User manual | Healthy start in life

a
healthy start
in life
a nutrition manual for health professionals
2008
First published by Queensland Health, 1997
First revised 1999
Revised 2008
Second edition
Copyright © Queensland Health 2008
Copyright protects this publication. However Queensland health has no objection
to this material being reproduced with acknowledgement, except for commercial
purposes or where the material is being modified.
Requests and enquiries concerning reproduction rights should be directed to the
Principal Project Officer - Intellectual Property
Queensland Health
GPO Box 48
BRISBANE QLD 4001
ISBN: 978-1-921021-83-1
Property of Queensland Health
Designed by VC Graphics
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A HEALTHY START IN LIFE
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Acknowledgements
Many people have provided time, expertise, feedback and support throughout the development of
this resource. This project would not have been possible without funding from Golden Casket and
project management provided by Southern Area Population Health Public Health Units Nutrition
Team.
The steering committee: Lyza Norton, Barbara Radcliffe, Doug Shelton, Peta Patterson and Jacqui
Kaye.
The reference group which included Public Health Nutritionists, Child Health Nurses, Paediatric
Dietitians, Midwives, Lactation Consultants and other health professionals.
Authors: Jacqui Kaye, Peta Patterson, Susan Croaker, Lyza Norton and Fiona Lewis.
Reviewers: Helen Vidgen, Michelle Harrison, Sue Wellings, Jillian Dymock,
Penny Beatty, Vicki Attenborough, Liz Good, Judy Wilcox, Jan Branch, Amanda Allen,
Renee Watts, Barbara Radcliffe, Doug Shelton, Helen Clifford, Peter Smith and the Australian
Breastfeeding Association.
The health professionals involved in the focus groups
Southern Area Population Health Units
Southern Area Child and Youth Health Clinical Network
Gold Coast Health Service District Librarians
Mater Misericordiae Public Hospital Department of Nutrition and Dietetics
Royal Children’s Hospital Health Service District Department of Nutrition and Dietetics and
Community Child Health Service
Golden Casket
Australian Breastfeeding Association
Australasian Society of Clinical Immunology and Allergy
This manual is on the Queensland Health Internet site at www.health.qld.gov.au
A HEALTHY START IN LIFE
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Contents
Acknowledgements
Glossary
c
i
1.0 Introduction
1
1.1
1.2
1.3
1.4
Abbreviations
Symbols
Communicating with clients
Key documents
1.5
Food groups
1.6
Nutrient reference values 1.7
Physical activity
The Dietary Guidelines for Children and Adolescents in Australia 5
8
The Australian Guide to Healthy Eating
The Aboriginal and Torres Strait Islander Guide to Healthy Eating
Bread, cereal, rice, pasta, noodles
Vegetables, legumes
Fruit
Milk, yoghurt, cheese
Meat, fish, poultry, eggs, nuts, legumes
Extra foods
Putting it all together
11
11
11
12
12
13
13
For infants and children
Energy
Protein
Fat
Carbohydrate
Iron
Zinc
Calcium
Folate/folic acid
Vitamin B12
Vitamin B6
Vitamin C
14
14
14
15
15
15
16
17
18
19
19
20
Benefits
Barriers
Physical activity recommendations
Strategies to promote physical activity
Family activities
Sport and recreation resources
Useful websites and resources
21
21
21
22
22
22
23
Cultural competence in early life
How culturally competent is your health service?
How to go about cultural competence
Multicultural profile of Queensland
Vulnerable migrants: refugee and asylum seeker
Females: special considerations
Working with interpreters
Communication style
Religion Case studies: an African woman new to Australia
Nutritional risks identified
Useful websites and resources
References
24
24
24
25
25
25
26
26
27
28
28
29
30
Current health and nutritional status
Recommendations from the Dietary Guidelines for Australians
Protocols for engaging with
Aboriginal and Torres Strait Islander communities
Antenatal nutrition
Breastfeeding Useful websites and resources
31
32
1.8Culturally and Linguistically Diverse (CALD) Communities
1.9
d
9
Aboriginal and Torres Strait Islander nutrition
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32
33
34
37
2
2
3
4
10
14
21
24
31
2.0 Antenatal nutrition
2.1
2.2
Nutrition during pregnancy
Sample meal plan
2.3
Special considerations during pregnancy
2.4
Weight gain during pregnancy
Folate during pregnancy
Iron during pregnancy
Iodine
Multivitamin supplements
Alternative and herbal remedies
3
4
5
5
5
Listeria
Mercury
Caffeine
Artificial sweeteners
Alcohol
Morning sickness
Constipation
Heartburn
6
7
7
7
8
8
10
10
Healthy eating to increase weight gain Healthy eating to control weight gain Returning to pre-pregnant weight Healthy eating tips for those trying to lose weight
Healthy eating tips for those trying to gain weight
12
13
13
14
14
Vegetarian and vegans
Teenagers
Aboriginal and Torres Strait Islander women
Obese pregnant women
Women with diabetes in pregnancy
Pre-existing Type 1 and Type 2 diabetes
Gestational diabetes
15
17
17
17
18
18
18
Guide to education
23
2.5Groups requiring special attention during pregnancy
2.6
2.7
1
Exercise during pregnancy
Antenatal breastfeeding education 1
2
6
11
15
19
22
3.0 Feeding for the first 6 months
3.1
3.2
3.3
Breastfeeding: best for baby, best for mum
The benefits of breastfeeding
Natural patterns of breastfeeding
The first breastfeed
One or both breasts at each feed?
Breastmilk
The sleepy infant
The unsettled infant
How often should I breastfeed my baby? Identification of correct attachment
Sore and cracked nipples
Is baby getting enough milk?
Guidelines for practitioners:
Monitoring progress: in the first month of life
Monitoring progress: from 1 to 6 months
4
5
5
6
7
8
9
10
11
16
16
17
Energy requirements
Physical activity
Dieting during breastfeeding
Alcohol
Caffeine
Food sensitivities 20
20
23
24
24
25
Nicotine
Prescription and/or over the counter medications
Drugs to relieve headache, aches, pain or fever
Cold, flu and asthma drugs
Hayfever and allergies
Contraception
27
28
28
29
29
29
3.4Why not to introduce cow’s milk before 12 months
3.5 Nutrition and breastfeeding 3.6
1
Breastfeeding and non nutritive substances
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3
4
18
19
27
e
3.7
Constipation
Vitamins, minerals and herbal preparations Antidepressants
Smoking
Illicit drugs
29
30
30
30
30
Absolute contraindications for breastfeeding
Relative contraindications to breastfeeding
32
33
Breast care options during weaning
Women and paid work 37
38
Breastfeeding in specific situations
3.8 Expressing and storing breastmilk
3.9Points to consider when discussing breastfeeding cessation
3.10When an infant is not receiving breastmilk - infant formula
3.11 Useful websites and resources
32
34
36
39
42
4.0 Introduction to solids
4.1
4.2
4.3
When should solids start?
How should solids be started?
What solids should be started and when?
4.4
4.5
4.6
4.7
Drinks
Salt in food
Sugar in food
Useful websites and resources
From 6 months
From 8 months
From 9 months
From 12 months
1
5
6
8
9
2
4
5
11
12
12
13
5.0 Toddler nutrition
1
5.1Why is nutrition important in toddlers?
Understanding how children approach eating 2
What affects toddler’s daily intakes?
Suggested meal plan for a toddler
4
5
5.2
What should toddlers eat?
5.3
What should toddlers be offered to drink?
5.4Assessing whether their children are meeting their dietary needs
Food diary
Growth monitoring
When to refer
7
7
7
5.5
5.6
5.7
Tips for toddler eating Safety tips
Milk matters
5.8
5.9
Fussy eating
Useful websites and resources
How much milk?
How much fat?
11
11
1
3
6
7
9
10
11
14
19
6.0 Preschool nutrition
1
6.1
6.2
Eating patterns
Nutrition during preschool years
6.3
6.4
6.5
6.6
6.7
Suggested meal plan for a 4-7 year old
Eating habits Growth
Appetite
Physical activity Suggested sample servings for children aged 4 –7 years 4
Treats Healthy snacks Healthy drinks 7
7
7
6.9 Food preferences
6.10 Useful websites and resources
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2
3
5
5
6
6
6
8
9
7.0 Clinical nutrition
7.1
Adverse food reactions 7.2
Colic
7.3
Constipation – keeping things moving!
Understanding food allergies and intolerances
Understanding food allergies
Management
Dietary intervention
Chemical threshold Food intolerance reactions
Management of food intolerances Elimination diets
Coeliac disease
1
1
1
4
4
5
5
5
5
6
Resources
10
Definition
Normal bowel function
Aetiology of constipation
Fibre, fluid and exercise
Fibre content of foods
Cow’s milk protein allergy
Clinical presentation of constipation
13
14
15
16
16
17
17
Management of children with constipation Education
Maintenance therapy
Relapse
17
17
18
18
Definition
Growth
Causes of failure to thrive
Consequences Primary care management
Weighing
Dietary assessment
The role of the general practitioner / paediatrician Checklist for failure to thrive (adapted from 6)
20
21
22
23
23
23
23
23
24
Fluoride and breastfeeding
Fluoride and formula feeding Fluoride guidelines
Useful websites and resources
27
27
27
28
Management
Signs of dehydration
Recommended hydration strategies for the dehydrated child 29
30
30
Recommended hydration strategies for the non‑dehydrated child Sample meal plan
Useful webstes and resources
31
31
32
Types of charts
Using growth charts
Weight and length/height
Poor growth
Overweight and obesity
Head circumference
33
34
34
34
35
35
Keeping Kids on Track
Defining overweight and obesity in children
Nutrition strategies
Energy in
Food labels High fat
High sugar
Snack food dilemmas
Energy out
Useful websites and resources
37
38
39
40
40
41
42
43
45
48
7.4Failure to Thrive (Slow weight gain and undernutrition) 7.5
Fluoride
7.6
Gastroenteritis
7.7
Growth charts 7.8
Healthy weight
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9
13
20
27
29
33
37
g
7.9
Iron deficiency
What is iron deficiency?
Symptoms of iron deficiency and iron deficiency anaemia (1)
Treatment
Bioavailability of iron
What are the best sources of iron?
Assessing the diet
– asking about iron consumption for infants and toddlers
Useful websites and resources
51
52
54
55
55
Causes of lactose intolerance Management
Useful websites
60
61
62
Diagnosis
Reflux and poor weight gain
Management
63
64
64
7.10 Lactose intolerance
7.11 Regurgitation and gastro-oesophageal reflux
56
59
50
60
63
Resource list
1
Tables
Table 1
Table 2
Table 3
Table 4
Table 5
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Table 16
Table 17
Table 18
Table 19
Table 20
Table 21
Table 22
Table 23
Table 24
Table 25
Table 26
Food group recommendations
Open questions for use in CALD communities
Factors influencing the rates of breastfeeding (in a Melbourne Aboriginal community)
Age of introduction to solids (in a Melbourne Aboriginal community)
Food recommendations during pregnancy
Recommended total weight gain during pregnancy, proportional to weight for height
The general guide to the pattern of weight gain during pregnancy
Types of vegetarians and major food sources
The Australian Guide to Healthy Eating recommendations for breastfeeding women
Energy expenditure variations during breastfeeding
Storage of expressed breastmilk for infant use
Typical physical and social/ personal characteristics related to eating during the preschool years
Recommended fat content of milk for 1 to 5 year olds
Typical physical and social/personal characteristics related to eating during the preschool years
Clinical presentation of constipation
Not included
Possible strategies for increasing energy intake
Fluoride is important to healthy teeth
Comparison of CDC2000 and WHO growth charts
NHMRC current classifications for BMI percentile ranges
Comparison of fat content of various foods
Comparison of sugar content of various foods and drinks
Possible causes of a child being above their natural body weight
Definitions of impaired iron status
Lactose content of common foods
Figures
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
The Australian Guide to Healthy Eating
The Aboriginal and Torres Strait Islander Guide to Healthy Eating
Body Mass Index chart
Attachment
Not oncluded
Continuum of changes in iron stores and distribution in the presence
of increased or decreased body iron content
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Glossary
Growth The acquisition of tissue and the consequent
increase in body size.
Development The increased ability of the body to function
physically and intellectually. Physical and intellectual
development proceed at different rates in different
individuals.
Breastfeeding duration The total length of time during which an infant
receives any breastmilk at all - from initiation until
breastfeeding has ceased.
Breastmilk substitute
Any food being marketed or otherwise represented
as a partial or total replacement for breastmilk,
whether or not it is suitable for that purpose. In
Australia, this term is considered inappropriate
because it implies an equivalence to breastmilk.
The term infant formula is used throughout this
document, although it is acknowledged that other
foods and fluids are used in place of breastmilk.
Infant formula is the term used in Australia New
Zealand Food Standards Code, volume 2.
Complementary food
Any food - manufactured or locally prepared suitable as a complement to breastmilk or infant
formula, when either becomes insufficient to satisfy
the nutritional requirements of the infant. Such food
is also commonly called weaning food or breastmilk
supplement. In this document the following working
definition is used any nutrient-containing foods or
liquids (other than breastmilk) given to infants who
are breastfeeding.
Complementary feeding The infant or child is receiving both breastmilk and
nutrient-containing foods, which includes any food
or liquid containing non-human milk.
Caregivers
Those who provide care to the infant/child.
Exclusive breastfeeding An infant receives only breastmilk from his or her
mother or a wet nurse, or in the form of expressed
breastmilk, and no other liquids or solids apart
from drops or syrups containing vitamins, mineral
supplements or medicines.
Fully breastfed A HEALTHY START IN LIFE
This term embraces the WHO indicators of
‘exclusive’ breastfeeding and ‘predominant’
breastfeeding. It refers to infants who are receiving
almost all of their nutrients from breastmilk but take
some other liquids such as water, water-based
drinks, oral rehydration solutions, ritual fluids, and
drops or syrups. It excludes any food-based fluids.
INTRODUCTION
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Infant
A child aged less than 12 months.
Infant formula An infant formula product represented as a
breastmilk substitute for infants and which satisfies
the nutritional requirements of infants aged up to
4 to 6 months. Australia New Zealand Food
Standards (volume 4 to 6)
Preschool child
A child aged from 3 to 5 years of age.
Solid foods Any nutrient-containing foods (semi-solid or solid)
for example, dilute infant cereals. Excludes
breastmilk and breastmilk substitutes, fruit and
vegetable juices, sugar water, and so on.
Supplementary feed Fluids or foods dissolved in fluids given to completely
replace a breastfeed. The distinction between
complementary feeds and supplementary feeds
is important there seems to be a great deal of
confusion among health professionals.
Toddler A child aged from 1 to 2 years.
Weaning The period during which an infant is introduced to
breastmilk substitutes or solid foods, or both, with
the intention of ceasing breastfeeding. (This term
should be used with care in the literature, weaning,
weaning foods and weaned are used in different
ways).
Weaned The infant or child no longer receives any breastmilk.
Young child
A child aged less than 5 years.
6 months Is defined as the end of the first 6 months of life
(180 days), when the infant is 26 weeks old as
opposed to the start of the 6th month of life, that
is at 21-22 weeks of age. For pre term infants this
means 6 months corrected age.
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A HEALTHY START IN LIFE
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1.0 Introduction
This manual covers the nutrition needs of pregnant and lactating women, and also that of infants
and children, from birth to 6 years. It has been developed for use by community and child health
nurses and may extend to other health professionals.
A healthy start in life was last reviewed in 1999. This revision was initiated to update the nutrition
information available to child health professionals. Golden Casket provided funding to Southern
Area Population Health Units to undertake this review.
This manual covers a wide variety of nutrition issues. It is intended to be used as a resource
manual to clarify, instruct and supplement the base level of knowledge of community and child
health nurses and other health professionals.
It has been developed in consultation with child health nurses and dietitian/nutritionists throughout
Queensland, and should therefore provide information from a broad perspective.
The information presented in this manual assumes there is a varied baseline level of nutrition
knowledge amongst health professionals. It aims to supplement this knowledge, providing a
consistent and reliable source of nutrition information across Queensland. It also includes available
parent resources to aid in client education.
While all pregnant women, mothers, infants and families are entitled to appropriate and accessible
antenatal, birthing and postnatal care and support, some population groups are less likely to
access health services during the antenatal period and/or to breastfeed. These include: women
from low socioeconomic groups; Aboriginal and Torres Strait Islander women, particularly in urban
areas; women from culturally and linguistically diverse backgrounds, particularly Asian women;
young women; and obese women.
Specific coverage of cultural and linguistically diverse populations and Aboriginal and Torres
Strait Islander people has been included in this manual to enable practitioners to address specific
concerns from these populations.
There are many people who might consider themselves experts in feeding babies and young
children. These may include grandparents, parents-in-law, friends, workmates, brothers and
sisters who have had a baby. Whilst valuable, advice from all angles often makes feeding young
children more complicated and confusing for parents it’s important to recognise that while there
are general guidelines to help new parents, all babies and young children are individuals with
their own growth rates, activity and development that may influence their appetite and food
preferences.
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1.1 Abbreviations
BMI
Body Mass Index
FSANZ
Food Standards Australia and New Zealand
NHMRC
National Health and Medical Research Council
RDI
Recommended Dietary Intake
NVR
Nutrient Reference Value
kg
kilogram
g
gram
mg
milligram
ug
microgram
ml
millilitres
L
litre
Tbsp
tablespoon
wt
weight (kg)
ht
height (cm/m)
kJ
kilojoules
cm
centimetres
m
metres
1.2 Symbols
Parent handouts
Web resource
Professional development resource
ecommendations from the R
Dietary Guidelines for Children and Adolescents in
Australia
2
A HEALTHY START IN LIFE
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1.3 Communicating with clients
Some of the techniques you may use to find out what information a mother needs and to help her
make the best use of this information are listed below.
Listening
Listening well lets the parent/caregiver explain the situation as they see it. Body language and non
verbal communication is also important.
Showing you understand
Use your own words to explain what you have heard. This lets you check with the parent/caregiver
that you have understood what she has said.
Asking about what has been tried already
Before you offer suggestions ask what the parent/caregiver has already tried. This gives you a
better picture of the situation and helps to identify what might work.
Asking about previous advice
Everyone seems to be an expert on pregnancy and babies. Parent/caregivers can get very
confused if they are being given conflicting advice. It is important to know what the parent/
caregiver has been told before you offer your own information and suggestions. Be careful not to
put down the advice given by anyone else.
Offering suggestions
It is our job to offer ideas about what she could do. It is up to the parent/caregiver to decide what
will work best in her situation and what she is able to do.
Helping believe they can do it
It is important not only to give information and make suggestions but also to provide the skills
needed.
Identifying support
Some will need more support than others. Talk to the parent/caregiver about what support they
would like and who could provide it. Give referrals to other staff or agencies if appropriate.
Summarising
At the end of a session go over the main points of your discussion.
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3
Client education action checklist
✔✔ What information, knowledge or skill does the client already have?
✔✔ Explore previous experiences … Have you seen this before? … Have you
heard about? …
✔✔ What does the client want and need to know?
✔✔ Base your information/client education on the priorities set by the client.
✔✔ Work from known to the unknown: from simple to complex.
✔✔ Get client’s attention.
✔✔ Clarify what you want to do.
✔✔ Present content using appropriate strategies.
✔✔ Adjust the content so it is relevant to the client and their experiences.
✔✔ Get feedback from client of their understanding of the content.
✔✔ Reinforce learning (praise, acknowledgement and more praise).
✔✔ What take away material/information is available?
✔✔ Summarise what you have covered.
✔✔ Document client education.
1.4 Key documents
The key nutrition guiding documents used in this resource are:
■■ Dietary Guidelines for Children and Adolescents in Australia
■■ Australian Guide to Healthy Eating
■■ Nutrient Reference Values (including RDIs)
National Breastfeeding Strategy
National Physical Activity Guidelines
Report of the Chief Health Officer Queensland, 2006
Clinical practice guidelines used in this document include:
■■ NHMRC Clinical practice guidelines for the management of overweight and obesity
in children
■■ NHMRC Child health screening guidelines
■■ WHO Infant and young child feeding: standard recommendations for the European
Union
■■ Specific Clinical Practice guidelines are available at www.mja.com.au
Queensland Health Optimal Infant Feeding: evidence based guidelines 2003-2008
Queensland Health: Enhanced Child Health Model of Care for Community Health Services
(0-12 years)
Infant and Child Nutrition in Queensland 2003
www.health.qld.gov.au/healthieryou/food_nutrition.asp
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A HEALTHY START IN LIFE
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The Dietary Guidelines for Children and Adolescents in
Australia
The Dietary Guidelines for Australians are the best guide to food, nutrition and health. The Dietary
Guidelines for Children and Adolescents in Australia highlight the groups of foods and lifestyle
patterns that foster good nutrition and health. The latest edition available was revised in 2003.
The Dietary Guidelines give evidence based principles for healthy eating and apply to the total diet.
They are not ranked in order of importance and should be considered in their entirety ie. not just
individual guidelines in isolation.
The Dietary Guidelines incorporate The Australian Guide to Health Eating.
The NHRMC Dietary Guidelines for Children and Adolescents incorporating the infant feeding
guidelines for health workers provide a comprehensive overview of appropriate food choices for
infants and children at various developmental stages and the risks associated with the introduction
of inappropriate foods. Health workers should refer to these documents for guidance when
advising pregnant women, mothers, families and carers about infant nutrition.
For copies of the Dietary Guidelines for Children and Adolescents in Australia contact:
Population Health Publications Officer Commonwealth Department of Health and Ageing 1800 020 103
Email: [email protected]
Web: www.nhmrc.gov.au/publications/synopses/dietsyn.htm
Summary document ww.population.health.wa.gov.au/Promotion/resources/Infant%20
w
Feeding%20Guidelines.pdf
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6
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7
The Australian Guide to Healthy Eating
The Australian Guide to Healthy Eating shows the types and amounts of foods to enjoy eating
every day from the five core food groups. Use this as a guide to fill your plate according to the
portions from the different food groups as shown on the plate diagram below.
The Australian Guide to Healthy Eating uses the dietary guidelines, core food groups and
Recommended Dietary Intakes to develop a healthy eating plan. Use these to help families
develop a specific daily meal plan.
To order a copy of The Australian Guide to Healthy Eating
Ph:
toll free on 1800 020 103
Web: www.health.gov.au/internet/wcms/publishing.nsf
Figure 1
8
The Australian Guide to Healthy Eating
A HEALTHY START IN LIFE
INTRODUCTION
The Aboriginal and Torres Strait Islander Guide
to Healthy Eating
This guide is adapted from The Australian Guide to Healthy Eating. It shows how much food is
required every day from each food group for good nutrition and health. Healthy eating throughout
life will help reduce the risk of health problems later in life such as type 2 diabetes, heart disease,
cancer and obesity. The foods included in the guide are those that can be found at the store as
well as some local bush and seafoods. This guide helps you to make healthy food choices.
Resource and education manual available on the internet at:
www.nt.gov.au/health/comm_health/food_nutrition/atsi_flyer.pdf
www.nt.gov.au/health/comm_health/food_nutrition/educator%27s%20resource.pdf
Figure 2
The Aboriginal and Torres Strait Islander Guide to Healthy Eating
A HEALTHY START IN LIFE
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9
1.5 Food groups
A number of food selection guides have been developed in Australia over the last 50 years,
including the Five Food Groups model and the Healthy Eating Pyramid. The core food groups
model was endorsed by the NHMRC in 1994. The main use of the Core Food Groups was to
provide a scientific basis for the development of up to date nutrition education tools. This has seen
the replacement of the Five Food Groups model with the Australian Guide to Healthy Eating.
The Australian Guide to Healthy Eating highlights the importance of promoting the inclusion of a
wide variety of foods in the diet. The table below outlines the recommended quantities of the food
groups required for different age groups and status.
Recommended serves apply only to that portion of the population greater than 4 years. They
cannot be applied to children less than 4 years. The NHMRC have not developed nationally
endorsed food group servings for 1‑3 year olds as it has for children 4 years and older. At this age
there is marked variability in the amount individual children eat. How much food is eaten varies
from child to child and from day to day and is influenced by growth and activity levels.
Within each of the five food groups, different foods provide more of some nutrients than others. It
is important to consume a variety of foods from both within and across the food groups. This will
ensure that the body’s nutrient requirements are met.
Table 1
Food group recommendations
Food Group Serves
Sex / Age
Group
Breads,
Vegetables,
Cereals,
Legumes
Rice, Pasta,
Noodles
Fruit
Milk,
Yoghurt,
Cheese
Meat, Fish,
Poultry,
Eggs,
Nuts and
Legumes
Extra
Foods
Children
4-7 yrs
5-7
2
1
2
½
1-2
8-11 yrs
6-9
3
1
2
1
1-2
12-18 yrs
5-11
4
3
3
1
1-3
19-60 yrs
4-9
5
2
2
1
0-2 ½
60+ yrs
4-7
5
2
2
1
0-2
Pregnant
4-6
5-6
4
2
1½
0-2 ½
Breastfeeding
5-7
7
5
2
2
0-2 ½
19-60 yrs
6-12
5
2
2
1
0-3
60+ yrs
4-9
5
2
2
1
0-2 ½
Women
Men
Adapted from: The Australian Guide to Healthy Eating
10
A HEALTHY START IN LIFE
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Bread, cereal, rice, pasta, noodles
Why?
The nutrients provided by the foods in this group include carbohydrates, protein, fibre and a
wide range of vitamins and minerals including folate, thiamin, riboflavin, niacin and iron.
Wholemeal or wholegrain varieties provide more fibre, vitamins and minerals. Some foods in this
group may have fibre, vitamins and minerals added during processing.
What?
A sample serve of bread, cereal, rice, pasta, noodles is:
2 slices bread
1 medium bread roll
1 cup cooked rice, pasta, noodles
1 cup porridge, 11/3 cups breakfast cereal flakes
½ cup muesli
Vegetables, legumes
Why?
Vegetables and legumes are a good source of vitamins, minerals, dietary fibre and carbohydrate.
■■ capsicum, broccoli, cauliflower, cabbage and tomatoes are high in vitamin C
■■ dark green vegetables eg spinach, broccoli, and orange vegetables eg carrots and
pumpkin are high in vitamin A
■■ green vegetables, dried peas, beans and lentils are a good source of folate
What?
A sample serve of vegetables, legumes is:
75 g or ½ cup cooked vegetables
75g or ½ cup cooked dried beans, peas or lentils
1 cup salad vegetables
1 potato
Fruit
Why?
Fruit is a good source of vitamins, including vitamin C and folate. It also provides carbohydrates in
particular natural sugars and fibre, especially in the edible skins. Juices belong to this group, but they have a much lower fibre content than fresh fruit.
What?
A sample serve of fruit is:
1 medium piece, eg apple, banana, orange, pear
2 small pieces, eg apricots, kiwi fruit, plums
1 cup diced pieces or canned fruit
½ cup juice
dried fruit, eg 4 dried apricot halves, 1 ½ tablespoons sultanas
A HEALTHY START IN LIFE
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11
Milk, yoghurt, cheese
Why?
Milk, yoghurt and firm cheeses are the three important foods in this group.
The foods in this group are an excellent source of calcium; very few other foods in the Australian
diet contain as much of this important nutrient. These foods are also a good source of protein,
riboflavin and vitamin B12.
The milk, yoghurt, cheese group can increase the fat content of your diet if you choose full cream
products. For most people, 2 years and over, the best choices are reduced fat milk, yoghurt and
cheese. For children under 2 years of age, full cream varieties are recommended because of their
high energy needs.
What?
A sample serve of milk, yoghurt, cheese is:
250 ml (1 cup) fresh, long-life or reconstituted dried milk
½ cup evaporated milk
40 g (2 slices) cheese
200g (1 small carton) yoghurt
250 ml (1 cup) custard
Meat, fish, poultry, eggs, nuts, legumes
Why?
There is a wide variety of foods in this group. It consists of all kinds of meat, poultry, fish, eggs,
nuts and nut pastes such as peanut butter, legumes, and some seeds such as sunflower and
sesame seeds.
The foods in this group are a good source of protein, iron, niacin and vitamin B12. Within this
group, red meats are a particularly good source of iron and also zinc. The iron in animal foods is
more easily absorbed by the body than the iron in plant foods. Red meat should be eaten 3 to
4 times a week, or high iron replacement foods will be required. This is especially true for girls,
women, vegetarians and athletes.
What?
A sample serve of meat, fish, poultry, eggs, nuts, legumes is:
65-100 g cooked meat, chicken
½ cup lean mince
2 small chops
2 slices roast meat
½ cup cooked (dried) beans, lentils, chick peas, split peas, or canned beans
80-120 g cooked fish fillet
2 small eggs
1/3 cup peanuts or almonds
¼ cup sunflower seeds or sesame seeds
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Extra foods
Why?
Some foods do not fit into the five food groups. They are not essential to provide the nutrients
the body needs and some contain too much added fat, salt and sugars. These foods are likely to
contribute large amounts of energy. However, they can add to the enjoyment of eating a healthy
diet.
What?
A sample serve of extra foods is the amount of food that provides 600 kJ.
