Feeding Toddlers and Pre-school Children 1 to 5 Years

7/30/2019 Feeding Toddlers and Pre-school Children 1 to 5 Years

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Feeding Toddlers andPreschool Children

1-5 Year Olds


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Section 4Feeding Toddlers andPreschool Children1- 5 Year Olds

Toddlers and preschool children between 1 and 5 yearshave high nutrient requirements relative to their size, asthey are still undergoing rapid growth and developmentand usually very active. Good nutrition is important orchildren o this age:

Toensurethattheyaregettingabalancedvaried dietthatmeetstheirnutrientrequirements

Dietaryhabitsadoptedintheearlyyearswillbe takenforwardintolaterchildhoodandadultlife

Continuetodevelopselffeedingskills

Eatingtogetherhelpschildrendevelopsocialskills

Helpspreventchildhoodobesity

This section covers:

Nutritional requirements o 1-5 year olds Food saety Dental health Common eeding challenges................................................................................


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Nutritional requirementso 1-5yr olds

Toddlersandpre-schoolchildrenhavehighnutrientrequirementsrelativetotheirsizeastheyarestillundergoingrapidgrowthanddevelopmentandareusuallyveryphysicallyactive.

Their average energy requirements are:

Ref:Dietaryreferencevalues(DH,1991).

Ahealthybalanceddietfor1-5yroldsisbasedonthe4foodgroupsaseachgroupprovidesdifferentkeynutrients.

Toachievethenutritionalrequirementschildrenshouldbeencouragedtoenjoydifferentfoods.Toachievethistheyshouldbeprovidedwithfoodsfromeachofthefourfoodgroupseveryday:

Bread,rice,potatoes,pastaandotherstarchyfoods Fruitandvegetables Milkanddairyfoods Meat,sh,eggs,beansandothernon-dairysourcesofprotein

Bycombiningthefoodgroupseachdaythecorrectbalanceofnutrients

willbeprovided.ApartfrommeetingtheirrequirementsforvitaminsA&Dthesewillonlybemetwithasupplement(seepage76)................................................................................

Age Kilo calories / day

Boys Girls

1-3years 1230 1165

4-6years 1715 1545


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The 4 ood groups and the nutrients they provide are:

Thewiderthevarietyoffoodseatenwithineachfoodgroupthebetterthebalanceofnutrientsprovided.................................................................................

Food groups Food included Main nutrientsRecommendedservings

Bread, rice, potatoes,pasta and otherstarchy oods

Bread,chapatti,breakfastcereals,rice,couscous,pasta,millet,potatoes,yam,andfoodsmadewithoursuchaspizzabases,buns,pancakes

CarbohydrateBVitaminsFibreSomeIronZincCalcium

Serveateachmealandsomesnacks

Fruit and vegetablesFresh,frozen,tinnedanddriedfruitsandvegetables

VitaminCCaroteneswhichareaformofVitaminAFibreZinc

Iron

Serveateachmealandsomesnacks

Milk and dairy

Cowsmilk,goatsmilk,milks,yoghurts,cheese,calciumenrichedsoymilksanddesserts,tofu

CalciumPhosphorusProteinIodineRiboavin

3servingseachday

Meat, fsh, eggs,beans and other

non-dairy sourceso protein

Meat,sh,eggs,nutsandpulsese.g.lentils,dhal,chick

peas,hummus,kidneybeansandothersimilarstarchybeans

IronProteinZincMagnesiumBVitamins

VitaminAOmega3&Omega6fatsOmega3longchainfattyacids:EPAandDHAfromoilysh

2servingsaday


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Bread, rice, potatoes, pastaand other starchy oods___________________

Thisgroupprovidesa goodsourceofenergy, carbohydrates,bre andBvitamins

Starchyfoodsshouldmake upaboutathirdofthediet

Wholegrainvarietiesofbread andcerealssuchasriceand pastaprovidebreandcanbe graduallyintroducedintothe dietsofchildrenfromtheage of2years

Aimforavarietyofwholegrain andwhitebreadsandcereals

acrossmealsandsnacks eachweek

Toomuchbreinyounger childrencanbeverylling andcanalsobindwithcertain mineralstherebyreducing theirabsorption................................................................................

Fruit and vegetables___________________

Fruitandvegetablesare importantsourcesofmany nutrientsincludingvitaminA andC,zinc,ironandbre

Ensureavarietyoffruitsand vegetablesareofferedat everymealandwithsnacks

Fruitandvegetablescanbe

fresh,frozenortinned.Ifusing tinnedvegetablescheckthat theydonothaveaddedsalt andonlyusefruittinnedin naturaljuice

Driedfruitandfruitjuice(100% unsweeteneddiluted1part juiceto1partwater)canbe includedbutonlyatmeal timesastheycontainsugars thatmaydamageteeth................................................................................

