2009)
Ensure that the corrected age is clearly marked in the child
health record, so that all health professionals involved with
the infant are reminded the child was born prematurely.
Ensure that the corrected age is clearly marked in the child
health record, so that all health professionals involved with
the infant are reminded the child was born prematurely.
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38
What is Normal Growth & When to Refer On
What is Normal Growth & When to Refer On
In the UK, normal birth weight is 3.3-3.5kg in both sexes.
Some weight loss (up to 10% birth weight) is expected
during the first 5-7 days of life whilst feeding is established
(Wardley B.L. et al 1997). Birth weight is usually regained
by 2 weeks of age. After this, average weight gain is:
In the UK, normal birth weight is 3.3-3.5kg in both sexes.
Some weight loss (up to 10% birth weight) is expected
during the first 5-7 days of life whilst feeding is established
(Wardley B.L. et al 1997). Birth weight is usually regained
by 2 weeks of age. After this, average weight gain is:
200g per week from 0-3 months
150g per week from 3-6 months
100g per week from 6-9 months
50-75g per week from 9-12 months
200g per week from 0-3 months
150g per week from 3-6 months
100g per week from 6-9 months
50-75g per week from 9-12 months
Increase in Length during the first year of life = 25cm
(Shaw V & Lawson M 2007).
Increase in Length during the first year of life = 25cm
(Shaw V & Lawson M 2007).
Weight usually tracks within one centile. Acute illness can
lead to weight loss and a fall off the centile but a child’s
weight usually returns to its normal centile within 2-3
weeks. Less than 2% of infants will show a sustained drop
through 2 or more centile spaces when using the UK
WHO charts (RCPCH, 2009). It is acceptable for
premature infants to track within 2 centiles of their birth
weight.
Weight usually tracks within one centile. Acute illness can
lead to weight loss and a fall off the centile but a child’s
weight usually returns to its normal centile within 2-3
weeks. Less than 2% of infants will show a sustained drop
through 2 or more centile spaces when using the UK
WHO charts (RCPCH, 2009). It is acceptable for
premature infants to track within 2 centiles of their birth
weight.
The decision regarding whether to refer the infant on for
further assessment should be made on the basis of the
whole clinical picture (in collaboration with the parents/
carers) and not the growth chart alone (Hall D & Elliman D,
2006). Any child with measurements consistently under
the 0.4th centile should be assessed in more detail by a
consultant paediatrician. It is helpful for a copy of the
child's centile chart to be sent with the referral, and to
remind the parents/carers to take their child health record
along to the consultation.
The decision regarding whether to refer the infant on for
further assessment should be made on the basis of the
whole clinical picture (in collaboration with the parents/
carers) and not the growth chart alone (Hall D & Elliman D,
2006). Any child with measurements consistently under
the 0.4th centile should be assessed in more detail by a
consultant paediatrician. It is helpful for a copy of the
child's centile chart to be sent with the referral, and to
remind the parents/carers to take their child health record
along to the consultation.
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39
Obesity
Obesity
Obesity should be assessed on a BMI centile chart for
boys & girls. Adult charts should not be used. The
paediatric dietitian at your local hospital will have access to
BMI charts for children. Body Mass Index (BMI) is
calculated using the following equation:
Obesity should be assessed on a BMI centile chart for
boys & girls. Adult charts should not be used. The
paediatric dietitian at your local hospital will have access to
BMI charts for children. Body Mass Index (BMI) is
calculated using the following equation:
BMI = Wt (kg)
Ht 2 (m)
BMI = Wt (kg)
Ht 2 (m)
So for an 18 month old child with a weight of 16kg & length
86cm the BMI will be :
So for an 18 month old child with a weight of 16kg & length
86cm the BMI will be :
BMI = 16
0.86 x 0.86
BMI = 16
0.86 x 0.86
=
21.6 kg/m2
=
21.6 kg/m2
=
99.6th centile
=
99.6th centile
BMI usually decreases in preschool children between the
ages of 1 & 5 years. The 91st centile for BMI is generally
used as a cut off for overweight & the 98th for clinical
obesity. All 0-2 year olds with a BMI>98th centile should
be referred to a consultant paediatrician.
BMI usually decreases in preschool children between the
ages of 1 & 5 years. The 91st centile for BMI is generally
used as a cut off for overweight & the 98th for clinical
obesity. All 0-2 year olds with a BMI>98th centile should
be referred to a consultant paediatrician.
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40
7. Oral Health
7. Oral Health
Diet
Diet
Frequency of sugar is a major factor in the development
of dental caries. Foods containing added sugars should be
restricted to mealtimes only.
Frequency of sugar is a major factor in the development
of dental caries. Foods containing added sugars should be
restricted to mealtimes only.
Care should especially be exercised during weaning.
Many manufactured baby foods have added sugars including familiar first foods. Low sugar does not mean no
sugar and often means the product has only a small
amount less than the standard product. Encouraging a
"sweet tooth" is to be avoided.
Care should especially be exercised during weaning.
Many manufactured baby foods have added sugars including familiar first foods. Low sugar does not mean no
sugar and often means the product has only a small
amount less than the standard product. Encouraging a
"sweet tooth" is to be avoided.
Drinks
Drinks
Drinks containing added sugar contribute towards dental
caries and drinks containing fruit or that are carbonated
contribute to dental erosion. The most appropriate drinks
between meals are milk and water. The risk to teeth from
other drinks can be reduced by diluting them, keeping
them to meal times and not making them last a long time.
Drinks containing added sugar contribute towards dental
caries and drinks containing fruit or that are carbonated
contribute to dental erosion. The most appropriate drinks
between meals are milk and water. The risk to teeth from
other drinks can be reduced by diluting them, keeping
them to meal times and not making them last a long time.
Care should be taken in the choice of spouted drinking
cups as valved no-spill designs carry the same risks to
teeth as drinking from a bottle. Free flow spouted cups are
messier but will encourage the carer to supervise drinking,
keep drinking times short and discourage using the drink
as a comforter.
Care should be taken in the choice of spouted drinking
cups as valved no-spill designs carry the same risks to
teeth as drinking from a bottle. Free flow spouted cups are
messier but will encourage the carer to supervise drinking,
keep drinking times short and discourage using the drink
as a comforter.
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41
Oral Hygiene
Oral Hygiene
Plaque starts to form on teeth once they emerge, therefore
tooth brushing should commence as soon as the first tooth
appears in the mouth. This should be carried out by a parent/carer. When the child is able to hold a toothbrush he/
she should be encouraged to practise cleaning the teeth.
However, the parent/carer should always complete the
tooth brushing for the child. Supervision, assistance and
encouragement should continue until the child is about six
to eight years old depending on the child's capability.
Plaque starts to form on teeth once they emerge, therefore
tooth brushing should commence as soon as the first tooth
appears in the mouth. This should be carried out by a parent/carer. When the child is able to hold a toothbrush he/
she should be encouraged to practise cleaning the teeth.
However, the parent/carer should always complete the
tooth brushing for the child. Supervision, assistance and
encouragement should continue until the child is about six
to eight years old depending on the child's capability.
Fluoride is not added to the water in West Sussex so it is
important that fluoride toothpaste is used regularly. For babies and children up to 3 years it is recommended that
a smear of toothpaste containing no less than 1000ppm
fluoride is used. For babies and children over 3 years a
pea sized amount may be used, once spitting is mastered.
The toothpaste should contain 1350-1500ppm fluoride.
This should be dispensed by an adult onto a toothbrush
with a small head and soft bristles. Children should be encouraged to spit out the bubbles but not to rinse off the residual toothpaste as the fluoride continues to strengthen
tooth enamel. Toothpaste should be kept out of reach of
young children to prevent them from consuming it.
Fluoride is not added to the water in West Sussex so it is
important that fluoride toothpaste is used regularly. For babies and children up to 3 years it is recommended that
a smear of toothpaste containing no less than 1000ppm
fluoride is used. For babies and children over 3 years a
pea sized amount may be used, once spitting is mastered.
The toothpaste should contain 1350-1500ppm fluoride.
This should be dispensed by an adult onto a toothbrush
with a small head and soft bristles. Children should be encouraged to spit out the bubbles but not to rinse off the residual toothpaste as the fluoride continues to strengthen
tooth enamel. Toothpaste should be kept out of reach of
young children to prevent them from consuming it.
Teeth should be cleaned once in the morning, either before breakfast or at least half an hour after eating. Bedtime
brushing should be after last milk drink from one year old
to protect teeth from natural sugars. Water only should be
given if the child wakes and is thirsty in the night.
Teeth should be cleaned once in the morning, either before breakfast or at least half an hour after eating. Bedtime
brushing should be after last milk drink from one year old
to protect teeth from natural sugars. Water only should be
given if the child wakes and is thirsty in the night.
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Dental Visits/Fluoride
Dental Visits/Fluoride
Parents should be encouraged to register their infants with
their family dentist and begin to seek individual advice on
prevention of disease by about six months of age. This
should include individual advice regarding the use of fluoride supplements and toothpaste.
Parents should be encouraged to register their infants with
their family dentist and begin to seek individual advice on
prevention of disease by about six months of age. This
should include individual advice regarding the use of fluoride supplements and toothpaste.
If a Health Visitor is concerned about a child’s oral health
and the family have been unable to register their infant
with a dentist then they can be referred to the West Sussex Community Personal Dental Services.
If a Health Visitor is concerned about a child’s oral health
and the family have been unable to register their infant
with a dentist then they can be referred to the West Sussex Community Personal Dental Services.
The water authorities in West Sussex have advised that
there is no fluoride added to the drinking water supply. The
fluoride content naturally occurring is too low to help in the
prevention of dental caries.
The water authorities in West Sussex have advised that
there is no fluoride added to the drinking water supply. The
fluoride content naturally occurring is too low to help in the
prevention of dental caries.
Fluoride supplements should only be used if prescribed by
a dentist.
Fluoride supplements should only be used if prescribed by
a dentist.
It is important that families moving out of the district are
advised to contact the local water authority, family dentist
or Community Personal Dental Service before continuing
with fluoride supplementation or family strength fluoride
toothpaste as their new home may be located in a
fluoridated area. To find a dentist locally call West Sussex
& Surrey Dental Helpline 0300 1000899.
It is important that families moving out of the district are
advised to contact the local water authority, family dentist
or Community Personal Dental Service before continuing
with fluoride supplementation or family strength fluoride
toothpaste as their new home may be located in a
fluoridated area. To find a dentist locally call West Sussex
& Surrey Dental Helpline 0300 1000899.
Medicine
Medicine
If children need to take medicine, a sugar free preparation
should be prescribed if available.
If children need to take medicine, a sugar free preparation
should be prescribed if available.
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43
8. Vegetarian/Vegan Diets
8. Vegetarian/Vegan Diets
A well balanced, varied vegetarian diet can be nutritionally adequate. There is increasing evidence that people
who are vegetarian are less likely to suffer from diseases such as coronary heart disease, cancer, diabetes, obesity and hypertension.
A well balanced, varied vegetarian diet can be nutritionally adequate. There is increasing evidence that people
who are vegetarian are less likely to suffer from diseases such as coronary heart disease, cancer, diabetes, obesity and hypertension.
Provided that parents are well informed regarding their
child’s nutritional needs and offer their child an adequate varied diet, a vegetarian diet can provide all the
nutrients needed for a growing infant.
Provided that parents are well informed regarding their
child’s nutritional needs and offer their child an adequate varied diet, a vegetarian diet can provide all the
nutrients needed for a growing infant.
Young children & infants receiving a vegan or
macrobiotic diet have a high risk for the development of
nutritional deficiencies. They are not recommended for
children (ESPGHAN, 2008).
Young children & infants receiving a vegan or
macrobiotic diet have a high risk for the development of
nutritional deficiencies. They are not recommended for
children (ESPGHAN, 2008).
The following table details the main types of vegetarian
and vegan diets and nutrients at risk of deficiency.
The following table details the main types of vegetarian
and vegan diets and nutrients at risk of deficiency.
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44
Partial
Vegetarian
Foods
Excluded
Protein
Sources
Nutrient at
Risk of
Deficiency
Red Meat
Offal
Poultry
Eggs
Fish
Beans
Milk
Lentils
Cheese
Nuts
Yoghurt
Quorn®
Tofu/Soya
Iron
Red Meat
Offal
Poultry
Gelatine
Fish
Yoghurt
Milk
Lentils
Eggs
Beans
Cheese
Nuts
Tofu/Soya
Quorn®
Iron
Red Meat,
Offal
Poultry, Fish
Rennet
Gelatine
Milk
Lentils
Yoghurt
Eggs
Beans
Cheese
Quorn®
Tofu/Soya
Nuts
Iron
(Semi/Demi)
Pescatarian
(Eat fish but not
meat)
Lacto-ovovegetarian
(Most common
type of
vegetarian)
45
Partial
Vegetarian
Foods
Excluded
Protein
Sources
Nutrient at
Risk of
Deficiency
Red Meat
Offal
Poultry
Eggs
Fish
Beans
Milk
Lentils
Cheese
Nuts
Yoghurt
Quorn®
Tofu/Soya
Iron
Red Meat
Offal
Poultry
Gelatine
Fish
Yoghurt
Milk
Lentils
Eggs
Beans
Cheese
Nuts
Tofu/Soya
Quorn®
Iron
Red Meat,
Offal
Poultry, Fish
Rennet
Gelatine
Milk
Lentils
Yoghurt
Eggs
Beans
Cheese
Quorn®
Tofu/Soya
Nuts
Iron
(Semi/Demi)
Pescatarian
(Eat fish but not
meat)
Lacto-ovovegetarian
(Most common
type of
vegetarian)
45
Foods
Excluded
Protein
Sources
Nutrient at
Risk of
Deficiency
Red Meat,
Offal
Poultry,
Eggs
Fish,
Rennet,
Gelatine,
Quorn®
Milk
Lentils
Yoghurt
Nuts
Cheese
Beans
Soya/Tofu
Iron
Vitamin D
Vegan
Red Meat,
Offal
Poultry,
Fish
Milk,
Cheese
Eggs,
Yoghurt
Quorn®,
Honey
Rennet,
Gelatine
Beans
Lentils
Nuts
Soya/Tofu
Protein,
Energy,
Iron
Fat-soluble
Vitamins
(A,D,E,K)
Riboflavin (B2)
Vitamin B12
(Cobalamin)
Calcium, Zinc
Essential Fatty
Acids
Raw Food
Vegan
(More
restrictive
than
vegan)
As Above –
limited
cooked foods
– 80% diet is
raw plants
500g/day
green leafy
veg,
sweet fruit,
high fat
plants
As vegan –
Vitamin D &
B12 particularly at risk if
not
supplemented
Lacto
Vegetarian
(Eat dairy
products but
not eggs)
46
Foods
Excluded
Protein
Sources
Nutrient at
Risk of
Deficiency
Red Meat,
Offal
Poultry,
Eggs
Fish,
Rennet,
Gelatine,
Quorn®
Milk
Lentils
Yoghurt
Nuts
Cheese
Beans
Soya/Tofu
Iron
Vitamin D
Vegan
Red Meat,
Offal
Poultry,
Fish
Milk,
Cheese
Eggs,
Yoghurt
Quorn®,
Honey
Rennet,
Gelatine
Beans
Lentils
Nuts
Soya/Tofu
Protein,
Energy,
Iron
Fat-soluble
Vitamins
(A,D,E,K)
Riboflavin (B2)
Vitamin B12
(Cobalamin)
Calcium, Zinc
Essential Fatty
Acids
Raw Food
Vegan
(More
restrictive
than
vegan)
As Above –
limited
cooked foods
– 80% diet is
raw plants
500g/day
green leafy
veg,
sweet fruit,
high fat
plants
As vegan –
Vitamin D &
B12 particularly at risk if
not
supplemented
Lacto
Vegetarian
(Eat dairy
products but
not eggs)
46
Foods
Protein
Excluded Sources
Nutrient at
Risk of
Deficiency
Fruitarian
As vegan
plus
Lentils
Nuts
None
- eat only
uncooked
fermented
cereals and
seeds
Major Protein
Energy
Malnutrition,
Multiple
Vitamin,
Mineral &
Trace
Element
deficiencies
Macrobiotic
Animal
Products,
Fruits & Veg
are
gradually
removed
from the diet
until the final
goal of
consuming
only brown
rice is
achieved,
fluids are
also
severely
restricted
None
As for
Fruitarian plus
risk of
dehydration
Nutritional
content depends
on stage of diet
- 10 stages of
dietary
elimination
47
Foods
Protein
Excluded Sources
Nutrient at
Risk of
Deficiency
Fruitarian
As vegan
plus
Lentils
Nuts
None
- eat only
uncooked
fermented
cereals and
seeds
Major Protein
Energy
Malnutrition,
Multiple
Vitamin,
Mineral &
Trace
Element
deficiencies
Macrobiotic
Animal
Products,
Fruits & Veg
are
gradually
removed
from the diet
until the final
goal of
consuming
only brown
rice is
achieved,
fluids are
also
severely
restricted
None
As for