Some examples are:
1 (40 g) doughnut
60 ml spirits (2 standard drinks)
4 (35g) plain sweet biscuits
600 ml light beer (1½ standard drinks)
1 slice (40 g) plain cake
400 ml regular beer (1½ standard drinks)
½ small bar (25 g) chocolate
1 can (375 ml) soft drink
2 tablespoons (40 g) cream, mayonnaise
1/3 (60 g) meat pie or pastie
1 tablespoon (20 g) butter, margarine, oil
12 (60 g) hot chips
200 ml wine (2 standard drinks)
1½ scoops (50g scoop) icecream
Putting it all together
People’s need for energy, carbohydrates, fats and protein, vitamins and minerals varies depending
on their age and sex and is altered when pregnant or breastfeeding. These quantities represent
the minimum amounts of food which need to be consumed in order to meet the requirements for
a healthy diet.
A HEALTHY START IN LIFE
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13
1.6 Nutrient reference values
www.nhmrc.gov.au/publications/synopses/_files/n35.pdf
NH&MRC has recently developed Nutrient Reference Values for Australia and New Zealand (2005).
It replaces the RDI system. Nutrient Reference Values include:
RDI: Recommended Dietary Intake
The average daily intake that is sufficient to meet the nutrient requirements of nearly all
(97-98%) healthy individuals in a particular life stage or gender group.
AI: Adequate Intake used when RDI cannot be determined
The average daily nutrient intake level based on observed or experimentally-determined
approximations of nutrient intake by a group of apparently healthy people that are assumed
to be adequate.
EER: Estimated Energy Requirement
The average dietary energy intake that is predicted to maintain energy balance in a healthy
adult or child.
UL: Upper Level of Intake
Highest average daily nutrient intake level likely to post no adverse health effects to almost
all individuals. This may be of interest to those people taking supplements.
For infants and children
As with pregnancy, certain nutrients have been identified as being particularly important for infants
and children during their growing years.
Energy
The largest growth spurt is seen in the first year of an infant’s life. During this time nutritional needs
are high. However between the ages of 1-5 years children still continue to have high nutritional
needs despite a slower growth rate. This slower growth rate can be reflected in a less reliable
appetite. A child’s rate of growth is often an indicator of dietary adequacy.
Protein
Protein is essential for growth, repair, and maintenance and importantly must be provided in
quantities appropriate to the growth period. Protein rich foods include meat, fish, poultry, eggs,
nuts, legumes, milk, yoghurt and cheese.
14
0-12 months
AI 10 g/day
1-3 yrs
RDI 14 g/day
4-8 yrs
RDI 20 g/day
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Fat
Fat is an important source of energy and fat soluble vitamins in the infant and child’s diet and
should be provided in adequate amounts. Fats provide not only energy, but also a source of
essential fatty acids, necessary for growth and development, particularly of the spine and brain.
■■ 0-6 months
AI 31 g/day
■■ 7-12 months
AI 30 g/day
■■ 1-8 yrs
no recommendation for total fat
Fat requirements of infants and children
From 6 months to 2 years of age infants should be receiving at least 40% of energy intake from
fat. Skim milk and reduced fat milks should not be used in children less than 2 years of age.
From 2 - 5 years of age a gradual increase in proportion of energy from carbohydrate will occur
and fat intake should provide 35-40% of energy.
From 5-14 years of age 35% of energy should be provided from fat.
Growth and development should be monitored and checked against accepted percentile growth
trends.
Carbohydrate
Carbohydrate provides energy to cells, particularly the brain. Carbohydrate rich foods include
breads, cereals, rice, pasta, noodles, fruit, some vegetables, milk and yoghurt.
■■ 0-12 months AI 60 g/day
■■ 1-8 yrs
o recommendation for carbohydrate intake (45-65% of total energy
n
predominantly from low energy density and/or low glycaemic index
foods)
Iron
■■ 0-6 months
AI 0.2 mg/day
■■ 7-12 months
RDI 11 mg/day
■■ 1-3 yrs
RDI 9 mg/day
■■ 4-8 yrs
RDI 10 mg/day
Iron is important for the transport if oxygen in the blood. Two forms of iron exist in food: haem and
non haem. Haem iron (found in meat, fish and poultry) is well absorbed. Non haem iron is present
in cereals and vegetables and is not as well absorbed. The presence of vitamin C and heam iron
increases the absorption of non heam iron.
Haem iron sources
Food type iron content (mg)
Lean beef (~100 g) 3.0
Lean lamb (~100 g) 2.8
Chicken (~100 g) 0.6/0.7
Fish (~100 g) 0.5
Egg (55-60 g) ~0.9-1.3
Liver (~100 g) ~10-11
Kidney (50 g) 5.7
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15
Non haem iron sources
Food type iron content (mg)
Rolled oats (~1⁄2 cup) 0.9
Breakfast cereals (small serve - 30 g) ~1.9 - 2.8
Bread - wholemeal (1 slice) ~0.7 - 0.9
Bread - white (1 slice) ~0.25 - 0.3
Rice - brown/white (1⁄2 cup - 100 g) ~0.3/0.4
Baked beans (1⁄2 cup - 100 g) ~1.5 - 1.8
Legumes (1⁄2 cup - 100 g) 2.5
Dried fruit (prunes, apricots) (5-6) 1.6 - 1.8
Spinach (1⁄2 cup) 1.4 - 2.2
Nuts (40 g) ~0.4 - 1.2/1.5
Milo (1 tablespoon) 1.4
Zinc
■■ 0-6 months
AI 2 mg/day
■■ 7-12 months
RDI 3 mg/day
■■ 1-3 yrs
RDI 3 mg/day
■■ 4-8 yrs
RDI 4 mg/day
Zinc is needed for the growth of tissues and bones. Animal flesh and shellfish are the best sources
of zinc. Wholegrain breads, cereals and nuts provide zinc in smaller amounts.
Food type zinc content (mg)
Lean beef (100 g) 5.2 - 6.0
Chicken (100 g) 0.8 - 1.0
Fish (100 g) 0.5 - 0 8
Egg (60 g) 0.9
Liver (100 g) 4.0 - 5.0
Spinach (1⁄2 cup) 0.3 - 0.5
Bread - wholemeal (1 slice) 0.4 - 0.6
Legumes (1⁄2 cup -100 g) ~1.0
Nuts (40 g) ~1.0
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Calcium
■■ 0-6 months
AI 210 mg/day
■■ 7-12 months
AI 270 mg/day
■■ 1-3 yrs
RDI 500 mg/day
■■ 4-8 yrs
RDI 700 mg/day
Calcium is particularly required during infancy and childhood to provide for the adequate formation
and development of strong bones and teeth.
Milk, yoghurt and cheese are rich in calcium, however calcium can also be found in calcium
fortified soy drinks, legumes and some vegetables. Fish with edible bones (eg salmon) can be
incorporated into an older child’s diet as they are also a rich source of calcium.
Practical tips to increase calcium in the diet:
■■ Offer the infant (over 12 months of age) milk to drink rather than sweetened drinks or fruit
juices. Skim milk and reduced fat milks should not be used in children less than 2 years
of age.
■■ Encourage breakfast cereals with milk as a convenient snack.
■■ Provide desserts based on milk or calcium fortified soy drinks eg custard, yoghurt and
milk puddings.
■■ Add skim milk (or soy) powder to soups
■■ Sprinkle grated cheese on vegetables, include cheeses in sandwiches and as snacks.
Food type calcium content (mg)
Milk (per 250 ml) - Whole/UHT 300
- Skim 310
- Reduced fat 350
- Modified skim 415
- Soy milk drinks containing 115 mg/100 mL) 300
- Buttermilk 300
- Custard (per 100 mL) 150
Yoghurt, 200 g (flavoured/unflavoured)
- Plain 330
- Low fat 360
Cheese - Cottage/ricotta (100 g) 65
- Hard cheeses eg. cheddar (35 g) 275
Ice cream - 2 scoops 140
Tofu ice confection - 2 scoops 30
Firm tofu/bean curd (100 g) 130 - 200
Tahini - 1 Tbsp (20 g) 280
Meat - beef/lamb/pork/chicken/boneless fish (100 g) 10 - 23
Fish with bones - Salmon (100 g) 100
- Sardines/anchovies (100 g) 400
Spinach/broccoli - 1⁄2 cup 30
Dried apricots/currants - 45
Fresh fruit - 1 piece 20
Bread - 1 slice 15
Breakfast cereals - 1 cup 40
Brazil nuts, nuts, almond - 80
Cashews - 10 - 15 nuts
A HEALTHY START IN LIFE
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Folate/folic acid
■■ 0-6 months
AI 65 ug/day
■■ 7-12 months
AI 80 ug/day
■■ 1-3 yrs
RDI 150 ug/day
■■ 4-8 yrs
RDI 200 ug/day
Not only is folate/folic acid required by the infant during the mother’s pregnancy, but it continues to
be important throughout life for the formation of normal and healthy red blood cells. Folate is found in fruits, vegetables and fortified cereals.
Food type folate content (micrograms)
Liver (100 g) 140
Fish (100 g) 14
Chicken (100 g) 8
Rump steak (100 g) 10
Orange juice (250 ml) 90
Banana (100 g) 20
Avocado (1/2- 150 g) 70
Cabbage (50 g) 45
Broccoli (40 g- 1/2 cup) 40
Brussel sprouts (3-30 g) 40
Lettuce leaves ( 2-20 g) 35
Chick peas (60 g) 40
Baked beans (125 g) 30
Bread - wholemeal (1 slice) 40
- white (1 slice) 30
Almonds (10-15 g) 100
Hazelnuts (10-15 g) 70
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A HEALTHY START IN LIFE
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Vitamin B12
■■ 0-6 months
AI 0.4 ug/day
■■ 7-12 months
AI 0.5 ug/day
■■ 1-3 yrs
RDI 0.9 ug/day
■■ 4-8 yrs
RDI 1.2 ug/day
Vitamin B12 is essential for normal functioning and metabolism within cells, especially those of
the nervous system, gut, bone and marrow, and also for growth. Vitamin B12 deficiency results in
megaloblastic anaemia and neuropathy.
Animal products are the only reliable sources of B12. The B12 content in mushrooms is unreliable.
Vegans (people who obtain all their nutrients from plant foods) have a very low B12 intake and are
at risk of becoming deficient. Folate supplements may mask vitamin B12 deficiency. It is therefore
worth considering whether the client is at risk of being B12 deficient eg. check if vegetarians are:
■■ consuming some animal products eg. milk, cheese, eggs
■■ consuming B12 fortified soy beverages
■■ or taking a vitamin B12 supplement.
Food type vitamin B12 content (g)
Beef (100 g) 1.6
Lamb (100 g) 1.0
Pork (100 g) 1.0
Chicken (100 g) trace amounts
Eggs (2) 1.8
Milk (1 cup) trace amounts
Vitamin B6
■■ 0-6 months
AI 0.1 mg/day
■■ 7-12 months
AI 0.3 mg/day
■■ 1-3 yrs
RDI 0.5 mg/day
■■ 4-8 yrs
RDI 0.6 mg/day
The functions of vitamin B6 are closely linked with the metabolism of proteins. Lean meat, fish,
poultry, avocado and bananas are good sources of B6.
Food type vitamin B6 content (mg)
Avocado (1⁄2 -150 g) 0.6
Banana (1 medium -100 g) 0.5
Lean beef, chicken, fish (~100 g) 0.4
Salmon, tuna (100 g) 0.4
Bread - wholemeal (1 slice) 0.025
Walnuts (40 g) 0.2
Peanut butter (20 g - 1 tablespoon) 0.1
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19
Vitamin C
■■ 0-6 months
AI 25 mg/day
■■ 7-12 months
AI 30 mg/day
■■ 1-3 yrs
RDI 35 mg/day
■■ 4-8 yrs
RDI 35 mg/day
Vitamin C is essential in the diet for cellular metabolism, collagen production (blood vessels, skin,
bones, tendons) and wound healing. Fruits and vegetables are rich sources of vitamin C.
Food type vitamin C content (mg)
Brussel sprouts (100 g) 88
Orange (1 medium) 80
Strawberries (12-14) 58
Cauliflower (90 g -1 flower + 1 stem) 50
Cabbage (1 cup shredded) 50
Broccoli (90 g -1 flower + 1 stem) 42
Mandarin (1 medium) 40
Grapefruit (1⁄2 medium) 37
Capsicum (1⁄3 cup chopped) 35
Tomato (1 medium) 24
Banana (1 medium) 16
Potato (1 medium - boiled) 13
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A HEALTHY START IN LIFE
INTRODUCTION
1.7 Physical activity
Physical activity is a normal and essential component of everyday life for infants and children. It is
important for growth, development of skills and essential in maintaining a healthy weight.
Benefits
■■ Improved movement skills and coordination.
■■ Cardiovascular fitness.
■■ Stronger bones.
■■ Weight control.
■■ Social enjoyment and skills such as turn taking, cooperation, wining and loosing.
■■ Improved mental health.
■■ Better school performance.
Barriers
There are many suggested reasons why physical activity levels may not be optimised. Activities
such as television, videos, computer games and the internet are part of a child’s life but limits
should be placed on these to ensure sufficient physical activity occurs. These are the main reason
behind insufficient physical activity.
Other barriers include:
■■ the use of motorised transport in place of walking or riding
■■ insufficient community facilities for outdoor play
■■ busy family life
■■ safety concerns
■■ peer influences
■■ cost concerns
All these perceived barriers can be overcome and it is important to discuss solutions or
alternatives to ensure adequate physical activity.
Physical activity recommendations
The Australian Government has recently developed Physical Activity Recommendations for
Children and Young People.
1 Children and young people should participate in at least 60 minutes (and up to several
hours) of moderate to vigorous intensity—physical activity every day.
2 Children and young people should not spend more than 2 hours a day using electronic
media for entertainment (eg computer games, Internet, TV) particularly during daylight
hours.
The recommendations are intended to identify the minimum level of physical activity required for
good health in children and young people from 5 – 18 years of age.
www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-physical-activity-kids-pdfcnt.htm/$FILE/kids_phys.pdf
www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-physical-activity-youth-pdfcnt.htm/$FILE/youth_phys.pdf
A HEALTHY START IN LIFE
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21
Strategies to promote physical activity
■■ Manage the time children spend in front of television, watching videos, on the internet
and playing computer games.
■■ Ensure enjoyable activities are available as an alternative to sedentary recreation.
■■ Consider active transport .
■■ Be a physically active adult and a positive role model.
Family activities
Role modelling an active lifestyle for children is very important and has an influence over the
child’s physical activity level. While it is appropriate for children to be involved in organised sports,
physical activity can also be a family activity.
■■ Play cricket, soccer, frisbee or barefoot lawn bowls in the backyard.
■■ Show kids some of the active games you played as a kid like hopscotch, quoits,
skipping games, hide-and-seek or tiggy.
■■ Get a basketball or netball hoop for the yard .
■■ Fly a kite.
■■ Join neighbours at the local park for a fun game of footy, cricket or softball.
■■ Explore the neighbourhood on a bike.
■■ Go on a picnic or a walk together.
Sport and recreation resources
Move Baby Move
A booklet designed to help parents and early childhood carers incorporate safe, active movement
into their baby’s daily routines.
www.sportrec.qld.gov.au/school_community/active_baby.cfm
Active Alphabet
A resource designed especially for parents, carers and their toddlers to use together to learn basic
active movement skills while also learning important health messages
www.sportrec.qld.gov.au/school_community/active_toddler.cfm
Let’s Get Moving
A fun resource for preschool children (3-6 year olds) to learn basic movement skills and important
health messages while their parents, carers or teachers learn all about the importance of
movement for their preschooler.
www.sportrec.qld.gov.au/school_community/active_preschooler.cfm
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INTRODUCTION
Useful websites and resources
Websites
Eat Well Be Active
www.eatwellbeactive.qld.gov.au/eatwellbeactive/default.asp
Building a Health, Active Australia
www.healthyactive.gov.au/getmoving
Australian Sports Commission
www.ausport.gov.au/
Raising Children Network
raisingchildren.net.au/
Sport and Recreation Queensland
www.sportrec.qld.gov.au
ActiveAte
education.qld.gov.au/schools/healthy/active-ate/
Parent handouts
www.eatwellbeactive.qld.gov.au/eatwellbeactive/documents/fact/tips_for_children_fact_
sheet.pdf
www.eatwellbeactive.qld.gov.au/eatwellbeactive/documents/fact/tips_for_families_fact_
sheet.pdf
www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=301&id=1977
Books
Parents can check their local libraries for books/CDs/DVDs promoting physical activity.
FitKIDS by Mary Galvin MD, Steven A. Dowshen MD, and Neil Izenberg
MD, Dorling Kingsley Ltd, London, 2004
Fit Kids by Lisa Curry, a Harper Collins book, published by Curry Kenny Promotions, 2000,
Sydney
“501 TV Free Activities for Kids by Di Hodges, published by Hinkler Books Pty. Ltd., 2000,
Dingley, Victoria
References
1. Queensland Health: Kids on Track program Parent Manual (2006) Gold Coast Health
Service District
2. Department Health and Ageing Physical Activity Guidelines for Children and Young People
(2005)
3. NHMRC (2003) Dietary Guidelines for Children and Adolescents in Australia
4. Pediatrics Vol 117 No 5 May 2006 pp 1834-1842 Active Healthy Living: Prevention of
Childhood Obesity Through Increased Physical Activity
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23
1.8Culturally and Linguistically Diverse (CALD)
Communities
Cultural competence in early life
How culturally competent is your health service?
■■ Do women of a variety of cultures use your health service?
■■ Is your client profile representative of your population with respect to cultural diversity?
■■ Do you have education materials using graphics for clients illiterate in their first language
and your collection of translated educational materials are well used for literate clients.
■■ Your service understands how to deliver culturally appropriate support and advice.
Australia is a multicultural society; however, mainstream parenting practices are based on
Anglo‑Australian values and ideals. Parents and carers can feel conflicted between the advice they
receive from health professionals and advice from their own parents (1).
In all countries women adapt their feeding practices to their own circumstances and the
environment they live in. Women adapt to their infant’s needs, and infants adapt to their mothers’
availability (2).
Parenting practices are cultural phenomena that such change and are reinvented over time and
place. Therefore, cultural competence requires continued learning and not resorting to simplistic
stereotypes.
How to go about cultural competence
1 Attend cultural awareness - training and begin to understand the cultural lens you view your
work with other people through. A realisation of your own biases and prejudices toward
other cultural groups.
2 Identify culturally diversity in your region i.e. what languages do the people speak, what
religions and faiths are practiced, have they migrated from rural or metropolitan regions?
3 Meet with other health professionals experienced with working with other cultural groups,
undertake training in how to use an interpreter in your health service.
4 Next, identify what skills you need to develop, such as explorative communication
techniques to illicit information. As you become more culturally competent your knowledge
deepens, this can be facilitated through cultural encounters, and these connections with
your communities can enhance partnerships and participation, but may only be achieved
with a desire or willingness to understand others.
5 Finally, cultural competency encourages the creation of culturally safe environments to
promote equitable health outcomes. Share your learnings with other health professionals,
advocate for improved service delivery for people from culturally and linguistically diverse
backgrounds.
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Multicultural profile of Queensland
Queensland is a culturally diverse state. In 2001 of the Queensland population:
■■ 17% were born overseas
■■
of these 9% came from a non-English speaking country regardless of the length of
time spent in Australia, females were less likely than males to speak only English at
home.
■■
the most popular languages spoken were Italian, Cantonese, Mandarin, Vietnamese,
German, South Slavic and Greek.
■■ 216 different countries represented
■■ More than 130 different languages spoken
■■ More than different faiths practised
Migration to Queensland has occurred over different periods of time with ethnic groups arriving
under a range of business, skill, family reunion and humanitarian immigration programs. Since
2001, there has been increasing migration from Asian, Pacific Islander countries and refugees
from Middle Eastern and African countries (4).
Vulnerable migrants: refugee and asylum seeker
People from culturally and linguistically diverse backgrounds (CALDB) are particularly vulnerable as
the greater the differences between country of origin and Australia, the greater are the difficulties
in integration and settlement.
Migration categories are fundamental to the way people adapt to their new environments. There
is an important distinction to be made between humanitarian and non-humanitarian immigrants.
Since 1991, Australia’s Humanitarian Program has focused on people from the former Yugoslavia,
the Middle East and the Horn of Africa. It is well documented that refugees from these regions
are likely to have suffered extreme hardship due to conflict and war in their country of origin.
They may have spent considerable time in prisons and/or refugee camps with limited access
to basic human services, such as water, food and adequate protection from the elements. As a
consequence of the refugee experience, many new arrivals are in poor physical health and may
suffer psychological problems that tend to persist long after their arrival (3)
Females: special considerations
There are also gender differences in the settlement experience of male and female migrants, with
women being more vulnerable to settlement and adjustment problems. Female immigrants and
refugees generally have poorer English proficiency than men and are more likely to immigrate as
dependents rather than in their own right. Compared with men, women are more likely to have
limited economic means and can be subjected to traditional family constraints on behaviour.
Separation from family and kin-based social support systems is a particularly important factor for
women.
Unfavourable employment and housing circumstances, prejudice and discrimination in the labour
market and in the community also have disproportionate impacts on women (5). An understanding
of settlement and the process of adaptation is crucial to anyone working with immigrants and
refugees.
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INTRODUCTION
25
Working with interpreters
Communication style
Cultural differences in learning styles between, as well as within, groups will influence the best way
to communicate:
■■ determine the most appropriate communication method either language or literacy or
both; note some migrant groups, and particularly women may be illiterate in their first
language, therefore translation of resources will not help
■■ always ask if an interpreter is required, refer to Queensland Health Language Services
Policy. Some groups may prefer didactic style, while others may learn better through
discussion and sharing information and experiences and some may prefer an interactive
approach
■■ become familiar with the forms of address, rules of politeness, the ‘yes’ syndrome, non-
verbal behaviour, acceptance of touching and personal space of the cultural group to
assist your communication process
■■ this information can often be sought from organisations such as Ethnic Communities
Council of Queensland, Transcultural Mental Health Unit, and Multicultural Affairs
Queensland Training Unit or from www.ethnomed.org
■■ Create a comfortable cross cultural interaction and use the LEARN guidelines for
negotiating a culturally sensitive treatment plan (6). L: Listen with sympathy and understanding to a client’s perception of a problem
E: Explain your perceptions of the problem
A: Acknowledge and discuss differences and similarities
R: Recommend treatment that is relevant, concise and practical
N: Negotiate agreement
Useful open questions
When exploring another cultural perspective it is better to use open questions encouraging more
dialogue, these for example have been taken from (7).
Table 2
Open questions for use in CALD communities
When are women expected to start raising families?
How is birth control viewed?
What type of care is expected or usual during
pregnancy?
How is the pregnancy viewed? (with shame or
pride?)
Is pregnancy considered an illness or wellness period?
Who takes primary responsibility for the care of
the infant?
What are the beliefs and attitudes about
breastfeeding?
What are the first foods introduced to the infant,
when does this occur?
Are parent-child relationships seen as hierarchical or
democratic and equal?
What do the parents see as obligations to their
children?
What are the children’s obligations to their parents?
How is success defined for a young girl, a young
boy?
How do parents decide when it is appropriate to seek
medical care for their children? What are their cues to
action?
How do they carry out health workers
instructions?
Is any preventative health care done?
Adapted from Gopal-McNicol et al 1998 (7)
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INTRODUCTION
Nutritional risks
When working with people from refugee background, it is important to note they may have
sub-optimal nutrition, nutritional deficiencies (eg. iron, folate, Vitamin D), undetected nutritional
problems such as poor oral health, limited exposure to diet and lifestyle health promotion
messages, problems associated with inadequate water intake (eg. headaches/constipation),
reduced or no appetite and growth and developmental problems in children due to past
deprivation.
■■ Encourage women of child bearing age to take a folate supplement
■■ Stress the importance of drinking water and the safe supply in Australia.
■■ Discuss strategies for rebuilding appetite, for both adults and children.
■■ Check for nutritional deficiencies, Vitamin D is not uncommon especially people who
are dark-skinned, veiled and those for whom the body has little exposure to the sun
because of the style of clothing.
■■ Promote exclusive breast-feeding for at least the first 6 months, as new arrivals do not
see Australian women breastfeeding so regularly, some believe you are not allowed to
breastfeed in Australia (8).
■■ Be aware some people may have limited understanding of basic dietary principles,
shopping and cooking skills and require assistance.
■■ Support new arrivals to re-establish healthy food and lifestyle routines. Much of the
healthy food in Australia is unfamiliar to people from CALDb communities, particularly in
how to prepare it. An appropriate, safe and healthy food for children’s school lunchbox is
a significant issue for parents.
■■ Demonstrate an interest in, and respect of, people’s traditional foods and associated
rituals. For example, peanut butter and halva are eaten by ‘ten thousands of children’ in
the treatment of malnutrition from 6 months of age (9).
Religion
When working with people from migrant background, the influence of religion is likely to have a
significant impact on eating habits, rituals associated with pregnancy, breastfeeding and child
rearing. For example Islamic beliefs and practices raise important issues in relation to the provision
of health services. Many Muslim parents want to be able to continue observing and practicing
their religion when they are in hospital, for example, by having a quiet place to pray and by eating
halal food (10). Health workers need to understand the influence Islam can have on shaping new
parents’ needs for antenatal and postnatal services. Insensitivity to these issues can adversely
affect Muslim women’s use of maternity care.
A HEALTHY START IN LIFE
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27
Case studies: an African woman new to Australia
Ayen, when I first met her was a mother of two young children aged 6 yrs and 18 months, and
nine months pregnant and complained of tiredness. Ayen was an Acholi speaking Sudanese who
had a very good understanding of English. She had worked as a nurse in the refugee camp, but
her qualifications were not recognised in Australia. Ayen was married to Goreng and required
his permission to leave the house. Goreng and Ayen leased a motor car necessary for Goreng
to gain work, this expense and their rented home left little money for food, clothing and personal
needs. Ayen said she regularly only had only $50 to purchase food for her family of four and soon
to be five. Ayen, a vegetarian, would often miss meals allowing sufficient food for her husband.
During her pregnancy Ayen asked if she could eat the dirt, geophagia is common in Africa. Ayen
understood the need to visit the doctor regularly during her pregnancy, but would often miss the
appointments. It is customary just before the birth of her new child, that a young girl of about
18 years is organised to stay with soon to be mums by the women in their community. This girl
would learn the ways of early infant care and care for the younger girls, however Ayen although
Sudanese did not have many of her ‘tribe’ to help her out. On arrival at home from hospital, Ayen
constantly carried the infant or rested in bed with him and would breastfeed on demand, the infant
was rarely without his mother. Ayen breastfed her newborn for approximately 2 months, before
deciding her she did not have enough good quality milk and started complementing with formula.
At around 5 months the infant was eating a type of porridge, meat and some vegetables.
The child who was 18 months, would constantly guzzle from a bottle of milk, he appeared chubby
and happy, but he ate very little of the family meal. The young girl who was attending primary
school would ask her mother to buy brightly coloured packets of biscuits and poppers for school
lunch, because she said the Australian children took those in their lunchbox.
Nutritional risks identified
■■ Ayen has limited support from the community due to her language difference as most
of the Sudanese are Dinka speakers. This lack of support for household chores and
shopping possibly contribute to Ayen being tired. Sudanese men generally do not assist
with the cooking or other household chores.
■■ Ayen had limited finances to purchase sufficient healthy food for her family of four. A vegetarian diet needs to be well balanced to ensure adequate protein, iron and zinc. The multiple pregnancies and life in refugee camp may mean Ayen is anaemic.
■■ Ayen is unfamiliar with the foods to pack in her daughter’s lunchbox and does not use a
water bottle that could be frozen overnight for temperature control of the lunch food or
to provide a healthier fluid than cordial.
■■ A child of 18 months of age should be drinking milk from a cup (if not breastfed) and
have up to 2 cups per day allowing the consumption of other foods (and textures)
providing essential micronutrients not found in milk. This link provides a colourful
brochure “Teach your baby to drink from a cup” in 4 languages. www.mhcs.health.
nsw.gov.au/mhcs/topics/Infant_and_Child_Feeding.html
■■ The young infant is missing the opportunity to receive exclusively breastmilk for the first
6 months of his life, mostly due to factors that can be controlled.
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A HEALTHY START IN LIFE
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Useful websites and resources
Good Food for New Arrivals:
www.asetts.org.au/nutrition.htm
This Western Australian web site provides a variety of resources for use in school and
community settings, many suitable for low literate audience that may be downloaded or
ordered. Resources available specifically for Sudanese on anaemia, appetite and healthy
lunchboxes.
Nourishing New Communities:
www.health.qld.gov.au/multicultural/health_workers/support_tools.asp
This Queensland web site provides resources for use in both school and community
settings with families and students. Resources include, culturally appropriate shopping lists
and menu plans for major refugee groups, healthy lunchbox resources including drinking
water promotion.
NSW Multicultural Health Communication Service:
This New South Wales website provides numerous resources for health professionals.
www.mhcs.health.nsw.gov.au/
Victorian Health Translations
Translated health information on this Victorian website provides numerous resources for
health professionals.
www.mhcs.health.nsw.gov.au/
A HEALTHY START IN LIFE
INTRODUCTION
29
References
1. Chalmers, S. 2006. Culture, Health and Parenting in Everyday Life. University of Western
Sydney. NSW.
2. Small, M. 1997. Our babies, ourselves. Natural History, Oct., pp.42-51.
3. Ackerman, L. 1997. Health Problems of Refugees. J American Board Family Practice 10 (5)
pp 337-348.
4. ABS, 2001. Census of Population and Housing
5. Wooden M., Holton R., & Sloan J., (1994) Australian Immigration: A Survey of the Issues,
AGPS: Canberra.