Milk and dairy oods___________________

Foodsfromthisgroupsareagoodsource ofenergy,calciumandvitaminA

Fullfatcowsmilkshouldbegivenuntilachildis atleast2yearsoldandsemi-skimmedmilkcan beintroducedfromthisage.Skimmedmilkis notsuitableasthemaindrinkforchildren under5yearsofageasitdoesnotprovide enoughenergyandcontainsverylittlevitaminA

Drinksofmilkshouldbeofferedincups,feeding bottlesshouldbediscouraged

Milkordairyfoodsshouldbeprovidedat2-3 mealsandsnackseachday

Childrenshouldhavethreeservingsperdayof thesefoods.Aservingfor1-5yearoldsis:

-Cupofmilk(120ml/3-4oz) -Cheeseinasandwichorsauce, oronpastaorpizza -Asmallpotyoghurt(about120g)................................................................................


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Meat, sh, eggs, beans and othernon-dairy sources o protein___________________

Foodsfromthisgroupprovide protein,ironandzinc

Thisfoodgroupistherichest sourceofironandasignicant numberofchildrenbecome anaemicfromnothaving enoughfoodfromthisgroup

Ifchildrendonoteatmeatit isimportanttheyreceivetwo orthreeportionsperdayof analternativesourceof protein,forexample,beans chickpeas,lentilsanddhal. Processedmeatalternatives

shouldnotbeofferedmore thanonceperweek

Oilyshprovidelongchain omega3fattyacids,vitamin DandAhowever,shouldnot beservedmorethantwice aweekasoilyshcan containdioxinsand polychlorinatedbiphenyls

Shark,swordshandmarlin

shouldbeavoidedbecause oftheirmercurycontent

Groundandchoppednuts andnutbutterscanbe offeredbutwholenutsshould notbegivenastheycan causechokingorseverelung inammationifinhaled

Foods and drinks highin at and/or sugar___________________

Theseenergydensefoodsshouldbelimited tosmallamounts

Puddingsthataremadewithcereals, milkandfruitcanbeincludedinahealthy balanceddietforyoungchildrenbutthese shouldonlybeservedwithmealsandnot assnacks

Fatsandoilsareneededincookingand canbeusedasspreadsonbread

Usefruitandfruitpuretosweetendishes................................................................................

Salt and sodium___________________

TheFoodStandardsAgencyrecommendsthatsaltandsodiumshouldbelimitedtolessthan:

2gofsalt(0.8gsodium)perdayor 1-3 year olds

3gofsalt(1.2gsodium)perdayor 4-6 year olds

Note:Saltandsodiumarenotthesame.Ifafoodlabelonlyprovidesanamountforsodium,toconverttosalt,multiplytheamountofsodiumby2.5,forexample0.4gsodium=1gsalt.

Thisishardtoestimateasmanyfoodsnaturallycontainsomesodium.Butinpracticeitmeans:

Saltshouldnotbeaddedtofood atthetable

Herbsandspicesratherthanextrasalt canbeusedtoavourfood

Ifusingtinnedfoodschooseoneswithout addedsalt,limittheamountofprocessed foodsofferedastheseusuallyhavea highersaltcontentthanhomecookedfoods

Limitsaltysnackfoodssuchascrispsand cornsnacks.Foraswellasbeinghighin salt,theyarelowinkeynutrients................................................................................


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Vegetarian and vegan diets

Vegetarianismcanbedividedintofourmaingroups:

Partialvegetarian-

redmeatandoffalareexcluded Lacto-ovovegetarian- redmeat,offal,poultryandsh areexcluded

Lacto-vegetarian- redmeat,offal,poultryandsh andeggsareexcluded

Vegans- allanimalproductsincludingeggs andcowsmilkareexcluded................................................................................

Vegetarian diets___________________

Themainnutrientatriskfor1-5yearoldsthatdonoteatmeatisiron.Ironfromvegetarianfoodsisless

wellabsorbedthanfrommeatandsh.Omega3fatmaybelowindietsthatexcludeallsh.

Nutritionalrequirementsforgrowthanddevelopmentcanbeachievedby:

Offering3servingsperdayofthe vegetarianproteinsourcesuchas eggs,nutsandpulses

AfoodhighinvitaminCshouldbeoffered ateachmealtoincreasetheironuptake fromtheplantbasedfoods

Choosingbreakfastcerealswithaddediron

IncreasingOmega3fatsfromplantsources forthoseexcludingshbyusing:

-Rapeseedoilforcooking -Walnut,soyaoroliveoilfordressings -Choppedwalnutsinplaceofother choppednuts -Asupplementofomega3fattyacids maybeconsidered

Vegan diets___________________

Vegandietsarenotrecommendedforyoungchildrenastheyareunlikelytoprovidealltheenergyandnutrientsrequiredinadequate

amounts.Thisisbecausethesechildrenmaynotbeabletoeatenoughveganfood,whichisbulkyandhighinbre,toobtainalltheenergy(calories)andnutrientstheyneedforgrowthanddevelopment.

Achildonavegandietshouldalwaysbereferredtoadietitianforassessmenttoensurethatthefoodsconsumedbythechildcontainalltheessentialnutrients.

Calciumenrichedsoyamilkcanbeusedasasubstitutefordairyfoods.However,anextrasupplementmaybeneededforthekeyatrisknutrientswhichareiron,zinc,calciumandvitaminB12.

Veganmotherswhoarebreastfeedingshouldalsohavetheirdietsassessedastheymayneedasupplementofcalcium,

vitaminsDandB12.

