Welcome to our Winter 2016 edition of Mums, Babies & You
For healthcare professionals in Ireland
The Cow and Gate Healthcare Nutrition Team have been busy redesigning our quarterly healthcare professionals’ newsletter. You will now receive your newsletter by email instead of by post. Our updated ezines each consist of a medical article written by experts in the healthcare industry. These articles will cover a wide range of topics, which deal with common issues experienced from pregnancy through to toddlerhood. It will also keep you up to date with upcoming seminars, plus any new product launches as they arrive.
We would love to hear any feedback you may have on our Winter 2016 edition of Mums, Babies & You, or any suggestions for future topics you would like us to include in upcoming editions. Please let us know your thoughts by contacting us on 1800 371 371, or by emailing firstname.lastname@example.org.
Foundations of Lifelong Health
Article written by dietician Therese Dunne
The foundations of lifelong health are built in early childhood. In recent years there has been a remarkable explosion of new knowledge about the developing brain and human genome, telling us that early experiences are built into our bodies and that early childhood is a time of both great promise and considerable risk. In 2006 Harvard University established its Centre on the Developing Child1 and in 2008 the UK think tank ‘Centre Forum’ produced a report for Government called ‘Parenting Matters: early years and social mobility’2. 0 – 5 years are now considered the foundation years of a person’s life, and interventions in these early years of life make the biggest differences3. Adequate intake of both macronutrients (carbohydrate, protein and fat) and micronutrients (vitamins and minerals) is particularly important in the early years of life, when body growth and brain development are more rapid than during any other period. Research suggests that a child’s tastes and eating habits are formed early in life with consequences for child health, obesity and also health outcomes3. Poor nutrition during these early years may lead to increased risk of chronic diseases later in life such as such as obesity, diabetes, hypertension and coronary heart disease4.
National Nutrition Guidelines
National nutrition guidelines in other countries recommend that toddlers and pre-schoolers need to eat small, frequent meals throughout the day as they have small stomachs relative to their high energy needs. 3 meals and 2 – 3 healthy snacks is about right. Planned snacks contribute significantly to a child’s daily energy intake. Parents/caregivers should provide regular scheduled meals and snacks daily to instil security and comfort around food, to provide energy as needed and to support the development of healthy eating patterns5. Excellent guidelines are now available on ‘Best Practice for Infant Feeding in Ireland’6 and ‘Healthy Eating and Active Living for Adults, Teenagers and Children over 5 Years’ 7 but apart from the ‘Food and Nutrition Guidelines for Pre-School Services’5 there are currently no nutritional guidelines available in Ireland for the critical period of 1 to 5 years of age.
Expected growth and fussy eating
According to a recent review paper published by the Nutrition and Gastroenterology Committee of the Canadian Paediatric Society on ‘Picky Eaters’, approximately 25 – 35% of toddlers and pre-schoolers are described by their parents as poor or picky eaters8. Children’s feeding and eating problems are a frequent cause of parent-child conflict and can cause tremendous concern for parents. During the first year of life, an average infant gains 5.8kg in weight and 24.5cm in length. During the second year of life, growth is about 2.5kg and 12cm, with most toddlers reaching an average weight of 11.8kg and height of 87cm at two years of age. Between 2 and 5 years of age, rate of growth slows down. Most children gain between 2 – 3.0 kg and 6 – 9 cm per year9. This reduction in growth causes a physiological decrease in appetite between two and five years of age.
Between 2 – 5 years of age, children’s appetites tend to be erratic and intake at meals during the day can vary considerably. Parental reassurance is necessary and healthcare professionals need to promote the message that healthy children have a remarkable capacity to maintain their energy balance over time when offered an assortment of nutritious foods. Although food intake may fluctuate considerably from day to day, toddlers are able to maintain stable growth. While parents are responsible for which foods children are offered to eat, the child is responsible for how much they eat10. In other words, parents should choose nutritious foods of appropriate texture and taste for the child’s age, and provide structured meals and snacks, but allow children to decide how much and what to eat. Research has found, that children require up to 15 exposures of a new food before it is ‘trusted’ and thus tasted11. Conversely it has been consistently shown that parental pressure to consume foods is associated with higher expression of food neophobia 12. There are several dietary practices that can disrupt children’s self regulation of appetite including excessive juice and milk consumption.