6. Berlin & Fowkes, 1983
7. Gopaul-McNicol, S. & Brice-Baker, J. 1998. Cross-Cultural Practice, Assessment, Treatment
and Training. John Wiley & Sons: USA pp39-41
8. Good Food for New Arrivals, 2007. Breastfeeding in Africa and Australia. Newsletter Vol
3, Issue 7 April 2007. Assisting Torture and Trauma Survivors. Western Australia. www.
asetts.org.au/nutrition.htm Accessed April 11th, 2007.
9. Patel, M., et al. 2005. Supplemental feeding with ready-to-use therapeutic food in
Malawian children at risk of malnutrition. J Health Population Nutrition, Dec 23(4) pp 351-7.
www.bioline.org.br/request?hn05047 Accessed April 11th, 2007.
10. Balarajan, R., Raleigh, V.S., 1995, Ethnicity and Health, Department of Health. HMSO,
London.
11. A World of Food, A manual to assist in the provision of culturally appropriate meals for
older people, 1995. www.culturaldiversity.com.au/Resources/ServiceProviderResources/
FoodServices/tabid/88/Default.aspx Accessed April 11th, 2007.
12. Davidson, N., et al. An issue of access: Delivering equitable health care for newly arrived
refugee children in Australia. J. Paediatr. Child Health, 40, pp569-575.
13. Diversity Figures. Multicultural Affairs Queensland, Community Engagement Division,
Department of the Premier and Cabinet and the Office of Economic and Statistical
Research, Queensland Treasury
14. www.multicultural.qld.gov.au Accessed April 10th, 2007.
15. Easing the Transition, A resource guide for health and settlement workers supporting
those recently arrived in Australia to maintain a healthy diet and lifestyle, 2000. Victorian
Foundation for Survivors of Torture Inc.
16. Gopalkrishnan, N. 2005. Cultural Diversity and Civic Participation in Queensland, Centre for
Multicultural and Community Development
17. University of the Sunshine Coast. Sippy Downs, Queensland.
18. Munns, C. et al. 2006. Prevention and treatment of infant and childhood vitamin D deficiency
in Australia and New Zealand: a consensus statement. Medical Journal of Australia, 185,5,
pp 268 – 272.
19. NHMRC, 2006. Cultural Competency in Health. A guide for policy, partnerships and
participation. Canberra. ACT. www.nhmrc.gov.au/publications/synopses/hp25syn.htm
Accessed April 11th, 2007.
20. Renzaho, A.M.N., & Burns, C. 2006. Post-migration food habits of sub-Saharan African
migrants in Victoria: A cross sectional study. Nutrition & Dietetics, 63, pp 91-102.
21. Sivagnanam, R. 2004. Experiences of Maternity Services: Muslim Women’s Perspectives,
Maternity Alliance, NHS. UK
30
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1.9 Aboriginal and Torres Strait Islander nutrition
Current health and nutritional status
“Queensland is home to 27% of the national Indigenous population… numerically Queensland has
the second largest Indigenous population” (1) in Australia, behind New South Wales. Indigenous
Queenslanders include both Aboriginal and Torres Strait Islander peoples, two culturally distinct
Indigenous groups.
Aboriginal and Torres Strait Islanders’ views of health tend to be comprehensive and holistic
and emphasise social, emotional and cultural well-being. Traditionally, they make little distinction
between the wellbeing of the individual and the wellbeing of the community.
An example of this is the concept of health; Aboriginal languages do not contain expressions for
health (2). Sickness or injury in an individual Aboriginal person is likely to be interpreted in relation to
its effect on the person’s ability to fulfil social and other community commitments.
Secondly the methods of acquisition of health knowledge need to be understood. “Aboriginal and
Torres Strait Islander peoples, like many other Indigenous peoples, have culturally-specific ways
of knowing about health: stories from oral tradition, authoritative knowledge of elders, spiritual
knowledge, commonsense models of illness and health, and knowing oneself” (2).
Thirdly, among Aboriginal and Torres Strait Islander peoples, personal identity is defined in terms of
kinship and other relationships with people, communities and nature, especially land.
Health is not just the physical wellbeing of the individual but the social, emotional and cultural
wellbeing of the whole community. This is a whole-of-life view and it also includes the cyclical
concept of life-death-life (2).
All the available evidence suggests that, traditionally, Indigenous Australians were fit and healthy
(3) and lived in harmony with the environment. With the transition of a traditional hunter gatherer
lifestyle to a settled westernised existence, Aboriginal and Torres Strait Islander people’s diet has
generally changed from a varied, nutrient-dense diet to an energy-dense diet that is high in fat and
refined sugars (3).
The issues facing the Indigenous people of Australia are well documented, with consistent
evidence in the past decade showing health disparities increasing. Indigenous life expectancy
is 15-20 years less than that of non-Indigenous Australians. Infant mortality is three times higher
in Indigenous infants when compared to non-Indigenous data (5). Additionally, Aboriginal and
Torres Strait Islander children are almost five times more likely to die before the age of five as non
Indigenous children (4).
“The statistics of infant and perinatal mortality are our babies and children who die in our arms….
The statistics of shortened life expectancy are our mothers and fathers, uncles aunties and elders
who live diminished lives and die before their gifts of knowledge and experience are passed on” (4).
Good maternal nutrition and adequate nutrition during infancy are fundamental to the achievement
and maintenance of health throughout the lifecycle and assists in preventing chronic diseases such
as diabetes and cardiovascular disease.
Low birth weight, failure to thrive and inappropriate child growth are serious concerns in Indigenous
Australian communities (3). Several causal factors are implicated including maternal ill health,
smoking and malnutrition (6).
Aboriginal and Torres Strait Islander people are less likely to eat a diet consistent with the dietary
guidelines and more likely to suffer from both over nutrition and under nutrition. The impact of past
policies and practices, economic disadvantage and the ‘introduced’ diet are major causes of poor
health outcomes (7).
A HEALTHY START IN LIFE
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31
Recommendations from the Dietary Guidelines for
Australians
■■ Choose store bought food that are most like traditional bush foods
■■ Enjoy traditional bush foods whenever possible
Encourage the whole family to include a variety of nutritious foods.
Use the Aboriginal and Torres Strait Islander Guide to Healthy Eating as a resource.
Protocols for engaging with Aboriginal and Torres
Strait Islander communities (8)
KIndly adapted from Protocols for consultation and negotiation with Aboriginal people (8)
Each Aboriginal and Torres Strait Islander community has their own local protocols. These should
be adhered to when you are seeking to engage with individual people or groups within the
community. There are some broad guidelines which may assist when seeking to consult for the
first time.
Hints - general
■■ be open, honest and sincere and take a genuine interest in people
■■ genuine respect for local beliefs, opinions and lifestyle is essential
■■ be aware that in some communities some people may not be comfortable with direct
eye contact and you will need to modify your behaviour accordingly
■■ it is important that you allow plenty of time to develop the context of your
communication to ensure there is an understanding of what you want to discuss
Hints - Communication
■■ speak clearly, without using jargon, acronyms or technical terms
■■ hints and invitations to volunteer information are preferred to direct questioning
■■ speak in a moderate tone; avoid trying to be forceful or speaking loudly
■■ in a dialogue with an Aboriginal and Torres Strait Islander person:
■■ listen carefully without interruption until the other person has finished speaking this may
take some time — be attentive and patient
■■ when replying, paraphrase what has been said to clarify the other speaker’s meaning
and to indicate that you are listening and understand what has been said
■■ respect and learn to become comfortable with silences in communication, particularly
when seeking or sharing information of a sensitive nature
■■ recognise the tendency of Aboriginal and Torres Strait Islander people to say ‘yes’ in
answer to a direct question
■■ recognise the part played by non-verbal communication and body language in
Aboriginal and Torres Strait Islander communication Be aware of your own body
language and non-verbal communication and be sure to look, as well as listen for a
response
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Hints - gender issues
■■ Recognise that in some communities there are matters that are designated as ‘men’s
business’ and ‘women’s business’. Seek advice from a key community member before
discussing such sensitive matters. Likewise, sensitive issues should only be approached
by members of the same gender.
Hints - talking to families
■■ Where possible, speak to members of your own gender as there may be protocols for
communication with the opposite sex.
■■ Work towards building relationships and don’t expect people to accept you immediately.
■■ Be conscious of verbal and non-verbal cues before introducing the purpose of your visit,
especially when discussing matters of a sensitive nature.
■■ Take a local community member with you on your first visit, or ask for a key community
member to introduce you.
■■ Try to be open-minded and flexible in your communication.
Antenatal nutrition
Compared with other Australian mothers, Aboriginal mothers are twice as likely to give birth to low
birth weight babies (13). Low birth weight is also an issue among Torres Strait Islander people yet
in lower proportions than Aboriginal people.
■■ Anaemia is common for a number of reasons eg. poor nutrition, multiple pregnancies.
■■ Folic acid deficiency is commonly seen among this group.
■■ Increased incidence of infant mortality.
■■ Increased incidence of multiple pregnancies. Studies show Aboriginal women have
higher fertility rates. Multiple pregnancies do not allow sufficient time for the mothers’
nutrient stores to be replenished between each pregnancy. Multiple pregnancies also
encourage an increase in weight. With each pregnancy, weight increases since there is a
shortened time to return to pre pregnancy weight.
■■ High incidence of teenage pregnancies.
■■ Lactoferrin concentrations are reduced in the breastmilk of malnourished mothers.
■■ Lactoferrin is an iron binding protein with antibacterial properties, and reduced
concentrations may render infants more susceptible to infection
■■ The incidence of overweight is high in this group due to high intakes of foods which are
high in fat, sugar and salt (such as takeaways and convenience foods). In isolated areas
access to affordable fresh foods is often limited.
■■ Lack of cooking facilities can impact on the nutritional intake of Indigenous people.
■■ It is essential to discuss with Aboriginal and Torres Strait Islander women and their
families, ways of ensuring good nutrition during pregnancy.
A HEALTHY START IN LIFE
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33
Refer to Growing Strong topics
■■ healthy mums
■■ pregnancy issues
■■ keeping food safe
■■ how to breastfeed
■■ expressing breastmilk
■■ diabetes during pregnancy*
■■ alcohol, tobacco and other drugs during pregnancy and breastfeeding*
■■ physical activity during and after pregnancy*
■■ young mums*
■■ how dads can help*
■■ how grandparents can help*
* Topics included in the update in 2007
Breastfeeding
“Breastfeeding is associated with a reduced infant and child mortality and is increasingly recognised
as fundamental for long term health” (9). The nutritional and immunological effects of prolonged
breastfeeding are particularly important in communities with a high prevalence of infectious diseases
(3, 6).
Duration of breastfeeding
National breastfeeding data for Indigenous Australians is limited. The 1995 National Health Survey
found that Indigenous mothers breastfed longer than non-Indigenous mothers (3). Traditionally,
Aboriginal mothers breast-fed their babies exclusively and frequently for at least 6 months, and
continued to breastfeed for up to 4 years (10).
However, Indigenous Australians have lower breastfeeding levels than non-Indigenous Australians,
except where more traditional lifestyles have been maintained. “In Queensland, 70.5% of Indigenous
males and 69.7% of Indigenous females under the age of 13 had been breastfed as an infant” (9).
In a Brisbane study it was noted that although 59% of Indigenous mothers initiated breastfeeding,
only 25% were still breastfeeding by 6 months (6). Another study in Melbourne found ‘most mothers
who start to breastfeed plan to do so for at least 6 months, so it is likely that those who stopped
sooner had encountered problems… women said that most would want to breastfeed for at least a
year (10) (Table 1).
Furthermore, a study in Western Australia found Aboriginal “mothers understood the benefits
of breastfeeding but needed support and assistance to enable them to initiate and continue
breastfeeding for an optimal period of time” (7).
What you can do
Focus group discussions with Aboriginal people in Melbourne identified that most Aboriginal
women wanted and expected to breastfeed. They perceived their community as supportive of
breastfeeding, though they often lacked people to turn to for advice and support (9,10)
You, as a health professional can provide invaluable assistance to new mothers when they start
breastfeeding. It is important to provide culturally appropriate, factual information, sympathetic
support and include demonstrations of practical skills. It is important to ensure Aboriginal and
Torres Strait Islander families are aware of, and are comfortable accessing culturally appropriate
support services within their community for continued support.
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A HEALTHY START IN LIFE
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Table 3
Factors influencing the rates of breastfeeding (in a Melbourne Aboriginal community)
Factors that help mothers to continue
breastfeeding beyond 6 to 12 weeks
postpartum
%
Factors in mothers’ decision to stop
breastfeeding before 6 to 12 weeks
postpartum
%
Best for baby, healthy, enjoyable, cleaner,
good for mother
95
Baby not getting enough milk or not feeding
properly
71
Convenient, easier quicker
50
Breast problems (mastitis, cracked nipples)
23
Cheaper
18
Mother stressed, sick, tired, impatient,
shamed or bay preterm or sick
23
Decision based on experiences with
feeding a previous infant
13
Mother’s preference
6
Advice of a health professional or family
encouragement
9
Adapted from Holmes, et al, 1997 (10)
Refer to Growing Strong topics
■■ breastfeeding: good for baby, good for mum
■■ how to breastfeed
■■ expressing breastmilk
■■ alcohol, tobacco and other drugs during pregnancy and breastfeeding*
■■ how dads can help*
■■ how grandparents can help*
■■ formula feeding your baby
■■ sanitising bottles
* Topics included in the update in 2007
Introduction of solids
Introduction of appropriate solids at around 6 months is essential to ensure appropriate growth
and development (3,6). Traditionally, solids were not introduced until teeth erupted and the age
of weaning depended on the arrival of other siblings (3). Solids should be given in adequate
quantities, on a consistent basis to provide optimum nutrition.
Table 4
Age of introduction to solids (in a Melbourne Aboriginal community)
Age solids commenced
% of infants
< 4 weeks
2
4 to 7 weeks
7
8 to 11 weeks
7
12 to 16 weeks
6
Not commenced at 16 weeks
78
Adapted from Dietary Guidelines for Children and Adolescents in Australia: Incorporating the Infant
Feeding Guidelines for Health Workers 2003 (3)
Health professionals should encourage mothers to delay introducing solid foods and to continue
breastfeeding until 6 months. The early introduction of solid foods, including sugar, may lead to a
decrease in maternal milk production as the baby suckles less (10).
A HEALTHY START IN LIFE
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35
Refer to Growing Strong topics
■■ starting solids
■■ iron rich foods
■■ drinks for babies*
* Topics included in the update in 2007
Growth
Dietary Guidelines for Children and Adolescents in Australia Recommendations
Ensure the growth of young children is checked regularly
13 percent of Indigenous babies born in Australia are of low birth weight (4)
Normal growth results from the combined effects of favourable genetic and environmental
influences… when these factors are compromised, growth of the foetus, infant and young child is
likely to be inadequate (9).
For growth assessment, refer to growth chart section.
Growth faltering amongst Aboriginal infants after the age of four to 6 months has been
consistently noted (3,6). Relatively poor growth has been shown to persist in older children,
although overweight and obesity are becoming increasing concerns, particularly among Torres
Strait Islander children (6).
Diarrhoeal and respiratory infections in Aboriginal and Torres Strait Islander infants have the most
significant impact on growth (5).
Children have an in-built hunger alert and satiety mechanism, so they know when they are
hungry and when they are full, and they eat accordingly. A healthy child will never starve itself,
so encourage parents to trust their child to eat enough. A traditional practice among Aboriginal
people is to wait until a child demands food before breastfeeding or giving other foods. This
tradition will not adversely affect a well nourished child.
However, lack of hunger and apathy are common results of mild malnutrition. Hence, children who
have even mild growth failure may not be very hungry and need to be encouraged to eat. They
would be disadvantaged if their mothers waited for signs of hunger before feeding them (9).
Refer to Toddler section
Refer to Growth chart section
Refer to Growing Strong topics
■■ growth spurts*
■■ overweight and obesity in children*
■■ healthy food for age 1 – 4 years*
■■ healthy drinks for age 1 – 4 years*
■■ healthy food ideas for toddlers*
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A HEALTHY START IN LIFE
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Lactose intolerance
Lactose intolerance after the age of three to five years may be problematic in some areas or
individuals (3,11) and may affect consumption of lactose containing foods.
A small study in Western Australia found 70% of children aged between 6 and 14 were found to
be lactose malabsorbers (12) .
Refer to Lactose Intolerance section
Iron deficiency
Studies in New South Wales and the Top End of the Northern Territory showed the rate of
anaemia in Aboriginal children to be much higher than in non-Aboriginal children (9). Iron
deficiency may remain more of a problem amongst children, particularly in urban areas, when
compared to communities in remote areas, where iron intake may be high due to a more
traditional meat based diet (9).
Refer to Growing Strong topics
■■ iron rich foods
Useful websites and resources
NHMRC Dietary Guidelines for Children and Adolescents in Australia
National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-2010.
Nutrition in Aboriginal and Torres Strait Islander Peoples: An Information Paper NHMRC,
2000
Close the Gap: Solutions to the Indigenous Health Crisis facing Australia. A policy Briefing
paper from the national Aboriginal Community Controlled Health Organisation and OXFAM
Australia, 2007
Professional development tools
Communicating positively: A guide to appropriate Aboriginal Terminology. New South Wales Health, 2004
www.health.nsw.gov.au
Protocols for consultation and negotiation with Aboriginal people
Department of Aboriginal and Torres Strait Islander Policy and Development 2000,
Published by Queensland Government, Brisbane
www.qld.gov.au/indigenous/
www.datsip.qld.gov.au/resources/cultures.cfm
Healthy jarjums make healthy food choices
This program is aimed at teaching young Aboriginal and Torres Strait Islander children
about foods that are good for their bodies, so that they may improve their quality of
life through better nutrition. The program is designed to guide and assist educators by
presenting suggested activities, lessons and resources.
www.health.qld.gov.au/eatwellbeactive/documents/jarjum_notice.pdf
A HEALTHY START IN LIFE
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37
Indigenous traditional games
Traditional games provide the opportunity to learn about, appreciate and experience
aspects of Aboriginal culture. They also provide essential training in social interaction.
It is possible to include traditional games in classroom lessons, outdoor education and
adventure activities, physical education classes and sport education activities.
www.health.qld.gov.au/eatwellbeactive/documents/jarjum_notice.pdf.
One Talk
Queensland Health’s Aborignal and Torres Strait Islander Community Engagement Manual,
2005.
Parent handouts
The Aboriginal and Torres Strait Islander Guide to Healthy Eating
This guide shows how much food is required every day from each food group for good
nutrition and health. The foods included in the guide are those that can be found at the
store as well as some local bush and seafoods. This guide helps you to make healthy food
choices
www.health.qld.gov.au/eatwellbeactive/documents/atsig_the_brochure.pdf
www.health.qld.gov.au/eatwellbeactive
A note on Growing Strong
The Growing Strong resources have been developed to help staff talk with Indigenous families
about nutrition for mothers, babies and young children. Information is presented in two forms: a book using straightforward language and plenty of illustrations, and a manual with more detailed
background.
Growing Strong resources provide information about eating well during pregnancy as well
as offering suggestions for dealing with some common food and nutrition elated problems.
Information is also provided about common breastfeeding issues including how to know when a
baby gets enough breastmilk and correct positioning and attachment. Growing Strong resources
are currently being updated. Topics included in the update in 2007 as denoted with an asterisk (*).
For more information about Growing Strong contact:
Nutrition Promotion Officer (Indigenous Health)
Northern Area Health Service
Public Health Nutrition Team
PO Box 1103
Cairns QLD 4870
Ph (07) 4050 3600
Fax (07) 4050 3662
Nutrition Promotion Officer (Indigenous Health)
Central Area Health Service Public Health Nutrition Team
PO Box 946
Rockhampton QLD 4700
Ph (07) 4920 7383
Fax (07) 4920 6865
Indigenous Nutrition Promotion Officer
Brisbane Southside Population Health Unit
PO Box 333
Archerfield QLD4108
Ph (07) 3000 9148
Fax (07) 3000 9121
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References
1. The Indigenous Population of Queensland. Planning Information and Forecasting Unit
Planning Services. Brisbane, August 2000
2. The National Aboriginal Health Strategy, 1989, AGPS
3. Dietary Guidelines for Children and Adolescents in Australia: Incorporating the Infant
Feeding Guidelines for Health Workers, NHMRC, Canberra 2003.
4. Close the Gap: Solutions to the Indigenous Health Crisis facing Australia. A policy Briefing
paper from the national Aboriginal Community Controlled Health Organisation and
OXFAM Australia
5. National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan
2000-2010.
6. Queensland Public Health Forum (2002). Eat Well Queensland 2002–2012: Smart Eating
for a Healthier State. Brisbane, Queensland Public Health Forum.
7. Eades S., The Bibbulung Gnarneep Team ‘Breastfeeding Among Urban Aboriginal
Women in Western Australia’ Aboriginal and Islander Health Worker Journal 24(3) 2000 pp 9-14
8. Department of Aboriginal and Torres Strait Islander Policy and Development 2000,
Protocols for consultation and negotiation with Aboriginal people, Published by
Queensland Government, Brisbane.
9. Nutrition in Aboriginal and Torres Strait Islander Peoples: An Information Paper NHMRC,
2000
10. Holmes W., Phillips J., Thorpe L., Initiation rate and duration of breastfeeding in the
Melbourne Aboriginal community. Australian and New Zealand Journal of Public Health
1997: 21(5) pp 500-3
11. Buttenshaw R., Sheridan J., Tye V., Miller O., Carseldine J., Battistutta D., Gaffeny P/.
Lawrence G., Lactose Malabsorption and its temporal stability in Aboriginal Children.
Proc. Nut Aust (1990) 15 pp228
12. Brand J.C., Darnton-Hill I., Gracey M.S., Spargo R.M., Lactose Malabsorption in Australian
Aboriginal Children Am J Clin Nutr 1985;41:620-622
13. Johnston T., Coory M., Information Circular, Epidemiology Services Unit, Health
Information Branch. Trends in perinatal mortality, birth weight and gestational age among
Aboriginal and Torres Strait Islander, and non Indigenous babies in Queensland.
A HEALTHY START IN LIFE
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39
2.0 Antenatal nutrition
2.1 Nutrition during pregnancy (1,2,3,4,5)
Nutritious foods and an active lifestyle can help achieve optimal health throughout life. Good nutrition is important at all stages throughout life and particularly during pregnancy. The health and nutritional status of mothers and children are intimately linked (1).
Beginning pregnancy with a healthy diet is giving the baby the best possible nutritional advantage.
A wide varied diet is vital in supporting the growth and development of the foetus and the
maintenance of the woman’s own health. Nutritional requirements for most nutrients increase
during pregnancy, particularly folate, iron, zinc and vitamin C (2). There is only a small rise in
energy requirements, which can be achieved by eating for example an extra 2 – 3 slices of bread
per day (3).
Table 5
Food recommendations during pregnancy
Food group
Number of serves 1 serve
Bread, cereal , rice,
pasta, noodles
4–6
Fruit
4
Vegetables, legumes
5–6
Meat, fish, poultry,
eggs, nuts and
legumes
1½
Dairy
2
Extra foods
0 – 2½
2 slices bread
1 medium bread roll
1 cup cooked rice, pasta or noodles
1 cup breakfast cereal flakes or porridge
½ cup muesli
1 piece medium sized fruit
2 pieces smaller fruit
8 strawberries
20 grapes or cherries
½ cup juice
1 cup diced/canned fruit
1 ½ Tbsp sultanas
1 medium potato/yam
½ medium sweet potato
1 cup lettuce or salad vegetables
½ cooked vegetables
65 – 100g cooked meat/chicken
80 – 120g cooked fish
2 small eggs
1/2 cup cooked dried beans, lentils, chick peas,
split peas or canned beans
1/3 cup peanuts/almonds
1 cup milk
40g (2 slices) cheese
200g yoghurt
1 cup custard
1 Tbsp margarine or oil
1 can soft drink
½ small chocolate bar
4 plain sweet biscuits
Adapted from the Australian Guide to Healthy Eating
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1
2.2 Sample meal plan
The following examples illustrate how the Australian Guide to Healthy Eating can be
incorporated into a daily meal plan to meet minimum nutritional requirements.
Breakfast
1 cup breakfast cereal flakes/1 cup porridge
Milk (250ml)
1 cup strawberries/1 fresh orange/½ grapefruit
Morning tea
2 rice cakes/1 slice toast with 1 slice cheese and tomato
Lunch
Salmon/egg or tuna/and salad bread roll
1 piece fresh fruit
Afternoon tea
1 scone
½ cup fruit juice
Dinner
1 small steak (100g) with mixed vegetables (total 1½ cups)
1 small potato
1 cup fruit salad with 2 Tbsp yoghurt
Supper
2 slices raisin toast, scrape margarine
Parent handouts available at
qheps.health.qld.gov.au/ahwac/content/home_nemo.htm
2
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Folate during pregnancy
Folate is a B group vitamin needed for healthy growth and development. Its requirements are
increased during pregnancy for normal growth of the unborn baby. Adequate folate intake helps to
prevent neural tube defects in the baby, such as spina bifida (2).
The vitamin is known as folate when it is found naturally in food and as folic acid when it is added
to food or used in dietary supplements (4).
The recommended intake of dietary folate for pregnant women is 600 µg/day throughout
pregnancy. However, to reduce the likelihood of neural tube defects in the baby, it is
recommended that women consume an additional 400 µg/day folic acid through a supplement or
in the form of fortified foods for at least 1 month before and 3 months after conception in addition
to consuming food folate from a varied diet (2).
It is difficult to get enough folate from natural sources alone to reduce the risk of neural tube
defects in pregnancy. Folic acid supplements are available over the counter. Women who have
a family history of neural tube defects like spina bifida require medical advice before becoming
pregnant (4) as they may need even higher amounts of folic acid.
Good sources of folate include leafy vegetables, whole grains, fortified cereals, peas, nuts,
avocados and yeast extracts (eg Marmite, Promite, Vegemite etc).
For further information and parent handouts:
www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm
Check
✔✔ diet contains rich sources of folate before and during pregnancy
✔✔ advise women to take folate supplements for 1 month before conception
and during the first trimester of pregnancy
✔✔ if dietary intake is poor, consider continuing folate supplement after
the first trimester
✔✔ folic acid intakes should not exceed 800 – 1000 µg/day.
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3
Iron during pregnancy
Iron is a component of haemoglobin, the component of blood which carries oxygen around the
body. The peak iron requirement in pregnancy occurs throughout the second and third trimesters.
This is to support the expansion of the maternal red blood cell mass, the growing foetus and
the placenta. A lack of iron may result in anaemia. Women whose diet prior to pregnancy was
low in iron, may have low iron stores. This increases their risk of developing iron deficiency
anaemia during pregnancy. Dietary iron is used by the growing baby first, leaving the mother’s
stores depleted if her intake is inadequate. Low iron levels in early pregnancy have been linked to
premature birth and low birth weight.
The RDI for iron in pregnancy is 27 mg/day (5). A mixed diet of animal and plant foods can help
you achieve your iron intake. Absorption of iron is better from animal foods compared to plant
sources and the recommended dietary intakes are based on a mixed Western diet.
There are two types of iron in food: iron from animal foods (called haem iron) and iron from plant
foods (called non-haem iron).
Haem iron is taken up by the body about 10 times better than non-haem iron. Meats are the best
source of iron. The redder the meat, the higher it is in iron. This means beef and lamb are higher in
iron than pork, chicken or fish. Coloured flesh fish, such as tuna and mullet are higher in iron than
reef fish, such as barramundi.
Non-haem iron is found in some plant foods such as:
■■ wholegrain and iron fortified breads and cereals foods, eg. breakfast cereal with added iron
■■ legumes, eg. kidney beans, baked beans
■■ green leafy vegetables, eg. spinach and broccoli
■■ nuts and dried fruit.
Remember that iron from these foods is not taken up by the body as well as iron from animal
foods. You will need to eat more of these foods if they are your only iron source.
Adding a glass of fruit juice or other foods rich in vitamin C (such as tomato, broccoli or capsicum)
to a meal will increase the amount of iron the body absorbs. In contrast, tea, coffee and
unprocessed bran can inhibit iron absorption.
Indicators of iron deficiency
Iron status is determined by measuring blood levels of haemoglobin, serum ferritin and serum
transferrin. Serum ferritin is the best indicator of iron stores. Low serum ferritin levels indicate
depleted iron stores. Haemoglobin is not a sensitive indicator of iron status, with levels decreasing
often only when ferritin stores are severely depleted. In addition, haemoglobin levels decrease
during the third trimester of pregnancy due to haemodilution effects. Ferritin levels remain
unchanged during this time. Serum transferrin transports iron in the blood. Transferrin values
increase with iron deficiency and decrease with iron overload. Iron intake should be increased
when serum ferritin levels are low. Ideally the diet should be examined for adequate iron intake. If
the diet appears to provide adequate iron despite low ferritin levels, supplements may be considered.
4
A HEALTHY START IN LIFE
ANTENATAL NUTRITION
Check
✔✔ if serum ferritin levels are low, iron intake needs to be increased
✔✔ iron supplements may cause constipation. Constipation may be minimised
by consuming adequate intakes of dietary fibre and fluid. Foods from the
meat/meat alternatives group provide the best sources of iron. Vegetarians
need to consume vitamin C rich foods with meals to increase iron
vabsorption and eat a good variety of non-haem iron sources.