Dietsmorerestrictedthanavegandiete.g.ZenMacrobiotic,Fruitarianandrawfooddiets,are notrecommendedforyoungchildrenastheycannotprovidealltheenergyandnutrientsforgrowth

anddevelopment.................................................................................


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Vitamin supplements

TheDepartmentofHealthrecommendthatallyoungchildrenaregivenavitaminsupplementcontainingvitaminsA&Dastheyhavehighrequirementsforboththesevitamins.

TheHealthyStartSchemereplacedtheWelfareFoodSchemeinNovember2006.Children

whosefamiliesarereceivingtheHealthyStartvoucherscanusethemtopurchasecowsmilk,freshfruitandvegetablesaswellasvitamindropscontainingA,CandD.................................................................................

Drinks

Drinksshouldbeofferedinopencupsorifusingaliddedcupitshouldbeafree-owingone.Childrenshouldbeoffered6-8

drinks(of100-120mls)perdaytoprovideadequateuid.Theymayneedmoredrinksinveryhot

weatherorafterextraphysicalactivityasyoungchildrencandehydratequitequickly.

Water and milkarethesafestdrinkstoofferbetweenmealsastheydonotcausetootherosionorincreasetheriskofdentaldecay.Upto3drinksperdaycanbemilkbutthisshouldnotbeexceeded

Pure ruit juicesdoprovidenutrientsfromfruitbuttheycontainlargeamountsofthefruitsugar,fructose,andtheyareacidic.Boththissugarandacidcancausedentaldecay.Tolowertheacidandsugarcontentfruit

juicesshouldbegivendiluted(1partjuiceto1partwater)andonlybegivenatmealtimestolessentheriskofdentaldecay.

Avoid all sot drinks such as

squashes, zzy drinks, energydrinks, and favoured watersregardlessofwhethertheysaysugarfree,noaddedsugarorreducedsugarcancontributetotoothdamageandprovidelittlenutritionalvalue.

Avoid tea, coee, cola or anyother drinks with added caeinetheyarenotrecommendedfor

youngchildrenascaffeineisastimulant.Teaandcoffeecontain

tanninsandcaninterferewithiron.................................................................................


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Mealtime routines

Withtheirsmallstomachsbuthighenergyandnutrientneeds,toddlersshouldbeofferedfoodat3mealsand2-3nutritioussnacksperday.Adviseparentstoestablishadailyroutinewithmealsandsnacksatregulartimes,evenlyspacedthroughouttheday,aroundanydaytimesleeps.

Mealtimesshouldbeahappy socialoccasion

Wherepossibleparentsandor carersshouldeatwithchildren

Childrenshouldbesittingcomfortably andutensilsshouldbeappropriate

tothechildsage Ifthefamilysitatatabletoeat,the chairandtableshouldbeatthe rightheightforchildrentoeat

Allowplentyoftimeforthemeal, butensureitisnotprolonged beyondabout30minutes

Sweetsshouldnotbe usedasbribesortreats

Encourageself-feeding asmuchaspossible. Toddlersuptoabout3 maystillneedhelptoeat

Acceptmessasanormal partofthefeedingprocess

5.1


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Specic oods and ingredients___________________

TheFoodStandardsAgencycurrentlyadvisethatthefollowingcoloursandpreservativesshouldbeavoidedastheymayaffectchildrensbehaviour:

Colours:

Tartrazine E102

Ponceau E124

Sunsetyellow E110

Carmosine E122

Quinolineyellow E104

Allurared E129

Preservative:

SodiumbenzoateE211

................................................................................

Food Saety

Choking___________________

Childrenunder36monthsaremoreatriskfromchokingthanolderchildren,

however,childrenabovethisagecanalsobeatrisk.Aschildrengetolder,theyputlessnon-edibleitemsintotheirmouthsbutfoodrisksarepresentatanyage.

Tominimisetherisk:

Adviseparentsthatchildren shouldnotrunaroundorplay whilsteating,andthatall mealtimesaresupervised. Youngchildrenshouldbe seatedandinacalm atmospherewheneating

Advisethatfoodsare cutupintosmalllengths ratherthanroundpieces Grapes,cherrytomatoes canbecutintoquarters................................................................................

The oods that present themselves

time and time again in chokingincidents are:

Sweets Popcorn Grapesandcherries Hardfruit Hardvegetables especiallypeas,celery,carrots Hotdogs/sausages Burgers Chunksofcheese Meatballs

Peanutsandlargenutsand seeds(crunchypeanutbutter alsocancausearisk)


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Dental Health

Dentalcariesarecommoninunder-vesandaremainlyduetopoordentalhealthcareinthehome.TheNDNSDentalSurvey(HindsandGregory1995)foundthat30%of3-4yearoldshadsomeexperienceofdentaldecayandthiswashigherinchildren:

Fromlowersocio-economicgroups

Whoseteethbrushingbeganatalaterage

Whoseteethwerebrushedlessfrequentlythantwiceaday

Whoalwaysbrushedtheirownteethcomparedtothose whohadanadulthelpingthem

Whousedabottle,dinkyfeederordummy

Whomorefrequentlyatesugarandconfectioneryanddrink

carbonateddrinks Whohadadrinkcontainingnon-milkextrinsicsugarsinbedatnight

Sugarandacidinfoodanddrinkscausedentaldecay.Bylimitingthequantityandfrequentconsumptionoftheseproductscanreducetheriskofdecay.Decay(caries)isthebreakdownandwearingawayofenamelcausedbyconstantexposuretoacidthatiseithercontainedinfoodanddrinkorproducedbybacteriaintheplaqueonteeth...............................................................................