Fruitarian plus
risk of
dehydration
Nutritional
content depends
on stage of diet
- 10 stages of
dietary
elimination
47
The Vegetarian Diet During Pregnancy
The Vegetarian Diet During Pregnancy
The health of the mother and baby is influenced by diet in
pregnancy and preconception. Normal nutritional advice
applies as for non vegetarian women. As a precaution, a
vegetarian over the counter nutritional supplement suitable
for pregnancy can be advised.
The health of the mother and baby is influenced by diet in
pregnancy and preconception. Normal nutritional advice
applies as for non vegetarian women. As a precaution, a
vegetarian over the counter nutritional supplement suitable
for pregnancy can be advised.
Breast Feeding the Vegetarian Child
Breast Feeding the Vegetarian Child
Mothers who are vegetarian or vegan should be
encouraged to breast feed. If the mother does not
consume dairy products then a calcium supplement is
required to meet increased calcium needs whilst
breastfeeding (1250mg Calcium/day). Breastfeeding on
demand should be encouraged as for all infants. If the
maternal diet is adequate, breast feeding will meet the
infants nutritional needs for the first 4-6 months of life.
Vegan mothers may require a vitamin B12 supplement.
Mothers who are vegetarian or vegan should be
encouraged to breast feed. If the mother does not
consume dairy products then a calcium supplement is
required to meet increased calcium needs whilst
breastfeeding (1250mg Calcium/day). Breastfeeding on
demand should be encouraged as for all infants. If the
maternal diet is adequate, breast feeding will meet the
infants nutritional needs for the first 4-6 months of life.
Vegan mothers may require a vitamin B12 supplement.
Bottle Feeding the Vegetarian Child
Bottle Feeding the Vegetarian Child
Most infant formula contain Long Chain Polyunsaturated
Fatty Acids (LCPs) which are known to be important for
infant brain & retinal development. These LCPs are usually
derived from fish oils. At present there is no formulae
suitable for babies following a vegetarian diet that contains
LCPs. Parents may wish to consider the benefits of fish
oils.
Most infant formula contain Long Chain Polyunsaturated
Fatty Acids (LCPs) which are known to be important for
infant brain & retinal development. These LCPs are usually
derived from fish oils. At present there is no formulae
suitable for babies following a vegetarian diet that contains
LCPs. Parents may wish to consider the benefits of fish
oils.
Soya formulae are unsuitable for infants under 6 months of
age. Unmodified soya, “home made” milks, goats, rice &
sheeps milk are also not recommended. Please contact
your Registered Dietitian for advice on the suitability of
disease specific formula for vegetarians.
Soya formulae are unsuitable for infants under 6 months of
age. Unmodified soya, “home made” milks, goats, rice &
sheeps milk are also not recommended. Please contact
your Registered Dietitian for advice on the suitability of
disease specific formula for vegetarians.
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48
Children on Restricted Diets—when to be
Concerned
Children on Restricted Diets—when to be
Concerned
Many infants are successfully weaned on to a vegetarian
diet. Provided the diet is well balanced & the parents are
well informed regarding the diet, the risk of nutritional deficiency is low.
Many infants are successfully weaned on to a vegetarian
diet. Provided the diet is well balanced & the parents are
well informed regarding the diet, the risk of nutritional deficiency is low.
The more restrictive the diet the greater the risk and
hence the likelihood that a child’s growth or health may
be affected. For example the raw food vegan diet is very
unlikely to meet the child’s nutritional needs and would
not be advocated for an infant or child.
The more restrictive the diet the greater the risk and
hence the likelihood that a child’s growth or health may
be affected. For example the raw food vegan diet is very
unlikely to meet the child’s nutritional needs and would
not be advocated for an infant or child.
If you have concerns regarding the nutritional adequacy
of an infants diet or their growth a referral to a registered
dietitian at your local hospital should be considered.
If you have concerns regarding the nutritional adequacy
of an infants diet or their growth a referral to a registered
dietitian at your local hospital should be considered.
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49
Weaning the Vegetarian Child
Weaning the Vegetarian Child
Breast milk or infant formula milk provides sufficient nutrition
until the infant reaches 6 months of age. Solids should be
introduced gradually increasing flavours and textures as per
normal weaning advice (Chapter 3 Weaning).
Breast milk or infant formula milk provides sufficient nutrition
until the infant reaches 6 months of age. Solids should be
introduced gradually increasing flavours and textures as per
normal weaning advice (Chapter 3 Weaning).
Emphasis should be made on maximising the calorie content
of the diet as vegetarian diets can sometimes be very high in
fibre (which is filling for the infant, and can limit the
absorption of some nutrients) and lower in energy, vitamins
and minerals.
Emphasis should be made on maximising the calorie content
of the diet as vegetarian diets can sometimes be very high in
fibre (which is filling for the infant, and can limit the
absorption of some nutrients) and lower in energy, vitamins
and minerals.
Vegetarian diets should include foods which have little or no
fibre such as eggs, milk and cheese so as to provide baby
with sufficient calories. Semi-skimmed milk should not be
introduced before the age of two years and skimmed milk
should not be introduced before the age of five years.
Vegetarian diets should include foods which have little or no
fibre such as eggs, milk and cheese so as to provide baby
with sufficient calories. Semi-skimmed milk should not be
introduced before the age of two years and skimmed milk
should not be introduced before the age of five years.
Pulses provide a valuable source of protein from 6 months;
these should be well cooked to destroy naturally occurring
toxins which may cause diarrhoea and vomiting.
Pulses provide a valuable source of protein from 6 months;
these should be well cooked to destroy naturally occurring
toxins which may cause diarrhoea and vomiting.
Tofu and Quorn can be introduced from 7 months. Finely
ground nuts and nut butters are a good source of protein and
fat, these can be included from 6 months provided there is
no family history of food or nut allergy or atopy.
Tofu and Quorn can be introduced from 7 months. Finely
ground nuts and nut butters are a good source of protein and
fat, these can be included from 6 months provided there is
no family history of food or nut allergy or atopy.
The infant should continue with at least 568ml 1 (pint) of
breast or formula milk/day.
The infant should continue with at least 568ml 1 (pint) of
breast or formula milk/day.
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50
Vegan parents should be discouraged from giving their
child soya products before 6 months of age. See following page for vegetarian & vegan sources of nutrients.
Vegan parents should be discouraged from giving their
child soya products before 6 months of age. See following page for vegetarian & vegan sources of nutrients.
Vitamins
Vitamins
A daily vitamin supplement, for example Dalivit, Abidec
or Healthy Start Children's Vitamin Drops, is beneficial
for children aged 6 months to 5 years following a vegetarian diet. If children are following a vegan diet they
should also take a daily vitamin supplement and a Vitamin B12 (Cobalamin) supplement (1-2 micrograms/day).
A daily vitamin supplement, for example Dalivit, Abidec
or Healthy Start Children's Vitamin Drops, is beneficial
for children aged 6 months to 5 years following a vegetarian diet. If children are following a vegan diet they
should also take a daily vitamin supplement and a Vitamin B12 (Cobalamin) supplement (1-2 micrograms/day).
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Vegetarian & Vegan Sources of Nutrients
Vegetarian & Vegan Sources of Nutrients
Nutrient
Vegetarian
Source
Vegan Sources
Nutrient
Vegetarian
Source
Vegan Sources
Protein
Milk, Yoghurt,
Cheese, Eggs,
Cereals, pulses, finely ground
nuts & seeds
Protein
Milk, Yoghurt,
Cheese, Eggs,
Cereals, pulses, finely ground
nuts & seeds
B Vitamins
Quorn®, eggs,
whole milk, yoghurt
Fortified cereals, fortified soya
milk & mince, tofu, yeast
extract, finely ground nuts,
avocado, green leafy
vegetables
B Vitamins
Quorn®, eggs,
whole milk, yoghurt
Fortified cereals, fortified soya
milk & mince, tofu, yeast
extract, finely ground nuts,
avocado, green leafy
vegetables
Vitamin A
Vitamin C
Vitamin D
Iron
Calcium
Essential
Fatty
Acids
Yellow & orange vegetables eg. Such as carrots
and peppers
Fresh fruit & vegetables including citrus fruits, kiwi
and potatoes, fruit juices.
Sunlight, fortified (soya) margarine, fortified soya milk
Eggs, chocolate,
Absorption aided
by: Vitamin C rich
foods eaten at the
same meal
Absorption limited
by: phytates
(bran), oxalates
(spinach, rhubarb)
tannins (tea)
Dairy products
Vitamin C
Vitamin D
Wholegrain & fortified cereals,
pulses, dried fruit, green leafy
vegetables, cocoa, molasses,
curry powder, wholegrain
bread
Iron
Fortified soya milk, green leafy
vegetables , pulses, white
bread, finely ground cashew
nuts & almonds, sunflower, &
sesame seeds
Calcium
Oils, Wholegrains, Finely Ground Nuts & Seeds
52
Vitamin A
Essential
Fatty
Acids
Yellow & orange vegetables eg. Such as carrots
and peppers
Fresh fruit & vegetables including citrus fruits, kiwi
and potatoes, fruit juices.
Sunlight, fortified (soya) margarine, fortified soya milk
Eggs, chocolate,
Absorption aided
by: Vitamin C rich
foods eaten at the
same meal
Absorption limited
by: phytates
(bran), oxalates
(spinach, rhubarb)
tannins (tea)
Dairy products
Wholegrain & fortified cereals,
pulses, dried fruit, green leafy
vegetables, cocoa, molasses,
curry powder, wholegrain
bread
Fortified soya milk, green leafy
vegetables , pulses, white
bread, finely ground cashew
nuts & almonds, sunflower, &
sesame seeds
Oils, Wholegrains, Finely Ground Nuts & Seeds
52
9. Food Hypersensitivity
9. Food Hypersensitivity
Food hypersensitivity is defined as an adverse reaction to
food.
Food hypersensitivity is defined as an adverse reaction to
food.
Non-allergic Food Hypersensitivity
Non-allergic Food Hypersensitivity
Non-allergic food hypersensitivity is caused by substances
in food other than food proteins with no involvement of the
immune system. Histamine release, pharmacological
effects or enzyme deficiencies may cause such reactions.
They can be acute and severe (although rarely lifethreatening) and are often difficult to diagnose.
Non-allergic food hypersensitivity is caused by substances
in food other than food proteins with no involvement of the
immune system. Histamine release, pharmacological
effects or enzyme deficiencies may cause such reactions.
They can be acute and severe (although rarely lifethreatening) and are often difficult to diagnose.
Food Allergy
Food Allergy
Food allergy is a specific reaction resulting from an
abnormal immunological response to a food protein which
can be severe and life threatening, but can also develop
more slowly (non-IgE-mediated e.g. eczema, vomiting,
diarrhoea) or may even show a mixed pattern.
Food allergy is a specific reaction resulting from an
abnormal immunological response to a food protein which
can be severe and life threatening, but can also develop
more slowly (non-IgE-mediated e.g. eczema, vomiting,
diarrhoea) or may even show a mixed pattern.
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53
Food Allergy
Food Allergy
The symptoms of food allergy are typically present in one
or more of 3 organ systems (DoH 2011):
The symptoms of food allergy are typically present in one
or more of 3 organ systems (DoH 2011):
 The Gastrointestinal Tract: common symptoms include
vomiting, gastro-oesophageal reflux & diarrhoea.
 The Gastrointestinal Tract: common symptoms include
vomiting, gastro-oesophageal reflux & diarrhoea.
 The Respiratory Tract: symptoms include
rhinoconjunctivitis, wheeze & oedema.
 The Respiratory Tract: symptoms include
rhinoconjunctivitis, wheeze & oedema.
 The Skin: usual symptoms include skin rash, eczema
and urticaria.
 The Skin: usual symptoms include skin rash, eczema
and urticaria.
In the young infant, cow’s milk and soya are the most
common problem foods. As the child gets older and
additional foods are introduced the vast majority of allergic
reaction are caused by peanuts, tree nuts, fish, wheat, egg
and shellfish in addition to milk and soy.
In the young infant, cow’s milk and soya are the most
common problem foods. As the child gets older and
additional foods are introduced the vast majority of allergic
reaction are caused by peanuts, tree nuts, fish, wheat, egg
and shellfish in addition to milk and soy.
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54
Diagnosis of Food Allergy
Diagnosis of Food Allergy
If a patient history points to an IgE-mediated reaction, tests
are available that can detect food-specific IgE antibodies.
It should be noted however that these tests could give both
false negative and false positive results that may be
misleading and difficult to interpret. Referral for allergy
testing should be directed to the Consultant Paediatrician
or paediatric dietitian at your local hospital.
If a patient history points to an IgE-mediated reaction, tests
are available that can detect food-specific IgE antibodies.
It should be noted however that these tests could give both
false negative and false positive results that may be
misleading and difficult to interpret. Referral for allergy
testing should be directed to the Consultant Paediatrician
or paediatric dietitian at your local hospital.
Skin Prick Tests (SPT) – This is an in vivo test that can
indicate the likelihood of a patient reacting to a particular
food depending on the size of the skin reaction. It should
be noted that SPT in this age group are difficult, as the
patient needs to sit still for 20 minutes. Generally SPT will
be considered in children older than 3 years. In some
cases however it is possible in young babies.
Skin Prick Tests (SPT) – This is an in vivo test that can
indicate the likelihood of a patient reacting to a particular
food depending on the size of the skin reaction. It should
be noted that SPT in this age group are difficult, as the
patient needs to sit still for 20 minutes. Generally SPT will
be considered in children older than 3 years. In some
cases however it is possible in young babies.
Radioallergosorbent test (RAST) – This is an in vitro test
that can measure the concentration of food specific IgE in
a patients blood. The higher the concentration of IgE the
higher the likelihood of reaction to the food protein. RAST
are sent onto a reference laboratory via the Clinical
Chemistry Department at your local hospital.
Radioallergosorbent test (RAST) – This is an in vitro test
that can measure the concentration of food specific IgE in
a patients blood. The higher the concentration of IgE the
higher the likelihood of reaction to the food protein. RAST
are sent onto a reference laboratory via the Clinical
Chemistry Department at your local hospital.
Other more controversial tests e.g. cytotoxic food tests,
hair and nail tests, pulse testing and sublingual
provocative testing which are less sensitive, have been
developed to diagnose allergy. They are not available on
the NHS and their reproducibility has been shown to be
very poor. "Alternative Practitioners" providing therapy for
food intolerance and allergies vary in their training and
perceptions. Many of their diagnostic tools would not
withstand scientific scrutiny and for these reasons they are
not recommended.
Other more controversial tests e.g. cytotoxic food tests,
hair and nail tests, pulse testing and sublingual
provocative testing which are less sensitive, have been
developed to diagnose allergy. They are not available on
the NHS and their reproducibility has been shown to be
very poor. "Alternative Practitioners" providing therapy for
food intolerance and allergies vary in their training and
perceptions. Many of their diagnostic tools would not
withstand scientific scrutiny and for these reasons they are
not recommended.
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55
Dietary Investigation of Food Hypersensitivity
Dietary Investigation of Food Hypersensitivity
Manipulative dietary investigations should not be
undertaken lightly. Infants may be nutritionally at risk due
to dietary constraints. A paediatric dietitian should assess
the diet in order to ensure long-term nutritional adequacy
and the complete removal of potential allergens.
Manipulative dietary investigations should not be
undertaken lightly. Infants may be nutritionally at risk due
to dietary constraints. A paediatric dietitian should assess
the diet in order to ensure long-term nutritional adequacy
and the complete removal of potential allergens.
Breast milk is the best milk for infants with food allergies. It
may be necessary for the mother to change her diet to
ensure that the breast milk does not contain the offending
allergen. The paediatric dietitian can advise on this. If
breast milk is not available and a milk allergy is suspected
then the following options can be advised:
Breast milk is the best milk for infants with food allergies. It
may be necessary for the mother to change her diet to
ensure that the breast milk does not contain the offending
allergen. The paediatric dietitian can advise on this. If
breast milk is not available and a milk allergy is suspected
then the following options can be advised:

Infants 6 months of age and under - offer an
extensively hydrolysed cows milk formula e.g.
Nutramigen Lipil 1 (Mead Johnson)

Infants 6 months of age and under - offer an
extensively hydrolysed cows milk formula e.g.
Nutramigen Lipil 1 (Mead Johnson)

Infants over 6 months of age - offer an extensively
hydrolysed cows milk formula e.g. Nutramigen Lipil 2
(Mead Johnson)

Infants over 6 months of age - offer an extensively
hydrolysed cows milk formula e.g. Nutramigen Lipil 2
(Mead Johnson)

Infants over 12 months of age - offer an extensively
hydrolysed cows milk formula e.g. Nutramigen Lipil 2
(Mead Johnson) or a soya infant formula e.g. SMA
Wysoy (SMA Nutrition), Infasoy (Cow & Gate).

Infants over 12 months of age - offer an extensively
hydrolysed cows milk formula e.g. Nutramigen Lipil 2
(Mead Johnson) or a soya infant formula e.g. SMA
Wysoy (SMA Nutrition), Infasoy (Cow & Gate).

Soya infant formula milk should not be recommended
for infants under 6 months of age (BDA 2003b, SACN
& COT 2003).

Soya infant formula milk should not be recommended
for infants under 6 months of age (BDA 2003b, SACN
& COT 2003).

Soya milks (off the shelf) should only be used as a
main drink from the age of 2 years.

Soya milks (off the shelf) should only be used as a
main drink from the age of 2 years.
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56

Alternatives to soya milk such as oat milk & coconut
milk should only be used as a main drink from the
age of 2 years.

Alternatives to soya milk such as oat milk & coconut
milk should only be used as a main drink from the
age of 2 years.

Rice milk is not recommended as a main drink in
children under 4½ years of age (FSA 2009a).

Rice milk is not recommended as a main drink in
children under 4½ years of age (FSA 2009a).

Goat’s milk & sheep’s milk are not recommended in
the treatment of milk allergy.

Goat’s milk & sheep’s milk are not recommended in
the treatment of milk allergy.

If the infant does not respond to the above formula,
there is colitis, failure to thrive associated with the
atopy, multiple food allergy or anaphylaxis an amino
acid formula such as Nutramigen AA (Mead Johnson)
or Neocate LCP (SHS) should be tried.

If the infant does not respond to the above formula,
there is colitis, failure to thrive associated with the
atopy, multiple food allergy or anaphylaxis an amino
acid formula such as Nutramigen AA (Mead Johnson)
or Neocate LCP (SHS) should be tried.
As with all formula milk substitutes good dental hygiene
should be practiced due to their sugar content (See
Chapter 7 Oral Health).
As with all formula milk substitutes good dental hygiene
should be practiced due to their sugar content (See
Chapter 7 Oral Health).
Potential hazards of anaphylaxis or other life-threatening
symptoms may result from the reintroduction of foods. If
doubt exists over the risks of food challenges the child
should be referred to a paediatric dietitian orConsultant
Paediatrician for assessment, with planned hospital
admission if needed.
Potential hazards of anaphylaxis or other life-threatening
symptoms may result from the reintroduction of foods. If
doubt exists over the risks of food challenges the child
should be referred to a paediatric dietitian orConsultant
Paediatrician for assessment, with planned hospital
admission if needed.
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57
The Prevention of Infant Developing Allergic
Disease.
The Prevention of Infant Developing Allergic
Disease.
Some infants are at greater risk of developing allergic
disease. If they have a parent or sibling with atopy then they
are more likely to develop allergic disease. The following are
practical dietary prevention strategies for infants at risk of
developing allergic disease (BDA 2010).
Some infants are at greater risk of developing allergic
disease. If they have a parent or sibling with atopy then they
are more likely to develop allergic disease. The following are
practical dietary prevention strategies for infants at risk of
developing allergic disease (BDA 2010).

Mother should eat a healthy, balanced diet during
pregnancy and lactation. Their diet can include all
major allergens unless they have a food allergy
themselves.

Mother should eat a healthy, balanced diet during
pregnancy and lactation. Their diet can include all
major allergens unless they have a food allergy
themselves.

Ideally breast milk should be the sole source of nutrition
until 6 months of age.

Ideally breast milk should be the sole source of nutrition
until 6 months of age.

Recommended alternatives to breast milk are
extensively hydrolysed formula milks.

Recommended alternatives to breast milk are
extensively hydrolysed formula milks.

Other milks including soy, goat and standard cows milk
formula or off the shelf cow, goat, sheep, soy or rice
milk should not be given.

Other milks including soy, goat and standard cows milk
formula or off the shelf cow, goat, sheep, soy or rice
milk should not be given.

Weaning should never commence before the age of 17
weeks and any foods given between 4-6 months should
be low-allergen weaning foods such as carrot, rice,
pear etc.

Weaning should never commence before the age of 17
weeks and any foods given between 4-6 months should
be low-allergen weaning foods such as carrot, rice,
pear etc.

From the age of 6 months once weaning has been
established with low allergenic weaning foods, higher
allergenic weaning foods can be introduced.