Iodine
The RDI for iodine in pregnancy is 220 ug/day (5). Iodine deficiency in pregnancy can affect
growth and development in the unborn child, increase the chance of miscarriage and have
serious implications for intellectual development. Iodine can be found in dairy products ie milk
and yoghurt, bread baked with iodised salt and saltwater fish. It is very important for mothers
to consume sufficient iodine from the time of conception, just as it is for the more well-known
nutrients of iron and folate (5).
Multivitamin supplements
Apart from the recommended folate supplement, it is best to obtain nutrients from a healthy diet.
Multivitamins not designed for pregnancy are not recommended as there are dangers associated
with excessive doses of nutrients such as Vitamins A, D and B6 (2).
Alternative and herbal remedies
Most herbal and homeopathic remedies have not been tested to determine their safety during
pregnancy. Many herbal preparations have a drug-like effect and should be used with the same
caution as with other drugs during pregnancy. Herbal preparations should be avoided during
the first trimester. The National Prescribing Service (NPS) Medicines line can provide information
regarding alternative treatments in pregnancy, phone 1300 888 763.
Patient handouts available at
qheps.health.qld.gov.au/ahwac/content/home_nemo.htm
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5
2.3 Special considerations during pregnancy
Listeria
Listeria are bacteria carried in some foods that can cause an infection called listeriosis. The
bacteria commonly inhabit soil, water, plants and sewerage. The infection may cause few or no
symptoms in healthy people, including pregnant women. However, the risk of transmission from
the infected pregnant woman to her unborn child is higher. Infection of the foetus can lead to
miscarriage, stillbirth, premature birth or severe illness in newborn babies (2).
The best ways to avoid listeria infections include hygienic preparation, storing and handling of
food. Foods should be eaten fresh, or thoroughly cooked, or well washed if eaten raw (fruit and
vegetables). Leftovers can be eaten if they have been refrigerated immediately and stored for less
than 24 hours.
The foods most likely to carry the bacteria, increase the risk of infection and therefore should be
avoided, include:
■■ soft and semi soft cheeses, eg. brie, camembert, ricotta, blue, fetta
■■ soft serve ice cream
■■ unpasteurised dairy products
■■ pate
■■ chilled seafood
■■ salads - fruit/vegetable, eg. prepared, prepackaged, smorgasbord/salad bars
■■ cold meats, including chicken, eg. deli, sandwich bars, and packaged ready-to-eat.
Healthy tips
✔✔ always wash hands before preparing or serving food and after handling
animals or visiting the toilet
✔✔ animals can carry the toxoplasmosis parasite which can cause disease in
humans so keep them out of the kitchen; avoid touching faeces and wear
rubber gloves under garden gloves
✔✔ wash cookware and utensils well after use
✔✔ store raw foods down low in the fridge and check fridge temperature
regularly
✔✔ foods and leftovers that belong in the fridge should always be refrigerated
as soon as possible
✔✔ thaw frozen meats in the fridge
✔✔ once cooked, pasta and rice should be stored in the fridge
✔✔ look for ‘best before’ and ‘use by’ dates on packaged foods.
For further information:
www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm
6
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Mercury
Fish is a safe and important part of the Australian diet. It contains an excellent source of protein, is
low in saturated fat, high in omega 3 fish oils and is an excellent source of iodine. There has been
some concern regarding the level of mercury in fish, specifically accumulation of mercury in fish
that are higher up the food chain.
Food Standards Australia and New Zealand (FSANZ) advises pregnant women, and women
planning pregnancy, to eat a variety of fish as part of a healthy diet. However, pregnant women
should limit their intake of certain types of fish.
Table 6.
Recommendations of fish consumption during pregnancy
Pregnant women and women planning pregnancy (1 serve = 150 g)
1 serve per fortnight of shark (flake) or billfish (swordfish/broadbill and marlin) and NO other fish that fortnight
OR
1 serve per week of orange roughy (deep sea perch) or catfish and NO other fish that week
OR
2 – 3 serves per week of any other fish and seafood not listed above
Adapted from Food Standards Australia and New Zealand
For further information:
www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm
Caffeine
Caffeine is a chemical found in many foods and drinks, including coffee, tea and cola. It affects the
nervous system and can cause irritability, nervousness and sleeplessness. During pregnancy it
takes longer to breakdown caffeine.
While having large amounts of caffeine does not appear to cause birth defects, drinking high
amounts of caffeine may make it more difficult to become pregnant and may increase the risk of
miscarriage.
It is best to limit the daily amount of caffeine to:
■■ 2 cups of coffee, or
■■ 4 cups of tea, or
■■ 4 cups of cola drink, or
■■ less than 1 cup of cola or energy drinks that contain extra caffeine, or
■■ decaffeinated varieties are an option which contains little caffeine however safe levels of
decaffeinated products for pregnant women are unknown.
(Reproduced with the permission of Commonwealth Department of Health and Ageing)
Artificial sweeteners
The use of only some artificial sweeteners is considered to be safe during pregnancy. FSANZ
has listed aspartame (marketed in food products as Equal, Hermesetas and Nutrasweet) and
sucralose (Splenda) as safe to use during pregnancy (2).
A HEALTHY START IN LIFE
ANTENATAL NUTRITION
7
Alcohol
During pregnancy alcohol crosses the placenta and can lead to physical, growth and mental
problems in some babies. Babies affected by alcohol tend to have low birth weights. They may
also have physical and behaviour problems at birth and throughout childhood. (2)
There are no known safe levels of alcohol consumption in pregnancy. Therefore, it is best to avoid
drinking alcohol during pregnancy as much as possible.
The Australian National Health and Medical Research Council (NHMRC) has made the following
recommendations for women who are pregnant or planning a pregnancy:
Women may consider not drinking alcohol at all
It is most important not to become intoxicated
Women who choose to drink should have less than 7 standard drinks per week
Women should have at least 2 alcohol free days a week
On any 1 day no more than 2 standard drinks should be consumed. These drinks should be spread
over at least 2 hours.
Drinking larger quantities at any one time may affect the developing foetal brain.
■■ 1 standard drink is equal to:
■■ 100 ml wine
■■ 1 ‘pot’ of beer (285 ml)
■■ 1 can/stubbie (375 ml) low alcohol beer
■■ 1 nip of spirits (30 ml)
■■ 60 ml fortified wine (port or sherry).
Check
✔✔ alcohol consumption is reduced to nil where possible. If alcohol is consumed,
the intake should not exceed more than 2 standard drinks per day.
Morning sickness
Morning sickness is a common symptom of early pregnancy and, in many cases, goes away by
the end of the first trimester. It is caused by changes in hormones during pregnancy and may
make eating difficult. Although it is called ‘morning sickness’, nausea (with or without vomiting)
can happen at any time of the day. A small number of women experience severe vomiting which
can lead to dehydration and electrolyte imbalances. Such women require medical assistance
and possibly hospital admission for correction. In other cases, frequent and prolonged nausea/
vomiting can lead to an inadequate energy intake which results in weight loss. This weight loss
usually ceases once nausea reduces and appetite improves.
Check
✔✔ adequate energy intake to prevent weight loss
✔✔ if morning sickness persists with vomiting more than twice daily for more
than 2 days, medical intervention should be sought as hospitalisation may
be required. Ensure adequate fluid replacement to avoid dehydration.
Patient handouts available at
qheps.health.qld.gov.au/ahwac/content/nemo_review.htm
The following page can be used as a parent handout.
8
A HEALTHY START IN LIFE
ANTENATAL NUTRITION
Morning sickness
Morning sickness does not usually cause any problems for the unborn
baby. Some food and eating suggestions that may help manage
symptoms of morning sickness or nausea include:
■■
eat smaller meals more often. missing meals can make nausea worse
■■
avoid large drinks. have frequent small drinks between meals
■■
limit fatty, spicy and fried foods
■■
food has a stronger odour or smell when it is heated, which may make
nausea worse. if possible, have other people help with cooking, or prepare
your food at times of the day when you feel better
■■
try eating a dry biscuit before you get out of bed in the morning
■■
eat a healthy snack before you go to bed at night. this might include fruit
(fresh, tinned, dried), crackers with hard cheese or yoghurt
■■
avoid foods if their taste, smell or appearance make you feel sick
■■
if vomiting, it is important to drink enough fluids. It may be easier to have
lots of small drinks than to try and drink a large amount in one go. Try
a variety of fluids such as water, fruit juice, lemonade and clear soups.
Sometimes it can be helpful to try crushed ice, slushies, ice blocks or even
suck on frozen fruit such as grapes or orange segments.
Note: T
he stomach acids in vomiting can soften teeth enamel. It is best not to use a toothbrush to clean the teeth straight after
vomiting as this may damage them. Have a drink of water to
clean your mouth.
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9
Constipation
Constipation is common in pregnancy for the following reasons:
■■ Intestinal muscle appears to lose tone, making it difficult for food to pass through:
■■ the baby in latter pregnancy, places pressure on the intestine, exacerbating the problem
■■ iron supplementation may cause constipation in some women.
Constipation can be minimised by ensuring:
■■ adequate exercise
■■ high fibre intake
■■ adequate fluid intake (1.5 – 2 L per day).
Check
✔✔ ensure adequate fibre intake by eating fruit, vegetables and wholemeal/
wholegrain breads and cereals
✔✔ ensure adequate fluid intake (ie. 1.5 l/day)
✔✔ regular activity
✔✔ regular use of laxatives is not recommended.
Parent handouts available at
http://qheps.health.qld.gov.au/ahwac/content/nemo_review.htm
Heartburn
Heartburn occurs for a number of reasons including:
■■ Relaxation of the oesophageal muscles during pregnancy (under hormonal influences)
allows acid to run into the oesophagus, and pressure from the growing baby on the
stomach causes a backflow of acid. Some suggestions for relief of heartburn include:
■■
Eat smaller meals frequently
■■
Chew food well
■■
Avoid fatty and spicy foods which may irritate the condition
■■
Drink fluids separately to meals
■■
Snack on dry biscuits or toast
■■
Sipping milk may ease heartburn temporarily
■■
Relax while eating
■■
Avoid lying down or bending over directly after meals
■■
Don’t smoke
■■
Avoid alcohol
■■
Care needs to be taken to ensure none of the food groups are omitted from the diet,
since this can reduce the nutritional adequacy of the diet
■■
Some antacids are safe to take during pregnancy, but may inhibit iron absorption.
Recommend use under medical supervision.
Parent handouts available
qheps.health.qld.gov.au/ahwac/content/nemo_review.htm
www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm
10
A HEALTHY START IN LIFE
ANTENATAL NUTRITION
2.4 Weight gain during pregnancy
A healthy weight gain during pregnancy can vary between individuals and depends on prepregnant weight. It is recommended women who are planning a pregnancy should attempt
to reach a healthy body weight before they become pregnant as being overweight or obese,
or underweight, prior to conception is associated with an increased risk of a number of
complications.
An average weight gain during pregnancy for a person of a healthy weight is 10-15 kg. The breakdown of this weight gain is illustrated in Tables 7 and 8. The maternal fat stores are used
later in the production of breastmilk. Healthy weight gain is mostly seen in the second and third
trimesters (after the first 3 months) of pregnancy. This is the time of pregnancy when mother’s
energy (kilojoule) requirements increase. However, it is best to focus on food quality rather than
quantity to meet the nutritional needs in pregnancy. There is no reason to increase food quantity
to the point of ‘eating for two’ as this is likely to lead to extra weight gain.
However it must be stressed that pregnancy is not the time for weight loss diets. Restricting food
and nutrient intake compromises both the development of the baby and the mother’s nutritional
status. Women who are underweight or have some form of eating disorder place their baby and
themselves at nutritional risk. If the mothers’ diet is inadequate, maternal stores will be depleted.
This can compromise the mothers’ health, since the baby takes the nutrients it requires first.
The Institute of Medicine (IOM) recommends weight gain ranges based on pre-pregnancy
body mass index (BMI) (8). Research has shown pregnancy weight gain within these ranges is
associated with the best outcome for both mothers and infants. To calculate BMI use the following
equation or refer to Figure 3.
BMI = w (kg) / ht (m)2
Figure 3
Body Mass Index chart
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.%#%
-%#%
,%#%
+%#%
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A HEALTHY START IN LIFE
ANTENATAL NUTRITION
11
Table 7
Recommended total weight gain during pregnancy, proportional to
weight for height
Weight-for-height category
Recommended total gain (kg)
Low (BMI<19.8)
12.5-18
Normal (BMI 19.8-26.0)
11.5-16
High (BMI >26-29.0)
7-11.5
Obese (BMI >29.0)
> 6.0
Table 8
The general guide to the pattern of weight gain during pregnancy
Trimester
Healthy weight Underweight
Overweight
Obese
1st
0-2
1-3
0-1
0-1
2nd
4-6
5-8
3-4
2-3
3rd
4-6
5-8
3-4
2-3
Total
11-16kg
12-18kg
7-11kg
< 7kg
The pattern of weight gain varies for each woman and each pregnancy. Specific advice for
individual needs should be sought from a qualified dietitian or health professional.
Healthy eating to increase weight gain
Sometimes if women suffer from morning sickness early in pregnancy it may be difficult to gain
weight and sometimes may lose a small amount. This is not cause for concern as long as weight
gain starts in the second trimester of the pregnancy.
Inadequate weight gain in pregnancy can adversely affect the health of mother and baby. If not gaining enough weight suggest these ideas:
■■ Eat 3 meals a day
■■ Include snacks between meals
■■ Enjoy healthy snack foods such as:
12
■■
Fresh or dried fruit
■■
Yoghurt
■■
Nuts and seeds
■■
Muesli bars
■■
Biscuits and cheese
■■
Milk drinks
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ANTENATAL NUTRITION
Healthy eating to control weight gain
Pregnancy is not a time for strict dieting. However, excessive weight gain during pregnancy
can cause problems with high blood pressure, gestational diabetes for the mother, a large for
gestational age baby and delivery complications. If mother is overweight it is important control
weight gain in pregnancy.
Limit the amount of fat eaten
■■ Limit intake of biscuits and cakes
■■
Limit intake of chips and crisps
■■
Reduce the amount of fat used in cooking
■■
Choose low fat dairy products including milk, yoghurt, and cheese
■■
Avoid cream and sour cream
■■
Trim all the fat off meat before cooking
■■
Remove the skin from chicken
■■
Limit high fat take-away foods
Limit high sugar foods
■■
Drink water not soft drink or cordial
■■
Use “diet” or low joule products
■■
Limit fruit juices to once a day, these are high in sugar
■■
Limit chocolates, lollies and sweets
■■
Limit intake of desserts
■■
Minimise snacking
■■
Increase physical activity
Check
✔✔ weight loss is not recommended during pregnancy
✔✔ weight gain education provided based on pre-pregnant BMI.
Returning to pre-pregnant weight
Many women are concerned about weight gained during pregnancy and are keen to return to their
pre-pregnancy weight as soon as possible after their baby is born. It is important to remember
that a woman’s nutritional requirements remain increased while breastfeeding. It is essential that
intake is not restricted to a point where nutritional requirements are not met.
Women who gain excessive weight during pregnancy are at risk of post partum weight retention
(9). The greatest amount of weight loss occurs in the first 3 months after birth and then continues
at a slow and steady rate until 6 months after birth (9).
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13
Healthy eating tips for those trying to lose weight
Exercising is a good way of stimulating weight loss. Not only does it have physical benefits eg.
weight loss and improved general health, but also psychological benefits for the mother. The
exercise need not be vigorous. In fact, regular walking is a very good form of activity. Encourage
mothers to exercise regularly - at least 5 times a week for 30 minutes at a time.
Frequent breastfeeding can be beneficial for weight loss and increases with the length of the
lactation course.
The extra energy required to breast feed can often be significant. The surplus fat stores laid down
during pregnancy (ie. around hips) can be used to meet these additional energy needs.
Encourage mothers to eat regular meals. Skipping meals can result in snacking between meals. It
can also slow down the body’s metabolism, making it more difficult to lose weight.
Avoid choosing foods with a high fat content ie choose lean cuts of meat, skinless chicken and
fish; choose cooking methods that use minimal fat; choose low fat products where possible; use
less margarine, butter, oil; avoid cakes, biscuits, chocolates, lollies, cordials and soft drinks.
Healthy eating tips for those trying to gain weight
Some women also lose a lot of weight while they are breastfeeding and find it difficult to maintain
an acceptable weight. This is NOT an indication that breastfeeding should stop. The following lists
give some ideas for gaining and maintaining weight.
■■ Don’t skip meals.
■■ Have three main meals and three between meal snacks.
■■ Keep easy to prepare nutritious snacks on hand eg crackers and cheese, fresh fruit,
yoghurt, nuts, seeds, dried fruit, canned beans, flavoured milk, fruit smoothies, breakfast
cereals and milk.
■■ Prepare a packed lunch or variety of snacks to have in a container beside you when
baby feeds.
■■ Prepare and freeze meals in advance when possible (or ask your friends/family to help).
Check
✔✔ if client is experiencing problems returning to healthy weight range
recommend consultation with a dietitian/ nutritionist.
14
A HEALTHY START IN LIFE
ANTENATAL NUTRITION
2.5Groups requiring special attention during
pregnancy
Vegetarian and vegans
Vegetarianism means different things to different people. Table 9 outlines the various eating
practices of different groups of vegetarians and their major food sources (refer to sample
vegetarian meal plan below). It is possible to meet nutrient requirements while following a
vegetarian meal plan. However, time must be spent ensuring the nutritional adequacy of the diet,
particularly with the increased requirements of pregnancy and lactation. The following nutrients
require particular attention when planning a balanced vegetarian meal plan.
Table 9
Types of vegetarians and major food sources
Foods eaten
No red meat
Lacto-ovo
vegetarian
Ovovegetarian
Lacto
vegetarian
Vegan
Plants
✔
✔
✔
✔
✔
Animal meats
(Chicken and
fish)
Eggs
✔
✔
✔
Milk and milk
products
✔
✔
✔
Energy
Because vegetarian diets tend to be high in fibre they increase satiety and cause people to ‘fill
up’ quicker. It is, therefore, important to ensure adequate food is provided and weight gain is
appropriate. High energy vegetarian foods include nuts, nut or other seed pastes eg. tahini,
peanut butter and dried fruits.
Protein
Essential or ‘indispensable’ amino acids must be obtained from the diet as the body is unable
to make them. Animal foods including; milk, milk products, fish and meat are complete proteins
as they contain all the essential amino acids in the proportions required. In contrast, plant foods
are incomplete protein sources as they do not contain the correct balance of the essential amino
acids. It is, therefore, important that vegetarians who are avoiding animal products, consume a
variety of plant foods to ensure all the essential amino acids are obtained. Iron, zinc, calcium and
vitamin B12 are nutrients that may be lacking.
Zinc (2)
Zinc is a component of various enzymes that help maintain structural integrity of proteins and help
regulate gene expression: Therefore, getting enough is particularly important for the rapid cell
growth that occurs during pregnancy. The RDI for zinc during pregnancy is 11mg/day. Zinc can be found in lean meat, wholegrain cereals, milk, seafood, legumes and nuts.
Vitamin B12
Significant amounts of B12 are usually found in animal products, so intake could be limited. A
good amount can be consumed by having at least two serves of soy milk fortified with B12 daily.
Food fermented by micro-organisms (soy sauce, miso, tempeh), manure-grown mushrooms,
spirulina and yeast may contain small amounts of vitamin B12, but this is not sufficient to meet
requirements for vitamin B12.
A HEALTHY START IN LIFE
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15
A sample vegetarian meal plan:
Breakfast
½ cup muesli or 2 wheat biscuits
Milk
1 slice wholemeal toast with peanut butter
1 orange
Morning tea
2 wholemeal crackers with tomato and cheese
Fresh fruit
Lunch
Wholemeal roll, 1 - 2 cups of salad with an avocado
Milk and 2 tsp Milo
Afternoon tea
½ cup almonds and 4 Tbsp raisins
Dinner
1 cup kidney beans
2 - 3 cups serves vegetables including broccoli
Fruit yoghurt
Supper
2 slices of raisin toast with margarine
Soy beverage, fortified with calcium and vitamin B12 could replace milk in vegan meal plans
Check
✔✔ foods from the meat, fish, poultry, eggs, nuts, legumes groups and iron
fortified cereals should be consumed each day for adequate iron and zinc
intake. Soy beverages should be fortified with calcium (containing at least
115mg per 100mL) and B12
✔✔ ensure sufficient energy is consumed and appropriate weight gained
✔✔ consider supplementation with a multivitamin (which includes iron, zinc,
calcium and B12) if needs are not being met
✔✔ refer to dietitian for individual assessment and advice.
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Teenagers
The nutrient requirements of pregnant teenagers are increased. Not only must they eat to provide
the nutrients required for the pregnancy, but also to provide for their own growth and development
during puberty. Pregnant teenagers should be treated as a separate group. There are specific
RDIs for pregnant teenagers between 14-18 years. Girls with a low gynaecological age (difference
between age of menarche and age at conception) require additional nourishment as they are often
still growing. Even if they have stopped growing, teenage girls with a low gynaecological age are
likely to have inadequate nutrient stores, because it takes about 2 years to build up stores after
menarch (10).
It is important to ensure teenage mothers have an appropriate weight gain during pregnancy.
Pregnant adolescents are at risk of both inadequate and excessive weight gain (11). They are at
risk for adverse outcomes including low birth weight, preterm delivery, anaemia, and excessive
post partum weight retention due to a combination of physiological, socioeconomic, and
behavioural factors (11). It is worth bearing in mind that at this time in a teenager’s life, there are a
number of other factors which impact on their eating patterns, for example: peer pressure, social
supports, lack of shopping and cooking skills and a fear of gaining weight and becoming “fat”.
Aboriginal and Torres Strait Islander women
See Aboriginal and Torres Strait Islander section
Obese pregnant women
Maternal overweight and obesity is now an important issue in about one third of all pregnancies in
the Australian context (13). Increased maternal body mass index (BMI) at conception is associated
with a range of adverse maternal, obstetric and neonatal outcomes. Hypertensive disorders of
pregnancy, impaired glucose metabolism, gestational diabetes, hyperlipidemia, caesarean section
delivery, prolonged maternal hospitalization, foetal and neonatal death, birth defects and neonatal
intensive care admission are all consequences of maternal obesity (13,14,15).
Overweight and obesity has been associated with reduced initiation and duration of breastfeeding
(16,17). The causes for this may be multifactorial. Factors to consider in poor lactation performance
include:
■■ Socio-cultural factors, such as concern about body shape, low self esteem and poor
mental health (16)
■■ Physical factors for example, women with large breasts may have mechanical difficulties
with breastfeeding (16)
■■ Physiological factors such as reduced prolactin response to suckling (18)
Check
✔✔ overweight and obese women identified as high risk during pregnancy
✔✔ advice about appropriate weight gain
✔✔ oral glucose tolerance test (OGTT) taken 24 – 28 weeks gestation
✔✔ targeted for post partum lactation consultant assistance with
breastfeeding.
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17
Women with diabetes in pregnancy
Pre-existing Type 1 and Type 2 diabetes
Women with pre existing diabetes can have a healthy and successful pregnancy. However
they need close monitoring by a team including an obstetrician, endocrinologist (or physician
experienced in diabetes care during pregnancy), diabetes educator and dietitian to ensure the
diabetes is well managed during the pregnancy.
Women with pre-existing diabetes have a higher risk of infants:
■■ having a birth defect;
■■ being born prematurely;
■■ having a low birth weight or being macrosomic;
■■ having dangerously low blood sugar levels after birth.
It is important that women control their blood sugar levels before becoming pregnant and
throughout the pregnancy to minimise these risks.
Gestational diabetes
In some women during pregnancy their ability to utilise glucose becomes impaired. The hormones
produced by the placenta cause insulin resistance. If the body is unable to meet the increased
need for insulin gestational diabetes develop usually around the 24th – 28th week of gestation.
Gestational diabetes is more likely to occur in (19):
■■ Women over 30 years of age
■■ Women with a family history of Type 2 diabetes
■■ Women who are overweight
■■ Aboriginal and Torres Strait Islander women
■■ Certain ethnic groups are also at increased risk: Indian, Chinese, Polynesian/Melanesian,
Vietnamese, Middle Eastern
■■ Women who have had gestational diabetes during previous pregnancies
■■ Women who have had difficulty carrying a pregnancy to term.
Gestational diabetes is diagnosed after a Glucose Challenge Test (GCT) which is a screening test.
If this is abnormal an Oral Glucose Tolerance Test (OGTT) is necessary.
If gestational diabetes is untreated there is increased risk of a large for gestational age baby,
delivery complications and low blood sugar levels of the baby at birth.
There are four basic components to treatment of gestational diabetes: dietary modifications, physical
activity, medications and monitoring blood glucose levels.
These women should be referred to a dietitian for individualised nutritional advice. The most
important points are for regular carbohydrate distribution and low glycemic index (GI) diet.
After the birth of the baby, the mother’s blood sugar levels should return to normal and an OGTT at
around 6 weeks post partum should be done to confirm this.
Women who develop gestational diabetes are at increased risk of developing Type 2 diabetes later in
life with a 30% – 50% chance of developing it within 15 years after pregnancy (19).
18
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2.6 Exercise during pregnancy (20,21,22)
Regular exercise during pregnancy is in most cases, safe for both mother and baby. Women
should be encouraged to initiate or continue exercise during this time to obtain the health benefits
associated with such activities.
A doctor, physiotherapist or exercise physiologist can provide individual advice for women about
exercise during pregnancy.
Benefits of exercising regularly throughout pregnancy include:
■■ resistance to fatigue
■■ reduced back pain, constipation, bloating and swelling
■■ improved posture
■■ improved weight control
■■ stress relief
■■ improved sleep
■■ preparation for physical demands of labour
■■ faster recuperation after labour
■■ faster return to pre-pregnancy fitness and healthy weight.
Body changes during pregnancy
Hormones produced during pregnancy, such as relaxin, soften the ligaments that support joints,
resulting in joints being more mobile and increasing the risk of joint injury.
Extra abdominal weight shifts the body’s centre of gravity, placing stress on the pelvis and lower
back joints, and can affect balance.
Pregnancy increases resting heart rate.
General exercise suggestions
■■ Aim for 4 to 5 exercise sessions per week.
■■ Don’t try to exercise too far beyond current fitness level.
■■ Warm up and cool down for around 10 minutes.
■■ Try to exercise on soft surfaces, such as grass or carpet.
■■ Avoid exercising in the middle of the day or hot humid conditions—take care not to
overheat.
■■ Maintain a moderate intensity—keep heart rate below 140 beats per minute.
■■ Rest frequently, particularly if feeling breathless.
■■ Wear a supportive bra and footwear.
■■ Where cool, loose fitting clothing.
■■ Change positions slowly and gradually.
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19
Suggested activities
■■ Water activities
■■ Walking
■■ Swimming
■■ Yoga
■■ Dancing
■■ Pilates
■■ Pregnancy exercise classes
■■ Cycling on a stationary bike
Exercises to avoid
■■ Contact sports or those activities where there is potential for loss of balance that could
result in trauma to baby.
■■ Exercising in water where the temperature is greater than 32º C.
■■ Activities that involve jolting, jarring or rapid changes of direction, particularly in the latter
stages of pregnancy.
■■ After 16 weeks avoid activities involving lying flat on back—the weight of the uterus and
baby compress the main artery back to the heart. This can lower blood pressure and
result in feelings of dizziness and light headedness.
■■ Scuba diving - babies are not protected from decompression sickness.
■■ Don’t exercise when ill.
Conditions requiring medical supervision while exercising in
pregnancy
■■ Cardiac disease
■■ Restrictive lung disease
■■ Persistent bleeding in the second and third trimesters
■■ Pre-eclampsia or pregnancy-induced hypertension
■■ Preterm labour (previous/present)
■■ Intrauterine growth restriction
■■ Cervical weakness/cerclage
■■ Placenta praevia after 26 weeks
■■ Preterm pre labour rupture of membranes
■■ Heavy smoker (more than 20 cigarettes a day)
■■ Orthopaedic limitations
■■ Poorly controlled hypertension
■■ Extremely sedentary lifestyle
■■ Unevaluated maternal cardiac arrhythmia
■■ Chronic bronchitis
■■ Multiple gestation (individualised and medically supervised)
■■ Poorly controlled thyroid disease
■■ Malnutrition or eating disorder
■■ Poorly controlled diabetes mellitus
■■ Poorly controlled seizures
■■ Anaemia.
20
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Warning signs to cease exercise
■■ Excessive shortness of breath
■■ Chest pain or palpitations
■■ Pre-syncope or dizziness
■■ Painful uterine contractions or preterm labour
■■ Leakage of amniotic fluid
■■ Vaginal bleeding
■■ Excessive fatigue
■■ Abdominal pain, particularly in back or pubic area
■■ Pelvic girdle pain
■■ Reduced fetal movement
■■ Dyspnoea before exertion
■■ Headache
■■ Muscle weakness
■■ Calf pain or swelling
Medical advice should be sought if any of the above symptoms occur.
Pelvic floor exercise should be done before, during and after pregnancy.
Care should be taken with back support.
Whenever changing position, bending and lifting:
■■ tighten abdominal muscles - particularly the transverse abdominal muscle which forms a
natural corset in the lower part of the abdomen
■■ tighten pelvic floor muscles
■■ use leg muscles.
Information sheet can be found at:
www.betterhealth.vic.gov.au
Check
✔✔ women have no contraindications to exercise
✔✔ advise of benefits of exercising in pregnancy
✔✔ inform of criteria to cease exercise.