To reduce the risk o dental decay___________________

Limittheconsumptionoffoodanddrinkcontainingsugar and/oracidtomealtimes

Waterandmilkaretheonlysafedrinkstogivebetweenmeals shouldbegiveninanopenorliddedbeaker

Salivahasaprotectiveeffectonteethbutsalivaproduction reducesduringsleep.Hencesweetoracidicdrinksgivenat bedtimeareveryharmful.Mostharmfularesweetandacidic drinksgiveninafeedingbottle.

A child should never be let alone sucking on a bottle

Ifanyconfectioneryorchocolateisincludeditshouldonlybe offeredattheendofamealandnotbegivenbetweenmeals

Medicines___________________

Childrenwhorequirefrequentandmultiplemedicationsareparticularlyatriskofdentaldecayandassociateddentaltreatment.Effectivepreventionofdentaldiseaseshouldthereforebeapriority.Sugarfreemedicinesshouldbeusedwherepossible.................................................................................


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Brushing teeth___________________

Brushingteethreducestheplaquecoatingonteeththatcontainsthebacteriathatconvertssugarintoacid.Brushingshouldstarteitherattheintroductionofsolidfoodsaroundsixmonthsorifsooner,asthersttoothappearstobreakthrough.Cleaningteethlastthingatnightandatoneothertimeinthedayshouldbeencouragedandsupervisedbyanadultuntilthechildisatleast7yearsold.................................................................................

Children under the age o 3 years___________________ Useatoothpastecontainingnolessthan1000ppmuoride

Applyasmearofpaste (athinlmcoveringnolessthanthree-quartersofthebrush)

Oncebrushingiscompletedwipeawaythefrothwithacloth untilspittingcanbeencouraged

Donotrinse

Neverallowtoothpastetobeeatenorlickedfromthetube

Formaximumcontrolofcariesatoothpastecontaining 1,3501,500ppmuoridecanbeused,buttheadvice abovemustbefollowed.

Children over the age o 3 years___________________

Useatoothpastecontainingnolessthan1000ppmuoride Applyapea-sizeamounttothebrush (ablobcovering3tuftsoflaments)

Oncebrushingiscompletedspitoutexcessfrothandpaste

Donotrinse

Neverallowtoothpastetobeeatenorlickedfromthetube

Formaximumcontrolofcariesatoothpastecontaining 1,3501,500ppmuoridecanbeused,buttheadvice abovemustbefollowed

Registering with a dentist___________________

Allinfantsandyoungchildrenshouldberegisteredwithadentistandhaveregularcheckups.

TondadentistinBristolcontact

NHSDirect-08454647

NHSDentalHelpline-08451206680 NHSChoices-www.nhs.uk

NHSBristol-www.bristol.nhs.uk


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Iron deciencyanaemia

Irondeciencyisacommonnutritionalproblemofearlychildhood(Gregory1995).ItisnotuniquetoanypopulationalthoughitsincidencetendstobehigherininnercityareasandamongstAsianpopulations(Lawson1998).

Children1-5yearsoldareathighriskofirondeciencyanaemiaifthey:

Werechangedtocowsmilk astheirmaindrinkbefore12 monthsofage

Consumeexcessiveamounts ofcowsmilk-frequentlyfrom abottle(anexcessismore than600mlsor1pintperday)

Eatanunbalanceddietwith excesslownutrientfoods andeattoolittlegooddietary sourcesofironsuchasmeat, fortiedcerealsandvegetables

Symptoms o irondeciency include:

Poorappetite Lethargy Poorweightgain Developmentaldelay Frequentinfections

Irondeciencyisdiagnosedfromabloodtest.

TheWHOdenitionofirondeciencyanaemiaisahaemoglobinof


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Causes o obesity in under ves___________________Thegenes,ethnicgroupandenvironmentofachildallcontributetotheirriskofobesity.Howeverformostundervespooreatingpatternsandlowactivitylevelsarethemainreasonforbeingoverweight.Ifthefoodenergy(calories)eatenisinexcessoftheenergyexpendedforphysicalactivity,growthanddevelopment,thentheexcessenergyisstoredasbodyfat(adiposetissue).

Medicalcausesareveryrareandinclude:

Endocrinedisordersoftensignalledbyshortstature suchashypothyroidism,Cushingssyndrome, growthhormonedeciencyandleptindeciency

ChromosomaldisordersSuchasPrader-Willisyndrome................................................................................

Risk actors or developing obesity(Reillyetal.2005)___________________

Parentalobesityofoneorbothparents

Highbirthweightand/orrapidweightgain intherstyear

Sedentarybehaviour: morethaneighthours watchingTVperweekat3years

Lessthantenhourssleepperdayatthreeyears................................................................................