From the age of 6 months once weaning has been
established with low allergenic weaning foods, higher
allergenic weaning foods can be introduced.
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58
 High allergenic food such as wheat, egg and milk
should be commenced by adding each food singly
starting with a small amount and introducing no more
than one allergenic food at a time.
 High allergenic food such as wheat, egg and milk
should be commenced by adding each food singly
starting with a small amount and introducing no more
than one allergenic food at a time.
 By the age of 12 months all major allergens which
would normally be suitable for a child of this age
should have been introduced with the exception of
peanuts.
 By the age of 12 months all major allergens which
would normally be suitable for a child of this age
should have been introduced with the exception of
peanuts.
 There is no evidence that delaying the introduction of
high allergenic foods after the age of 6 months is
beneficial to at-risk infants.
 There is no evidence that delaying the introduction of
high allergenic foods after the age of 6 months is
beneficial to at-risk infants.
 Delayed weaning beyond 6 months could adversely
affect the normal dietary and developmental
milestones essential to establishing a good, varied
diet.
 Delayed weaning beyond 6 months could adversely
affect the normal dietary and developmental
milestones essential to establishing a good, varied
diet.
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59
10. Fussy/Selective Eaters
10. Fussy/Selective Eaters
Food refusal/fussy eating is very common in children
(especially those under 5) and is a normal part of growing
up and showing independence. Most children will go
through phases of refusing individual foods or at times
complete refusal to eat. However, parents can become
anxious and mealtimes can often become a ‘battle’.
Reassuring parents that food refusal is usually only short
lived and therefore not likely to cause any long term
problems is advised.
Food refusal/fussy eating is very common in children
(especially those under 5) and is a normal part of growing
up and showing independence. Most children will go
through phases of refusing individual foods or at times
complete refusal to eat. However, parents can become
anxious and mealtimes can often become a ‘battle’.
Reassuring parents that food refusal is usually only short
lived and therefore not likely to cause any long term
problems is advised.
Encourage a regular eating pattern i.e. 3 meals plus 2
small snacks. Offer 2 courses at each meal time e.g. 1
savoury plus 1 sweet. The sweet course is often used as a
’bargaining tool’ by parents to convince children to eat the
savoury part but this should be discouraged.
Encourage a regular eating pattern i.e. 3 meals plus 2
small snacks. Offer 2 courses at each meal time e.g. 1
savoury plus 1 sweet. The sweet course is often used as a
’bargaining tool’ by parents to convince children to eat the
savoury part but this should be discouraged.
One meal should be offered and removed without
comment if the child refuses to eat it. Do not offer
alternatives.
One meal should be offered and removed without
comment if the child refuses to eat it. Do not offer
alternatives.
Meal times should be fun. Encourage the use of brightly
coloured plates and cups and present food in fun,
attractive ways.
Meal times should be fun. Encourage the use of brightly
coloured plates and cups and present food in fun,
attractive ways.
Only positive feedback or praise should be given. Ignore
the behaviour you don’t like and praise the behaviour you
do.
Only positive feedback or praise should be given. Ignore
the behaviour you don’t like and praise the behaviour you
do.
Allow at least 1 hour between a snack and next meal and
do not offer drinks just before a meal or large volumes of
fluid during a meal.
Allow at least 1 hour between a snack and next meal and
do not offer drinks just before a meal or large volumes of
fluid during a meal.
Try not to rush mealtimes, but set a maximum of 30
Try not to rush mealtimes, but set a maximum of 30
60
60
minutes so it doesn’t drag on for too long.
minutes so it doesn’t drag on for too long.
Encourage families to work together to deal with the issue so
the child is not hearing conflicting messages from different
people. They may need to involve other people like
grandparents or a childminder, who the child may be with at
mealtimes.
Encourage families to work together to deal with the issue so
the child is not hearing conflicting messages from different
people. They may need to involve other people like
grandparents or a childminder, who the child may be with at
mealtimes.
Discourage rewards of food when a child eats well. Other
reward ideas include taking them to the park or going to see
friends.
Discourage rewards of food when a child eats well. Other
reward ideas include taking them to the park or going to see
friends.
Families should be encouraged to eat together whenever
possible and in a calm, relaxed area without distraction such
as toys or television. Children will often learn from parents
and siblings and be more inclined to try new foods if they are
being eaten by those around them.
Families should be encouraged to eat together whenever
possible and in a calm, relaxed area without distraction such
as toys or television. Children will often learn from parents
and siblings and be more inclined to try new foods if they are
being eaten by those around them.
Food should not be withheld as a punishment for not eating.
Food should not be withheld as a punishment for not eating.
Do not force feed.
Do not force feed.
Do not offer large portions that are unlikely to be finished
or insist on clean plates.
Do not offer large portions that are unlikely to be finished
or insist on clean plates.
Encourage parents to speak with friends/other parents who
are going through or have gone through similar experiences
so they know they are not alone.
Encourage parents to speak with friends/other parents who
are going through or have gone through similar experiences
so they know they are not alone.
Perseverance is they key to success! Although things may
get worse initially, it is likely to improve once the child gets
used to the changes and responds to the positive praise he/
she is now receiving
Perseverance is they key to success! Although things may
get worse initially, it is likely to improve once the child gets
used to the changes and responds to the positive praise he/
she is now receiving
If the problems start to affect growth and/or development,
refer on to the GP or paediatric dietitian for further
assessment and advice (See Chapter 6 Growth).
If the problems start to affect growth and/or development,
refer on to the GP or paediatric dietitian for further
assessment and advice (See Chapter 6 Growth).
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61
11. Iron Deficiency
11. Iron Deficiency
Iron deficiency anaemia is the most common nutrient
deficiency in childhood worldwide (Mira et al 1996). It is
not unique to any population, but it is more common in
families of African and Afro Caribbean origin (Shaw et al
2007). Eighty four percent of children aged 1½ to 4½ in
the UK have iron intakes below the recommended intake,
with 16% at serious risk of a deficiency (Gregory et al
1995).
Iron deficiency anaemia is the most common nutrient
deficiency in childhood worldwide (Mira et al 1996). It is
not unique to any population, but it is more common in
families of African and Afro Caribbean origin (Shaw et al
2007). Eighty four percent of children aged 1½ to 4½ in
the UK have iron intakes below the recommended intake,
with 16% at serious risk of a deficiency (Gregory et al
1995).
Iron is a component of haemoglobin, myoglobin and
several enzymes and has many metabolic functions in
addition to its role in transportation of oxygen.
Iron is a component of haemoglobin, myoglobin and
several enzymes and has many metabolic functions in
addition to its role in transportation of oxygen.
Those most at risk of developing iron deficiency anaemia
include:-
Those most at risk of developing iron deficiency anaemia
include:-
Pre-term infants
Fussy/selective eaters
Children who drink excessive amounts of cow’s milk.
Infants introduced to cow’s milk as a main drink before
12 months
Infants weaned later than 6 months.
Pre-term infants
Fussy/selective eaters
Children who drink excessive amounts of cow’s milk.
Infants introduced to cow’s milk as a main drink before
12 months
Infants weaned later than 6 months.
Iron Deficiency can result in:-
Iron Deficiency can result in:-
Poor growth
Psychomotor delay
Lethargy and tiredness
Poor appetite
Breathlessness
Frequent infections
Behavioural problems
Poor growth
Psychomotor delay
Lethargy and tiredness
Poor appetite
Breathlessness
Frequent infections
Behavioural problems
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Iron Requirements
Iron Requirements
Infants and toddlers have relatively high requirements for
iron due to their rapid growth rate. Requirements for iron
vary with age (GOS 2009).
Infants and toddlers have relatively high requirements for
iron due to their rapid growth rate. Requirements for iron
vary with age (GOS 2009).
Age
Male &
Female
(mg)
Age
Male &
Female
(mg)
0-3 months
1.7
0-3 months
1.7
4-6 months
4.3
4-6 months
4.3
7-12 months
7.8
7-12 months
7.8
1-3 years
6.9
1-3 years
6.9
Meeting Iron Requirements
Meeting Iron Requirements
Iron in food is found in haem (animal) and non-haem
(plant) forms, with those from an animal source being
better absorbed. Taking vitamin C with a meal can
increase the absorption of non-haem iron. Tannin (the
brown colouring) in tea can reduce iron absorption so
ideally this should be avoided around meal times.
Iron in food is found in haem (animal) and non-haem
(plant) forms, with those from an animal source being
better absorbed. Taking vitamin C with a meal can
increase the absorption of non-haem iron. Tannin (the
brown colouring) in tea can reduce iron absorption so
ideally this should be avoided around meal times.
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63
Foods Rich in Iron
Foods Rich in Iron
The following table provides information on the iron
content of some everyday foods (Food Standards Agency
2002).
The following table provides information on the iron
content of some everyday foods (Food Standards Agency
2002).
Quantity
Food
Quantity
Food
100g
90g
1 (60g)
2 (80g)
80g small breast
2
46g
20g/1 tsp
90g
1
1 slice
1 slice
25g
2
1tbsp
60g
small bar
Handful
2 spears
1 small tin (150g)
2
4
50g
125g can
Savoury minced beef
Roast beef
Beefburger
Sausages
Chicken
Fish fingers
Tuna
Peanut butter
Roast lamb
Egg
White bread
Wholemeal bread
Fortified Breakfast cereal
Ginger biscuits
Lentils (cooked)
Quorn
Milk chocolate
Raisins
Broccoli
Baked beans
Weetabix
Dried Apricots
Chick peas
Sardines in tomato sauce
1.4
2.6
1.5
1.0
0.4
0.4
0.5
0.4
1.4
1.0
0.6
0.9
2.0
0.8
1.4
0.4
0.8
1.1
0.9
2.0
4.8
1.1
0.7
3.6
100g
90g
1 (60g)
2 (80g)
80g small breast
2
46g
20g/1 tsp
90g
1
1 slice
1 slice
25g
2
1tbsp
60g
small bar
Handful
2 spears
1 small tin (150g)
2
4
50g
125g can
Savoury minced beef
Roast beef
Beefburger
Sausages
Chicken
Fish fingers
Tuna
Peanut butter
Roast lamb
Egg
White bread
Wholemeal bread
Fortified Breakfast cereal
Ginger biscuits
Lentils (cooked)
Quorn
Milk chocolate
Raisins
Broccoli
Baked beans
Weetabix
Dried Apricots
Chick peas
Sardines in tomato sauce
1.4
2.6
1.5
1.0
0.4
0.4
0.5
0.4
1.4
1.0
0.6
0.9
2.0
0.8
1.4
0.4
0.8
1.1
0.9
2.0
4.8
1.1
0.7
3.6
3tbsp (40g)
1 small
1 large slice
50g
1 thin slice (38g)
100g
Garden peas
Baked potato + skin
Watermelon
Red kidney beans
Corned beef
salmon
0.6
0.7
0.6
1.3
1.0
0.5
3tbsp (40g)
1 small
1 large slice
50g
1 thin slice (38g)
100g
Garden peas
Baked potato + skin
Watermelon
Red kidney beans
Corned beef
salmon
0.6
0.7
0.6
1.3
1.0
0.5
Iron
(mg)
64
Iron
(mg)
64
12. Common Gut Problems
12. Common Gut Problems
(i) Infantile Colic
(i) Infantile Colic
Colic is a common, harmless but distressing complaint of
unknown cause in both breast and bottle fed infants. The
term colic is sometimes applied to prolonged crying
episodes in an otherwise healthy baby, particularly in the
first 3 months of life. Many infants have unsettled periods
during the day, especially in the evening. This is known as
"3 month colic" or "evening colic".
Colic is a common, harmless but distressing complaint of
unknown cause in both breast and bottle fed infants. The
term colic is sometimes applied to prolonged crying
episodes in an otherwise healthy baby, particularly in the
first 3 months of life. Many infants have unsettled periods
during the day, especially in the evening. This is known as
"3 month colic" or "evening colic".
Fortunately, "three month colic" is a benign, self-limiting
condition, which disappears spontaneously at about three
months of age without any intervention. However,
occasionally, these episodes can mask a more serious
condition e.g. milk protein or lactose intolerance or
intussusception, which require intervention.
Fortunately, "three month colic" is a benign, self-limiting
condition, which disappears spontaneously at about three
months of age without any intervention. However,
occasionally, these episodes can mask a more serious
condition e.g. milk protein or lactose intolerance or
intussusception, which require intervention.
Colic should be recognised as causing considerable
parental anxiety and managed sympathetically by staff.
Colic should be recognised as causing considerable
parental anxiety and managed sympathetically by staff.
An assessment of the baby's feeding pattern should be
undertaken, including: feeding position, feed
concentration, over feeding, teat size and winding method.
An assessment of the baby's feeding pattern should be
undertaken, including: feeding position, feed
concentration, over feeding, teat size and winding method.
All infants causing parental concern should be reviewed by
the health visitor who will refer on if necessary (Garrison &
Christakis, 1998)
All infants causing parental concern should be reviewed by
the health visitor who will refer on if necessary (Garrison &
Christakis, 1998)
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65
Ways of managing colic include:
Ways of managing colic include:
Feeding Pattern
Feeding Pattern



Offering more frequent feeds of reduced amount,
but maintaining the same total volume.
Checking that the infant is well positioned during
feeding.

Offering more frequent feeds of reduced amount,
but maintaining the same total volume.
Checking that the infant is well positioned during
feeding.
Drugs
Drugs



Dicyclomine hydrochloride (Merbentyl) should not
be used for infants less than 6 months old due to
the risk of apnoea.
Simethicone (Infacol) Dentinox and Colief (lactase)
are currently marketed for colic.