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21
2.7 Antenatal breastfeeding education
Health professionals often leave discussion of breastfeeding until later in the pregnancy. Research
demonstrates that the earlier in the pregnancy a decision to breastfeed is made the more likely the
breastfeeding will be successful (23). The decision is usually made before pregnancy and is based
on life experiences, beliefs and attitudes of family and others to breastfeeding (24).
Antenatal education should include:
■■ importance of exclusive breastfeeding for the first 6 months
(including the nutritional and protective benefits)
■■ basic breastfeeding management
■■ coping with minor problems (23).
Mothers should be encouraged to become familiar and comfortable with handling their breasts
(23).
Virtually every mother can breastfeed, but for some it is not so easy and learning and patience are
necessary (23).
Benefits of breastfeeding for mother
■■ Helps uterus return to pre-pregnant state faster
■■ Can help with weight loss after baby
■■ Reduces likelihood of ovarian and premenopausal breast cancer
■■ Lessens likelihood of mothers with gestational diabetes developing Type 2 diabetes (24).
Formula feeding increases the risk of baby developing:
■■ Infections and diseases such as urinary tract infections, gastrointestinal infections (eg.
diarrhoea) and respiratory illnesses (eg. asthma) and some childhood cancers
■■ Allergies and food intolerances such as coeliac disease
■■ Obesity, diabetes and heart disease later in life.
Benefits of breastfeeding to the community
■■ Reduced health care costs from illness and chronic disease prevention
■■ Reduced ecological damage from production, packaging, and disposal of breastmilk
substitutes and containers. It also saves food resources, fuel and energy.
22
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Guide to education
Early pregnancy
•
Ask questions ‘how do you plan to feed your baby?’
•
Importance of decision about feeding choice
•
Assess knowledge and perceptions regarding breastfeeding
•
Reasons mothers choose
•
Explore and identify concerns and feelings
•
Acknowledge and validate feelings
•
Educate using targeted messages to address individual concerns
•
Benefits of breastfeeding (infant, mother, community)
•
Risks of formula-feeding
•
Ease of breastfeeding, difficulties that may be encountered
•
Breastfeeding with modesty
•
Family involvement
•
Lack of dietary restrictions and lifestyle changes
•
Feasibility with employment
•
Availability of people to assist
•
Identify breastfeeding resource network (family and friends, health care providers and
mother-to-mother support groups).
Later in pregnancy
•
Practical skills on how to breastfeed
•
Possible difficulties and how to overcome these
•
Importance of skin-to-skin contact and rooming in
More information can be found on the following sites
How do I start breastfeeding?
www.health.qld.gov.au/phs/documents/cyhu/28099.pdf
Breastfeeding Getting Started
www.health.qld.gov.au/phs/documents/cyhu/28098.pdf
Antenatal checklist
✔✔ education on healthy eating and special considerations in pregnancy
provided
✔✔ calculate pre-pregnant BMI - provide education on appropriate
weight gain
✔✔ breastfeeding education provided
✔✔ glucose screen for gestational diabetes at 24-28 weeks gestation.
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23
References
1. WHO. Global strategy for infant and young child feeding. Geneva: World Health
Organisation; 2003.
2. Australian Government Department of Health and Ageing. (2006). Healthy eating at
various lifestages: pregnant women. [Accessed 2007 May 8]. www.healthyactive.gov.au/internet/healthyactive/publishing.nsf/Content/pregnant-women.
3. WHO. Healthy eating during pregnancy and breastfeeding. Geneva: World Health
Organisation; 2001.
4. FSANZ. (2005). Folic acid and pregnancy advice for women. [Accessed 2007 May
8]. www.foodstandards.gov.au/_srcfiles/FSANZ%20Folic%20Acid.pdfhttp://www.
foodstandards.gov.au/_srcfiles/FSANZ%20Folic%20Acid.pdf
5. National Health and Medical Research Council. Nutrient reference values for Australia and
New Zealand: Commonwealth of Australia; 2006.
6. Anderson J., Iodine Essence article Vol 43,No2 March 2007
7. Food Standards Australia & New Zealand, 2005 Food and Pregnancy. [online] www.foodstandards.gov.au/foodmatters/pregnancyandfood.cfm March 2007.
8. Institute of Medicine. (1990) Nutrition during pregnancy, weight gain and nutritional
supplements. Report of the Subcommittee on Nutritional Status and Weight Gain during
Pregnancy, Subcommittee on Dietary intake and Nutrient Supplements during Pregnancy
and Lactation, Food and Nutrition Board. Washington, DC: National Academy Press:
1-233.
9. Crowell DT. (1995) Weight change in the postpartum period: a review of the literature.
Journal of Nurse Midwifery; 40: 418-23.
10. Job J, Capra S, Ash S. (1995) Nutritional assessment of pregnant teenagers attending a
metropolitan public maternity hospital in Brisbane. 1. Nutritional Intakes. Australian Journal
of Nutrition and Dietetics, Vol 52, No. 2:76-82.
11. Neilsen J, Gittelsohn J, Anliker J, O’Brien K. (2006) Interventions to Improve Diet and
Weight Gain among Pregnant Adolescents and Recommendations for Future Research.
Journal of the American Dietetic Association; 106:1825- 1840.
12. SIGNAL: National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan
2000 – 2010. National Aboriginal and Torres Strait Islander Nutrition Working Party
13. Callaway LK, P.J., Chang AM, McIntyre HD, The impact and prevalence of overweight and
obesity in an Australian obstetric population. Med J Aust, 2005.
24
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14. Cnattingius, S., et al., Prepregnancy weight and the risk of adverse pregnancy outcomes.
N Engl J Med, 1998. 338 (3): p. 147-52.
15. King J. (2006) Maternal Obesity, metabolism, and Pregnancy Outcomes
16. Donath SM, Amir LH. (2000) Does maternal obesity adversely affect breastfeeding
initiation and duration? Breastfeeding Review; 8 (3):29-33
17. Lovelady CA. (2005) Is maternal obesity a cause of poor lactation performance? Nutrition
Reviews; 63, 10: 352-355.
18. Rasmussen KM, Kjolhede CL. (2004) Prepregnant overweight and obesity diminish the
prolactin responses to suckling in the first week postpartum. Pediatrics;113: 1388-9
19. Diabetes Australia. (2004) Gestational Diabetes. Diabetes Australia.
20. Royal College of Obstetricians and Gynaecologists. (2006) Exercise in Pregnancy
(Statement No. 4).
21. Better Health Channel 2006. Pregnancy and Exercise Fact sheet. [online] www.betterhealth.vic.gov.au. March 2007.
22. American College of Obstetricians and Gynaecologists. (2003) Exercise During Pregnancy
Patient Education.[online] www.acog/publications/patient_education/bp119.cfm?printerFriendly=yes. March 2007.
23. National Health and Medical Research Council. (2003) Food for Health. Dietary Guidelines
for Children and Adolescents in Australia incorporating the Infant Feeding Guidelines for
Health Workers. Commonwealth of Australia, Canberra.
24. Brodribb W. (2004) Breastfeeding Management. Third edition. Australian Breastfeeding
Association.
25. Queensland Health (2005) Child and Youth Health Fact sheets Breastfeeding: best for baby, best for you. [online] www.health.qld.gov.au/child&youth/factsheets
26. Riordan J. (2005) Breastfeeding and Human Lactation. Third edition. Jones and Bartlett
Publishers Inc.
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25
3.0 Feeding for the first 6 months
3.1 Breastfeeding: best for baby, best for mum
“Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development
of infants.... with important implications for the health of mothers” (1).
This section of is not about how to breastfeed, nor the anatomy of the breast. There are many
professional resources you can refer to, including the Australian Breastfeeding Association (refer to
key documents section) who provide reviews and summaries of available resources for both your
professional development and parent information.
In Australia, it is recommended that infants be exclusively breastfed until 6 months of age. It is
further recommended infants continue breastfeeding until 12 months of age – and beyond if both
mother and infant wish (2).
We have approached this section from the stance that breastmilk is the sole food (and normal
nutrition) for the first 6 months of life and to be used complementarily until at least 12 months of
age.
Almost all mothers are capable of breastfeeding their infants. Outcomes are much improved
where the mother has the support and encouragement of the infant’s father, other family
members, the hospital, and the community. Many mothers – perhaps the majority – encounter
some difficulties with breastfeeding but, with support and encouragement from health
professionals and community organisations, they can nearly always continue to breastfeed.
Further, most mothers can continue breastfeeding if they choose to return to paid work or study.
All health workers have an obligation to promote breastfeeding in the community and to ensure
best practice in breastfeeding is followed. In comparison with some other countries, Australia’s
breastfeeding record is good, but it is important for the health of the nation’s mothers and infants
that initiation rates and the duration of breastfeeding be increased.
In 2003, most Queensland children (92%) under 5 years had been breastfed at some point. This is
in line with the NHMRC objective of breastfeeding initiation rate in excess of 90% (2). At 6 months
of age, the rate of breastfeeding had fallen to 57% (3, 4). It is an Australian objective to have 80
percent of infants being breastfed at the age of 6 months (2).
Approximately three in five mothers (60%) surveyed in the Queensland Infant Nutrition Survey,
2003, “who had ever breastfed their child sought help or support with breastfeeding after leaving
hospital. These mothers usually went to at least two different sources of support and advice.
The main source was family and friends, followed closely by the local community or child health
centre” (3).
We want to ensure parents are making informed decisions. Breastfeeding and bottle feeding with
artificial infant milks are not comparable.
Women need information about why breastfeeding is normal and about the problems associated
with infant formula, so they can make an informed decision about feeding method (7).
In this chapter you will find some practical advice, tools and further resources for you to
incorporate into your daily practice to encourage, support and promote exclusive breastfeeding
until 6 months of age and continued breastfeeding along with complementary foods until beyond
the infant’s first birthday.
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1
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
Encourage, support and promote exclusive breastfeeding for the first 6 months of life to achieve
optimal growth, development and health (14). Followed by the introduction of appropriate solid
food at this age and continued breastfeeding… breastfeeding to continue until 12 months of age,
and thereafter as long as mutually desired (1,2,5).
Reprinted with permission from the Report of the Chief Health Officer Queensland, 2006. Adapted
from the National Health and Medical Research Centre. Infant feeding guidelines, Canberra 2002.
The nourishment for the foetus is taken from the mother’s body stores by the blood and transported
through to the placenta, via the umbilical cord to the baby. All that happens when the baby is born
is these nutrients are taken in the bloodstream to the breast, changed into milk and the baby simply
needs feeding as often as the infant is hungry (6).
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3.2 The benefits of breastfeeding (2,5,9,10,11)
Baby
■■ Breastmilk is dynamic and living. It constantly changes in its nutrient composition to
meet the needs of the baby throughout different times of feeding.
■■ Breastfeeding protects against gastrointestinal and (to a lesser extent) respiratory
infection, and the protective effect is enhanced with the greater duration and exclusivity
of breastfeeding (9).
■■ Prolonged and exclusive breastfeeding has been associated with a reduced risk of the
sudden infant death syndrome (SIDS) (9).
■■ Breastfeeding reduces the likelihood of later diseases and health risks including obesity,
diabetes, heart disease(10), Crohns disease and lymphoma (9).
■■ Breastmilk is ready when your baby needs it.
■■ Breastmilk is hygienic.
■■ Babies digest breastmilk easily.
■■ Breastmilk contains a lot of natural substances that help a baby’s development and
growth.
Mother
■■ Breastfeeding helps in the physical recovery from childbirth.
■■ Breastfeeding helps the mother in weight stabilisation after pregnancy and childbirth.
■■ Breastfeeding may possibly also reduce the risk of some cancers, such as breast or
ovarian cancer (9,10).
■■ Bonding happens between the mother and baby during breastfeeding.
■■ Breastmilk is inexpensive and does not need to be prepared.
■■ Increased fertility control (5).
■■ Reduction in the risk of mothers with a history of gestational diabetes developing Type 2 diabetes (5).
■■ Possible protection against osteoporosis (9).
Parent handout can be found at
www.health.qld.gov.au/child&youth/factsheets/
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3
3.3 Natural patterns of breastfeeding
The first breastfeed
Studies have shown that mothers who feed or have skin contact with their babies in the first
2 hours after birth are more likely to breastfeed for longer than those who do not (7).
Ideally uninterrupted skin-to-skin contact should be maintained following birth. This will increase
the chance of the infant attaching correctly at the first feed (7). Many infants are not ready to feed
directly following delivery. The infant is often quiet and alert during the first 20 minutes or so,
then spontaneously begins the instinctive prefeed behaviour, orientating itself to the breast and
preparing to feed (7).
If the infant is left skin-to-skin, prone on mother’s abdomen following birth, the infant will gradually crawl to the breast, find the nipple, attach and begin to suckle unaided, usually within 70-90 minutes (7).
A successful first breastfeed has a number of positive effects (2)
■■ It builds the mother’s confidence in her ability to breastfeed.
■■ The infant starts to receive the immunological benefits of colostrum.
■■ The infant’s digestion and bowel function are stimulated.
■■ Correct sucking at the breast at this stage may avert later sucking difficulties.
■■ The bonding and attachment between mother and infant are enhanced.
Unless there is a medical reason, mother and infant should remain together for at least the
first hour after birth, prior to weighing and bathing to allow the infant to follow their instinctive
behaviours. Thereafter mother and infant should room-in together, so breastfeeding begins
and proceeds according to the infant’s needs – without restriction on the number and length of
feeds (2). This also ensures the infant receives colostrum early to prevent or reduce early weight
loss; stimulates the passage of meconium, reducing the risk of neonatal jaundice; and confers
immunological protection to the infant (7).
Colostrum
Colostrum, which is produced in the breast during late pregnancy and for the first 30 to 40 hours
after birth, is yellowish and thicker than mature milk (2). Colostrum provides all the nutrients,
including water, required by the neonate (2). It is high in protein, and sodium, and low in lactose
(7). It also contains lactoferrin, immunoglobulin A, enzymes, maternal antibodies, living cells—
leukocytes, neutrophils and macrophages—and non-pathogenic bacteria and prebiotics, which
help to colonise the gut of the newborn and limit the growth of pathogenic bacteria and viruses
and to protect against illness (2).
Initiation of breastfeeding introduces the wide range of normalcy experienced by individual women
throughout their feeding practices. Feeds within the first 48 hours, produce only a small amount
of colostrum (as little as half a teaspoon). Anywhere from 2-4 days after birth, supply will rise to
500-800ml of milk per day (6)
4
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Exclusive breastfeeding ensures an infant receives the full nutritional and protective benefits of
colostrum and breastmilk (2).
Information can be found at www.health.qld.gov.au/phs/documents/cyhu/28099.pdf
Further information on baby led attachment can be found at www.breastfeeding.asn.au, or
contact the breastfeeding helpline.
One or both breasts at each feed?
As a general rule, the baby should be allowed to finish feeding from the first breast before
switching to the other breast. This allows the baby to receive the higher-fat milk as the breast
empties (7).
While the majority of babies will indicate they have finished the first side by coming off the breast
spontaneously, others will stay on the breast, without actively sucking or swallowing. If this is
occurring, the mother should be encouraged to swap to the second side after 20-30 minutes (7).
Even when the mother initiates swapping sides, there are some babies who:
■■ have damp but not wet nappies
■■ cry constantly but sleep within a minute or two of the breast being offered
■■ sleep for long periods, especially overnight
■■ have poor weight gains.
These babies need to be swapped one side to the other more frequently, as soon as the
swallowing intervals lengthen or after 5 minutes of active feeding. The infant will get a rush of milk
as the infant swaps from breast to breast and will be inclined to suck more efficiently.
Some infants who come off the breast spontaneously only need to feed from one breast at some
or all feeds… Occasionally, if a mother has an abundant milk supply feeding from just one breast
at each feed may settle an upset, crying infant (7). If the infant is only taking one breast at each
feed, ensure the other breast is offered first the next time (7).
If milk withdrawal has not started within 3 days post-partum, the changes in milk
composition with lactogenesis are reversed and the likelihood of the establishment of
successful breastfeeding declines (2).
Breastmilk
Breastmilk is constantly changing – throughout lactation and throughout the feed (2).
Human milk uniquely adapts to the changing needs of the infant during the course of lactation. It requires a complex combination and interplay of hormones, together with an infant who initiates
and maintains lactation, and a mother responsive to her infant needs (7).
The composition of the first secretion after birth gradually changes as lactation is established and
production of milk begins in the breast tissue. Milk comes in about 48 to 72 hours after birth. By 7 to 14 days after birth, lactation should be established and the transition from colostrum to
mature milk should be under way.
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5
Colostrum and breastmilk can vary greatly in colour and consistency. The colour is irrelevant to the
quality of the milk (8).
The colour of colostrum varies from clear to pale yellow to bright orange. Mature breastmilk varies
from creamy to opalescent. Vitamin supplements and some foods taken by the mother can alter
the colour of milk (8).
The presence of blood may cause red to pinkish brown or “rusty” discolouration of breastmilk.
Small amounts of blood in colostrum may be due to duct hyperplasia – an extra growth of cells in
milk ducts during pregnancy, which causes bleeding when dislodged as the milk begins to flow.
It is usually of no significance and will disappear in a few days (8).
Trauma to the mother’s nipple is the most common cause of blood-stained milk. It is important to
establish the cause of blood-staining and treat it. However, it will cause no harm to the infant (8)
although it may cause vomiting if there are significant amounts of blood in the stomach.
The rate of milk production is regulated to match the amount of milk removed from each breast at
each breastfeed ie. SUPPLY = DEMAND. Unrestricted feeding, both day and night, is an important
factor in successfully establishing breastfeeding and results in adequate milk production.
Additionally, the anatomy of the breast varies greatly between women. Some women can store up
to six times more milk than other women. Women with large storage capacity have more flexibility
in feeding frequency, whereas women with a smaller storage capacity need to feed fairly evenly
and frequently throughout the 24-hour day.
Other variances include rate of milk flow, nature of mouth-breast positioning … Advice should be
tailored for individual differences (2).
The sleepy infant
After the initial alert period following birth, some infants become very sleepy for the next 24 hours
or so. The infant may be affected by a long labour, or medications given during labour.
Skin-to-skin contact is best practice following birth. This can assist with the instinctive behaviours
of both mothers and infants and lessen the chance of feeding difficulties in the days ahead.
The first 72 hours are very important for the stimulation of breastmilk. If the infant has fed well at
least once in the first day following birth there is no cause for concern. During the daytime, if the
infant does not ask for a feed after about 5 hours, rouse the infant and put him/her on the breast
(2).
A number of strategies can be used to rouse an infant: (2, 12)
■■ skin-to-skin contact, allowing the infant to feed when ready
■■ changing the nappy
■■ expressing a little colostrum and giving it by a teaspoon, syringe or cup can give the
infant the ‘taste’ and the infant will then want to start sucking from the breast
■■ unwrapping the infant, talking to the infant, gently stroke legs, tummy, cheeks and lips
■■ cuddling the infant
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Most infants soon recover from the initial sleepy period and begin to seek feeds frequently.
This can be very tiring for the mother, but the midwife can prepare her for this and reassure her
about the benefits of early frequent feeding. This gives the infant colostrum, stimulates full milk
production, and reduces the chance of breast engorgement (2).
If the infant does not take the breast in spite of all efforts and is otherwise well, it is essential to
express the colostrum and feed it by teaspoon, syringe or cup (2). Refer to lactation consultant.
Parent handout at: www.health.qld.gov.au/child&youth/factsheets/default.asp
The unsettled infant (2)
Infants cry for many reasons. This is the infant’s most powerful means of communication.
It is normal for infants to have at least one unsettled period per day. It usually occurs in the evening
but can happen at any time. During these times, the infant may want to feed frequently. This often
causes mothers to be worried about their milk supply but it is rarely the cause of the problem.
Reassure the mother her milk production is continuous over a 24 hour period, and the rate of
production varies according to the fullness of the breast (2).
These frequent feeds ‘put in the order’ for the next day and should be welcomed as they will
ensure continued milk supply. Bottles of infant formula are not needed in these instances and can
affect the mother’s milk supply.
Regurgitation is common and may occur in about 40% of infants under 3 months. Most infants
with regurgitation or reflux are healthy and grow well. It is only a problem if it is causing the infant
great distress and/or insufficient milk is staying down to enable the infant to grow.
By 6-10 months, as the infant spends more time during the day in an upright position, the
condition usually settles. Breastfeeding is not the cause and does not make the condition
any worse. In fact, it is usually worse with artificial feeds. In those cases when it is a problem
management techniques may help. In severe cases medical intervention may be necessary.
Parent handout at: www.health.qld.gov.au/child&youth/factsheets/default.asp
ABA Booklet: Gastro-oesophageal Reflux and the Breastfed Baby www.mothersdirect.com.au/prod790.htm
Breastfeeding does not cause colic or reflux. Bottles and dummies may cause confusion in the infant
when breastfeeding is established. If these products are to be used they should be introduced after
1 to 2 months and be used infrequently.
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7
Summary
■■ Some new infants may need to be woken to feed. You can help infants wake up to feed by:
■■
placing them skin-to-skin on their mother’s chest
■■
changing their nappy
■■
unwrapping the infant
■■
stroking their legs, tummy, lips and cheeks
■■
encouraging mums to cuddle them
■■ Most infants have at least one unsettled period a day often in the afternoon/evening –
when they need to feed more often and be cuddled more.
■■ Regular evening feeds stimulate the production of milk supply for the next day.
■■ Swapping a breastfeed for a bottle of artificial infant milk can upset the milk supply.
■■ Many infants regurgitate their milk, and this usually settles by 6-10 months.
■■ Breastfeeding does not cause colic or reflux.
How often should I breastfeed my baby?
(7, 2, 12)
The infant will vary its feeds according to his or her needs and the rate of milk transfer. Allowing
the baby unrestricted access to the breast in the early days ensures regular drainage and
stimulation of the breast. This in turn enables the mother to establish her milk supply according to
the infant’s needs, conditions the let down reflex and minimises venous engorgement (7).
During the first few days after birth, babies vary considerably in how often they need to be fed.
Some babies will want to be fed every 1 or 2 hours, and then, as the milk comes in, will increase
the intervals between feeds. Others appear to be quite sleepy at first, feeding every 4 hours or so,
and then reducing time interval between feeds as they become more wakeful (7).
Each breastfeeding dyad will develop a feeding pattern that fits with the mother’s storage capacity
and the infant’s appetite (7).
Adherence to a strict feeding schedule may cause a mother to be anxious and ill at ease.... and
her anxiety is likely to inhibit her let down reflex (7).
■■ Infants need to feed often, especially in the early weeks. They can have around 8-12 in
24 hours, not necessarily evenly spaced.
■■ The infant will vary the feeds according to his/her needs and the rate of milk transfer.
Also, ‘demand feeding’ allows infants to let mothers know their needs.
■■ Infants will know when they are hungry so feeding can be done to suit the infant’s
needs. Infants may become unsettled and want to feed more often from time to time.
■■ Feeding times vary from feed to feed and infant to infant. As infants get older and
are able to suck more efficiently, they often have shorter feeds and may sleep longer
between some feeds or be awake and content.
■■ Breastmilk is easily digested, and most babies want and need to be fed more
frequently than 3 to 4 hourly, especially as the gastric emptying time of human milk is
approximately 90 minutes (7).
8
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■■ It is fine to give infants an extra feed or ‘top-up’ to settle him/her when needed.
■■ Encourage mums to let an infant feed as long as the infant wants to. Some infants will
have a rest at the breast and then start sucking again, let the infant decide when to
come off.
If an infant is feeding longer than 30 to 45 minutes, there may be some problems with attachment.
Refer to lactation consultant, or Australian Breastfeeding Association Helpline.
For how long should an infant breastfeed? (10)
Breastmilk gives the infant all the nutrients requirements for around the first 6 months of life. After
this time babies need solid food in addition to breastmilk. Queensland Health, the National Health
and Medical Research Council recommends breastfeeding is continued until the infant is 12
months old, and then for as long as mutually desired.
Check: tips to share with mums
✔✔ Feed when your baby asks for it, as all babies have different feeding
requirements.
✔✔ Breastmilk is easily digested, so baby may feed often.
✔✔ As baby grows and sucks more, she/he may have shorter feeds and sleep
longer between feeds.
Identification of correct attachment
47% of mothers who have ever breastfed said they experienced problems with breastfeeding:
the problem most commonly experienced was attachment, 30.7% (3)
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
Pay particular attention to the importance of correct attachment and positioning when breastfeeding.
Effective, rapid management of any breastfeeding difficulties is important to extend the duration of
breastfeeding.
Indicators for correct attachment
■■ Breastfeeding should not be painful. Most women experience nipple sensitivity and
tenderness in the first few days and this is normal, but pain is not.
■■ If the cheeks are being sucked in or you can hear a ‘clicking’, infant is not attached
properly.
■■ If mum reports it hurts when infant sucks or you suspect poor attachment, advise mum
to put her finger in infant’s mouth to break the suction and try again. Just pulling infant
off will hurt.
■■ Swallowing can be seen / heard.
■■ Infant looks comfortable, relaxed and not tense or frowning.
■■ After feeding, mum’s nipples will appear slightly longer but should not look squashed,
flattened, white or ridged.
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9
Figure 4
Attachment
Good and poor attachment
Attachment – outside appearance
Good attachment
Good attachment
Poor attachment
Poor attachment
Source: World Health Organisation, ‘Breastfeeding counselling: A training course’, 1993,
UNICEF, New York. Reproduced by permission.
Ongoing pain is not normal when breastfeeding. It shows something is wrong. Advise mum to talk
to a lactation consultant or call the Breastfeeding Helpline.
Looking after mum
47% of mothers who have ever breastfed said they experienced problems with breastfeeding:
The second most common problem experienced was ‘sore, cracked nipples’, 28.0% (3)
Sore and cracked nipples
Prevention
■■ Educate mother about the importance of correct positioning and attachment
■■ Educate mother about the likelihood of nipple sensitivity in the first few days
Tender nipples
Some nipple tenderness is normal at the start of feeds in the first 1-2 weeks. After these early
days, incorrect attachment is the most common cause of nipple pain. Sore nipples after a period
of comfortable feeding indicates the distinct possibility of infection, fungal, bacterial or both.
Tip sheet visit www.health.qld.gov.au/child&youth/factsheets/
Cracked nipples
Seek assistance from a trained health professional experienced in breastfeeding management.
Poor attachment is the most common cause of cracked nipples. In some cases, issues such as
tongue-tie may be contributing, so anatomical problems need to be ruled out.
Continuing breastfeeding with attachment corrected will resolve problems more quickly than
taking the infant off the breast (13). However, if it is too painful to breastfeed, advise mum not to
feed on the sore breast (for 12-24 hours) and express during this period. Advise mum to apply her
own breastmilk after feeds and let her nipples air dry naturally. Research suggests the application
of nipple creams is ineffective in most cases (12). The infant can be breastfed on the less sore side
and cup or bottle fed any expressed breastmilk.
Tip sheet visit www.health.qld.gov.au/child&youth/factsheets/
Ongoing pain is not normal when breastfeeding. It shows something is wrong. Advise mum to talk to
a lactation consultant or call the Breastfeeding Helpline
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Is baby getting enough milk?
Changes in milk supply
A mother may perceive her milk supply as low for the following reasons (7):
■■ an infant is fussy and does not settle after feeds. The infant may cry more than the
parent expects
■■ the infant has low weight gains, especially over a short period of time
■■ after initial fullness and engorgement, the breasts settle down and become softer, as the milk supply adjusts to the infant’s needs
■■ the infant requires a lot of comfort sucking
■■ expressed breastmilk looks different to cow’s milk (or could just ‘look different’)
■■ the infant keeps turning his or her head and opening mouth, as if wanting to suck. this is the ‘rooting reflex’ , present from birth to 3 or 4 months of age (2)
■■ the mother may not be able to express much milk. It must be remembered that the
ability to express is not a reflection of how much milk the infant takes (2).
Check
✔✔ All infants, regardless of how they are fed, require careful monitoring of growth and
development, with appropriate interventions undertaken when clinically indicated (9).
If the fully-breastfed infant shows two or more of the signs below the infant is most likely having
enough milk.
■■ At least 5 to 7 heavily-wet disposable nappies (or 6 to 8 very wet cloth nappies) in 24 hours provided no other fluids or solids are being given.
■■ A very young infant will usually have two or more soft bowel movements a day for
several weeks. An older infant may have fewer than this.
■■ Small quantities of strong, dark urine or formed bowel motions indicate that the infant is
in need of more breastmilk.
■■ Good skin colour and muscle tone.
■■ The infant is alert and reasonably contented and does not constantly want to feed. She
will probably wake for night feeds. A few infants sleep through the night at an early age,
while most will wake one or more times during the night for quite some time.
■■ Some weight gain and growth in length and head circumference. Record this in the
infant’s Personal Health Record.
Kindly adapted from Australian Breastfeeding Association www.breastfeeding.asn.au
Child Health Fact sheet available at: www.health.qld.gov.au/phs/documents/cyhu/28100.pdf
Unless medically indicated, there is no need to supplement breastmilk with other foods or fluids (15).
Studies suggest that partially breastfed and formula fed infants consume 20% more calories than do
exclusively breastfed infants. Excessive weight during the first 4-6 months of life is associated with
future risk of overweight in babies who are not exclusively breastfed (15).
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11
Prompting questions
Here are some prompting questions and responses you can use when talking with mums
(adapted from the Dietary Guidelines for Children and Adolescents in Australia)
■■ Is your infant losing or gaining weight and growing in length?