Obesity

Obesityin1-5yearoldsisbecomingincreasinglyprevalent.

TheNationalChildMeasurementProgrammeinBristolfor2008/09revealedthatof4-5yearoldsmeasured:

14.6%wereoverweight

10.4%wereobese

Inmostcasesthecauseoftheobesitywillbemulti-factorialandasinglesolutionwillnot

suiteveryfamily.


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Preventing and treatingobesity in under ves in Bristol___________________Thereiscurrentlylimitedevidenceofwhatworksintermsoftreatmentbutprimarilytherehastobeengagementofthewholefamily.BristolsHealthyWeightStrategyhasbeendesignedinlinewithNICEguidance2006andtheFacultyofPublicHealthsLighteningtheLoadtoolkit.

AChildhoodHealthyWeightCarePathwayisbeingwrittenaspartofthisStrategy,andwillbeavailableontheNHSbristolwebsite.................................................................................

www.bristol.nhs.uk

................................................................................

Health proessionals and early years settingscouldofferarangeofinteractiveparental

educationsessionstopreventobesitysuchas:

Interactivecookingactivities

Videosandgroupdiscussionsonpracticalissues suchashealthyeating,mealplanningand shoppingforfoodanddrink

Encourageactivateplayby:

-Givingideasforfamilyactivitiesinvolving physicalactivity -Promotinglocalfacilitiesforactiveplay -Overcominganysafetyconcernsthatlimit

physicalactivityofyoungchildren -Encouragingmorewalkinginsteadofusing thecarorpushchair

Obeseundervesdonotneedtoloseweightbutthefamilylifestylewillneedtochangesothatweightgainslowsdown.Professionalsneedanempathicandnon-judgementalapproachtoempoweringfamiliesandcarerstomakelifestylechanges.Thismayinvolvesupportforparentsbyenhancingtheirparentingskills.

TheGovernmentsChange4Liecampaignaimstogetfamilieseatingwell,movingmoreandhencelivinglonger.Start4lieisasub-brandforthecampaignaimedatfamilieswithchildrenunder2

years.Informationonthecampaignscanbefound:................................................................................

www.nhs.uk/change4lie

www.nhs.uk/start4lie................................................................................


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Healthy amily liestyles are the key to success___________________

Encourage physical activity

___________________Toddlersshouldhaveopportunitiesandbeencouragedtotakepartinactiveplayeverydaytopromotedevelopmentofco-ordination.

Mostundervesdonotneedencouragementtoplayandwillenjoyactiveplay.Howevermany3-5yearoldchildrenmaybemoderatelyorvigorouslyactiveforonly20to25minutesperday(BHF2004).

Opportunitiesforfreeactiveplayareavailableatcertainplayspacesforchildren.Formoreinformationsee:................................................................................

www.bristol.gov.uk/parkswww.goplacestoplay.org.uk................................................................................

Encourage healthy eating___________________

Encourageabalanceddietincludingfoodsfromallthefoodgroups:

Bread,rice,potatoes,pastaandotherstarchyfoods

Fruitandvegetables

Milkanddairyfoods

Meat,sh,eggs,beansandothernon-dairy sourcesofprotein

Changingeatinghabitsisoftendifcultbutparticularsupportisneededforfamilieswho:

Havelimitedknowledgeofhealthyeating

Donothavethecookingskillsnecessarytoprepare simplehome-cookedfoodandinsteadrelyon conveniencefoodswhichareusuallyenergydense

andhighinfat,sugarandsalt Donothavesetmealtimesandconsequently frequentsnackingformspartoftheireatingpattern................................................................................

Limit sedentary behaviour___________________

ManytoddlersspendalotoftimewatchingaTV/DVD/video.TheAmericanAcademyofPaediatricsrecommendsnomorethantwohoursperdayofsedentarybehavioursuchasTVviewing.ParentsmayneedhelpexploringactivitiesthatcanbesubstitutedforswatchingTVorDVDs.................................................................................

Encourage12hourssleepin children under ve___________________

Undervesnormallysleepabout12hoursineach

dayandthisisimportantforgrowth.

................................................................................


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Fussy eating and ood neophobia

Bothfussyeatingandfoodneophobia(fearofnewfoods)areconsiderednormaldevelopmentstagesinyoungchildren.Evidenceshowsthatfussyeatingeffectsabout10-20%ofchildrenunderve.Severeselectiveeatingisrareandgenerallyhasitsrootsinearlyfeedingdifcultiesor

signicanthealthproblems(Carruth,1998).Neophobiatypicallyemergesinthelatterhalfofthesecondyearoflifeinchildrenandisthoughttobeaninnatepredisposition(Cookeetal2007).................................................................................

Causes o ussy eating ___________________

Giving requent drinks o milk or juice:Manyyoungchildrenpreferdrinkingtoeatingandreadilyllthemselvesupwithdrinks(HoulihaneandRolls1995,SmithandLifshitz1994).Usefuladviceisthat

drinksshouldbelimitedtowaterinbetweenmeals.Cupsshouldreplaceanybottlesstillbeinggivenasthiswillhelptoreduceuidintake.