Dicyclomine hydrochloride (Merbentyl) should not
be used for infants less than 6 months old due to
the risk of apnoea.
Simethicone (Infacol) Dentinox and Colief (lactase)
are currently marketed for colic.
Diet
Diet
Gripe water which contains sugar and water, and herbal
drinks containing sugar are not recommended.
Gripe water which contains sugar and water, and herbal
drinks containing sugar are not recommended.
Colic should not be used as a reason to stop breastfeeding.
Colic should not be used as a reason to stop breastfeeding.
There is no specific nutritional advice that can be given
for colic as no one specific food has been proven to
cause it. Changing an infant's feed is not recommended; in fact changing from a whey to casein based
formula may well aggravate the problem. There is
some anecdotal evidence that casein-based formula
induce constipation and exacerbate "colic".
There is no specific nutritional advice that can be given
for colic as no one specific food has been proven to
cause it. Changing an infant's feed is not recommended; in fact changing from a whey to casein based
formula may well aggravate the problem. There is
some anecdotal evidence that casein-based formula
induce constipation and exacerbate "colic".
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ii) Vomiting and Regurgitation
ii) Vomiting and Regurgitation
Vomiting
Vomiting
All babies vomit occasionally. Vomiting in a baby who does
not usually vomit or vomiting associated with weight loss requires medical attention.
All babies vomit occasionally. Vomiting in a baby who does
not usually vomit or vomiting associated with weight loss requires medical attention.
Important questions to ask if a baby is vomiting:
Important questions to ask if a baby is vomiting:







what is the nature of the vomitus? e.g. does it contain
blood or bile?
is it forceful or regurgitant?
is it related to feeds?
how long after a feed?
are feeding volumes appropriate?
is the weight gain normal?





what is the nature of the vomitus? e.g. does it contain
blood or bile?
is it forceful or regurgitant?
is it related to feeds?
how long after a feed?
are feeding volumes appropriate?
is the weight gain normal?
Regurgitation (passive, non forceful vomiting) is common in
infants of less than three months who may have a relaxed
lower oesophageal sphincter. This is gastro-oesophageal
reflux and will settle with time.
Regurgitation (passive, non forceful vomiting) is common in
infants of less than three months who may have a relaxed
lower oesophageal sphincter. This is gastro-oesophageal
reflux and will settle with time.
The baby’s stomach should be given a chance to empty before lying down. Lying on the left side is associated with less
reflux as the stomach is better able to store milk in this position, with less likelihood of milk entering the oesophagus.
The baby’s stomach should be given a chance to empty before lying down. Lying on the left side is associated with less
reflux as the stomach is better able to store milk in this position, with less likelihood of milk entering the oesophagus.
Babies who regurgitate a lot may benefit from thickening the
milk with a commercially available prescribed thickening
agent e.g. Carobel, Thixo-D or Thick and Easy. It can be
given as a gel before breast feeds. Pre-thickened formula
milks are also available, such as Enfamil AR and SMA Staydown. Infant Gaviscon is an alternative which can be added
to feeds.
Babies who regurgitate a lot may benefit from thickening the
milk with a commercially available prescribed thickening
agent e.g. Carobel, Thixo-D or Thick and Easy. It can be
given as a gel before breast feeds. Pre-thickened formula
milks are also available, such as Enfamil AR and SMA Staydown. Infant Gaviscon is an alternative which can be added
to feeds.
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Troublesome vomiting should be evaluated by the GP or Paediatrician. Pathological causes of vomiting e.g. pyloric stenosis may need to be ruled out. Milk intolerance can be a cause
of vomiting. A two week trial period of an extensively hydrolysed formula or amino acids formula should be used
(NASPGHAN & ESPGHAN, 2009)
Troublesome vomiting should be evaluated by the GP or Paediatrician. Pathological causes of vomiting e.g. pyloric stenosis may need to be ruled out. Milk intolerance can be a cause
of vomiting. A two week trial period of an extensively hydrolysed formula or amino acids formula should be used
(NASPGHAN & ESPGHAN, 2009)
(iii) Diarrhoea
(iii) Diarrhoea
Normal bowel frequency can vary from several stools a day to
one every four or five days. Diarrhoea is usually regarded as
the passage of four or more watery stools a day but is sometimes indicated by just a change in frequency or consistency.
Before advising treatment, confirm the diagnosis by taking a
history.
Normal bowel frequency can vary from several stools a day to
one every four or five days. Diarrhoea is usually regarded as
the passage of four or more watery stools a day but is sometimes indicated by just a change in frequency or consistency.
Before advising treatment, confirm the diagnosis by taking a
history.
Acute Diarrhoea
Acute Diarrhoea
Dehydration is uncommon in babies and young children with
gastroenteritis. Management aims to prevent and treat dehydration while maintaining adequate nutrition or resuming it as
early as possible.
Dehydration is uncommon in babies and young children with
gastroenteritis. Management aims to prevent and treat dehydration while maintaining adequate nutrition or resuming it as
early as possible.
Breastfed infants should continue breast feeding with
oral rehydration (OR) solution given in addition as part of rehydration therapy. Bottle fed infants should stop formula milk for
4-6 hours and replace with oral hydration solution to replace
prior and ongoing losses of fluid (DoH 2009).
Breastfed infants should continue breast feeding with
oral rehydration (OR) solution given in addition as part of rehydration therapy. Bottle fed infants should stop formula milk for
4-6 hours and replace with oral hydration solution to replace
prior and ongoing losses of fluid (DoH 2009).
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Oral rehydration solutions are not adequate nutrition and
should not be used alone. Sugary drinks e.g. cola should
not be used as a substitute for proprietary oral
rehydration solutions. Only use commercially prepared
oral rehydration solutions e.g. Dioralyte. Oral rehydration
solutions should be given in small frequent amounts.
When oral rehydration solutions are not immediately
available used cooled boiled water.
Oral rehydration solutions are not adequate nutrition and
should not be used alone. Sugary drinks e.g. cola should
not be used as a substitute for proprietary oral
rehydration solutions. Only use commercially prepared
oral rehydration solutions e.g. Dioralyte. Oral rehydration
solutions should be given in small frequent amounts.
When oral rehydration solutions are not immediately
available used cooled boiled water.
Bottle fed babies can return straight to full strength feeds.
Bottle fed babies can return straight to full strength feeds.
Diet should be recommenced after rehydration
Diet should be recommenced after rehydration
Normal Fluid Intake
Normal Fluid Intake
Feeding should be re-established as soon as possible as
withholding milk repeatedly or for prolonged periods can
be harmful. Infants and children should not be fasted as
they may become nutritionally compromised .
Feeding should be re-established as soon as possible as
withholding milk repeatedly or for prolonged periods can
be harmful. Infants and children should not be fasted as
they may become nutritionally compromised .
Age
Age
Volume
/ kg / 24 hours
Volume
/ kg / 24 hours
0 - 6 months
150 - 200 ml
0 - 6 months
150 - 200 ml
6 - 9 months
120 - 150 ml
6 - 9 months
120 - 150 ml
12 months
90 - 100 ml
2 years
80 - 90 ml
69
12 months
90 - 100 ml
2 years
80 - 90 ml
69
Stool frequency often increases when milk or solids are
reintroduced. This does not require a return to fasting oral
rehydration solution unless vomiting or dehydration recur.
This can be compensated by offering 10-30 ml/kg/loose
stool of oral rehydration solution.
Stool frequency often increases when milk or solids are
reintroduced. This does not require a return to fasting oral
rehydration solution unless vomiting or dehydration recur.
This can be compensated by offering 10-30 ml/kg/loose
stool of oral rehydration solution.
Diarrhoea which persists for longer than seven days after
gastroenteritis may be caused by transient lactose or cow’s
milk protein intolerance. This may require exclusion of dairy
products but care is needed to ensure the exclusion of other
lactose or milk protein containing foods. A specialised
formula milk (Chapter 9 Food Hypersensitivity) should be
used if the child is below 2 years of age. This should be
under the supervision of the general practitioner with advice
from a paediatric dietitian where appropriate.
Diarrhoea which persists for longer than seven days after
gastroenteritis may be caused by transient lactose or cow’s
milk protein intolerance. This may require exclusion of dairy
products but care is needed to ensure the exclusion of other
lactose or milk protein containing foods. A specialised
formula milk (Chapter 9 Food Hypersensitivity) should be
used if the child is below 2 years of age. This should be
under the supervision of the general practitioner with advice
from a paediatric dietitian where appropriate.
Toddler Diarrhoea
Toddler Diarrhoea
This poorly understood problem usually presents after six
months, often following weaning. The child shows increased
stool frequency or diarrhoea, passing undigested pieces of
food.
This poorly understood problem usually presents after six
months, often following weaning. The child shows increased
stool frequency or diarrhoea, passing undigested pieces of
food.
However, they are otherwise well and thriving with a normal
pattern of growth (see Chapter 6 Growth). This usually
resolves by three years but before making such a diagnosis,
other more serious causes of chronic diarrhoea must be
excluded by a medical practitioner.
However, they are otherwise well and thriving with a normal
pattern of growth (see Chapter 6 Growth). This usually
resolves by three years but before making such a diagnosis,
other more serious causes of chronic diarrhoea must be
excluded by a medical practitioner.
A brief dietary history should be taken to establish whether
the diet contains excess fibre or inadequate fat, and this
should be adjusted accordingly.
A brief dietary history should be taken to establish whether
the diet contains excess fibre or inadequate fat, and this
should be adjusted accordingly.
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(iv) Constipation
(iv) Constipation
Normal bowel frequency may vary from several stools
per day to 4-5 days between stools.
Normal bowel frequency may vary from several stools
per day to 4-5 days between stools.
Infants are not constipated if stools are soft but passed
infrequently.
Infants are not constipated if stools are soft but passed
infrequently.
Breast-fed babies are rarely constipated and bottle fed
babies who pass stools without excessive straining are
unlikely to have serious problems. Contributory factors
to bottle fed babies having constipation include:-
Breast-fed babies are rarely constipated and bottle fed
babies who pass stools without excessive straining are
unlikely to have serious problems. Contributory factors
to bottle fed babies having constipation include:-
1.
The milk feeds may be over-concentrated or
1.
The milk feeds may be over-concentrated or
2.
Inadequate fluid is taken
2.
Inadequate fluid is taken
Before advising treatment, make sure, by taking a
history, that the infant really is constipated. Parents
often become disproportionately anxious about their
baby's bowel habits, and often it is reassurance that is
required rather than action since the infants are not truly
constipated.
Before advising treatment, make sure, by taking a
history, that the infant really is constipated. Parents
often become disproportionately anxious about their
baby's bowel habits, and often it is reassurance that is
required rather than action since the infants are not truly
constipated.
There may also be a behavioural element to the
problem in toddlers.
There may also be a behavioural element to the
problem in toddlers.
Constipation in bottle-fed babies may be prevented by
offering cooled, boiled water at regular intervals.
Constipation in bottle-fed babies may be prevented by
offering cooled, boiled water at regular intervals.
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Stools may be small, greenish, pellet-like, hard, difficult
to pass and occasionally these may be blood-streaked if
a fissure develops. Fissures are painful and may
perpetuate the constipation.
Stools may be small, greenish, pellet-like, hard, difficult
to pass and occasionally these may be blood-streaked if
a fissure develops. Fissures are painful and may
perpetuate the constipation.
If constipation is a problem in young babies, the first
step should be to ensure that an adequate fluid intake is
being given. Extra drinks of cooled boiled water can be
helpful, as can fruit juices such as pure orange juice
diluted with water in the dilution of 1:12.
If constipation is a problem in young babies, the first
step should be to ensure that an adequate fluid intake is
being given. Extra drinks of cooled boiled water can be
helpful, as can fruit juices such as pure orange juice
diluted with water in the dilution of 1:12.
Sugary drinks are not recommended.
Sugary drinks are not recommended.
Diluted prune juice has also been found to be helpful.
Great care should be taken that this is not used
routinely in case it gives baby a "sweet tooth".
Diluted prune juice has also been found to be helpful.
Great care should be taken that this is not used
routinely in case it gives baby a "sweet tooth".
High-fibre foods can be encouraged in the diet eg
puréed fruits, vegetables, cereals, beans and pulses.
High fibre foods should gradually be increased in the
diet. Pure bran is not recommended for children under 2
years.
High-fibre foods can be encouraged in the diet eg
puréed fruits, vegetables, cereals, beans and pulses.
High fibre foods should gradually be increased in the
diet. Pure bran is not recommended for children under 2
years.
Movicol Paediatric Plain (Norgine) could be commenced
if dietary change is not effective.
Movicol Paediatric Plain (Norgine) could be commenced
if dietary change is not effective.
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(v) Coeliac Disease
(v) Coeliac Disease
Children with symptoms suggestive of coeliac disease (e.g.
chronic diarrhoea, poor weight gain, short stature) should have
their tissue transglutaminase IgA estimated (DoH) 2009). If
positive they should be referred to a Regional Paediatric Gastroenterology Service, eg Southampton General Hospital or
the Royal Alexandra Children's Hospital, Brighton for duodenal
biopsy by endoscopy under general anaesthetic. The test is
90% sensitive and specific, but can be negative if the child is
IgA deficient, hence children should be referred even if the test
is negative if there are strong reasons to suspect coeliac disease (e.g. positive family history). Children should not be
commenced on a gluten free diet until the endoscopy has
been performed.
Children with symptoms suggestive of coeliac disease (e.g.
chronic diarrhoea, poor weight gain, short stature) should have
their tissue transglutaminase IgA estimated (DoH) 2009). If
positive they should be referred to a Regional Paediatric Gastroenterology Service, eg Southampton General Hospital or
the Royal Alexandra Children's Hospital, Brighton for duodenal
biopsy by endoscopy under general anaesthetic. The test is
90% sensitive and specific, but can be negative if the child is
IgA deficient, hence children should be referred even if the test
is negative if there are strong reasons to suspect coeliac disease (e.g. positive family history). Children should not be
commenced on a gluten free diet until the endoscopy has
been performed.
The following groups of patients should be screened for
coeliac disease by estimating tissue transglutaminase IgA after
5 years of age:

Type 1 Diabetes

Dental enamel defects

IgA deficiency

Down’s syndrome

Turner syndrome

Williams syndrome

First degree relatives of patients with Coeliac Disease

Autoimmune thyroiditis
The following groups of patients should be screened for
coeliac disease by estimating tissue transglutaminase IgA after
5 years of age:

Type 1 Diabetes

Dental enamel defects

IgA deficiency

Down’s syndrome

Turner syndrome

Williams syndrome

First degree relatives of patients with Coeliac Disease

Autoimmune thyroiditis
Once diagnosed children with coeliac disease should be reviewed annually (BSPGHAN, 2008) preferably in a multidisciplinary clinic consisting of a consultant paediatric gastroenterologist and paediatric dietitian. The benefits of this include a regular review of nutritional intake, compliance, growth
assessment and networking with representatives from the food
industry and other children with coeliac disease.
Once diagnosed children with coeliac disease should be reviewed annually (BSPGHAN, 2008) preferably in a multidisciplinary clinic consisting of a consultant paediatric gastroenterologist and paediatric dietitian. The benefits of this include a regular review of nutritional intake, compliance, growth
assessment and networking with representatives from the food
industry and other children with coeliac disease.
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13. Paediatric Dysphagia
13. Paediatric Dysphagia
Whilst the main purpose of eating is to achieve an adequate
intake of food in order to sustain growth, the process of
eating is not just one of sustaining life. In human societies,
it is a social event. Infants undergo their earliest
communication experience during feeding.
Whilst the main purpose of eating is to achieve an adequate
intake of food in order to sustain growth, the process of
eating is not just one of sustaining life. In human societies,
it is a social event. Infants undergo their earliest
communication experience during feeding.
Dysphagia describes eating and drinking disorders. These
may occur in the oral, pharyngeal and oesophageal stages
of eating. Difficulties incurred may include one or a
combination of the following –
Dysphagia describes eating and drinking disorders. These
may occur in the oral, pharyngeal and oesophageal stages
of eating. Difficulties incurred may include one or a
combination of the following –
- Positioning food in the mouth.
- Oral movements including sucking and chewing.
- Swallow process.
- Positioning food in the mouth.
- Oral movements including sucking and chewing.
- Swallow process.
Eating and drinking is a highly complex skill, which involves
many systems:
e.g.
- Anatomic stability.
- Neuromuscular control and co-ordination
- Sensory perception
- The digestive process
- Cardio-respiratory support
- Integration from the autonomic nervous system.
Eating and drinking is a highly complex skill, which involves
many systems:
e.g.
- Anatomic stability.
- Neuromuscular control and co-ordination
- Sensory perception
- The digestive process
- Cardio-respiratory support
- Integration from the autonomic nervous system.
The client group for the Paediatric Dysphagia Service
includes babies, pre-school and school-aged children and
young people within the school system. They may have
additional anatomical, learning, communication and sensory
behavioural and physical needs. Their difficulties may be
acquired or congenital and can be associated with the
following –
The client group for the Paediatric Dysphagia Service
includes babies, pre-school and school-aged children and
young people within the school system. They may have
additional anatomical, learning, communication and sensory
behavioural and physical needs. Their difficulties may be
acquired or congenital and can be associated with the
following –
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- Prematurity.
- Neurological defects e.g. cerebral palsy, acquired
traumatic brain injury.
- Infectious disease e.g. meningitis.
- Neuromuscular disorders e.g. muscular dystrophy.
- Respiratory difficulties e.g. tracheostomy, structural
abnormalities of the upper respiratory tract.
- Cardiovascular disorders e.g. congenital heart
disease.
- Gastrointestinal difficulties e.g. gastro-oesophageal
reflux.
- Congenital syndromes e.g. Down’s Syndrome, Rett’s
Syndrome.
- Learning disability.
- Craniofacial conditions e.g. cleft palate, Pierre Robin
sequence, Apert Syndrome, Treacher-Collins
Syndrome.
- Prematurity.
- Neurological defects e.g. cerebral palsy, acquired
traumatic brain injury.
- Infectious disease e.g. meningitis.
- Neuromuscular disorders e.g. muscular dystrophy.
- Respiratory difficulties e.g. tracheostomy, structural
abnormalities of the upper respiratory tract.
- Cardiovascular disorders e.g. congenital heart
disease.
- Gastrointestinal difficulties e.g. gastro-oesophageal
reflux.
- Congenital syndromes e.g. Down’s Syndrome, Rett’s
Syndrome.
- Learning disability.
- Craniofacial conditions e.g. cleft palate, Pierre Robin
sequence, Apert Syndrome, Treacher-Collins
Syndrome.
The feeding management of children with cleft lip and
palate is the responsibility of the Multi-disciplinary Cleft Lip
and Palate team co-ordinated by the Clinical Nurse
Specialist within this team. The Cleft Lip and Palate team
serving the Sussex Community NHS Trust (West) is based
at Salisbury Hospital. The service to children with cleft lip
and/or palate in other areas may be different.
The feeding management of children with cleft lip and
palate is the responsibility of the Multi-disciplinary Cleft Lip
and Palate team co-ordinated by the Clinical Nurse
Specialist within this team. The Cleft Lip and Palate team
serving the Sussex Community NHS Trust (West) is based
at Salisbury Hospital. The service to children with cleft lip
and/or palate in other areas may be different.
There are some children with isolated eating and drinking
difficulties, which may be related to sensory difficulties e.g.
problems with smell or texture and/or sensitivities.
Children with autism and those with a traumatic feeding
history e.g. tube feeding or surgery, can fall into this
category.
There are some children with isolated eating and drinking
difficulties, which may be related to sensory difficulties e.g.
problems with smell or texture and/or sensitivities.
Children with autism and those with a traumatic feeding
history e.g. tube feeding or surgery, can fall into this
category.
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Children whose dysphagia is not managed appropriately
are at increased risk of the following –
Children whose dysphagia is not managed appropriately
are at increased risk of the following –
- aspiration
- respiratory infection
- choking
- poor nutrition and weight loss
- poor health
- hospital admission due to respiratory illness
- increased levels of anxiety and distress within the
family
- reduced quality of life
- aspiration
- respiratory infection
- choking
- poor nutrition and weight loss
- poor health
- hospital admission due to respiratory illness
- increased levels of anxiety and distress within the
family
- reduced quality of life
The Specialist Speech & Language Therapist for
Paediatric Dysphagia in Sussex Community NHS Trust
(West) works within a Multi-disciplinary Team framework,
which can include:
The Specialist Speech & Language Therapist for
Paediatric Dysphagia in Sussex Community NHS Trust
(West) works within a Multi-disciplinary Team framework,
which can include:
Paediatric Dietitian.
Paediatric Occupational Therapist.
Paediatrician.
Physiotherapist.
Paediatric Community Nurse.
Paediatric Dietitian.
Paediatric Occupational Therapist.
Paediatrician.
Physiotherapist.
Paediatric Community Nurse.
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This multi-disciplinary approach is essential within paediatric
eating and drinking management as it will ensure efficient
management, joint goal setting and minimises confusion for the
parents (McCurtin 1998).
This multi-disciplinary approach is essential within paediatric
eating and drinking management as it will ensure efficient
management, joint goal setting and minimises confusion for the
parents (McCurtin 1998).
Clinical input should occur in the most natural and comfortable
setting for the child – this can be at home, at school, respite
care, Child Development Centre, the children’s ward, Neonatal
Unit or Paediatric Outpatients.
Clinical input should occur in the most natural and comfortable
setting for the child – this can be at home, at school, respite
care, Child Development Centre, the children’s ward, Neonatal
Unit or Paediatric Outpatients.
Specialist Speech & Language Therapist offers an assessment
and advice service –
Specialist Speech & Language Therapist offers an assessment
and advice service –






Specialised assessment including objective methods
e.g.videofluoroscopy.
Safe maximisation of the child’s eating and drinking
potential using appropriate strategies that promote safe
and adequate nutritional intake within a setting which
supports and enhances the child’s wellbeing.
Where oral feeding will not be possible the Specialist
Speech & Language Therapist can support the child and
significant others in choosing between a number of
feeding options and strategies.
Supporting parents/significant others in the process of
making mealtimes pleasurable.
Identification and management of risks to the child as a
result of dysphagia.
It is recognised that any difficulties during mealtimes impact “not
only on the physical but also the emotional and well-being of the
individual” (Arvedson J.G. & Brodsky L. 1993).
77




Specialised assessment including objective methods
e.g.videofluoroscopy.
Safe maximisation of the child’s eating and drinking
potential using appropriate strategies that promote safe
and adequate nutritional intake within a setting which
supports and enhances the child’s wellbeing.
Where oral feeding will not be possible the Specialist
Speech & Language Therapist can support the child and
significant others in choosing between a number of
feeding options and strategies.
Supporting parents/significant others in the process of
making mealtimes pleasurable.
Identification and management of risks to the child as a
result of dysphagia.
It is recognised that any difficulties during mealtimes impact “not
only on the physical but also the emotional and well-being of the
individual” (Arvedson J.G. & Brodsky L. 1993).
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14 Premature Infants
14 Premature Infants
Definitions
Definitions
Term
Meaning
Term
Meaning
Premature
Delivery before 37 weeks completed gestation
Premature
Delivery before 37 weeks completed gestation
Small for Gestational
Age (SGA)
Birth weight <10% for gestational
age & sex
Small for Gestational
Age (SGA)
Birth weight <10% for gestational
age & sex
Intra Uterine Growth
Retardation (IUGR)
Foetus usually SGA & growth has
been restricted
Intra Uterine Growth
Retardation (IUGR)
Foetus usually SGA & growth has
been restricted
Symmetrical IUGR
Weight, length & head circumference reduced – difficult to distinguish from SGA
Symmetrical IUGR
Weight, length & head circumference reduced – difficult to distinguish from SGA
Unsymmetrical IUGR
Head & sometimes length growth
preserved compared to weight
Unsymmetrical IUGR
Head & sometimes length growth
preserved compared to weight
Low Birth Weight
(LBW)
Infants weighing less than 2500g
(5.5lb) at birth
Low Birth Weight
(LBW)
Infants weighing less than 2500g
(5.5lb) at birth
Very Low Birth Weight
(VLBW)
Infants weighing less than 1500g
(3lb) at birth
Very Low Birth Weight
(VLBW)
Infants weighing less than 1500g
(3lb) at birth
Extremely Low Birth
Weight (ELBW)
Infants weighing less than 1000g
(2.2lb) at birth
Extremely Low Birth
Weight (ELBW)
Infants weighing less than 1000g
(2.2lb) at birth
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Key factors affecting the nutritional needs of preterm
versus term infants:
Key factors affecting the nutritional needs of preterm
versus term infants:

Low nutrient stores of fat, glycogen and therefore
energy compared to term infant – due to shorter inutero period for accretion of nutrients.

Low nutrient stores of fat, glycogen and therefore
energy compared to term infant – due to shorter inutero period for accretion of nutrients.

Low weight – massive amount of growth required to
achieve “catch up”.

Low weight – massive amount of growth required to
achieve “catch up”.

High risk of perinatal problems – eg Necrotising
Entero colitis (NEC), sepsis, Chronic Lung Disease
(CLD), which result in increased energy needs.

High risk of perinatal problems – eg Necrotising
Entero colitis (NEC), sepsis, Chronic Lung Disease
(CLD), which result in increased energy needs.

Immature suck-swallow-breathe coordination - may
be weak/absent.

Immature suck-swallow-breathe coordination - may
be weak/absent.

Immature GI tract – which limits intake of enteral
feeds. Early minimal enteral nutrition as bolus trophic
feeds are given – reduces risk of NEC & sepsis.

Immature GI tract – which limits intake of enteral
feeds. Early minimal enteral nutrition as bolus trophic
feeds are given – reduces risk of NEC & sepsis.

Increased losses of electrolytes.

Increased losses of electrolytes.

Immaturity of some metabolic pathways.

Immaturity of some metabolic pathways.

Hence the nutritional needs of the preterm infant for
energy, protein, fluid, vitamins & minerals are greater
than for the term infant.

Hence the nutritional needs of the preterm infant for
energy, protein, fluid, vitamins & minerals are greater
than for the term infant.
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79
Which Milk?
Which Milk?
Milks on the NNU (SRH) in order of preference

Breast Milk – fed from the breast.