■■
Assure mums that the overall rate of growth is the most important factor and a
judgement is best made only after a series of measures.
■■
It is often assumed infant’s weight gain will be steady; however it is not uncommon for a
breastfed infant’s gain to be erratic – large one week and small the next. It is important
to look at the overall trend for a month or so, rather than week by week. This is
often reassuring to the mother who has an otherwise healthy infant. (7)
■■ Does your infant have 6 to 8 wet cloth nappies or at least 5 heavily wet disposable
nappies per day?
■■
This is typical in a breastfed infant.
■■ Are you concerned with bowel motions? (refer to constipation section)
■■
Breastfed infants are rarely constipated, so a dirty nappy can occur after each
feed. Typical breastfed infants’ bowel motions are a loose, mustard yellow but can
sometimes be green or orange. None of these changes are a problem in a healthy
breastfed infant. As the infant gets older, dirty nappies can occur less frequently.
It is important to discuss this with families
■■ Is infant’s urge to suck being met in another way?
■■
Breasts respond to frequent stimulation by producing more milk. Check if infant is
sucking on a dummy or a bottle, as the infant won’t feed as much and mum’s milk
supply will decrease. Complementary bottles should be completely avoided.
■■ Do you have any concerns with the changes in your daily life?
Changes after having an infant are normal…
■■
Infants can’t tell the time! In the first months of life infants don’t always become hungry
at the same time each day.
■■
Encourage mums not to feed on a rigid schedule – feed according to need.
■■
Encourage mums to create a flexible, evolving routine that meets both her and her
infant’s needs.
■■ Concerns with breast size or changes?
■■
Breast size has no relationship to milk production.
■■
Breasts may soften once mum’s body has settled into breastfeeding. This does not
necessarily mean a low supply. The milk supply has settled to the infant’s needs. Hard
breasts are engorged and this is not the normal state, just common in the early days.
■■ Changes in feeding patterns?
12
■■
The infant will want to feed more often from time to time and this is quite normal.
■■
How often the infant needs to feed and how long they take to feed differs a lot from one
infant to the next.
■■
The more mums feed, the more milk they make.
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■■ Not able to express much breastmilk?
■■
This is not a reflection of how much milk the infant actually takes.
■■
It possibly just means that the let-down reflex is not working when mum expresses.
■■ Is mum eating a nutritious diet?
■■
The Australian Guide to Healthy Eating provides recommendations on mum’s
intake. Help mum to follow the serving recommendations and limit extra foods.
■■ Is mum drinking plenty of water?
■■
Suggest drinking a glass of water each time she breastfeeds.
■■ Is mum getting as much rest as possible?
■■
Encourage mum to look at feeding time as rest time.
■■
She may like to lie down to feed for some feeds at home.
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
If a pacifier (dummy) is used, it should not be introduced until after 1 to 2 months and be used
infrequently.
Early use of dummies and bottles, especially before the first breastfeed, can interfere with the
natural processes of breastfeeding, reducing the infant’s sucking capacity and the stimulation of
the mother’s breasts (2).
Dummy use is associated with lower exclusivity and duration of breastfeeding (16).
Risks associated with the use of a pacifier and the non-nutritive sucking habit it promotes include:
■■ failure of breastfeeding
■■ dental deformities
■■ recurrent acute otitis media
■■ risk of accidents
■■ latex allergy
■■ tooth decay
■■ oral ulcers
■■ sleep disorders (17).
Breasts respond to frequent stimulation by producing more milk. If infant is sucking on a
dummy or a bottle, the infant won’t breastfeed as much and mum’s milk supply will decrease.
Complementary bottles should be completely avoided (2).
Remember: supply = demand
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13
Monitoring an infant’s progress
■■ Check infant’s growth regularly and make sure it is recorded on the growth chart in the
Personal Health Record book. A judgement on infant’s growth is best made only after a
series of measures. It is important to assess weight gain on a four week average (2).
■■ A one-off unusual measure is not usually cause for concern if infant is content and healthy.
Check the accuracy of measurements, use the same scales all the time and always weigh
without clothes (12).
Normal ranges of infant weight gain
A number of factors influence growth in infancy including (7):
■■ intrauterine environment
■■ birth size
■■ sex
■■ parental stature
■■ feeding mode.
Infants lose weight shortly after they are born, up to about 10% (7). They start to regain this weight
by day 4-6 and should have regained their birth weight by 2 weeks (2).
■■ Birth – 3 months: gain 150 to 200 g per week
■■ Age 3 to 6 months: gain 100 to 150 g per week
■■ Age 6 to 12 month: gain 70 to 90 g per week
It is often assumed infant’s weight gain will be steady; however it is common for a breastfed
infant’s gain to be erratic – large one week and small the next (7). After the first 2 weeks there
should be some weight gain on a regular (but not necessarily weekly) basis usually averaging at
least 500 g (7) to 600 g (2) per month. Infants usually double their birth weight by the age of 6 months; triple their birth weight by 1 year of age. (2)
Weight gain is only one aspect to consider. Positive support of the mother and clinical observations
of the infant are equally important.
Patterns of weight gain in breastfed infants are different from those of infant-formula-fed ones. They
should not be compared. (7)
Growth charts
Growth charts are useful to monitor infant growth, but should not be the sole determinant of the
need for the introduction of complementary feeding…; they are not an indication of the readiness
for complementary foods (15). Refer to Growth Chart section.
14
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Check
✔✔ Feeding patterns
■■
Feeding on demand.
■■
Length of feeds variable ( if >1/2 hour on first breast, check attachment).
✔✔ Urine output, after infant is 3 or 4 days old
■■
Cloth nappies soaked with pale or colourless urine 6 or more times per day.
■■
Very heavy disposal nappies at least 5 times per day.
✔✔ Bowel actions
■■
Breastfed infants are rarely constipated, so a dirty nappy can occur after each feed.
■■
Typical breastfed infants’ bowel motions are loose, mustard yellow but can
sometimes be green or orange.
■■
As your infant gets older, dirty nappies can occur less frequently.
✔✔ Growth
■■
The fact that your infant’s growth follows the general pattern or curve of the graph is
the most important thing.
(adapted from 2,12,14)
If the infant’s growth appears to be faltering, check for other indicators of wellbeing, and if
there seems to be insufficient milk, efforts should be made to increase the milk supply in
the first instance (5).
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15
Guidelines for practitioners:
Approximately 3 in 5 mothers (60%) surveyed in the Infant Nutrition Survey who had ever breastfed
their child sought help or support with breastfeeding after leaving hospital. These mothers usually
went to at least two different sources of support and advice. The main source was family and friends,
followed by the local community or child health centre (3)
Monitoring progress: in the first month of life
Adapted from Global Strategy for Infant and Young Child Feeding, WHO (14)
1 Mothers should be visited or otherwise communicated within 48 hours of discharge to check
exclusive breastfeeding is progressing satisfactorily. Most problems identified at this stage
can be easily solved. Difficult problems should be referred to a lactation consultant. The
longer the first visit is delayed the more difficult it is to solve any problems that might have
arisen.
2 During this visit observe a breastfeed to:
a. ensure correct position and attachment
b. confirm good milk transfer
c. reassure mum.. knowledge and practice of breastfeeding should be reinforced.
3 Breastfeeding problems such as sore nipples and breast engorgement do not require the
discontinuation of breastfeeding and short-term interruption is rarely needed
(see www.health.qld.gov.au/child&youth/factsheets/default.asp :
common breastfeeding concerns, or refer mums to their Child Health Information booklet).
4 Mothers perceiving infant crying and frequent feeding as breastmilk insufficiency need
explanation, reassurance and support. These episodes are normal; they are a regulating
mechanism of milk removal and milk synthesis to meet the evolving needs of the infant.
5 If a child fails to follow a growth curve check the effectiveness of breastfeeding and correct
feeding technique if necessary. Weight gain should always be calculated from the lowest
post-partum weight, not from birth weight.
6 If growth is above 95th centile, or below 5th centile, or crosses these centiles, (2) or should
growth faltering persist further investigation is required. Remember, though, that 5% of
normal infants will be above the 95th percentile and another 5% will be below the 5th.
16
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Monitoring progress: from 1 to 6 months
Adapted from Global Strategy for Infant and Young Child Feeding, WHO (14)
1 If exclusive breastfeeding is well established, there is no need to supplement breastmilk with
other food or fluids
2 Mothers should be advised to check growth, by arranging infant checks monthly.
3 Mothers should be advised to continue breastfeeding on demand
4 At around 6 months, most infants will show an interest in complementary foods as well as
breastfeeds. Provided infants are in good health parents should be advised to observe their
infant’s feeding behaviour and respond appropriately (ie never force infants to eat).
5 Growth charts are useful to monitor infant growth, but should not be the sole determinant of
the need for the introduction of complementary feeding.
6 To facilitate mothers in the paid workforce, a breastfeeding supportive workplace as well as
family and/or social support is helpful. Access to ongoing expert support, and information
on expression, safe handling and storage of breastmilk is also required
7 Exclusively breastfeeding mothers who use the Lactation Amenorrhoea Method (LAM)
of birth control have a high rate of protection from unwanted pregnancy until her infant
is 6 months old. After this, other contraceptive methods are required. Progestin-only
contraceptives are highly effective and usually have no inhibitory effect on lactation,
however, combination contraceptives appear to be associated with a decline in milk
production (see section on medications for further information). Occasionally, a mother
might find progestin-only contraceptives affect lactation, especially if begun very early
following the birth.
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17
3.4Why not to introduce cow’s milk
before 12 months (2)
Cow’s milk as a complete feed is not suitable for infants under 12 months of age for a number of reasons.
Composition
Breastmilk is a living tissue that includes many species-specific compounds (2). Because cow’s
milk is intended for calves, which have a much higher growth velocity than infants, the content of
nutrients essential for growth, like protein and some minerals are much higher (typically 2-3 times)
than in human milk (18) and too high for human infants.
■■ The composition of cow’s milk is not ideal for infants. Compared with breastmilk
and infant formula, cow’s milk contains higher levels of protein, sodium, potassium,
phosphorous and calcium and lower levels of iron, vitamin C and linoleic acid, adding to
the difficulty of providing a balanced diet for older infants (2,18,19).
■■ The higher levels of protein, sodium and potassium in cow’s milk have been associated
with an increase in renal solute load (2,18) that might cause dehydration and
hypernatremia during illness (18).
■■ The high phosphorous and calcium content of cow’s milk may decrease the
bioavailability of iron from other dietary sources such as infant cereals.
■■ The fat in cow’s milk is much harder for infants to digest due to the way fats are
hydrolysed. Long chain polyunsaturates are deficient in cow’s milk. These are essential
for an infant’s nervous system development and visual function (20).
Iron
■■ Cow’s milk is a poor source of iron and the iron it does contain is poorly absorbed: 50% of iron from breastmilk is absorbed compared with 10% in cow’s milk.
■■ Introducing cow’s milk before 12 months of age predisposes an infant to iron deficiency
at an age when their iron stores become depleted.
■■ Cow’s milk that has not been heat treated can cause gastro-intestinal bleeding (26),
exacerbating the problem of iron deficiency (2).
Health consequences
■■ Early introduction of cow’s milk may be associated iron deficiency.
■■ Avoiding cow’s milk during the first 12 months of the infant’s life will help protect against
the development of cow’s milk allergy (2).
■■ Early introduction of cow’s milk has been linked to an increased risk of developing
asthma or type 1 diabetes (5).
‘Milkaholics’
■■ A young child consuming either one litre of cow’s milk or an equivalent formula milk
product is meeting as much as two thirds of his or her energy requirements from this
source, leaving very little appetite for other more varied healthy foods (2).
18
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Breastfeeding and allergies
■■ Exclusive breastfeeding at least 6 months, and preferably longer is recommended.
■■ If breastfeeding is discontinued for any reason, seek professional advice: hydrolysed
protein formula may be recommended.
■■ Soy milk and goat’s milk formulas do not reduce allergies, and should not be used as an
alternative to cow’s milk formulas.
■■ Maternal dietary restrictions during breastfeeding are not recommended for prevention
(21)
■■ If an infant is breastfeeding and showing signs of allergies, refer to local general
practitioner or paediatrician.
3.5 Nutrition and breastfeeding
Healthy eating is important for all mothers. It is important for the mother to eat adequately for her
own nutrition needs as well as providing for the nutritional needs of her infant. With rigorous hours
and constant demands that need immediate attention, breastfeeding is a full-time job. And as with
any role that is physically and emotionally challenging, mothers need to regularly refuel to keep
their energy levels high.
Unless extremely malnourished, virtually all mothers can produce adequate amounts of breastmilk.
When the breastfeeding mother is undernourished, it is safer, easier, and less expensive to give
her more food than to expose the infant to the risks associated with breastmilk substitutes (22).
Lactation places high demands on maternal stores of energy and protein. These stores need to be
established, conserved, and replenished (22).
Breastfeeding can affect the mother’s nutritional status, depending on the mother’s diet. The
energy, protein, and other nutrients in breastmilk come from the mother’s diet or from her own
body stores. When women do not get enough energy and nutrients in their diets, repeated,
closely-spaced cycles of pregnancy and lactation can reduce their energy and nutrient reserves, a
process known as maternal depletion (22).
Breastfeeding mothers have an increased requirement for most nutrients compared to mothers
who do not breastfeed, as many vitamins and minerals in a breastfeeding mother’s diet are
transferred into the breastmilk.
A breastfeeding mother should eat regular nutritious meals and snacks to meet the extra energy
(kilojoules) needed for making breastmilk and feeding. Consuming a variety of foods each day is
important in meeting both the mother’s and infant’s nutritional needs.
Utilise the Australian Guide to Healthy Eating as a guide for mother’s intake.
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19
Energy requirements
The energy needs of a breastfeeding mother are increased because of milk production. In fact, the
energy requirements for breastfeeding mothers are, on average, 2000 kJ (445 kCal) per day more
than that of a usual adult woman’s daily energy needs. These energy requirements are based on
full breastfeeding in the first 6 months and partial breastfeeding after that time.
While it is normal (and expected) that mothers put on weight while pregnant, it is not
recommended that mothers follow a strict weight loss diet after childbirth. Breastfeeding naturally
allows for gradual weight loss. If weight is gained after birth, it is most likely mum is eating too
much food, or choosing foods high in energy (kilojoules).
Because there is individual variation in milk production, levels of physical activity and weight loss
during lactation, it is difficult to make an exclusive recommendation on energy needs during
breastfeeding.
For individualised advice, refer to a dietitian.
Physical activity
Regular, moderate physical activity is good for health. It appears most breastfeeding women can
participate in exercise without affecting their lactation.
It is best to combine exercise with balanced eating and adequate nutrition. It is also important to
drink plenty of fluids when breastfeeding and exercising.
For individual nutrient requirements such as those described below, the Nutrient Reference
Values for Australia and New Zealand Including Recommended Dietary Intakes provides an
average nutrient intake requirement for individuals and a value that would meet the needs of most
individuals in the population. Because it is difficult to assess an individual’s exact requirement
for a particular nutrient, you might like to aim for the upper figure to maximise the certainty that a
sufficient amount of the nutrient is obtained from food.
For health professionals
For more information go to www.nhmrc.gov.au/publications/_files/n35.pdf
The information in this next section is kindly adapted from the Healthy Active website. It is based on the Nutrient Reference Values for Australia and New Zealand Including
Recommended Dietary Intakes, the Dietary Guidelines for Children and Adolescents in Australia,
and The Australian Guide to Healthy Eating. These recommendations are for healthy women with
standardised weight, height and estimated energy requirements and may not meet the specific
nutritional requirements of individuals.
Specific advice for individual needs should be sought from a qualified dietitian.
Parent handouts can be found at www.qheps.health.qld.gov.au/ahwac/content/home_nemo.htm
20
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Healthy Eating Guidelines for Breastfeeding Women
Table 10
The Australian Guide to Healthy Eating recommendations for
breastfeeding women
Food group
Number of serves
Bread, cereal, rice, pasta,
noodles
1 serve
2 slices bread
Choose wholegrain/ wholemeal
varieties
5-7
1 medium bread roll
1 cup cooked rise, pasta
1 cup breakfast cereal, porridge
½ cup muesli
Fruit
1 piece medium sized fruit
5
2 pieces smaller fruit
20 grapes or cherries
½ cup juice
1 cup diced/canned fruit
1½ tbsp sultanas
Vegetables, legumes
1 medium potato
7
½ medium sweet potato
1 cup salad vegies
½ cup cooked vegetables
½ cup lentils, chick peas, canned beans
Meat, fish, poultry, eggs, nuts
and legumes
2 fish serves per week
65-100 g cooked meat/chicken
2
80-120 g cooked fish
2 small eggs
1/3 cup cooked dried beans, lentils, chick
peas, split peas or baked beans
1/3 cup nuts
Milk, yoghurt, cheese
Choose fat reduced varieties
1 cup milk
2
40 g (2 slices) cheese
200 g yoghurt
1 cup custard
Note: Plenty of fats and oils are obtained from the amount used with cereal foods and from meat,
eggs, cheese, peanut butter, margarine, etc so fats and oils aren’t included separately. For more information check out the Australian Guide to Healthy Eating at: www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strategfood-recommend.htm
The nutrients of particular concern during breastfeeding are:
✔✔ protein
✔✔ folate
✔✔ zinc
✔✔ vitamin A
✔✔ vitamin B6
✔✔ iodine.
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21
Protein
A breastfeeding mother needs additional dietary protein to build the protein in her
breastmilk. Protein is vital for the growth, maintenance and repair of cells. The RDI for
protein during breastfeeding is 67 g/day. Protein is found in a wide range of foods such
as meat (including fish and poultry), eggs, dairy, legumes (such as beans, pulses and soy
products) and nuts. Smaller amounts of protein are found in grain-based foods such as
bread and pasta.
Folate
Folate is a B vitamin, needed for healthy growth and development. The RDI for
breastfeeding mothers is 500 µg/day. Folate can be found in leafy vegetables, wholegrains,
beans, peas, peanuts, avocado and yeast extract (eg Promite, Vegemite, Marmite etc).
Zinc
Zinc is a component of various enzymes that help maintain structural integrity of proteins
and help regulate gene expression. Breastfeeding mothers require 12 mg/day. Zinc can be found in lean meat, wholegrain cereals, milk, seafood, legumes and nuts.
Vitamin A
Vitamin A is vital for normal growth and helps provide resistance to infections.
Breastfeeding mothers require 1,100 µg/day. Vitamin A can be found in milk, cheese, eggs,
fatty fish, yellow-orange vegetables and fruits such as carrots, pumpkin, mango, apricots,
and other (dark-green) vegetables such as spinach and broccoli.
Vitamin B6
Vitamin B6 is important for the metabolism of protein and the formation of red blood cells.
Breastfeeding mothers require 2 mg/day. Vitamin B6 can be found in muscle and organ
meat, poultry, fish, wholegrains, brussel sprouts, green peas and beans.
Iodine
Iodine is a vital nutrient for the thyroid gland to make thyroid hormones, and these are
essential for normal development of the brain and nervous system. Iodine content in
breastmilk reflects the mother’s intake, so if this is low, the amount transferred to the baby
will also be low. Until an infant can eat weaning foods containing iodine, the infant relies
entirely on supplies of this nutrient from his mother, across the placenta and then through
breastmilk (23). The RDI for iodine during breastfeeding is 270 µg/day.
Water (fluids)
Breastfeeding mothers should drink an additional 700 ml/day (at least) above non-lactating
requirements to replace the fluid lost through breastfeeding. This equals to a total of 9 cups
daily, and can be in the form of water, milk, soup, juice and other drinks (avoid alcohol and
limit caffeine-containing fluids, such as coffee, tea and cola). However, pure water should
be everyone’s main drink.
A practical idea you can advise mum is to have a drink at the time of each breastfeed, as
well as drinking regularly throughout other times of the day.
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Dieting during breastfeeding
Breastfeeding helps mothers to shape up. Weight loss diets are not recommended during
breastfeeding. Advise mothers on a few of these strategies to ensure they are maximising their
nutrient intake, whilst decreasing extras.
■■ Don’t skip meals.
■■ Limit foods high in fat and sugar such as lollies, chocolate, soft drinks, cakes, sweet
biscuits, chips and fatty takeaways.
■■ Use healthy cooking methods such as steam, boil, microwave, and grill or stir fry.
■■ Trim fat from meats and avoid chicken skin.
■■ Do some gentle exercise such as taking your baby for a walk - consult a physiotherapist.
Parent handout
qheps.health.qld.gov.au/ahwac/content/home_nemo.htm
Excess weight loss and breastfeeding
Encourage the mother to continue breastfeeding. Help them to find ways to eat more. Some suggestions:
■■ don’t skip meals
■■ have three main meals and three between meal snacks
■■ keep easy to prepare nutritious snacks on hand eg crackers and cheese, fresh fruit,
yoghurt, nuts, seeds, dried fruit, canned beans, flavoured milk, fruit smoothies, breakfast
cereals and milk
■■ prepare a packed lunch or variety of snacks to have in a container beside you when
baby feeds
■■ prepare and freeze meals in advance when possible (or ask your friends/family to help).
When the breastfeeding mother is undernourished, it is safer, easier and less expensive to give her
more food than to expose an infant under 6 months of age to the risks associated with feeding infant
formula or other foods (22)
Parent handout
qheps.health.qld.gov.au/ahwac/content/home_nemo.htm
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23
Foods that may adversely affect a breastfed infant
Some foods that breastfeeding mothers eat or drink can affect the infant:
■■ alcohol
■■ caffeine
■■ any foods that are not part of her normal diet, eg for some, spicy foods
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
Encourage breastfeeding mothers not to drink alcohol.
Alcohol
The level of alcohol in breastmilk is virtually the same as a mother’s blood alcohol level. Even
if one standard drink is ingested, a small quantity of ethanol passes into the breastmilk and is
subsequently taken by the suckling infant if she feeds the infant while intoxicated (2). As the liver
removes the alcohol from the blood, the alcohol also leaves the milk.
It is advised not to drink any alcohol when breastfeeding an infant, especially in the first 3 months
because it is not clear what negative effects alcohol has on the infant’s rapidly-developing brain.
Additionally, mothers also report a lower tolerance to alcohol whilst breastfeeding (24). An
intoxicated mother should not breastfeed. High intakes of alcohol may affect the mother’s ability
to look after her infant and increases her risk of developing depression. Large quantities of alcohol
have also been seen to displace good nutrition.
If mothers do drink, advise them to limit the amount and take it just after feeding. This will allow a
lower alcohol level in the breastmilk by the time of the next feed (25).
Caffeine
Some breastfeeding mothers report that their infant is unsettled, irritable, or even constipated if
they drink large volumes of coffee, strong tea, high energy drinks or cola. However, there appears
to be individual variation in how much caffeine is found in breastmilk after having a high caffeine
drink.
Peak levels of caffeine are found in breastmilk approximately 60 minutes after ingestion. Newborns
metabolise caffeine very slowly, the half life of caffeine being 80 hours in a newborn compared to
2.6 hours in a 6 month old (24).
Caffeine can also affect the nutrient make up of breastmilk. The iron levels in the breastmilk of a
woman who drinks more than 3 cups of coffee a day during pregnancy and the early phases of
breastfeeding, are one-third less than that of a mother who does not drink coffee.
During breastfeeding, caffeine consumption should be limited to 2 to 4 cups of coffee, tea or cola
per day (25).
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Just how much caffeine is in that drink or food?
■■ Coffee
■■
80 to 350 mg caffeine per cup, depending on the type of beans and how it is
prepared
■■ Instant coffee
■■
60 to 100 mg caffeine per cup
■■ Decaffeinated coffee
■■
2 to 4 mg caffeine per cup
■■ Tea
■■
8 to 90 mg caffeine per cup
■■ Energy drinks and coffee flavoured milks
■■
up to 130 mg caffeine per 250ml serve (also high in sugar)
■■ Cola drinks
■■
35 mg caffeine per 250ml serve (also high in sugar)
■■ Cocoa and chocolate drink
■■
10 to 70 mg caffeine per cup
■■ Chocolate bars
■■
20 to 60 mg caffeine per 200 g bar (also high in sugar and fat).
Additionally, the mother should be warned that cigarette smoking compounds the effects of
caffeine in breastfed infants (24).
For more information about the caffeine content in food and drink:
www.foodstandards.gov.au/whatsinfood/caffeine/
www.breastfeeding.asn.au/bfinfo/drugs.html
Food sensitivities
Some breastfed infants may get upset or unsettled if their mothers eat a lot of rich or spicy foods,
or particular fruits or vegetables. If a breastfeeding mum is suspicious a food being consumed
is affecting the infant, advise her to stop eating it for a few days. If the infant settles down, advise
mum to introduce the food again to see how it affects the infant. It may be helpful to avoid that
food if the infant becomes unsettled again. It is advisable to speak with a dietitian or nutritionist for
further advice if avoidance of several different foods seems to be necessary.
Guidelines for pregnant and breastfeeding vegetarians and vegans can also be found at
www.qheps.health.qld.gov.au/ahwac/content/home_nemo.htm
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25
Sample meal plan for a breastfeeding woman
Breakfast
Wholegrain toast, thin scrape of margarine and vegemite/jam/honey Tub of low fat yoghurt (200g) with piece of fruit
OR
Bowl of wholegrain cereal and 1 cup low fat milk and 1 cup canned fruit in natural juice
A piece of fruit or a small glass of orange juice
Morning tea
Carrot and celery sticks with low fat dip / salsa
Lunch
2-4 slices of bread/bread roll/lavash bread 100g lean ham/turkey with mustard/cranberry sauce / 2 small eggs
Salad eg. lettuce, tomato, beetroot, cucumber
A piece of fruit
OR
Tin of tuna or salmon stirred through 1 cup cooked pasta Side salad
A piece of fruit
OR
Small tin baked beans on 2 slices toast and a banana/apple/orange/2 apricots or plums
Afternoon tea
Banana smoothie - made with 1 cup of milk, honey, banana
Handful of sultanas
Dinner
100g lean meat/chicken/fish/lamb/pork with 2 cups of a variety of vegetables eg. grilled steak or fish with mashed potato, peas, carrots, broccoli; curried meat with sweet potato, eggplant, carrots, chickpeas;
stir fried chicken with capsicum, ginger, garlic, bean sprouts, snowpeas, carrots
Pasta sauce with tinned tomato, mushrooms, capsicum, zucchini and pasta or rice
Supper
2 pieces of raisin toast with banana and honey
A glass of water
Parent handout: For menu ideas visit www.eatwellbeactive.qld.gov.au/eatwellbeactive/eatwelltips/menu_plan.asp
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Energy expenditure
Table 11
Energy expenditure variations during breastfeeding
Lifestyle / exercise level
Energy requirement (kJ/day)
At rest, exclusively sedentary or lying (eg chair-bound or bedbound)
8,800 kJ/day
Exclusively sedentary activity/seated work with little or no
strenuous leisure activity eg office employee
10,000 - 10,550 kJ/day
Sedentary activity/seated work with some requirement for
occasional walking or standing, but no strenuous leisure activity
11,100 - 11,700 kJ/day
A lifestyle that involves predominantly standing or walking eg
housewives, waiters, tradespersons
12,300 - 12,850 kJ/day
Heavy physical work or a highly active leisure
13,400 - 14,500+ kJ/day
Adapted from www.healthyactive.gov.au (10)
3.6 Breastfeeding and non nutritive substances
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia.
Encourage mothers who smoke to stop or reduce smoking and to avoid exposing their infant to
tobacco smoke. Even if a mother persists with smoking, breastfeeding remains the best choice.
Nicotine
Adapted from the Dietary Guidelines for Children and Adolescents in Australia, 2003 (2)
It is still better for the infant to be breastfed even if the mother continues to smoke than to be
formula-fed and have a smoking mother. Breastfeeding ameliorates some of the harm of smoking.
Nicotine is quickly transferred into breastmilk and has been linked to reduced milk production,
rapid heart rate and restlessness. Infants who grow up in a smoker’s environment are more likely
to suffer from respiratory and gastrointestinal illnesses and tend to have depressed immune
systems
Mothers should be encouraged to breastfeed exclusively for the first 6 months to maximise the
infant’s protection against respiratory disease, and continue to breastfeed as long as possible.
Additionally, mothers who smoke should be encouraged to quit. Lactation may be an ideal time to
do this since hormones and other substances released in the mother during lactation may help to
decrease her withdrawal symptoms (24).
The following can help to reduce harm to the infant.
■■ Mothers should completely avoid smoking in the 60 to 90 minutes (2,24) before feeding.
■■ Mothers should completely avoid smoking during feeding.
■■ Mothers should smoke only after a feed has been given.
■■ Others should smoke outside the house or car and should not take infants into smoky
environments.
■■ No one should smoke in the same room as the infant because of the dangers of passive
smoking.
■■ Mothers who use nicotine gum, which produces higher nicotine levels than patches,
should not breastfeed for 2-3 hours after using the gum.
Cigarette smoking can alter the taste of breastmilk (24).
Smoking can decrease a mother’s ability to produce breastmilk and thus affect the growth of the
infant (25).
See medications for more information on nicotine patches or gum.
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27
Prescription and/or over the counter medications
Adapted from Child Health fact sheets (12)
Most prescription drugs are compatible with breastfeeding, but each case should be specifically
assessed.
Human breastmilk is undoubtedly the most important food an infant can have. It is so
important that breastfeeding should only be discontinued if there is strong evidence
that a drug taken by the mother will harm the infant.
