Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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. 31 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/ 34 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. 35 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. 36 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 37 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. 38 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. 39 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. 40 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. 41 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. 42 42 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. 43 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. 44 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. 48 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. 49 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. 50 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). 51 51 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. 53 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. 54 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. 55 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. 56 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. 57 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. 58 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. 59 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). 61 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 62 62 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. 63 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) 65 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". 66 66 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. 67 67 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). 68 68 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. 70 70 (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. 71 71 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. 72 72 (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. 73 73 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 – 74 74 - 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. 75 75 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. 76 76 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). 77 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 78 78 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. 79 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. 80 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. 81 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. 82 82 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). 83 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. 84 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. 86 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. 88 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 90 90 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 91 91 Appendix 2 References Appendix 2 References Arvedsan JC and Bodsky L Eds (1993) Paediatric Swallowing and Feeding: Assessment and management Whurr Publishers, London. Arvedsan JC and Bodsky L Eds (1993) Paediatric Swallowing and Feeding: Assessment and management Whurr Publishers, London. Blossfield I et al (2007). Relationships between acceptance of sour taste and fruit intake in 18 month infants. Br J Nutr, 98:1084-1091. Blossfield I et al (2007). Relationships between acceptance of sour taste and fruit intake in 18 month infants. Br J Nutr, 98:1084-1091. Blossfield I, Collins A, Kiely M, et al. (2007)Texture preferences of 12-month-old infants and the role of early experiences. Food Qual Prefer 18-396-404. Blossfield I, Collins A, Kiely M, et al. (2007)Texture preferences of 12-month-old infants and the role of early experiences. Food Qual Prefer 18-396-404. Boehm G et al (2004) Prebiotics in Infant Formula. J Clin Gastro 38(6 supplement): S76-S79. Boehm G et al (2004) Prebiotics in Infant Formula. J Clin Gastro 38(6 supplement): S76-S79. British Dietetic Association (2010) Food Intolerance Specialist Group Consensus Statement- Practical Dietary Prevention Strategies for Infants at Risk of Developing Allergic Diseases. British Dietetic Association (2010) Food Intolerance Specialist Group Consensus Statement- Practical Dietary Prevention Strategies for Infants at Risk of Developing Allergic Diseases. British Dietetic Association (2003a) Paediatric Group Position Paper on Breastfeeding and Weaning onto Solid Foods. Journal of Family Health Care 13 (4) 92. British Dietetic Association (2003a) Paediatric Group Position Paper on Breastfeeding and Weaning onto Solid Foods. Journal of Family Health Care 13 (4) 92. British Dietetic Association (2010) Paediatric Group Position Statement on the use of Infant Formulae based on soy protein in infants. British Dietetic Association (2010) Paediatric Group Position Statement on the use of Infant Formulae based on soy protein in infants. BSPGHAN (2008). Guideline For The Diagnosis & Management of Coeliac Disease In Children. Coeliac Working Group of BSPGHAN, 2008. www.bspghan.org. BSPGHAN (2008). Guideline For The Diagnosis & Management of Coeliac Disease In Children. Coeliac Working Group of BSPGHAN, 2008. www.bspghan.org. Child Growth Foundation/Stanhope A, September 2000. Growth & Growth Disorders, 3rd edition, Chiswick, London. Child Growth Foundation/Stanhope A, September 2000. Growth & Growth Disorders, 3rd edition, Chiswick, London. Coulthard, H et al (2009) Delayed introduction of lumpy foods to children during the complementary feeding period affects child’s food acceptance & feeding at 7 years of age. Maternal & Child Nutrition 5: 75-85. Coulthard, H et al (2009) Delayed introduction of lumpy foods to children during the complementary feeding period affects child’s food acceptance & feeding at 7 years of age. Maternal & Child Nutrition 5: 75-85. 