Maternal Expressed Breast Milk (MEBM) +/- Breast
Milk Fortifier (BMF).

Infant Formula – appropriate to gestational age &
birth weight.
Milks on the NNU (SRH) in order of preference

Breast Milk – fed from the breast.

Maternal Expressed Breast Milk (MEBM) +/- Breast
Milk Fortifier (BMF).

Infant Formula – appropriate to gestational age &
birth weight.
Advantages of Breastfeeding
Advantages of Breastfeeding
Breast milk is the optimal feed for all newborns. The
advantages of breast milk extend beyond the neonatal
period. It is particularly important for the premature infant
who has missed the in-utero period of the last trimester
when maternal antibodies cross the placenta. Breast milk
potentially reduces the incidence of sepsis in preterm
infants and therefore the risk of life threatening conditions
such as NEC (Necrotising Entero Colitis). Evidence
suggests that the developmental outcome of breastfed
premature infants is superior.
Breast milk is the optimal feed for all newborns. The
advantages of breast milk extend beyond the neonatal
period. It is particularly important for the premature infant
who has missed the in-utero period of the last trimester
when maternal antibodies cross the placenta. Breast milk
potentially reduces the incidence of sepsis in preterm
infants and therefore the risk of life threatening conditions
such as NEC (Necrotising Entero Colitis). Evidence
suggests that the developmental outcome of breastfed
premature infants is superior.
Breastfeeding establishes bonding between mother and
baby it is an important positive contribution the mother can
make to their infant’s care whilst their infant is separated
from them on NNU (King & Jones 2005).
Breastfeeding establishes bonding between mother and
baby it is an important positive contribution the mother can
make to their infant’s care whilst their infant is separated
from them on NNU (King & Jones 2005).
Risks with Breast Milk
Risks with Breast Milk
Levels of protein, vitamins & minerals may not be
sufficiently adequate in breast milk to meet increased
requirements to allow infant catch-up growth. On these
occasions a Breast Milk Fortifier (BMF) is used.
Levels of protein, vitamins & minerals may not be
sufficiently adequate in breast milk to meet increased
requirements to allow infant catch-up growth. On these
occasions a Breast Milk Fortifier (BMF) is used.
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80
Breast Milk Fortifier (BMF)
Breast Milk Fortifier (BMF)
This may be used on NNU when the infant has reached
full feed tolerance (150-180ml/kg/day) but is not
demonstrating good weight gain, at the discretion of the
paediatrician. Various fortifiers are available including
Nutriprem BMF (Cow & Gate) & SMA BMF.
This may be used on NNU when the infant has reached
full feed tolerance (150-180ml/kg/day) but is not
demonstrating good weight gain, at the discretion of the
paediatrician. Various fortifiers are available including
Nutriprem BMF (Cow & Gate) & SMA BMF.
Breast Milk Fortifiers are not prescribable post discharge.
However, they may be continued as required on occasion
on the advice of the Paediatrician/Paediatric Dietitian and
would then be provided by NNU.
Breast Milk Fortifiers are not prescribable post discharge.
However, they may be continued as required on occasion
on the advice of the Paediatrician/Paediatric Dietitian and
would then be provided by NNU.
Rare Occasions when Breast Milk is Contra-indicated
Viral Illnesses – eg maternal HIV, Cytomegalovirus
Some maternal medications contraindicate breastfeeding.
Rare Occasions when Breast Milk is Contra-indicated
Viral Illnesses – eg maternal HIV, Cytomegalovirus
Some maternal medications contraindicate breastfeeding.
Infant Formula Milks
Infant Formula Milks
On NNU
On NNU
If breast milk is unavailable a preterm formula is the next
appropriate option for infants born < 34 weeks weighing
less than 2000g and should be continued until the infant
reaches 2000g. Growth restricted term infants >37 weeks
are given term formula in the absence of maternal milk.
Preterm formula is designed to meet the increased
nutritional needs of the preterm infant, with levels of
nutrients following nutritional guidelines for preterm infants
(ESPHGAN, 2010, Tsang et al 2005 and Klein 2002).
Formulas available include Nutriprem 1 LBW formula (Cow
& Gate) and SMA Gold Prem 1 & Aptamil Preterm
(Milupa). These are not prescribable post discharge.
If breast milk is unavailable a preterm formula is the next
appropriate option for infants born < 34 weeks weighing
less than 2000g and should be continued until the infant
reaches 2000g. Growth restricted term infants >37 weeks
are given term formula in the absence of maternal milk.
Preterm formula is designed to meet the increased
nutritional needs of the preterm infant, with levels of
nutrients following nutritional guidelines for preterm infants
(ESPHGAN, 2010, Tsang et al 2005 and Klein 2002).
Formulas available include Nutriprem 1 LBW formula (Cow
& Gate) and SMA Gold Prem 1 & Aptamil Preterm
(Milupa). These are not prescribable post discharge.
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81
Babies Being Discharged home from NNU
Babies Being Discharged home from NNU
Post Discharge Nutrient Enriched Formulae (PDNEF) are
prescribable formula which meet the nutritional needs of
the preterm infant when discharged. Formulas available
include SMA Gold Prem 2 & Nutriprem 2 (C & G). They
contain higher levels of energy, protein & other nutrients
than term formulae & negates the need for an iron
supplement at discharge. PDNEF can be used for infants
born prior to 34 weeks and under 2kg at birth once the
baby reaches 2.0kg, or for a few days before discharge.
Post Discharge Nutrient Enriched Formulae (PDNEF) are
prescribable formula which meet the nutritional needs of
the preterm infant when discharged. Formulas available
include SMA Gold Prem 2 & Nutriprem 2 (C & G). They
contain higher levels of energy, protein & other nutrients
than term formulae & negates the need for an iron
supplement at discharge. PDNEF can be used for infants
born prior to 34 weeks and under 2kg at birth once the
baby reaches 2.0kg, or for a few days before discharge.
PDNEF should be prescribed by the GP until the infant is
6 months corrected age.
PDNEF should be prescribed by the GP until the infant is
6 months corrected age.
Term formulae
These contain much lower levels of protein and iron and
therefore may only be suitable for well infants with a birth
weight >2kg.
Term formulae
These contain much lower levels of protein and iron and
therefore may only be suitable for well infants with a birth
weight >2kg.
Calorie Supplements
Calorie supplements eg Duocal (SHS) & Maxijul (SHS) are
not routinely recommended for preterm infants as protein
and other nutrient levels in supplemented milk are
inadequate to meet preterm infant needs.
Calorie Supplements
Calorie supplements eg Duocal (SHS) & Maxijul (SHS) are
not routinely recommended for preterm infants as protein
and other nutrient levels in supplemented milk are
inadequate to meet preterm infant needs.
Other Formula
In certain circumstances it may be advisable for the
preterm infant to be on a specialised formula eg
Pregestimil Lipil (Mead Johnson) on the advice of the
Paediatrician/Paediatric Dietitian.
Other Formula
In certain circumstances it may be advisable for the
preterm infant to be on a specialised formula eg
Pregestimil Lipil (Mead Johnson) on the advice of the
Paediatrician/Paediatric Dietitian.
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Vitamins – on NNU & Post Discharge
Vitamins – on NNU & Post Discharge
Abidec (Multivitamin preparation)
Abidec can be commenced when full milk feeds are
tolerated in all infants born at 35 weeks gestation or less. It
should be continued until the baby is weaned onto a full
mixed diet.
Abidec (Multivitamin preparation)
Abidec can be commenced when full milk feeds are
tolerated in all infants born at 35 weeks gestation or less. It
should be continued until the baby is weaned onto a full
mixed diet.
Sytron (Iron Supplement)
Sytron can be commenced when full milk feeds are
tolerated in all infants born at 35 weeks gestation or less,
who are breastfed or not on a PDNEF. It should be
continued until 1 year of age.
Sytron (Iron Supplement)
Sytron can be commenced when full milk feeds are
tolerated in all infants born at 35 weeks gestation or less,
who are breastfed or not on a PDNEF. It should be
continued until 1 year of age.
Other supplements
Fluoride drops are not routinely used on the NNU. Folic
acid is used in the treatment of haemolytic anaemia.
Infants requiring any additional supplements should be
under the supervision of a Consultant Paediatrician and
Paediatric Dietitian.
Other supplements
Fluoride drops are not routinely used on the NNU. Folic
acid is used in the treatment of haemolytic anaemia.
Infants requiring any additional supplements should be
under the supervision of a Consultant Paediatrician and
Paediatric Dietitian.
See chapter 3, page 28 for advice on vitamin
supplementation for all infants above 1 year of age.
See chapter 3, page 28 for advice on vitamin
supplementation for all infants above 1 year of age.
Weaning the Premature Infant
Weaning the Premature Infant
On discharge all parents should be given appropriate
information regarding the weaning of their preterm infant
onto solid foods (eg BLISS weaning leaflet). In line with
BLISS guidelines it is safe to start weaning the preterm
infant from 4 to 8 months uncorrected age from birth and
follow normal weaning guidelines as for term infants.
(Infant formula should continue to 12-18 months corrected
age depending on the adequacy of the weaning diet (King
& Jones 2005).
On discharge all parents should be given appropriate
information regarding the weaning of their preterm infant
onto solid foods (eg BLISS weaning leaflet). In line with
BLISS guidelines it is safe to start weaning the preterm
infant from 4 to 8 months uncorrected age from birth and
follow normal weaning guidelines as for term infants.
(Infant formula should continue to 12-18 months corrected
age depending on the adequacy of the weaning diet (King
& Jones 2005).
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83
15. Home Enteral Feeding
15. Home Enteral Feeding
The section provides general advice, and refers to the
service at St Richard’s Hospital. For advice regarding
individual patients please contact the dietitians at your
local hospital.
The section provides general advice, and refers to the
service at St Richard’s Hospital. For advice regarding
individual patients please contact the dietitians at your
local hospital.
Some infants and children require top up or total feeding
via a Naso Gastric (NG) tube, Naso Jejunal (NJ) tube,
gastrostomy “Button” or Percutaneous Endoscopic
Gastrostomy (PEG) tube at home to meet their nutritional
needs.
Tube feeding may be considered if the infant:

Has a medical condition which prevents them taking
in adequate nutrition orally and/or due to increased
nutritional needs, increased losses or special dietary
needs.

Is found to have an unsafe, or immature swallow
following an assessment by a paediatric specialist
SALT

Needs support through the transition to full oral feeds
in the otherwise well premature infant
Some infants and children require top up or total feeding
via a Naso Gastric (NG) tube, Naso Jejunal (NJ) tube,
gastrostomy “Button” or Percutaneous Endoscopic
Gastrostomy (PEG) tube at home to meet their nutritional
needs.
Tube feeding may be considered if the infant:

Has a medical condition which prevents them taking
in adequate nutrition orally and/or due to increased
nutritional needs, increased losses or special dietary
needs.

Is found to have an unsafe, or immature swallow
following an assessment by a paediatric specialist
SALT

Needs support through the transition to full oral feeds
in the otherwise well premature infant
Many children receiving home enteral feeding have
complex health needs & tube feeding may be only one
medical intervention parents or carers are undertaking at
home.
Many children receiving home enteral feeding have
complex health needs & tube feeding may be only one
medical intervention parents or carers are undertaking at
home.
The multidisciplinary team looking after the infant/child
should include a registered paediatric dietitian, Children’s
Community Nurses (CCNs), Paediatric Speech &
Language Therapist (SALT), Consultant Paediatrician,
supported by the Health Visitor/School Nurse and GP. The
aim is to provide a cohesive service & minimise
attendance at or admissions to hospital.
The multidisciplinary team looking after the infant/child
should include a registered paediatric dietitian, Children’s
Community Nurses (CCNs), Paediatric Speech &
Language Therapist (SALT), Consultant Paediatrician,
supported by the Health Visitor/School Nurse and GP. The
aim is to provide a cohesive service & minimise
attendance at or admissions to hospital.
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84
Feeding Devices
Feeding Devices
Naso-Gastric (NG) Feeding Tubes
Naso-Gastric (NG) Feeding Tubes
Types of Tubes
Types of Tubes
 PVC (Poly Vinyl Chloride) tubes - for short term use
and need to be changed weekly
 PU (Poly Urethane) “Silk” tubes are more comfortable
and are used for longer term feeding. They are
changed monthly.
 PVC (Poly Vinyl Chloride) tubes - for short term use
and need to be changed weekly
 PU (Poly Urethane) “Silk” tubes are more comfortable
and are used for longer term feeding. They are
changed monthly.
Use pH 2-9 Test Strips to check NG or NJ tube position.
Litmus paper and the “whoosh test” (auscultation) should
not be used (National Patient Safety Agency, 2011).
Use pH 2-9 Test Strips to check NG or NJ tube position.
Litmus paper and the “whoosh test” (auscultation) should
not be used (National Patient Safety Agency, 2011).
NG tube size should be reviewed regularly in line with the
infant/child’s growth and be alternated between each
nostril when replaced.
NG tube size should be reviewed regularly in line with the
infant/child’s growth and be alternated between each
nostril when replaced.
Button Gastrostomies
Button Gastrostomies









Inserted under a general anaesthetic.
Sit on the abdomen.
Held in place inside the stomach by a balloon inflated
with water.
Commonly used with infants/children when long term
feeding is anticipated.
An extension set is attached and used for feeding.
Common Button Types – Enteral UK Mini & MicKey.
85



Inserted under a general anaesthetic.
Sit on the abdomen.
Held in place inside the stomach by a balloon inflated
with water.
Commonly used with infants/children when long term
feeding is anticipated.
An extension set is attached and used for feeding.
Common Button Types – Enteral UK Mini & MicKey.
85
Percutaneous Endoscopic Gastrostomies (PEGs)
Percutaneous Endoscopic Gastrostomies (PEGs)







Inserted under a general anaesthetic in children.
Sit on the abdomen with a tube extending from the
stoma.
Held in place inside the stomach by a plastic disc or
flange.
Sometimes used as a temporary measure to form a
tract between the stomach and abdomen, before
being replaced at a later date by a button balloon
gastrostomy.
Common PEG Types – Merck Corflo, Fresenius,
Freka.