Choose the right medication
Mothers who are breastfeeding should not be given a medication unless there is convincing
evidence that it will really help the mother’s condition at the time. A worsening illness can have a
greater affect on a mother’s breastfeeding ability than some medical treatments. If there is a range
of suitable drugs available, your doctor or pharmacist should choose the drug that is the absolute
safest, based on evidence.
Exposure in the womb
Infants are exposed to more medication in the womb than through breastfeeding.
If mum has been taking medications during pregnancy – for example, drugs to control epilepsy –
the infant will already have been exposed to more drugs in the womb than through breastmilk.
Drugs taken by a breastfeeding mother may pass into the milk through the mother’s bloodstream,
usually in very small amounts. The extent to which this happens depends on a number of factors,
including the nature of the drug concerned, the fat content of the breastmilk and the drug level
in the mother’s body. Generally, the majority of medications do not need to be avoided when
breastfeeding. When breastfeeding mums do need medication, however, advise them to feed their
infant just before the next dose is due to reduce the infant’s exposure to the drug.
Some drugs may be contraindicated during breastfeeding, but this is a complex subject. Advice from the general practitioner or pharmacist should be sought (2). For more information contact the Royal Women’s Hospital Obstetric Drug Information
Service on (07) 3253 7300.
Use this fact sheet as a ready reference to work out which common drugs are safe to take. www.health.qld.gov.au/child&youth/factsheets/
Also see World Health Organisation ‘Breastfeeding and Maternal Medication’ (2002)
Drugs to relieve headache, aches, pain or fever
Paracetamol, when taken as directed, is quite safe to take while breastfeeding. Common brand
names for paracetamol include Panadol, Dymadon and Panamax. Aspirin (including Disprin, Aspro
and Solprin) is safe to take for pain occasionally, but not regularly. More severe pain can be treated
with stronger products, such as paracetamol-codeine combinations. These include Panadeine,
Dymadon Co and Codalgin. For period or muscular pain, take the above drugs. As well, antiinflammatory drugs such as ibuprofen (Nurofen, Actoprofen) and naproxen (Naprogesic, Naprosyn)
are very effective, but should be taken in low doses for short periods of time only. Creams and
sprays available for muscle aches and pains are safe to use. Ponstan and Indocid are best
avoided by breastfeeding mothers.
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Cold, flu and asthma drugs
Breastfeeding mothers should try to avoid cold and flu tablets containing pseudoephedrine,
such as Sudafed and Demazin. Pseudoephedrine can sometimes cause breastfeeding infants
to become irritable and restless. Pseudoephedrine can also cause a significant reduction in milk
volume.
Try nasal spray decongestants instead, like Sinex and Otrivin. Lozenges and gargles are safe
for sore throats, though it is best to avoid gargles containing povidone-iodine, such as found in
Viraban, Betadine, Minidine and Viodine.
Most cough mixtures are safe, but avoid products containing pseudoephedrine.
Asthma treatment should be the same for breastfeeding women as for those who are not
breastfeeding, and is quite safe.
Hayfever and allergies
There are some antihistamines on the market that do not cause sleepiness, and of those,
ioratadine (Claratyne) is the safest for breastfeeding mothers to use. Terfenadine (Teldane)
and astemizle (Hismanal) have occasionally been known to cause restlessness and irritability
in breastfed infants, so they are best avoided. Most of the older antihistamines may cause
drowsiness as a side effect. However they are safe to use while breastfeeding and include
dexchlorphenirimine (Polaramine) and pheniramine (Avil).
Nasal sprays such as budesonide (Rhinocort) and beclomethasone (Aldecin and Beconase) are
quite safe and may be prescribed for breastfeeding mothers by their doctor.
Contraception
If breastfeeding mothers want to take the contraceptive pill while breastfeeding, the mini-pill only
should be prescribed. Common brand names include Microlut, Microval and Micronor.
Other pills – like Nordette, Microgynon, Triphasil and Tranquilar – should not be taken. Theses
contain a hormone, oestrogen, which can decrease milk supply.
The morning-after pill (Postinor-2) is quite safe for emergency contraception.
Depot Provera and Depot Ralovera (both three-monthly injectable contraceptives) are excreted
into breastmilk in very low amounts, and are also safe for use. They should be given about six
weeks after the birth.
Note that occasionally, progesterone-only contraceptives can also affect milk supply or cause
infant fussiness. When other causes have been ruled out, this should be considered.
Constipation
The safest laxatives to use are fibre-based products, such as Metamucil and Fybogel, followed by
docusate (Coloxyl). Large doses of senna as found in Senokot, Coloxyl with Senna, and Nulax) or
bisacodyl (Durolax) can cause diarrhoea in the breastfed infant.
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29
Vitamins, minerals and herbal preparations
Some vitamin and mineral supplements are safe to use during the breastfeeding period.
In fact, B-group vitamins may be particularly beneficial to mothers lacking energy. And evening
primrose oil is safe to take while breastfeeding. Be aware, though, that natural drugs like herbal
preparations may be natural, but they may not necessarily be harmless. Many herbal drugs
contain chemical substances that may be dangerous to the infant and numerous poisonings have
been reported in the past.
So, if breastfeeding mothers want to take herbal supplements, advice from the general practitioner
or pharmacist should be sought. At all times, do not use more than the recommended standard
dose of herbal products, and use single ingredient products rather than combination products of
unknown herbs.
Antidepressants
Antidepressant drugs are of many different forms and have different pharmacological effects in the
body. Moreover, they can exert different effects in different women.
The extent of breastmilk passage of antidepressant drugs also differs with drug type and mother.
Antidepressants are excreted in small amounts in the breastmilk and it is currently unknown what
long term effects this might have on the infant. Therefore it is recommended that antidepressants
be used with caution during breastfeeding. There should be discussion with both medical
practitioner and pharmacist before taking these medications.
The ABA booklet Postnatal Depression and Breastfeeding contains valuable information for
parents and health professionals about depression, anti-depressants and breastfeeding.
Smoking
If breastfeeding mothers are smoking, encourage them to stop or decrease smoking as much as
possible. Nicotine patches or gum used to quit smoking is safer than continued smoking, as long
as you do not smoke as well.
Mothers who use nicotine gum, which produced higher nicotine levels than patches, should not
breastfeed for 2-3 hours after using the gum.
Illicit drugs
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
Encourage mothers to… avoid illicit drugs.
Illegal drugs like heroin or marijuana, or prescription drugs like morphine, methadone or oxycodone –
can lead to the infant being excessively drowsy and feeding poorly (12).
Prolonged exposure to these drugs can also result in both the mother and the infant becoming
dependent on the drugs (12).
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Marijuana
The use of marijuana or exposing infants to side stream smoke during both pregnancy and
lactation is discouraged. It is known that the active component of marijuana is fat soluble and
shows an eightfold accumulation in breastmilk compared to plasma (26).
Infants exposed to marijuana through breastmilk often exhibit signs of sedation, weakness and
poor feeding patterns. Marijuana use may also decrease milk production and the long term
effects on an infant’s rapidly developing brain are unknown (26). If possible it is best to avoid using
marijuana whilst breastfeeding (24, 27).
Heroin, methadone
The active components of methadone and heroin, like marijuana, are known to be fat soluble
and concentrate in the breastmilk. Heroin use can result in low birth weight infants, who can
experience breathing difficulties and infections (27). Ideally it is best to restrict such substances
during pregnancy and when breastfeeding. However if the mother does use heroin, it is not
advisable for her to stop using heroin suddenly. This will result in the mother and the infant
experiencing withdrawal. It is recommended that the mother goes on a methadone program
as this will help control the mother’s general health. Women who are on a methadone program
experience fewer complications during childbirth and pregnancy than those who use heroin.
Heroin and methadone cross through the breastmilk however the risk of complications for the
infant is reduced with methadone use (27). It is not recommended to breastfeed whilst using
heroin.
Cocaine
Cocaine is highly lipid soluble and readily crosses biological membranes and should not be
used during pregnancy or breastfeeding (28). Cocaine may cause premature labour and stillbirth,
reduce the blood supply to the infant during pregnancy and increase the heart rate of the mother
and infant (27). It is recommended that mothers stop using cocaine early in the pregnancy.
Cocaine increases irritability and can cause cocaine intoxication. It is therefore not recommended
while breastfeeding (27).
Amphetamines
Amphetamines are members of a class of drugs known as stimulants that includes caffeine,
cocaine, and nicotine. Stimulants have the common property of increasing activity in the central
nervous system (29).
Amphetamine accumulates in breastmilk, causing irritability and poor sleep patterns. Therefore,
amphetamine should not be used during pregnancy and lactation (29).
Parent handout found at
www.rwh.org.au/emplibrary/wads/PregAmphet.pdf
www.rwh.org.au/wads/health-info.cfm?doc_id=3844
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31
3.7 Breastfeeding in specific situations
Adapted from Dietary Guidelines for Children and Adolescents in Australia, 2003 (2)
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
At present, breastfeeding is contraindicated when a mother is known to be HIV positive (research into the possible benefits of antiretroviral drugs is continuing).
There are very few situations for which breastfeeding is contraindicated. Even mothers who have
serious conditions are able to breastfeed successfully; among these conditions are:
■■ type 1 diabetes
■■ type 2 diabetes
■■ gestational diabetes
■■ multiple sclerosis
■■ systemic lupus erythematosis
■■ hypothyroidism
■■ hypertension
■■ crohn’s disease and ulcerative colitis
■■ phenylketonuria
■■ cystic fibrosis
■■ fibrocystic disease.
Absolute contraindications for breastfeeding
Currently the NHMRC Dietary Guidelines for Children and Adolescents in Australia list the following
contraindications for breastfeeding (2).
■■ Active tuberculosis that has not yet been treated. Any contact with the infant, including
breastfeeding, is not permitted until the mother has finished two weeks of treatment. The
infant is usually prescribed prophylactic treatment. Lactation is initiated and maintained
by expressing breastmilk until contact is approved.
■■ Brucellosis (undulant fever) which, like tuberculosis, can pass from the mother’s blood to
the breastmilk.
■■ Recently acquired maternal syphilis with an unaffected infant. Mother– infant contact
and breastfeeding can begin after 24 hours of therapy, provided there are no lesions
around the breasts or nipples. If there are lesions around the breasts or nipples, feeding
may begin or resume once treatment is complete and the lesions are healed.
■■ Breast cancer detected during pregnancy.
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■■ HIV infection. In Australia, women who are HIV positive are advised not to breastfeed.
Transmission of the human immunodeficiency virus through breastfeeding is well
documented. The US Centers for Disease Control and Prevention advise women
with HIV infection not to breastfeed (2) The NHMRC and the American Academy of
Pediatrics have issued statements in support of this position. Other countries may have
different policies. For developing countries, the WHO and other UN agencies currently
recommend exclusive breastfeeding by HIV-positive mothers until 6 months of age
and then transfer to other methods of breastfeeding. Use of retroviral drugs assists
in reducing mother-to-infant transmission. It is estimated that the rate of mother-toinfant transmission during breastfeeding is 10–20%, but all the studies are fraught with
problems of definition of exclusive breastfeeding (2).
■■ Rare metabolic disorders of infants such as galactosaemia and maple syrup urine
disease, which severely limit or render impossible the infant’s use of certain milk
components. In cases of phenylketonuria, partial breastfeeding may be possible,
provided there is careful monitoring by a paediatrician and a dietitian with expertise in
metabolic disease.
■■ Hepatitis B infection, although breastfeeding may begin or resume once the infant has
been immunised.
Relative contraindications to breastfeeding
Currently the NHMRC Dietary Guidelines for Children and Adolescents in Australia list the following
conditions that may need to be considered on their merits before use of infant formula is advised.
■■ Maternal medications. Most drugs are excreted into the breastmilk but usually in
concentrations less than 1–2% of the maternal dose, which rarely poses a danger to the
infant. Some drugs may be contraindicated during breastfeeding, but this is a complex
subject and advice given may depend on factors such as the drug dose, the duration
of treatment, and the nature of the illness. The advice of the general practitioner who
prescribed the medication or the pharmacist at the nearest women’s or children’s
hospital should be sought if there is any doubt.
■■ Hepatitis C. There is as yet no evidence that hepatitis C is transmitted through
breastmilk.
■■ Specific illnesses in the infant. Breastfeeding can continue in almost all circumstances.
■■ Maternal illness and malignancy, depending on the mother’s health and the medications
used.
■■ Maternal psychiatric illness if there is definite danger to the infant. A psychiatrist’s advice
should be sought.
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33
3.8 Expressing and storing breastmilk
Parent handout at www.health.qld.gov.au/child&youth/factsheets/default.asp
Check
Storage tips (2,13)
Very little special handling of a mother’s milk is necessary. Since it is already sterile when it
comes from the breast, expressed breastmilk is safer to use than prepared infant formula.
It can be stored in glass or plastic containers, including sealable plastic bags. Freshly
expressed milk can be chilled in the refrigerator and added to frozen milk in the freezer.
The following is a simple guide for mothers storing expressed breastmilk at home.
■■ Wash hands thoroughly with soap and water.
■■ Refrigerate or freeze milk after expressing.
■■ Use fresh milk whenever possible.
■■ Freeze milk that will not be used within two days.
■■ Use the oldest milk first; date the container at the time of collection.
Refrigerator
Breastmilk is best used when fresh. A mother should try to provide fresh breastmilk daily
for her infant; if this is not possible, the milk can be stored in a refrigerator or freezer in clean
plastic containers.
Breastmilk refrigerated at 4°C for 48 hours suffers little loss of nutrients, or immunological
properties and the bacterial count is actually reduced. Breastmilk can be stored up to 5 days in the fridge.
Chill freshly expressed breastmilk before adding to cold or frozen milk.
Freezer
Never refreeze or reheat breastmilk.
Do not thaw or warm breastmilk in the microwave.
Thaw breastmilk by either placing it in cool or warm water (2).
When freezing breastmilk, leave some space at the top of container (it expands as it
freezes).
Freeze in small amounts to avoid unnecessary wastage, eg. 50ml.
Fat in breastmilk will separate and rise to the top – gently swirl to remix the separated fat.
Transport
Transport breastmilk in a cooler with an icebrick and place it in the refrigerator (or the
freezer if it is frozen) immediately when you arrive.
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Other hints to share with mums
✔✔ Label with date and time before freezing.
✔✔ When needed, use oldest milk first.
✔✔ Leftover expressed milk from feeding should be discarded.
✔✔ Encourage breastfeeding mums to tell their employer they are
breastfeeding.
✔✔ Encourage mums to take as long a break as possible from work and look
at flexible work options.
✔✔ Advise mums on expressing by hand or using pump (see parent handout).
✔✔ Provide mum with correct information on storage and transporting.
✔✔ Ensure expressing equipment such as bottles and pumps are adequately
cleaned.
Table 12
Storage of expressed breastmilk for infant use
Breastmilk status
Room temperature
Refrigerator
Freezer
Freshly expressed into
closed container
6-8 hours (26°C or
lower)
3-5 days (4°C or lower)
2 weeks in freezer
compartment inside a
refrigerator
If refrigeration is
available, store milk
there
Store in back of
refrigerator where it is
coldest
3 months in freezer
section of refrigerator
(with separate door)
6-12 months in deep
freeze (-18°C or lower)
Previously frozen –
thawed in refrigerator
but not warmed
4 hours or less (ie next
feed)
Store in refrigerator 24
hours
Do not refreeze
Thawed outside
refrigerator in warm
water
For completion of
feeding
Hold for 4 hours or until
next feeding
Do not refreeze
Infant has began feeding
Only for completion of
feeding, then discard
Discard
Discard
Adapted from the Dietary Guidelines for Children and Adolescents in Australia, 2003 (2)
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FEEDING FOR THE FIRST 6 MONTHS
35
3.9Points to consider when discussing
breastfeeding cessation
The most common reasons given by Queensland mothers for breastfeeding cessation
was ‘no milk or not enough milk’ (29.6%) (3)
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
Encourage, support and promote exclusive breastfeeding for the first
6 months of life.
Breastmilk gives the infant all the nutrients it needs for around the first 6 months of life. After this
time infants need solid food in addition to breastmilk. Queensland Health, the National Health and
Medical Research Council and the World Health Organization all recommend that breastfeeding
continues until the infant is 12 months old and for as long after as suits both mother and infant.
A mother’s decision to cease breastfeeding may be influenced by many factors including her
experience of breastfeeding. The most common reasons given by mothers for breastfeeding
cessation was ‘no milk or not enough milk’ (29.6%), followed by ‘child old enough to stop’ (16%)
and ‘child self weaned’ (16%) (3).
See ‘Is my infant getting enough milk?’ section
Parent handouts www.health.qld.gov.au/child&youth/factsheets
Support from family and friends is a really important part of establishing and continuing
breastfeeding (12)
As their infant gets older, mothers may experience some problems. They are not signs an infant is
ready to wean (12).
Low supply
Check breastfeeding mums are feeding on demand. Explain the concept supply = demand. Refer
to the section and parent handout ‘Is my infant getting enough milk’. If mother does have a low
supply provide her with information on how to increase her milk supply and refer to ABA Helpline
and/or lactation consultant.
Teeth
Teeth may initially make the feed feel different but should not cause any discomfort. Biting may
occur at this stage when the infant is getting used to and testing out her/his new teeth. When this
occurs, advise mums to temporarily remove their infant from the breast and return them when
they are ready to feed. The infant will soon learn not to bite at feeding time.
Distractions
As the infant gets older and more interested in and aware of the world around it, the infant may
frequently come off during a feed to have a look around. Advise mum to temporarily feed in a quiet
room with fewer distractions or turn off the TV during feeds. This stage too passes.
36
A HEALTHY START IN LIFE
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Breast refusal
Infants can sometimes refuse the breast – this can be one-off or repeated and is most often
temporary. Causes can be infant related (eg. a cold, distractions, teething) or mother related (eg.
hormonal changes, medications, change in perfume). Try to find and deal with the underlying
problem. If refusal continues, referral to an Australian Breastfeeding Association counsellor or
lactation consultant may be required.
Return of menstrual cycle
Due to the change in mum’s hormones, the infant may be a bit fussier with feeding, however this
will pass after the first few days of the cycle.
Breast care options during weaning (8)
There are several ways to manage breasts during sudden weaning. All options should be
discussed with the mother to allow her to make an informed decision regarding how she will care
for her breasts. The degree and duration of breast refilling depends on the amount of milk being
produced before weaning commences. The majority of breast discomfort should resolve within 72 hours.
Ideally all infants should be weaned slowly. That is, breastfeeds should gradually be replaced with
other milk feeds.
Some mothers have to wean suddenly eg, maternal illness, although this is seldom necessary, and
medications incompatible to breastfeeding. Proper care of the breasts is important to minimise
discomfort during this time.
Breast care options during sudden weaning
■■ Express for comfort only, until lactation diminishes.
■■ Express breasts fully twice a day and then once a day as lactation diminishes.
Express in between times for comfort only.
■■ Women with a large milk supply may find option two more comfortable.
■■ It is important to discuss contraception with mums during and after weaning as the
contraceptive effect of breastfeeding will cease once weaning begins.
A HEALTHY START IN LIFE
FEEDING FOR THE FIRST 6 MONTHS
37
Women and paid work (2)
Returning to paid work can have a significant impact on the experience of breastfeeding and
is commonly cited as a reason for ceasing to breastfeed. Among the factors that have limited
mothers’ ability to continue breastfeeding are:
■■ Lack of information that breastfeeding and working are compatible and practical ways
on how to do it.
■■ Lack of societal value in breastfeeding.
■■ The relative brevity of maternity leave, (returning to work commences before lactation is
fully established).
■■ Inflexible hours of work.
■■ Lack of paid breastfeeding (or pumping) breaks while at work.
Until recently, the rights of a woman in paid employment to breastfeed her infant have been
neglected; increasingly, though, the social environment in Australia is allowing mothers the
choice of working and breastfeeding and this is being recognised in employment contracts. The
booklet Balancing Breastfeeding and Work outlines the benefits of promoting breastfeeding—for
employers, mothers and infants.
Health workers need to be well informed and positive when advising parents about combining
breastfeeding and paid work. When it is not possible for the mother to go to her infant during
working hours, several options are available:
■■ replacing breastfeeds during work hours with expressed breastmilk fed from a cup or a
bottle
■■ for infants aged 6 months and over, replacing breastfeeds during work hours with food
from a spoon and water from a cup
■■ replacing breastfeeds during work hours with infant formula fed from a cup or a bottle.
Health workers need to be aware that breastfeeding and formula feeding can be combined: using
formula does not mean the mother has to cease breastfeeding. When formula is used during
working hours, breastfeeding can still continue before and after work and during weekends. A combination of both expressed breastmilk and formula can be given to an infant when there is
not enough expressed milk.
Check out the Queensland Health Work and Breastfeeding site
qheps.health.qld.gov.au/breastfeeding/home.htm
38
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3.10When an infant is not receiving breastmilk infant formula
Formula is widely used and introduced early. Twenty three percent (23%) of all children aged less
than 5 years, commenced formula before the age of 4 weeks (4).
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
■■ Parents should be informed of the benefits of breastfeeding and of the risks of not
breastfeeding when a change from breastfeeding is being considered.
■■ If complementary feeding is considered in hospital, the mother’s informed consent
should be obtained.
■■ If for any reason breastmilk is discontinued before 12 months of age, a commercial infant
formula should be used – instead of cow’s milk – as the main source of milk.
■■ Use soy-based or other special formulas only for infants who cannot take dairy-based
products or because of specific medical, cultural or religious reasons.
■■ Specialty formulas are indicated only for infants with detected or suspected pathology:
the advice of a health care professional should be sought.
■■ It is not appropriate to use nutritionally incomplete alternate milks as the sole source of
nutrition for infants.
Parent handout at
www.health.qld.gov.au/child&youth/factsheets/default.asp
If an infant is not breastfed or is partially breastfed, the commercial infant formulas are the most
acceptable alternative to breastmilk until 12 months of age (2).
If breastfeeding is not possible, the use of an infant formula with added vitamins, minerals, protein,
fat and carbohydrate is recommended. Cow’s milk based formula is suitable for most infants and
is recommended over formulas made from soy or goat’s milk. It is not recommended that infant
formula be changed regularly. There is little evidence that changing formula will help an unsettled
infant. Specialised formulas should only be used were there is a diagnosed indicated use and
should be done so in consultation with a dietitian or medical officer (8).
Regular unmodified cow’s or goat’s milk is not suitable for infants and should never be used in the
first 12 months (2).
Soy milk and goat’s milk formulas do not reduce allergies, and should not be used as an
alternative to cow’s milk formulas (2).
A HEALTHY START IN LIFE
FEEDING FOR THE FIRST 6 MONTHS
39
Dietary Guidelines for Children and Adolescents in Australia
recommendation:
If your infant is formula fed, please seek advice on formula from your doctor,
child health nurse or dietitian. It is recommended to keep your infant on
formula until 12 months of age.
When an infant formula is used, the instructions for preparation must be followed exactly.
Tips for families
Getting started
✔✔ Boil water for 5 minutes.
✔✔ Let it cool.
✔✔ Use the instructions on the can to make the formula just right for infant.
Too strong and it will hurt the kidneys; too weak and your infant won’t grow
well. Measure the formula carefully, using the scoop from the container.
Level with a knife. Take care not to mix up scoops from other containers.
✔✔ Refrigerate made-up milk if not using immediately.
✔✔ Only keep made-up formula in the fridge for 24 hours.
✔✔ Only put formula and water in the bottle. Do not add cereal, sugar, cordial
or anything else.
✔✔ Do not use a bottle to give soft drink, tea or cordial. These are not good
drinks for an infant and will greatly increase their chance of getting tooth
decay.
✔✔ Hold your infant close when feeding. Do not leave your infant alone to drink
the bottle.
✔✔ Do not put your infant to bed with a bottle containing anything other than
water.
Sterilising bottles
✔✔ Bottles can be sterilised using boiling, steaming or chemical methods.
✔✔ Use sterilising chemicals or commercial steamers according to the
manufacturers’ instructions.
Boiling method
✔✔ Wash hands.
✔✔ Wash teats and bottles in hot, soapy water using a bottle brush and rinse
well.
✔✔ Place equipment in a saucepan of cold water.
✔✔ Bring to the boil and boil for five minutes, turn off and allow to cool.
✔✔ Store sterilised equipment in a clean, covered container.
✔✔ Sterilised equipment can be stored in the refrigerator for up to 24 hours.
40
A HEALTHY START IN LIFE
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How much milk?
Bottle fed infants should be fed on demand. Each infant is different and needs vary from day to day.
As a guide:
5 days-3 months 150 ml/kg body weight/day
3-6 months
120 ml/kg bodyweight/day
6-12 months
100 ml/kg bodyweight/day
■■ It is important that infant formula is made up according to the directions and is not too
diluted or over concentrated.
■■ Avoid using the microwave for heating bottles. Microwaves do not heat liquids evenly.
Hot spots can form and burn the infant’s mouth.
■■ It may take a while to settle into a feeding routine that suits both caregivers and infants.
■■ The infant may want to be fed as often as every 3 hours during the day. An exact routine
does not need to be followed. When the infant sleeps through a night feed, it means
they no longer need it. Do not wake the infant to feed it. Feeding time may last 20 to 30 minutes.
How to feed
■■ Seat yourself comfortably and hold the infant in your arms while giving the bottle.
■■ Hold the bottle tilted, with the neck and teat filled with formula.
■■ If the infant does not firmly grip the teat, gently press under their chin with your thumb and
slightly withdraw the teat to encourage sucking.
■■ This method will help prevent the infant from swallowing air, which can cause wind pain.
■■ Check the bottle flow. When the bottle is upside down, the milk should drop at a steady
flow from the teat. Sometimes the teat gets clogged when a powdered formula is used.
Check teats often.
■■ Even when fed properly, an infant swallows some air. Burping them helps get rid of it. Hold
the infant upright over your shoulder or upright on your lap with your hand supporting
under the chin. Pat or rub the mid back gently until they burp. Do this halfway through the
feed and again at the end.
■■ Some infants need to be burped more often. However, if the infant is feeding happily, don’t
stop until they are ready!
■■ Watch for signs that your infant has had enough.
Remember
■■ If breastfeeding isn’t possible, feed your infant with infant formula.
■■ Talk to a doctor or child health nurse before you start bottle-feeding.
■■ Follow the instructions on the can to make the formula just right for your infant.
■■ Sterilise bottles by boiling, steaming or using special chemicals.
■■ Wash your hands before you prepare a bottle.
■■ Feed your infant on demand.
■■ Hold your infant while they’re drinking their bottle.
A HEALTHY START IN LIFE
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41
3.11Useful websites and resources
Baby friendly hospital initiative (BFHI)
Developed by WHO/UNICEF to encourage health care practices that support breastfeeding while
addressing those known to interfere with breastfeeding. The Ten Steps to Successful Breastfeeding,
which are outlined in the BFHI and which have been shown to positively influence breastfeeding
outcomes, are as follows.
1 Have a written breastfeeding policy that is routinely communicated to all health care staff.
2 Train all health care staff in skills necessary to implement this policy.
3 Inform all pregnant women about the advantages and management of breastfeeding.
4 Help mothers initiate breastfeeding within a half-hour of birth.
5 Show mothers how to breastfeed, and how to maintain lactation even if they should be
separated from their infants.
6 Give newborn infants no food or drink other than breastmilk, unless medically indicated.
7 Practice rooming-in - allow mothers and infants to remain together - 24 hours a day.
8 Encourage breastfeeding on demand.
9 Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding
infants.
10 Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from the hospital or clinic.
For more information: Tel. 1300 360 480 or
www.acmi.org.au or www.UNICEF.org
The WHO International Code of Marketing of Breast-milk Substitutes and the Marketing in Australia
of Infant Formulas: Manufacturers and Importers Agreement provide the basis for control of the
marketing of infant formula in Australia
The MAIF Agreement
The MAIF Agreement is the Marketing in Australia of Infant Formulas: Manufacturers and Importers
(MAIF) Agreement 1992 (30).
The MAIF agreement is Australia’s response to becoming a signatory to the World Health
Organisation’s International Code of Marketing of Breast-milk Substitutes (WHO code) (30).
Both the WHO Code and the MAIF Agreement are intended to protect infant health by protecting
and promoting breastfeeding, and ensuring the proper use of Infant formulas when they are
needed (31).
The MAIF agreement applies only to manufacturers and importers of infant formula and does not
include retailers or other milk products, foods, beverages or feeding bottles and teats.
42
A HEALTHY START IN LIFE
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Interpretation and implementation of the WHO Code in Australia (2)
The WHO Code has been implemented in Australia through the MAIF Agreement.
Following is a summary of the main points covered by these documents.
■■ The restrictions in the Code apply to infant formula and other products marketed or
represented as infant formulas and to feeding bottles and teats. Responsibilities are
outlined for companies that manufacture, market or distribute these products, as well as
for health workers and the health care system.
■■ Educational materials produced by companies for parents should be unbiased and
consistent; they should include all the facts, describe all the hazards, and avoid
reference to a specific product. Distribution of materials should be only through the
health care system, not through retail outlets.
■■ Companies are not permitted to promote their products to the general public, either
directly or through retail outlets. Companies may not give samples or gifts to parents.
Health workers may not give samples to parents.
■■ Health workers should consider the message about infant feeding that their actions and
their health care facility gives to mothers. There should be no display or distribution of
products or of company materials that refer to a product or encourage artificial feeding.