Frequent snacking:Somechildrenendupeatingmostoftheirfoodbetweenmealsandthesnackfoodoftentendstobehighinfat,sugarandsalt.Thereisoftenlittleornoincentiveforthetoddlertoeatanappropriatemealiftheyareallowedtolluponconfectionary,biscuitsandcrisps.Lessfrequentsnackingandmoreappropriatesnackssuchasfruitshouldbesuggested.

Snacks being given when a meal is reused: Childrenmayprefersnackfoodsandrefusemealsinordertobegivensnacksinstead.

Coercing children to eat more and/orextendingmealtimeswhenthechildhasindicatedtheyhavehadenoughtoeat.

Thesituationcansometimesbeexacerbatedbyparentsbecomingveryanxiousatmealtimes.


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Simple strategies or managemento ussy eating and neophobia___________________

Although,fussyeatingandneophobiaarethoughtbysometobebehaviourallydistinct,theycanbothbehelpedusingsimilartechniques.Aconsistentapproachisessentialandallthoseinvolvedinthecareofthechild,includingrelativesandchildcarersneedtoco-operatewithanymeasuresagreed.

Offersmallwell-spacedmealsandsnacks

Parentsand/orcarersshouldeatwithchildren wherepossible

Regularandrepeatedopportunitiestotaste newfoodsresultsinchildreninacceptingfoods,

10-15tastingsmayberequired

Donotallowmealtimestobetoolong20-30 minutesisaboutright

Givelotsofpraise,evenifthesmallestquantity offoodiseaten

Removeuneatenfoodwithoutcommentat theendofameal

Donotdiscusseatingandfoodwithothersin frontofthechild

Donotcoaxorforceachildtoeat

Donotusefoodasareward

Keepcalm

Preschoolchildrenseatinghabitscanimprove oncetheybegineatingwithotherchildrenon startingnurseryorschool

Feeding clinic___________________

InBristolthereisaFeedingDisordersClinicatFrenchayHospital,NorthBristolNHSTrust.Thismonthlyout-patientclinicisrunbyamultidisciplinaryteam.

Referralsaretakenforchildrenwhohave:

Feedingdifculties associatedwith physicaldisabilities

Chronicfoodrefusalwith

orwithoutfalteringgrowth Chronicseverebehaviour problemsassociatedwith feeding

FalteringGrowthassociated withorganicfactorswhere feedinghasbecome aversive

ChildrencanbereferredbyaPaediatrician,GP,Health

Visitor,SpeechandLanguageTherapistorDietitianhowevertheyshouldbeunderthecareofaPaediatricianorhavingbeenseenbyaPaediatrician................................................................................


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Faltering growth

Thisisassessedbyplottingweightsandheightsongrowthcharts.

In2002theChildrensSocietydenedfalteringgrowthas:

Causesoffalteringgrowthare:

Malnutritionthroughpooreating

Diseasesinvolvingmalabsorption ordecreasedappetite

Hormonalsyndromese.g.Hypothyroidism, Turnersyndrome,Growthhormoneinsufciency

Physicaloremotionalneglect

Mostfalteringgrowthin1-5yearoldsisduetopooreating.Only5%isduetodiseaseorhormonaldisorders.Itisestimatedthatafurther5%isduetoneglectandwillneedthesupportofthoseinvolvedinchildprotection.................................................................................

When to reer ___________________

Referraltoapaediatricianshouldbemadeifweightorheightisnoted,forthersttime,tobebelowthe0.4thcentile.

Areferralshouldbeconsideredif:

Weightorheightisbelowthe2ndcentile Weightorheightfallsthrough2centilespaces

Dietarytreatmentforgrowthfalteringwillinvolveincreasingcalorieintakeandthisisbestachieved

byincreasingthecaloriecontentoffoodsandmealsthatareeaten.Thiswillrequireappropriatemedicalanddieteticsupport.

Falthering growth

Weightfaltering

Weightfallingthroughcentilespaces,lowweightforheightornocatch-upfromalowbirthweight

Growthfaltering

Crossingdownthroughlength/heightcentile(s)aswellas

weight.Alowheightcentile

oraheightlessthanexpectedfromparentalheights


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Gastroenteritis andtoddler diarrhoea

Toddlerdiarrhoeamayoccurinchildrenwhoareotherwisehealthyandgrowingwell.Theconditionisthoughttobeduetoadegreeofimmaturityofgutfunctionandoftenimprovesspontaneouslyataroundthreetofouryearsofage.Frequentloosestoolscontainingrecognisablefoodmatter(peas,carrots,sweetcorn)maybepasseduptoeighttimesaday.

Adietarycausecanbetheconsumptionoflargequantities

ofsomesquashesandfruitjuicesbecausetheycontainlargequantitiesofnon-absorbablemonosaccharidesandoligosaccharides(Hoekstra1998).

Dietaryadviceshouldbeahealthybalanceddietwithalimitonsquashandfruitjuiceintake.Continueddiarrhoea(>7days)afteracutegastroenteritismaybeassociatedwithatemporary

intolerancetolactose(Davidsonetal.1984).Thismightrequiretheexclusionofdairyproductsandotherlactosecontainingfoodsforafewweeks.LactosefreemilkssuchasLactofreeoracalciumfortiedsoyamilkcanbeusedasadirectsubstituteforcowsmilk.................................................................................