Inserted under a general anaesthetic in children.
Sit on the abdomen with a tube extending from the
stoma.
Held in place inside the stomach by a plastic disc or
flange.
Sometimes used as a temporary measure to form a
tract between the stomach and abdomen, before
being replaced at a later date by a button balloon
gastrostomy.
Common PEG Types – Merck Corflo, Fresenius,
Freka.
Whichever type of feeding device is used – parents/carers
should receive full training by paediatric nurses on the
ward before discharge. Once in the community Children’s
Community Nurses (CCNs) will continue training, give
support and advice.
Whichever type of feeding device is used – parents/carers
should receive full training by paediatric nurses on the
ward before discharge. Once in the community Children’s
Community Nurses (CCNs) will continue training, give
support and advice.
NB - Syringes used for medication are provided by the
children’s community nurses.
NB - Syringes used for medication are provided by the
children’s community nurses.
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86
Feeding Methods
Feeding Methods
Bolus Feeding

Feeds are given via a 20ml or 60ml syringe (or
mobile pump) throughout the day.

Flexible – can be given when out and about.

Mimics meal times.

Sociable - child can be fed at and join in with family
mealtimes.
Bolus Feeding

Feeds are given via a 20ml or 60ml syringe (or
mobile pump) throughout the day.

Flexible – can be given when out and about.

Mimics meal times.

Sociable - child can be fed at and join in with family
mealtimes.
Pump Feeding

Can be used for bolus or continuous feeding

Variable rate of feeding – more exact than bolus
method

Useful for overnight feeding via button (not suitable
via NG tube due to risk of tube being dislodged)

Mobile pumps are available.
Pump Feeding

Can be used for bolus or continuous feeding

Variable rate of feeding – more exact than bolus
method

Useful for overnight feeding via button (not suitable
via NG tube due to risk of tube being dislodged)

Mobile pumps are available.
Feeds and Feeding Plans (Feed Regimens)
Feeds and Feeding Plans (Feed Regimens)
These should be devised by the Paediatric Dietitian in
conjunction with the parents/carers and child. Feed plans
will be calculated taking account of age and weight
appropriate nutritional and fluid needs, any current oral
nutritional intake, and medication. This assessment is
made in conjunction with the Children’s Community
Nurses & Paediatric Speech & Language Therapist.
These should be devised by the Paediatric Dietitian in
conjunction with the parents/carers and child. Feed plans
will be calculated taking account of age and weight
appropriate nutritional and fluid needs, any current oral
nutritional intake, and medication. This assessment is
made in conjunction with the Children’s Community
Nurses & Paediatric Speech & Language Therapist.



A variety of feeds are available for different age and
weight ranges, plus high/normal/low energy needs.
Need to consider normal daytime routine and
mealtimes.
87

A variety of feeds are available for different age and
weight ranges, plus high/normal/low energy needs.
Need to consider normal daytime routine and
mealtimes.
87




Feeds containing fibre may help resolve constipation and reduce need for aperients.
Feeding plans should be regularly reviewed
by a Paediatric Dietitian, parents/carers and
child alongside assessment of growth and
feed tolerance.
A typed feeding plan should be provided for
the parents/carers and others looking after
the child (eg school, respite, hospice, ward,
Multi Disciplinary Team).
Advice on good dental hygiene is important
even if the child is not eating




Feeds containing fibre may help resolve constipation and reduce need for aperients.
Feeding plans should be regularly reviewed
by a Paediatric Dietitian, parents/carers and
child alongside assessment of growth and
feed tolerance.
A typed feeding plan should be provided for
the parents/carers and others looking after
the child (eg school, respite, hospice, ward,
Multi Disciplinary Team).
Advice on good dental hygiene is important
even if the child is not eating
Feeding Equipment
Feeding Equipment
At St Richard’s Hospital the Paediatric Dietitian &
Children’s Community Nurses (CCNs) organise
the supply of feed & feeding equipment
(ancillaries) in the community. Infants are discharged from hospital with 7 days supply of feed.
At St Richard’s Hospital the Paediatric Dietitian &
Children’s Community Nurses (CCNs) organise
the supply of feed & feeding equipment
(ancillaries) in the community. Infants are discharged from hospital with 7 days supply of feed.
Each infant is registered with a home delivery service (Nutricia’s Homeward Home Delivery Service
- see useful contacts section), by the paediatric
dietitian (with parental consent) to provide a
monthly supply of feed & ancillary equipment. GP
prescriptions for feed are sent directly to the delivery company. Feeding equipment provided by this
service includes – replacement NG tubes, Buttons,
Extension Sets, Giving Sets, Feeding Pumps,
Feed, 60ml Enteral Feeding Syringes (for boluses), 5ml syringes (for balloon water changes).
Each infant is registered with a home delivery service (Nutricia’s Homeward Home Delivery Service
- see useful contacts section), by the paediatric
dietitian (with parental consent) to provide a
monthly supply of feed & ancillary equipment. GP
prescriptions for feed are sent directly to the delivery company. Feeding equipment provided by this
service includes – replacement NG tubes, Buttons,
Extension Sets, Giving Sets, Feeding Pumps,
Feed, 60ml Enteral Feeding Syringes (for boluses), 5ml syringes (for balloon water changes).
NB - Syringes used for medication are provided by
the children’s community nurses.
NB - Syringes used for medication are provided by
the children’s community nurses.
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88
Ongoing Care
Ongoing Care
Children who are tube fed should be reviewed regularly.
At St Richard’s Hospital children who are being tube fed
are reviewed at the Nutrition and Assisted Feeding Clinic
(NAF clinic) at the CDC. This is a multidisciplinary clinic
attended by the Paediatric Dietitian, Children’s Community Nurse (CCN) & Paediatric Speech & Language
Therapist (SALT). Close liaison is maintained with the
child’s Paediatrician and others involved in the child’s
care. Regular phone contact is maintained with parents/carers between appointments.
Children who are tube fed should be reviewed regularly.
At St Richard’s Hospital children who are being tube fed
are reviewed at the Nutrition and Assisted Feeding Clinic
(NAF clinic) at the CDC. This is a multidisciplinary clinic
attended by the Paediatric Dietitian, Children’s Community Nurse (CCN) & Paediatric Speech & Language
Therapist (SALT). Close liaison is maintained with the
child’s Paediatrician and others involved in the child’s
care. Regular phone contact is maintained with parents/carers between appointments.
If the Child’s NG Tube or Low Profile (Button) Falls
Out ..... (Specific to Chichester)
If the Child’s NG Tube or Low Profile (Button) Falls
Out ..... (Specific to Chichester)





If parents/carers are competent and happy to replace the feeding tube then they should replace the
tube as soon as possible.
If parents/carers cannot replace their child’s device
– within office hours (8am to 4pm Monday to Friday)
please contact the Children’s Community Nurses.
Telephone number 01243 815227.
Outside office hours the child should attend The
Children’s Unit at St Richard’s Hospital (please ensure parents contact the ward first and take their
spare NG tube or Button with them).
Replacement needs to happen ASAP as the tract
between the stomach and abdomen will close very
quickly (within 1 hour) and after this time may require surgical intervention at Southampton General
Hospital or Brighton Children’s Hospital.
89



If parents/carers are competent and happy to replace the feeding tube then they should replace the
tube as soon as possible.
If parents/carers cannot replace their child’s device
– within office hours (8am to 4pm Monday to Friday)
please contact the Children’s Community Nurses.
Telephone number 01243 815227.
Outside office hours the child should attend The
Children’s Unit at St Richard’s Hospital (please ensure parents contact the ward first and take their
spare NG tube or Button with them).
Replacement needs to happen ASAP as the tract
between the stomach and abdomen will close very
quickly (within 1 hour) and after this time may require surgical intervention at Southampton General
Hospital or Brighton Children’s Hospital.
89
Appendix 1 Useful Contacts
Appendix 1 Useful Contacts
Paediatric Dietitians
St Richards Hospital, Chichester, 01243 831734
Paediatric Dietitians
St Richards Hospital, Chichester, 01243 831734
Paediatric Dietitians
Worthing Hospital, Worthing, 01903 205111 x4546
Paediatric Dietitians
Worthing Hospital, Worthing, 01903 205111 x4546
Children’s Community Nurses
Chichester, 01243 815227 available Mon-fri 08.00-17.30
Children’s Community Nurses
Chichester, 01243 815227 available Mon-fri 08.00-17.30
Homeward Home Delivery Service
08457 623663
Homeward Home Delivery Service
08457 623663
The Children’s Unit
St Richards Hospital, 01243 831444
The Children’s Unit
St Richards Hospital, 01243 831444
Paediatric SALTs
Chichester 01243 793604
Paediatric SALTs
Chichester 01243 793604
Oral Health Promotion
St Richard’s Hospital 01243 790157.
Oral Health Promotion
St Richard’s Hospital 01243 790157.
West Sussex & Surrey Dental Helpline
0300 10000899
West Sussex & Surrey Dental Helpline
0300 10000899
St Richard’s Paediatric Pharmacist
01243 788122 bleep 45
St Richard’s Paediatric Pharmacist
01243 788122 bleep 45
Worthing Pharmacy Medicines Information
01903 205111 Ext 5471
Worthing Pharmacy Medicines Information
01903 205111 Ext 5471
PCT Prescribing Support Team
01903 708400
PCT Prescribing Support Team
01903 708400
Health Improvement Project Manager
Children's services, 01243 793654
Health Improvement Project Manager
Children's services, 01243 793654
Infant Feeding Specialist Midwife
07808 099816
Infant Feeding Specialist Midwife
07808 099816
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National Contacts
National Contacts
BLISS Tel 0207 3781122/0500 618140 (parent helpline)
www.bliss.org.uk
BLISS Tel 0207 3781122/0500 618140 (parent helpline)
www.bliss.org.uk
British Dietetic Association www.bda.uk.com
British Dietetic Association www.bda.uk.com
British Dental Health Foundation www.dentalhealth.org.uk
British Dental Health Foundation www.dentalhealth.org.uk
Cleft Lip and Palate Association (CLAPA) www.clapa.com
Cleft Lip and Palate Association (CLAPA) www.clapa.com
Coeliac UK www.coeliac.org.uk
Coeliac UK www.coeliac.org.uk
Contact A Family www.cafamily.org.uk
Contact A Family www.cafamily.org.uk
Down’s Syndrome Association www.downs-syndrome.org.uk
Down’s Syndrome Association www.downs-syndrome.org.uk
Healthy Start Scheme www.healthystart.nhs.uk/
Healthy Start Scheme www.healthystart.nhs.uk/
La Leche League (Great Britain) (Breast feeding help and
information) BM 3424, London WC1 6XX
Tel 0845 1202918 www.laleche.org.uk
La Leche League (Great Britain) (Breast feeding help and
information) BM 3424, London WC1 6XX
Tel 0845 1202918 www.laleche.org.uk
Muscular Dystrophy Campaign www.muscular-dystrophy.org
Muscular Dystrophy Campaign www.muscular-dystrophy.org
National Childbirth Trust (NCT)
Tel 0300 3300700 www.nct.org.uk
National Childbirth Trust (NCT)
Tel 0300 3300700 www.nct.org.uk
SCOPE www.scope.org.uk
SCOPE www.scope.org.uk
The Vegetarian Society of the United Kingdom,
Tel 01609 252000/ Fax 0161 9269182 www.vegsoc.org
The Vegetarian Society of the United Kingdom,
Tel 01609 252000/ Fax 0161 9269182 www.vegsoc.org
The Vegan Society, Tel 0121 5231730
www.vegansociety.com
The Vegan Society, Tel 0121 5231730
www.vegansociety.com
Together for Short Lives www.togetherforshortlives.org.uk
Together for Short Lives www.togetherforshortlives.org.uk
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© Copyright to Infant Feeding Guideline Working Group
Produced by the Paediatric Dietitians,
Western Sussex Hospitals NHS Trust
St Richard’s Hospital