92 92 De Chareau P & Wyberg B (1977) Long term effect on mother infant behaviour of extra contact in the first hour post partum. Acta. Paediatrica. Scandinavia 66:137 -151. De Chareau P & Wyberg B (1977) Long term effect on mother infant behaviour of extra contact in the first hour post partum. Acta. Paediatrica. Scandinavia 66:137 -151. Department of Health (1994) Weaning & the weaning diet. Report of Social Subjects 45. HMSO, London Department of Health (1994) Weaning & the weaning diet. Report of Social Subjects 45. HMSO, London Department of Health (2001) HIV and Infant Feeding. Department of Health (2001) HIV and Infant Feeding. Department of Health (2004a) Infant Feeding Recommendation. Department of Health (2004a) Infant Feeding Recommendation. Department of Health (2006a) Statement Advice on infant milks based on goats’ milk www.dh.gov.uk/ PolicyAndGuidance/HealthAndSocialCareTopics/ MaternalAndInfantNutrition (21.8.06) . Department of Health (2006a) Statement Advice on infant milks based on goats’ milk www.dh.gov.uk/ PolicyAndGuidance/HealthAndSocialCareTopics/ MaternalAndInfantNutrition (21.8.06) . Department of Health (2006b) NICE Clinical Guideline 37.Routine Postnatal Care of women and their babies. Department of Health (2006b) NICE Clinical Guideline 37.Routine Postnatal Care of women and their babies. Department of Health (2008) NICE Public Health Guidance 11. Maternal and child nutrition. Department of Health (2008) NICE Public Health Guidance 11. Maternal and child nutrition. Department of Health (2009) NICE Clinical Guideline 84. Diarrhoea & vomiting in children. Department of Health (2009) NICE Clinical Guideline 84. Diarrhoea & vomiting in children. Department of Health (2009) NICE Clinical Guideline 86. Coeliac disease. Department of Health (2009) NICE Clinical Guideline 86. Coeliac disease. Department of Health (2011) NICE Clinical Guideline 116 Food allergy in children and young people. Department of Health (2011) NICE Clinical Guideline 116 Food allergy in children and young people. Department of Health & Food Standards Agency. Guidance for Health Professionals on Safe Preparation, Storage & handling of powdered infant formula. (2006) www.food.gov.uk/multimedia/pdfs/formulaguidance.pdf. Department of Health & Food Standards Agency. Guidance for Health Professionals on Safe Preparation, Storage & handling of powdered infant formula. (2006) www.food.gov.uk/multimedia/pdfs/formulaguidance.pdf. 93 93 ESPGHAN (2008) Committee on Nutrition. Agostoni C et al. Medical Position Paper. Complementary feeding: A commentary by the ESPGHAN. ESPGHAN (2008) Committee on Nutrition. Agostoni C et al. Medical Position Paper. Complementary feeding: A commentary by the ESPGHAN. ESPGHAN (2010). Enteral nutrient supply for preterm infants: Commentary. Agostoni C et al. ESPGHAN (2010). Enteral nutrient supply for preterm infants: Commentary. Agostoni C et al. Fergusson DM et al (1981) Clin. Allergy.11:325-331. Fergusson DM et al (1981) Clin. Allergy.11:325-331. Fleith & Clandinin (2005) Dietary PUFA for preterm and term infants:review of clinical studies. Critical Reviews in Food Science & Nutrition 45(3):205-229 Fleith & Clandinin (2005) Dietary PUFA for preterm and term infants:review of clinical studies. Critical Reviews in Food Science & Nutrition 45(3):205-229 Food Standards Agency (2002) McCance and Widdowson’s The Composition of Foods Sixth Summary Edition. Cambridge: Royal Society of Chemistry. Food Standards Agency (2002) McCance and Widdowson’s The Composition of Foods Sixth Summary Edition. Cambridge: Royal Society of Chemistry. Food Standards Agency (2009a). Survey of Total and Inorganic Arsenic in Rice Drinks. Accessed from:http:// www.food.gov.uk/science/surveillance/fsisbranch2009/ survey0209 Food Standards Agency (2009a). Survey of Total and Inorganic Arsenic in Rice Drinks. Accessed from:http:// www.food.gov.uk/science/surveillance/fsisbranch2009/ survey0209 Garrison MM & Christakis DA (1998) A systematic Review of Treatments for Infantile Colic Br Med J 316: 1563-1569. Garrison MM & Christakis DA (1998) A systematic Review of Treatments for Infantile Colic Br Med J 316: 1563-1569. Gil (2002) Modulation of the immune response mediated by dietary nucleotides. European J Clin Nut:56 (suppl3):S1-S4. Gil (2002) Modulation of the immune response mediated by dietary nucleotides. European J Clin Nut:56 (suppl3):S1-S4. Great Ormond Street (GOS) Hospital for Children NHS Trust (2009) Nutritional Requirements for Children in Health and Disease 4th Edition. Great Ormond Street (GOS) Hospital for Children NHS Trust (2009) Nutritional Requirements for Children in Health and Disease 4th Edition. Gregory J R et al (1995) National Diet and Nutrition Survey for Children aged 1.5- 4.5 years. Vol 1.London HMSO. Gregory J R et al (1995) National Diet and Nutrition Survey for Children aged 1.5- 4.5 years. Vol 1.London HMSO. 94 94 Hall D & Elliman D (2006). Health for All Children, Revised 4th Edition, Oxford University Press. Hall D & Elliman D (2006). Health for All Children, Revised 4th Edition, Oxford University Press. Hall D & Voss LD,(2000) Growth Monitoring. Arch Dis Child 82, 10-15. Hall D & Voss LD,(2000) Growth Monitoring. Arch Dis Child 82, 10-15. Healthy Start http://www.healthystart.nhs.uk/ Healthy Start http://www.healthystart.nhs.uk/ King C & Jones E (Eds) (2005) Feeding & Nutrition in the Preterm Infant. Elsevier. King C & Jones E (Eds) (2005) Feeding & Nutrition in the Preterm Infant. Elsevier. Klein CJ (2002) Nutrient Requirements for Preterm Infant Formulas J. Nutr. 132: 1395S-1577S. Klein CJ (2002) Nutrient Requirements for Preterm Infant Formulas J. Nutr. 132: 1395S-1577S. Koletzko et al, (2008) The role of long chain polyunsaturated fatty acids in pregnancy, lactation and infancy: a review of current knowledge and consensus recommendations. J Perinatal Medicine 36(1): 5-14. Koletzko et al, (2008) The role of long chain polyunsaturated fatty acids in pregnancy, lactation and infancy: a review of current knowledge and consensus recommendations. J Perinatal Medicine 36(1): 5-14. MacDonald A (2007) Baby-led weaning. NHD 26 14-16. MacDonald A (2007) Baby-led weaning. NHD 26 14-16. McCurtin A (1998) The Manual of Paediatric Feeding Practice, Winslow Press, Oxford. McCurtin A (1998) The Manual of Paediatric Feeding Practice, Winslow Press, Oxford. Mira M et al (1996) Haem iron intake in 12-36 month old children depleted in iron :case control study. Br Med J 312 881-88. Mira M et al (1996) Haem iron intake in 12-36 month old children depleted in iron :case control study. Br Med J 312 881-88. NASPGHAN & ESPGHAN (2009) Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint recommendations of the NASPGHAN & ESPGHAN. J Paed Gastro & Nut 49:498-547. NASPGHAN & ESPGHAN (2009) Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint recommendations of the NASPGHAN & ESPGHAN. J Paed Gastro & Nut 49:498-547. 95 95 National Patient Safety Agency (2011) Alert NPSA/2011/ PSA002 10March 2011Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. National Patient Safety Agency (2011) Alert NPSA/2011/ PSA002 10March 2011Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. Northstone K et al (2001)The effect of age on the introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 & 15 months. J Hum Nutr Diet 14: 43-54. Northstone K et al (2001)The effect of age on the introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 & 15 months. J Hum Nutr Diet 14: 43-54. Royal College of Paediatricians & Child Health (2009), www.growthcharts.rcpch.ac.uk. Royal College of Paediatricians & Child Health (2009), www.growthcharts.rcpch.ac.uk. Scientific Advisory Committee on Nutrition (SACN) and Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) Report (2003) Soya based infant formula report. Scientific Advisory Committee on Nutrition (SACN) and Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT) Report (2003) Soya based infant formula report. Shaw V & Lawson M (Eds) (2007) - Clinical Paediatric Dietetics 3nd Edition, Blackwell Science. Shaw V & Lawson M (Eds) (2007) - Clinical Paediatric Dietetics 3nd Edition, Blackwell Science. Taitz LS and Scholey E (1989) Are babies more satisfied by casein based formulas? Archives of Disease in Childhood, 64 619- 621. Taitz LS and Scholey E (1989) Are babies more satisfied by casein based formulas? Archives of Disease in Childhood, 64 619- 621. Townsend E, Pitchford NJ. (2012) Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case-controlled sample. BMJ 2:e000298. Townsend E, Pitchford NJ. (2012) Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case-controlled sample. BMJ 2:e000298. Tsang RC et al (Eds) (2005) Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines, 2nd Edition Digital Educational Publishing. Tsang RC et al (Eds) (2005) Nutrition of the Preterm Infant: Scientific Basis and Practical Guidelines, 2nd Edition Digital Educational Publishing. 96 96 Wardley BL, Puntis JWL & Taitz LS (1997). Handbook of Child Nutrition, 2nd Edition, Oxford University Press. Wardley BL, Puntis JWL & Taitz LS (1997). Handbook of Child Nutrition, 2nd Edition, Oxford University Press. World Health Organisation (2003) Global Strategy for Infant and Young Child Feeding. Geneva, WHO. World Health Organisation (2003) Global Strategy for Infant and Young Child Feeding. Geneva, WHO. 97 97 Notes Notes ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— 98 98 Notes Notes ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— 99 99 Notes Notes ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— 100 100 Notes Notes ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— 101 101 Notes Notes ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— 102 102 Notes Notes ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— 103 103 Notes Notes ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— 104 104 Notes Notes ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— ——————————————————— —————————————————— 105 105 106 106 107 107 © Copyright to Infant Feeding Guideline Working Group Produced by the Paediatric Dietitians, Western Sussex Hospitals NHS Trust St Richard’s Hospital