National Pre-School Nutrition Survey
The National Pre-School Nutrition Survey investigated the eating habits of approximately 500 young children in Ireland aged between 1 – 4 years (i.e. from the age of 12 months up to their 5th birthday). Four day weighed food diaries were used to collect detailed food and beverage consumption data from these children. Findings from the study showed that for the most part, Irish pre-school children are well nourished and that their diet was adequate and met dietary recommendations for most nutrients. Milk/Formula was shown to be an important staple food in the diets of pre-school children, contributing almost a third of total daily calories in 1 year olds. While the proportion of total daily energy from milk/formula decreased with age, it remains an important contributor to energy (11%) at age 4 years13. A recent study on the effect of past food avoidance due to allergic symptoms on the growth of children at school age reported that at the age of 7 – 15 years, lower height and weight z scores were detected in children who had avoided two or more foods, particularly milk, at the age of three years14
Areas for concern highlighted in the National Pre-School Nutrition Survey included intakes of iron, vitamin D and salt. 23% of one year olds, 10% of two year olds and 11% of three year olds were estimated to have inadequate intakes of iron. The survey also indicated that a significant proportion of children may be at risk of inadequate intakes of Vitamin D, particularly in Winter. Overall, daily intakes of vitamin D were quite low with 70 – 84% of 1 – 4 year olds consuming less than the recommended 5 µg and 17 – 25% of these had intakes of less than 1 µg. This is unsurprising given that there are limited natural dietary sources of Vitamin D. Average daily salt intake exceeded the recommendations of 2g per day for 1 – 3 year olds and 3g per day for 4 to 6 year olds. Meat, especially cured and processed meats was the main contributor to salt intake. Nearly all four year olds (90%) consume processed meat while just over half (56%) consume fish13.
Iron is the world’s most common single nutrient deficiency15. Iron deficiency affects neuronal energy metabolism, the metabolism of neurotransmitters, myelination and memory function. Iron deficiency anaemia and iron deficiency without anaemia during infancy and childhood may have long lasting detrimental effects on neurodevelopment and behaviour and some of these effects may be irreversible 16. The American Academy of Pediatrics published a clinical report in 2010 stressing the importance of minimising iron deficiency anemia in toddlers even if an unequivocal relationship between iron deficiency anaemia and iron deficiency and neurodevelopmental outcomes has yet to be established. The report goes so far as to recommend universal screening of anaemia should be performed at approximately 1 year of age16.
To prevent iron deficiency and iron deficiency anaemia, toddlers 1 through 3 years of age should have an iron intake of 8mg per day17 and this would best be delivered by eating red meats, cereals fortified with iron, vegetables that contain iron (e.g. spinach, broccoli, green peas) and fruits with vitamin C which assist the absorption of iron. In the weaning diet red meat and vegetables with higher iron content should be introduced early. Research has shown the children within the first year of life may need only one exposure to a new food to double consumption18 compared to 15 exposures or more in older children11. For toddlers whose diet is limited a New Zealand study has shown the effectiveness of iron enriched toddler milks in improving the iron status of pre-school children. The consumption of iron-fortified milk in place of non-fortified milk for a period of 18 weeks increased mean serum ferritin concentration by 44% in the fortified milk group. Mean milk consumption was less than 500mls per day. The study also showed that for every additional 1g of red meat (beef, lamb or liver) eaten, this was associated with a 0.6% higher serum ferritin concentration19.