Constipation

Constipationinchildrenisoftenacomplexproblem.Itcanbeassociatedwithformulafeeding(seepage63)orbeginatthetimeof

weaningandagainataroundtwoyearsofage

inrelationtopottytraining.Itcanbeadistressingproblemforthechildandthefamily.

Symptomsincludeinfrequentdefecation,painanddistressandrefusaltodefecate.Causesincludeinsufcientintakeofdietarybreanduid,emotionaldisturbances,possiblechildhoodinfectionorachangeinroutine(BurnettandWilkins,2002).................................................................................

Dietary changes to suggest___________________

Encouragefoodswithahigherbrecontent e.g.wholegrainbreakfastcereals,wholemeal bread,fruit,vegetables,beans,pulsesandlentils e.g.bakedbeans

Offer6-8drinksperdayofabout120mls/4ozs each.Moremayberequiredinhotweather andafterphysicalactivity

Unprocessedbranshouldnotbegivento youngchildrenasitcancausebloatingand interfereswiththeabsorptionofmicronutrients suchasiron,calciumandzinc

Insomecircumstancesitmaybenecessaryfor amedicalpractitionertoprescribemedication


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Diagnosis___________________

Thereisnosimplediagnostictestforfoodallergyorfoodintolerance.Thegoldstandardtestistheplacebo-controlleddoubleblindchallenge.Inclinicalpractice,however,openchallengesareusuallyperformed.Thisinvolvesofferingafood,thoughttobethecauseofsymptomstothechildandmonitoringtheresponsetothatfood.Foodchallengesareanintegralpartofdiagnosisinorderto:

Detectaspecicfoodwhichcausessymptoms. Apositiveresultconrms theneedtoexcludethat foodfromthediet

Conrmthataspecic foodisnotresponsible. Anabsenceof symptomsconrms thatarestricteddiet isnotneeded

Manyfoodchallengescanbecarriedoutathomewithpriormedicalagreement.Howevertherearesomechildrenwhorequireahospitalsettingwhereimmediatemedicaltreatmentisavailable.Nutchallengesshouldneverbetriedathome.

Allchildrenwithfoodintoleranceshouldbeunderthe

careofaPaediatricianandGP.

AdditionalinvestigationsthatmaybehelpfulincludeRASTs(Radio-AllergosorbentTests),skinpricktests,patchtests,endoscopyandbiopsy.Thereisnoclinicalorscienticevidencetosupporttheuseofvariousothertestsincludinghairanalysis,kinesiologyand

bioresonanceinthediagnosisoffoodintolerance.................................................................................

Food hypersensitivity:ood allergy and ood intolerance

Thisaffects2-4%ofchildren1-3yearsoldandmostgrowoutofitbyabout3yearsofage(Zuberieretal.2004,Venteretal.2008).Foodhypersensitivityistheumbrellatermforfoodallergyandfoodintolerance

whicharedifferent(Johansen2003).................................................................................

Food allergy___________________

Thetermfoodallergyisusedwhentheimmunesystemistriggeredandtreatmentistoexcludethefoodcausingtheproblem.Howeverthisshouldonlybeundertakenundertheguidanceofamedical

practitioneranddietitian.Itisimportanttomonitortheconditionsothatfoodsarenotexcludedforlongerthanisnecessary.................................................................................

Food intolerance(ornon-allergicfoodhypersensitivity)___________________

Thesymptomsusuallyappearafewhoursorevendaysaftereatingthefoodandtheyarerarelylife-threatening.Virtuallyanyfoodcancausean

intolerance,althoughinpracticethisdoesnotoccur.Foodswhichcommonlycauseintoleranceincludemilk,chocolate,citrusfruits,fruitsandvegetables,foodscontainingMonosodiumglutamate,cheese,especiallyifmatured,fermentedfoodssuchasbluecheese,sauerkraut,fermentedsoyaproducts,

yeastextractssh,especiallyifstaleorpickledandmicrobialcontaminatedfoods.................................................................................


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Cultural diets

Minorityethniccommunitiesmayfollowthedietaryhabitsoftheirowncountry;thesepracticeswillvarynotonlyaccordingtoreligionbutalsoregion.Theymayrequiresupporttoensureanadequatedietandeliminateanypotentialnutrientdeciencies.Iron,vitaminB12andtotal

energyintakemaypresentaparticularproblem.

Thefollowingpracticalpointsmayactasaguidewhensupportingthesefamilies:

Findoutaboutthefamiliesusualdietaryintakeandmealpattern

Findoutaboutanydietaryrestrictionstheymayfollow

Workwithinthedecisionmakingstructureofthefamily

Whereanydietarychangesarenecessarymakesurethe advicegivenispractical

Checkthatunderstandinghastakenplace

Theremaybeperiodsoffastingthoughveryyoungchildrendonotnormallyfast.Howeverthemealsareeatenathomemaybedifferentduringfastingperiods,suchasamainmeallateatnightorbreakfastearly.

