Feeding Toddlers and Pre-school Children 1 to 5 Years
Transcript of 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
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Specic oods and ingredients___________________
TheFoodStandardsAgencycurrentlyadvisethatthefollowingcoloursandpreservativesshouldbeavoidedastheymayaffectchildrensbehaviour:
Colours:
Tartrazine E102
Ponceau E124
Sunsetyellow E110
Carmosine E122
Quinolineyellow E104
Allurared E129
Preservative:
SodiumbenzoateE211
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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
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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................................................................................