Vitamin D was identified in the early 20th century and in recent years interest in this vitamin has increased considerably. Clinical research has been stimulated by the discovery that many human cells carry the vitamin D receptor (VDR), and that vitamin D and VDR may play a role in the regulation of cell proliferation and differentiation, for example in cells of the immune system including T cells, macrophages, monocytes and antigen presenting cells20. While the main functions of vitamin D are the regulation of calcium and phosphate metabolism, other health effects have been proposed for children and adolescents, including prevention of immune related diseases (asthma, type 1 diabetes mellitus), infectious diseases (respiratory infections, influenza) amd cardiovascular disease. With the exception of bone health, there is currently insufficient evidence from interventional studies to support vitamin D supplementation for these other health benefits21. However public health policies throughout Europe and America recognise the importance of adequate vitamin D status for population health and Vitamin D supplementation policies have recently been revised in both the U.S.A and France22, 21. In February 2012 the four Chief Medical Officers of the United Kingdom wrote to healthcare professionals to highlight the importance of adequate vitamin D intake and to express concerns at the at the poor uptake of the free ‘Healthy Start’ Vitamins (7.5 µg Vitamin D3, 233 µg Vitamin A, 20mg Vitamin C ) by families qualifying for the scheme23. Vitamin D supplementation policies for infants and children usually take into account vitamin D intake from fortified formula or milk.
Vitamin D deficiency and rickets
Rickets is an example of extreme vitamin D deficiency and cases continue to be reported throughout the United States and Europe22,21. A retrospective study conducted by Dr. Jenny Bracken, Radiology Department at The Children’s University Hospital Temple Street in 2006 identified 12 children with Vitamin D deficient rickets over a four year period. The children’s ages ranged from 7 weeks to 10.5 years. All of the children, although born in Ireland were of immigrant origin, 11 Africans and 1 Polish. Most of the children had been breast fed without Vitamin D supplementation24. The European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published a consensus statement on ‘Vitamin D in the Healthy European Paediatric Population’ in 2013. ESPGHAN recommend that oral supplementation of Vitamin D for children beyond 1 year of age must be considered for at risk groups. At risk groups include children and adolescents with dark skin living in northern countries (e.g. Ireland), children and adolescents without adequate sun exposure (excessive use of sunscreen with high SPF, staying in doors for much of the day, wearing clothes covering most of the skin, living in Northern latitudes (e.g. Ireland) during the wintertime) and obese children21. In Ireland a daily vitamin D supplement of 5 µg is recommended for infants 0 – 12 months6 and children and teenagers over 5 years7. As no nutritional guidelines exist for children 1 – 5 years, there are no recommendations available for this group.
Fish and shellfish can be an important part of a healthy diet for young children, contributing to their proper growth and development. Fish and shellfish contribute high quality protein, are low in saturated fat and contain other essential nutrients including long chain omega-3 polyunsaturated fatty acids (PUFAs). DHA and EPA are two important long chain omega- 3 PUFAs. They are found in oily fish such as herring, mackerel, sardines, pilchards, kippers, salmon and trout. They are also found in breast milk and formula. The human body has very limited ability to make DHA and EPA. Therefore, they are sometimes referred to as essential fatty acids. They are important for brain and eye development in babies during pregnancy and early life. For older children and adults, DHA and EPA are also very important as they help prevent the formation of blood clots and protect against heart disease7.
The UK recommend toddlers and pre-school children should eat 2 portions of fish per week, one of which should be oily. For children aged 18 months to 3 years one portion equals to a ¼ to 1 small fillet or 1 – 3 tablespoons. For children aged 4 – 6 years one portion equals ½ to 1 small fillet or 2 – 4 tablespoons25. 30g of salmon or trout will provide 621 and 687mg of DHA respectively6. Shark, swordfish, marlin, ray and fresh tuna may contain concentrated sources of mercury and should be avoided by all children under 16 years of age25,6 The National Pre-School Nutrition Survey showed that only 44 – 59% of 1 – 4 year olds are eating fish13.
Nutritional guidelines for toddlers and pre-school children should seek to optimise physical and cognitive development, promote attainment of a healthy weight, encourage enjoyment of food and reduce the risk of chronic disease in later life. Parents, families and care givers have the greatest influence on children’s diets and activity levels during these early years and should be educated and supported to lay the best foundations possible for future diets and health.