Thefoodcustomsmayinvolvewhatfoodsareeaten,howthefoodsareprepared,whatcombinationsoffoodsareusedorwhenparticularfoodsareeaten.AguidetosomeofthedifferencesinfoodchoicecommonlyobservedbythosefromdifferentreligiousandculturalgroupsisshownAppendix2.................................................................................


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Reerences

BritishHeartFoundation(2004)Couchkidsthecontinuingepidemic.London;BHF.

BurnettC,WilkinsG(2002)Managingchildrenwithconstipation:acommunityperspective.JournalofFamilyHealth

Care2002;12(5):127-132.

ChildrensSociety(2002)Recommendationsforbestpracticefor

weightandgrowthfalteringinyoungchildren.London:TheChildrensSociety,2002.

CookeLJ,HaworthC&WardleJ(2007).Geneticandenvironmentalinuencesonchildrensfoodneophobia.AmericanJournalofClinicalNutrition,86,428-433.

DepartmentofHealth(1991)ReportNo41DietaryReference.ValuesforFoodEnergyandNutrientsfortheUK.ReportofthePanelonDietaryReferenceValuesoftheCommitteeonMedicalAspectsofFoodPolicy.HMSO.London.

DepartmentofHealth(1999)Reviewofthewelfarefoodscheme.London:StationaryOfce.

GregoryJRetal.(1995)NationalDietandNutritionSurvey:Childrenaged1.5-4.5years.London:HMSO.

HoulihaneJOB,RollsCJ(1995)Morbidityfromexcessiveintakeofhigh-energyuid:thesquashdrinkingsyndrome.ArchivesofDiseaseinChildhood72:141-143.

HindsK&GregoryJR.(1995)NationalDietandNutritionSurvey:childrenaged1.5to4.5years.Volume2:ReportoftheDentalSurvey.London:HMSO.

JohanssonSG,BieberT,DahlR,FriedmannPS,LanierBQ,LockeyRFetal.(2004)

Revisednomenclatureforallergyforglobaluse:ReportoftheNomenclatureReviewCommitteeoftheWorldAllergyOrganization,October2003.JAllergyClinImmunol113(5):832-6.

LawsonMS,ThomasM,HardimanA.(1998)IronstatusofAsianchildrenaged2yearslivinginEngland.ArchivesDiseasesinChildhood78(5):420-426.

ShawVandLawsonM(2007)ClinicalPaediatricDietetics3rded.LondonBlackwell.

SmithMM&LifshitzF(1994)Excessfruitjuiceconsumptionasacontributingfactorinnon-organicfailuretothrive.Paediatrics93(3):438-443.

VenterC,PereiraB,VoigtK,GrundyJ,

ClaytonCB,HigginsB,ArshadSH,DeanT.(2008)Prevalenceandcumulativeincidenceoffoodhypersensitivityintherst3yearsoflife63(3):354-9.

ZuberbierT,EdenharterG,WoemM,EhlersI,ReimannS,HankteTetal.(2004)PrevalenceofadversefoodsreactionstofoodinGermanyapopulationstudy.

Allergy59(3):338-45.

Further Inormation is available rom:

British Dietetic AssociationWeaningFactSheet................................................................................

www.bda.uk.com................................................................................

Comic CompanyResourcesonhealthyeatingandoralhealth................................................................................

www.comiccompany.co.uk................................................................................

Caroline Walker TrustEatingWellforUnder-5sinChildcare(2006)PracticalandNutritionalGuidelines.2ndEdition

EatingWellforUnder-5sinChildcare(2000)TrainingMaterialsforpeopleworkingwithundervesinchildcare................................................................................

www.cwt.org.uk................................................................................

EatingWellfor1-4yearolds(2010)

PracticalGuide&FoodPhotocards................................................................................

www.cwt-chew.org.uk................................................................................

Change4lie................................................................................

www.nhs.uk/change4lie................................................................................

Department o Health

BirthtoFiveBookDeliveringBetterOralHealth:

Anevidence-basedtoolkitforprevention.September2007................................................................................

www.dh.gov.uk................................................................................

Food Standards Agency website................................................................................

www.eatwell.gov.uk/agesandstages/

children/yrtoddler................................................................................

Harlow PrintingGrowthchartsandBMICharts................................................................................

www.healthorallchildren.co.uk................................................................................

Healthy Start................................................................................

www.healthystart.nhs.uk................................................................................

Knowledge ResourceInormation Service................................................................................

www.avon.nhs.uk/kris/deault.htm................................................................................

National Childminding Association................................................................................

www.ncma.org.uk

National Daycare andNurseries Association................................................................................

www.ndna.org.uk................................................................................

NHS Choices................................................................................

www.nhs.uk/LiveWell/Childhealth1-5................................................................................

Pre-school Learning alliance................................................................................

www.pre-school.org.uk................................................................................

School Food Trust................................................................................

www.schooloodtrust.org.uk/research/advisory-panel-on-ood-and-nutrition-in-early-years................................................................................

Start4lie................................................................................

www.nhs.uk/start4lie................................................................................

Documents

Feeding Toddlers and Pre-school Children 1 to 5 Years