- Centre Forum (2011) Parenting matters: early years and social mobility. Report prepared by Chris Patterson. ISBN 1-902622-91-X
- Sorhaindho & Feinstein (2006) Centre for Research on the Wider Benefits of Learning: Wider Benefits of Learning Research Report No 18 ‘Relationship between child nutrition and school outcomes’ & Feinstein et al. Dietary patterns relating to attainment in school: the importance of early eating patterns. J Epidemiol Community Health 2008; 62: 734-739
- Singhal A. & Lucas A. Early origin of cardiovascular disease: is there a unifying hypothesis? Lancet 2004; 363: 1642 – 1645
- Health Promotion Unit, Department of Health and Children (2004). Food and Nutrition Guidelines for Pre-School Services
- Food Safety Authority of Ireland (2012) Best Practice for Infant Feeding in Ireland. From pre-conception through to the first year of an infant’s life.
- Food Safety Authority of Ireland (2012) Healthy Eating and Active Living for Adults, Teenagers and Children over 5 years
- Leung, Marchand & Suave. The ‘picky eater’: The toddler or preschooler who does not eat. Paediatr Child Health 17 (8): 455 – 57
- WHO Child Growth Standards based on length/height, weight and age. Acta Paediatr Suppl 2006; 450: 76 – 85
- Satter E. Feeding dynamics: Helping Children to eat well. J Pediatr Health Care 1995; 9(4): 178 – 4
- Wardle, Carnell & Cooke. Parental control over feeding and children’s fruit and vegetable intake: How are they related? Journal of the American Dietetic Association. 105: 227 – 232
- Dovey, Staples et al. Food neophobia and ‘picky/fussy’ eating in children: A review. Appetite (2008); 50: 181 – 193
- National Pre-School Nutrition Survey. Summary Report: Food and nutrient intakes, physical measurements and barriers to healthy eating.2012
- Mukaida, Kusunoki, Morimoto et al. The effect of past food avoidance due to allergic symptoms on the growth of children at school age. Allergology International 2010; 59 (4): 369-374
- World Health Organisation. Worldwide Prevalence of Anaemia 1993 – 2005. Geneva: WHO Press 2008
- Baker, Greer and the Committee on Nutrition of the American Academy of Pediatrics. Diagnosis and Prevention of Iron Deficiency and Iron Deficiency Anaemia in Infants and Young Children (0 – 3 Years of Age). Paediatrics 2010; 126: 1040 (www.pediatrics.org/cgi/doi/10.1542/peds.2010-2576)
- Food Safety Authority of Ireland (1999) Recommended Dietary Allowances for Ireland.
- Birch, McPhee et al. What kind of exposure reduces children’s food neophobia? Looking versus tasting. Appetite (1987); 9: 171 – 178
- Syzmlek-Gay, Ferguson et al. Food based strategies to improve iron status in toddlers: a randomised controlled trial. Am J Clin Nutr (2009); 90: 1541 – 51
- DeLuca and Schnoes. Vitamin D: recent advances. Annu Rev Biochem (1983); 52: 411-39
- Braeger, Campoy et al. ESPGHAN Consensus Statement. Vitamin D in the Healthy European Paediatric Population. JPGN (2013); 56 (6): 692 – 701
- Wagner and Greer. Prevention of Rickets and Vitamin D Deficiency in Infants, Children and Adolescents. Pediatrics (2008); 122: 1142 -52
- Welsh Government, Department of Health, Social Services and Public Safety, Scottish Government & Department of Health. Chief Medical Officers’ letter (2012) to community healthcare professionals regarding ‘Vitamin D – advice on supplements for at risk groups’. Ref CEM/CMO/2012/04
- Bracken et al. Poster Abstract presented at the Annual Scientific Meeting, Faculty of Radiology, RCSI 2006. ‘Vitamin D Deficient Rickets – a Re-emerging Issue in our Immigrant Population’
- British Dietetic Association. Omega 3 fact sheet (2013). www.bda.uk.com/foodfacts