■■ Marketing personnel—even if they are health professionals—should have no contact
with parents and should not perform any educational or health care functions.
■■ Companies may provide scientific and factual information about their products directly to
health workers through meetings or materials.
■■ Companies may not offer, and health workers may not accept, gifts or other
inducements that might influence a health worker’s product recommendations
to parents or their health care facility. Study grants may be accepted in some
circumstances, but they must be disclosed.
■■ All products within the scope of the Code must conform to standards for quality,
composition and labelling.
■■ Independently of measures taken to implement the Code, companies and health
workers should take steps to conform to the principles and aim of the Code and to
monitor their own practices.
Modified from www.health.gov.au/pubhlth/strateg/brfeed/index.htm
The infant formula manufacturers have voluntarily signed onto the MAIF Agreement in the interest
of health and development of infants in Australia. Organisations involved in the MAIF Agreement
include:
■■ Heinz Watties Australasia
■■ Nestle Australia Limited
■■ Nutricia Australia Pty Ltd
■■ Wyeth Australia
■■ Abbott Australasia(10)
Despite this voluntary agreement, breaches to the agreement have and continue to occur.
A HEALTHY START IN LIFE
FEEDING FOR THE FIRST 6 MONTHS
43
Non-government organisations, individuals and professional groups have a responsibility to
monitor and report compliance or non-compliance with the Code (31).
For information on how to do this, contact
APMAIF Secretariat
Department of Health and Ageing
Mail Drop Point 15
GPO Box 9848 ACT 2601
Phone (02) 6289 5181
Website (health professionals):
www.health.gov.au/internet/wcms/publishing.nsf/content/health-pubhlth-strategfoodpolicy-apmaif.htm
Key state and national documents for health workers
National Health and Medical Research Council: Dietary Guidelines for Children and
Adolescents in Australia, incorporating the Infant Feeding Guidelines for Health Workers,
Canberra 2003.
Commonwealth Department of Health and Aged Care, National Breastfeeding Strategy
1996-2001, Canberra
Queensland Health: Optimal Infant Nutrition: Evidence Based Guidelines 2003-2008,
Brisbane
Queensland Health: Infant and Child Nutrition in Queensland 2003. Brisbane 2005
Queensland Health: The Health of Queenslander 2006, Report of the Chief Health Officer
Queensland, Brisbane
Queensland Health: Growing Strong: feeding you and your baby, Public Health Services,
Queensland Health 2003
Further professional development reading
Breastfeeding Management, 3rd edition. Wendy Brodribb. Ligare Pty, Ltd, Riverwood NSW
Ramsay D.T., Kent J.C., Hartman R.A., and Hartmann P.E. Anatomy of the lactating human
breast redefined with ultrasound imaging Journal Anatomy (2005) 206 pp 525World Health Organization: Breastfeeding and Maternal Medication, 2002
www.who.int/child-adolescent-health/publications/NUTRITION/BF_MM.htm
Thomas Hale: Medications and Mothers Milk 2006, 12th ed
Parent resources
Queensland Health: Child health information fact sheets www.health.qld.gov.au/child&youth/factsheets/
Queensland Health: Child Health Information: your guide to the first 12 months
Queensland Health: Growing Strong: feeding you and your infant, Public Health Services,
Queensland Health 2003
A range of parent resources are also available for purchase from the Australian
Breastfeeding Association
44
A HEALTHY START IN LIFE
FEEDING FOR THE FIRST 6 MONTHS
Booklets
Each booklet deals with specific topics related to breastfeeding. Drawing on current
medical and technical information and the vast counselling experience of the Australian
Breastfeeding Association counsellors, these easy to read booklets contain practical
suggestions and reflect Australian Breastfeeding Association policies on the management
of lactation. They vary in size, up to 36 pages. www.breastfeeding.asn.au
Posters
Books
Video and DVDs
Multilingual resources
Lactation aids
Lactation education aids
A note on Growing Strong: feeding you and your baby
The Growing Strong resources have been developed to help staff talk with Indigenous families
about nutrition for mothers, infants and young children. Information is presented in two forms: a
book using straightforward language and plenty of illustrations, and a manual with more detailed
background information. Growing Strong resources provide information about eating well during
pregnancy as well as offering suggestions for dealing with some common food and nutrition
related problems. Information is also provided about common breastfeeding issues including how
to know when a baby gets enough breastmilk and correct positioning and attachment.
For more information about Growing Strong contact:
Nutrition Promotion Officer (Indigenous Health)
Northern Area Health Service
Public Health Nutrition Team
PO Box 1103
Cairns QLD 4870
Ph 4050 3600
Fax 4050 3662
Nutrition Promotion Officer (Indigenous Health)
Central Area Health Service Public Health Nutrition Team
PO Box 946
Rockhampton QLD 4700
Ph 4920 7383
Fax 4920 6865
Indigenous Nutrition Promotion Officer
Brisbane Southside Population Health Unit
PO Box 333
Archerfield QLD 4108
Ph 3000 9148
Fax 3000 9121
A HEALTHY START IN LIFE
FEEDING FOR THE FIRST 6 MONTHS
45
A note on the Australian Breastfeeding Association:
The Australian Breastfeeding Association (ABA) is Australia’s leading source of breastfeeding
information and support to all sectors of the community. ABA is supported by health authorities
and specialists in infant and child health and nutrition. ABA operates a 7-day Breastfeeding
Helpline, where callers can contact volunteer breastfeeding counsellors to assist them with
breastfeeding issues. ABA provides an electric breast pump hire service as well as mother-tomother support through more than 75 Queensland groups. ABA’s Melbourne-based Lactation
Resource Centre specialises in providing comprehensive information and resources on all aspects
of human lactation. Study modules and the latest research articles on breastfeeding are available
for a fee.
For more information: ABA Queensland Branch Office (07) 3844 6488, 7-day Breastfeeding
Helpline Statewide contact numbers, (07) 3844 8166 or (07) 3844 8977 or www.breastfeeding.asn.au (21)
References
1. Global Strategy for Infant and Young Child Feeding, WHO 2003. [online]
2. National Health and Medical Research Council: Dietary Guidelines for Children and
Adolescents in Australia incorporating the Infant Feeding Guidelines for Health Workers,
Canberra 2003.
3. Queensland Health: Infant and Child Nutrition in Queensland 2003. Brisbane 2005
4. Queensland Health. The Health of Queenslanders 2006. Report of the Chief Health
Officer, Queensland, Queensland Health. Brisbane 2006.
5. Queensland Health: Optimal Infant Nutrition: Evidence Based Guidelines 2003-2008,
Brisbane.
6. Cox S. (2005) Breastfeeding with confidence.
7. Brodribb W. (2004) Breastfeeding Management. Third edition. Australian Breastfeeding
Association.
8. Queensland Health, Child Health Nurses Manual, draft Sept 2006
9. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. The Cochrane
database of systematic reviews. Updated Nov 2004
10. Australian Government Dept Health and Aging 2006 Healthy Eating at Various Lifestages:
Pregnant Women. [online] www.healthyactive.gov.au/internet/healthyactive/publishing.nsf/Content/pregnant-women.
March 2007.
11. Queensland Health, Child Health Record.
12. Child Health fact sheets [online March 2007] www.health.qld.gov.au/phs/documents/
cyhu/28101.pdf
13. Australian Breastfeeding Association, Breastfeeding confidence: ABA parent handout
46
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FEEDING FOR THE FIRST 6 MONTHS
14. Infant and young child feeding: standard recommendations for the European Union 2006
[online]
15. ilca.org/liasion/Infant-andYoungChildFeeding/EUPolicy06English.pdf
16. Dietary recommendations for Children and Adolescents: A Guide for Practitioners,
Paedatrics 2006:117;544-559
17. Callaghan A, Kendall G, Lock C, Mahony A, Payne J, Verrier L, Association between
pacifier use and breast-feeding, sudden infant death syndrome, infection and dental
malocclusion Int J Evid Based Healthc. 2005. 3: 147-167
18. Vallenas C, Savage F. Evidence for the ten steps to successful breastfeeding. Geneva:
World Health Organisation, 1998
19. Fleischer K., Cow’s milk in Complementary Feeding. Paeadtrics Vol 106, No 5,
Supplmenet Nov 2000 pp 1302-1303
20. The Use of Cow’s Milk in Infancy. Paedatircs Vol 89 No 6 June 1992pp 1105-1109
21. Tuckertalk: The Family Nutrition Education Manual. Department of Health and Community
Services, Tasmania. 2004
22. Prescott S.L., Tang M., (2004) The Australasian Society of Clinical Immunology and Allergy
position statement: Allergy prevention in children. [online] 10th April www.allergy.org.au/pospapers/Allergy_prevention.htm
23. www.aed.org/ToolsandPublications/upload/FAQMatNutEng.pdf [online] 27th April
24. Anderson J., Iodine Essence article Vol 43,No2 March 2007
25. Breastfeeding and the use of recreational drugs – alcohol, caffeine, nicotine and
marijuana, Breastfeeding Review 1998 6(2): 27-30
26. WHO Healthy eating during Pregnancy and Breastfeeding 2001
27. Hale T. (1998). Medications and Mother’s Milk. Pharmasoft Medical Publishing, Amarillo,
Texas.
28. Holmes, D. (1998). Alcohol, Other Drugs and Pregnancy. Department of Human
Services,Victoria.
29. Minchin, M.K. (1991) Smoking and Breastfeeding: An Overview. Journal of Human
Lactation, 7(4), 183-188.
30. corp.aadac.com/other_drugs/the_basics_about_other_drugs/amphetamines_beyond_
abcs.asp [online] 27th April
31. The MAIF agreement: what is it and what does it mean for you? [online]
32. www.health.gov.au/internet/wcms/Publishing.nfs/Content/health-pubhlth-strategfoodpolicy-apmaif.htm
33. Marketing Artificial Baby Milk in Australia: McGuire E., Hot Topic: Lactation Resource
Centre No 23, November 2006.
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47
4.0 Introduction to solids
The introduction of solids is an essential learning experience for both the infant and family. It is the
time when an infant’s eating and health habits begin to be established. The overall objective of
introducing solids is to gradually move an infant from breastmilk only at 6 months to eating a full
range of healthy family foods by 12 months.
First attempts at eating may be slow and awkward. All infants develop at different rates and so do
their feeding practices, appetite, etc. Caregivers should learn to respond to the infant’s cues with
patience so that feeding skills develop over a few months.
It is important to understand that the role of the caregiver is to choose the type of food, provide
and make the food, and it’s the infant’s role to decide if they want to eat and how much.
Introduction of solids helps with the beginnings of speech, teeth and jaw development.
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia (1)
The transition to solid foods
■■ Introduce solid food at around 6 months, to meet the infant’s increasing nutritional and
developmental needs.
■■ Start with low-allergenic foods such as single-grain baby cereals; follow this with
vegetables and fruits and then meats. Add only one food at a time and wait several days
before introducing a new food.
■■ To prevent iron deficiency, iron containing foods such as iron-fortified cereals are
recommended as the first foods, followed later by foods containing meats and other
iron-rich foods.
Alternate milk recommendations
■■ Use breastmilk or infant formula until the baby is 12 months.
■■ Pasteurised whole cow’s milk may be introduced to a child’s diet at around 12 months of
age and be continued throughout the second year of life – and, of course, beyond. It is
an excellent source of protein, calcium and other nutrients.
■■ Reduced fat milks (skim milk and milk with 1 or 2% fat) are not recommended in the first
2 years of life.
■■ Soy (except soy formula where specifically indicated), rice and other vegetarian
beverages—whether or not they are fortified—are inappropriate alternatives to
breastmilk, formula or pasteurised whole cow’s milk in the first 2 years of life.
Other fluids in infant feeding
■■ Boil water that is to be fed to the infant until 12 months.
■■ Limit the infant’s fruit juice intake, to avoid interfering with their intake of breastmilk or
infant formula.
■■ Do not use herbal teas, soft drinks or other beverages.
A HEALTHY START IN LIFE
INTRODUCTION TO SOLIDS
1
4.1 When should solids start?
Breastmilk or infant formula provide all the nutrients required by an infant for the first 6 months of
life and continue to be an important nutritional source until 12 months and beyond (1, 2, 3). At around 6 months the infant’s iron and zinc stores begin to fall and energy needs start to
increase. The infant should also be showing developmental signs consistent with a readiness to
eat.
An infant is ready to eat when: (4)
■■ The infant has good head control and can sit with support.
■■ The mouth opens easily as the spoon touches the lips or food approaches.
■■ Reduced tongue thrust reflex—the tongue does not protrude as strongly as food enters
the mouth.
■■ The infant can swallow instead of just being able to suck.
■■ Food stays in the mouth and is moved to the back of the mouth and swallowed.
■■ The infant is interested in the world around them, especially the caregivers eating.
It is important to note however that either early (before 6 months) or delayed introduction (after 6 months) of solids can be disadvantageous for the infant for the following reasons.
Early introduction of solids (1, 5, 6)
Early introduction of solids can displace nutrient-dense breastmilk or formula. This can result
in inadequate nutrients and energy for growth. In some infants, early introduction of solids may
encourage overfeeding and obesity if large amounts of solids are eaten in addition to usual
amounts of breastmilk or formula. Giving other foods and fluids can lead to a reduction in the
mother’s breastmilk supply.
Since a young infant’s digestive and immune system is not fully developed, the infant is placed at a
higher risk of allergy and intolerance. Breastmilk helps protect against allergy and is recommended
as the sole source of nutrition for the first 6 months.
Salivary amylases are present at 4 months, but pancreatic amylases which are responsible for
digestion of carbohydrates are absent until 3 months, and remain inadequate until 6 months, thus
affecting digestion.
The early exposure of infants to microbial pathogens potentially contaminating complementary
foods and fluids puts them at increased risk of diarrhoeal diseases.
Before 6 months of age, the kidney is not able to cope with the increased solute load caused by
solid foods and may result in overload and an excess of sodium in the blood.
There is an earlier return to fertility for mothers, because decreased suckling reduces the period
during which ovulation is suppressed.
The common reasons given by mothers for starting solids early include: it will help the baby gain
weight, it will help them sleep through, and they seemed ready for solids.
No benefits have been identified from introducing solid foods before the age of 6 months.
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Delayed introduction of solids (1, 5, 6, 7)
Breastmilk or formula alone may not provide enough energy and nutrients and may lead to growth
faltering and malnutrition.
Nutrient requirements change from 6 months. The iron and zinc stores present at birth have
begun to decrease and need to be met by consuming a variety of foods.
Delayed introduction of solids can slow down developmental progress. The introduction of solids
is important for jaw and muscle development and also for intellectual stimulation.
Growth can be affected if the amount of breastmilk or formula provided decreases and there is no
resulting increase in food provided.
Texture transition guide
It is important that infants get the right sort of food textures at the appropriate times so that their
oral muscles are exercised appropriately, and that they get plenty of practice so that they can
move on to the next type of texture.
Children who have difficulty in progressing often stay either on a pureed or soft diet or skip some
of the transitions. There are a number of possible causes for children not progressing with their
transition of solids. These include:
■■ children who have had previous difficulty with lumpy or chewy foods and may be
reluctant to try again
■■ children who have difficulty breaking down the lumpy or chewy food
■■ children who have difficulty using their tongue to move the lumps in their mouth
Children who are unable to progress through the textures will probably experience limited food
choices and, therefore, may limit their consumption of essential nutrients. For some children there
may also be a link between difficulty in progressing through food textures, and delays in their
speech and language development.
Developmental stages
Birth
■■ At this stage the tongue takes up most of the space in the mouth. This allows sufficient
sucking to occur with simple forward backward movements of the tongue.
4 – 7 months
■■ Improved motor function, eg head and neck control, hand movements.
■■ There is growth of the mouth giving the tongue more room to move and assist the baby
to gain control.
■■ ‘In and out’ movements characteristic of the first few months are gradually replaced by
‘up and down’ movements of the tongue.
■■ Feeding becomes voluntary with the tongue moving ‘up and down’ in the mouth.
■■ Early munching pattern of the jaw can be seen when fed pureed solids.
■■ Increased strength of suck.
■■ Movement of gag reflex from mid to posterior third of tongue.
■■ Early cup drinking can be introduced at this stage.
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3
7 – 12 months
■■ Hand to mouth coordination improves to facilitate self feeding.
■■ Baby starts to clear spoon with lips.
■■ Experimentation with sounds when hands, fingers or other objects are in their mouths.
■■ Development of ‘up and down’ and lateral tongue movements in preparation for
chewing.
■■ Lip control improves while chewing to prevent spillage of food.
■■ Jaw movements are characterised by ‘up and down’ movements, which is called the
munching pattern.
12 – 24 months
■■ Begin to self feed which is very important for tactile and motor development.
■■ At this stage the child is eating with the family and the main form of drinking is from the cup.
■■ Rotary chewing movement and improved jaw stability.
■■ Foods are moved efficiently around the mouth, spillage is uncommon.
■■ Chewing and the lip seal are well developed so that food and liquid are not lost from the mouth.
Please refer to parent handout
Fun not Fuss with Food Fact sheet 1 Importance of Nutrition
Growing Strong Starting Solids brochure
4.2 How should solids be started?
Initially, the introduction of solids may be slow and uncoordinated, but with patience, persistence
and time, the infant will develop skills. Breastmilk or infant formula should continue to be the
primary milk source for the first 12 months of life. The quantity of breastmilk or infant formula
consumed will decrease as the variety and quantity of other foods increases.
■■ Choose a time when the infant is happy and the caregiver is calm.
■■ Provide a secured sitting or slightly reclined position, eg on the lap.
■■ Offer about half a teaspoon, with smooth edges, of solids AFTER a breast or formula
feed.
■■ Start with offering solids once a day and gradually build up to 3 times a day over 2 months.
■■ 2 − 3 meals per day for infants aged 6 −8 months (8).
■■ 3 − 4 meals per day for infants aged 9 – 11 months and children 12−24 months.
■■ Introduce one single food at a time, one new food every 3 - 4 days.
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■■ Typically 8– 10 exposures are needed, with clear increases in food acceptance
appearing after 12 – 15 exposures (5)
■■ Once single foods have been introduced successfully, start to offer mixed meals, eg rice cereal, minced meat and vegetables.
■■ Do not add sugar, honey or salt to foods.
■■ Do not put the spoon or food in adult’s mouth before it’s given to the infant – this passes
in bacteria that can cause tooth decay.
■■ If any of the infant’s relatives are allergic to a food, wait until 12 months to introduce it
and wait 5 – 6 days before introducing the next food.
■■ The use of commercial foods may delay the infant’s acceptance of the family’s normal
diet and represents an unnecessary financial burden.
4.3 What solids should be started and when?
From 6 months
When starting solid food it needs to be warm, sloppy, smooth in texture and mild in taste. It is
important for the infant to learn the difference between liquid and solid foods, therefore solids
should not be provided in a bottle.
What
■■ Continue to breast feed on demand or formula feed (about 5 – 6 bottles of 200 ml each).
■■ Give solids after breastmilk or formula feeds.
■■ Single grain iron enriched baby cereal, eg iron fortified rice cereal. Mix with breastmilk or
formula to a smooth paste. Cereals with wheat are not suitable at this stage.
■■ Vegetables that can be cooked and finely mashed/sieved, skins removed. For example potato, sweet potato, pumpkin, carrot, zucchini, peas, and legumes.
■■ Fruit that has been pureed and sieved, skins and seeds removed. For example, soft cooked apple, pear, peach, apricot, banana, avocado, paw paw.
■■ Meats that have been cooked, pureed and sieved. For example, beef, lamb, pork, chicken, legumes.
■■ Cooled boiled water can be offered from a cup with a spout.
Texture
Smooth, pureed (use a blender, food processor or sieve). Semi liquid at first, then more paste like.
How much
Start with ½ teaspoon and build up to 2 – 4 tablespoons.
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5
Tips
■■ By starting vegetables first infants are more likely to enjoy the taste now and later in life.
Follow with fruit, and once the infant is eating a variety of vegetables and fruit start to
introduce meats.
■■ Foods prepared in the home with fresh ingredients are desirable because fresh foods:
■■
allow the infant to be introduced to a single food taste at a time,
■■
increase the variety of foods that can be offered,
■■
can be more economical and
■■
assist the infant in becoming familiar with normal family foods.
■■ Commercially prepared baby foods are a nutritious alternative. If relied on totally, they
restrict an infant from experiencing other food tastes, as they often contain foods in a
mixed form which are similar in taste and texture.
■■ It is often useful to prepare batches of food which can be frozen as ice cubes for later
use and sealed inside labelled plastic bags. They defrost quickly over hot water. The
food should be stirred well to even out the temperature and tested before giving to the
baby. Discard any food left over from a meal. It is best to discard prepared frozen foods
after 3 – 4 months. If the foods are stored in the refrigerator, they should be discarded
after 1 day.
■■ Prepare food without adding salt. It is best to allow an infant to develop tastes with
unseasoned foods.
■■ Once the infant has teeth, brush teeth twice a day using a clean soft cloth or small soft
toothbrush and a thin smear of low dose fluoride toothpaste.
■■ Continue to check growth regularly. Refer to growth chart section.
Please refer to parent handout
Child and Youth Health Fact Sheet Feeding from 6 months.
From 8 months
The infant should be eating pureed meats, baby rice cereal, pureed fruit and vegetables with
continued breastmilk or formula.
What
■■ Continue breastfeeding on demand or formula feeding (90-100 ml/kg body weight/day).
Give solids before breastmilk or formula feeds.
■■ Add mixed infant cereals, oats, barley, rye, semolina, rice pasta, wheat flaked biscuits
and rusks.
■■ Vegetables – all sorts cooked and mashed with soft lumps.
■■ Fruit – all kinds with skin and seeds removed.
■■ Meat – continue as at 6 months but add in fish (fresh or tinned unsalted water packed)
and egg yolks.
■■ Cooled boiled water from a cup with a spout.
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Texture
Mashed, some lumps can be tolerated. Stop pureeing. Important to encourage texture transition –
if this is delayed it can lead to fussy eating as the infant gets older.
How much
2 tablespoons to ½ cup
Build up to 3 times a day
Sample menu
Breakfast
Baby cereal (3-4 tablespoons) mixed with breastmilk, formula or water
Mashed fruit 2 tablespoons)
Breastmilk or infant formula
Mid morning
Breastmilk or infant formula
Lunch
Strained (blended) meat (2 tablespoons)
Strained (blended) vegetables (2 tablespoons)
Breastmilk or infant formula
Mid afternoon
Breastmilk or infant formula
Dinner
Strained (blended) meat or fish (2 tablespoons)
Mashed vegetables (2 tablespoons)
Strained (blended) fruit (2 tablespoons)
Breastmilk or infant formula
Check
✔✔ gradually change the texture from smooth puree, to mashed with a fork,
to mashed with lumps
✔✔ the infant is the only one who knows when they have had enough
✔✔ this period can be quit messy, but this is normal
✔✔ sugar and salt should not be added to solids
✔✔ check the infant’s growth regularly
Refer to growth chart section
Please refer to parent handout
Child and Youth Health Fact Sheet Feeding from 8 months.
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7
From 9 months
The infant should be eating meat and fish, cereals, fruit and vegetables as well as breastmilk
or infant formula. By 9 – 12 months, fine motor control and pincer grip should have developed.
An infant should be eating the same foods as the rest of the family and being encouraged to
experiment with finger foods and self feeding.
What
■■ Continue breastfeeding on demand, if formula fed (90 – 100 ml/kg body weight/ day) ie around 600 – 800 ml/day.
■■ Cereals – continue with infant cereal for iron, white or wholemeal bread and toast.
■■ Vegetables – include all vegetables, including some raw.
■■ Fruit – include all, remove tough skins and large seeds, soft fruits given in pieces.
■■ Meat – remove all skin, gristle and bones from meat.
■■ Dairy – full fat dairy products, eg yoghurt, custard, grated cheese and cottage cheese.
Pasteurised cow’s milk in the preparation of main meals and desserts. Milk should not be provided as a drink until 12 months.
■■ Cooled boiled water from a cup with a spout.
Texture
Pieces or chopped – finger food.
How much
3 meals a day with some snacks, about 1½ cups at each meal.
Tips
✔✔ The change in texture is very important for jaw and speech development.
✔✔ Finger foods are popular and the infant should start to self feed.
✔✔ Lollies, soft drinks, cordials or other sweetened foods are not
recommended. They can displace other important nutrients, interfere with
appetite, cause diarrhoea and lead to tooth decay.
✔✔ It is best to leave hard foods such as popcorn, corn chips, hard lollies
and some hard raw fruit and vegetables until four years of age to avoid
choking.
Please refer to parent handout
Child and Youth Health Fact Sheet Feeding from 9 months.
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From 12 months
The child should be eating a wide variety of family foods. Sweet, salty, processed or fatty foods
should be avoided.
What
Foods to include
■■ Full cream cow’s milk
■■ Whole egg
■■ Peanut butter
■■ Unboiled water
Texture
Family foods – some foods will need to be cut into small pieces.
How much
■■ Continued breastfeeding is recommended. Breastmilk still provides important nutrients
into the child’s second year of life.
■■ After 12 months infant formula can be replaced with cow’s milk. No need for infant follow -on formula.
■■ Give solids before fluids.
■■ 3 meals a day and snacks. This is dependant on age, growth and activity levels.
The National Health and Medical Research Council have not developed nationally endorsed food
group servings for 1-3 year olds as it has for children four years and older. At this age there is
marked variability in how much individual children eat. How much food is eaten varies from child to
child and from day to day and is influenced by growth and activity levels.
Ensure that the child has foods from all five core food groups and has a variety of foods from
within each food group. The emphasis is on healthy family foods and having an environment
around eating that encourages healthy food behaviours. Intake can be monitored by assessing the
child’s growth and development.
The following sample menu is a guide only.
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INTRODUCTION TO SOLIDS
9
Sample menu
Breakfast
Cereal made with milk
Toast with spread
Fruit
Breastfeed/milk drink
Morning tea
Toast or crackers with spread
Drink of milk
Fruit
Lunch
Meat/chicken/fish/egg/legumes
Vegetables (raw or cooked)
Bread
Afternoon tea
Yoghurt
Pikelet or fruit bread
Fruit
Dinner
Meat/chicken/fish/egg/legumes
Vegetables (raw or cooked)
Rice/pasta/noodles
Avoid honey for infants less then one year of age. The organism that causes infant botulism
has been found in some honeys in Australia. The infant’s gut at this age does not have enough
resistance to provide adequate protection from these bacteria which produces a lethal toxin. It should, therefore, be excluded from the diet until after 1 year of age (5).
Please refer to parent handout
Child and Youth Health Fact Sheet Feeding from 12 months.
Child and Youth Health Fact Sheet Solids Table.
Child and Youth Health Fact Sheet Recipes for Babies.
Fun not Fuss with Food Fact Sheet 2 Is this Normal?
Allergies
If there is a family history of allergy try to delay the commonly allergenic foods until 12 months
especially where there is a strong family history of previous reactions in caregivers or siblings.
Foods should never be restricted in children unnecessarily as growth and health may be affected.
If in any doubt the general practitioner should be consulted. A referral to a paediatrician and
dietitian can then be arranged.
Refer to section on allergies.
Please refer to parent handout
Child and Youth Health Fact Sheet Food Allergies.
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4.4 Drinks
Water is the fluid of choice. It needs to be clean and boiled for infants less than 12 months
of age. It is good to encourage children to accept the taste of water from an early age and to
consume appropriate amounts. Water is essential, not only to ensure the infant/child remains
well hydrated, but also to assist in maintaining regular bowel activity. Breastmilk is 87% water,
so exclusively breastfeed infants who are breastfed on demand will generally receive adequate
fluid. Non breastfed infants need at least 400 – 500 ml/day extra fluid from other sources when
complementary foods are given, as well as infant formula, and up to 1200 ml/day in a hot climate.
Fruit juices, soft drinks and cordials should be avoided. They contain sugars which, because
of their acidity can cause dental caries and erosion of the teeth and may replace the amount
of breastmilk or formula consumed and may also initiate a preference for sweet tastes. These
drinks are also very high in energy; while providing limited satiety they contribute a significant
amount of energy to the diet. These should never be given in a bottle. In 2003, 15% of children in
Queensland, less than 1 year of age, had been given sweet drinks regularly (9).
Tea is not suitable for infants and young children. Tea contains tannins and other compounds that
bind iron and reduce its bioavailability. Herbal drinks/preparations are not suitable for infants and
young children. Infants are potentially more vulnerable than adults to the pharmacological effects
of the chemical substances in herbal drinks. There is a lack of data on the safety of herbal teas for
infants.
Milk remains an important drink throughout childhood and as such, consumption of adequate
amounts should be encouraged. Include up to 500 ml/day only.
An infant or child should be encouraged to drink from a cup by about 6 months.
Parent handout
Growing Strong Healthy Drinks for Babies
NSW Health Teach your baby to drink from a cup.
Check
✔✔ Try not to expect too much. Infants and children have small appetites and
stomach capacities.
✔✔ Allow an infant to exert some independence. Do not force an infant or child
to finish everything on the plate.
✔✔ Turn a blind eye to the mess produced as a result of the feeding attempts.
✔✔ A relaxed and comfortable atmosphere during meals will facilitate good
eating practices, as well as providing an opportunity for social interaction
and cognitive development.
✔✔ It is normal for an infant’s stools to change in colour and consistency as
solids are introduced. Refer to constipation section for more information.
✔✔ Vegetarian diets in infants can be concerning due to the high risk of
nutritional deficiencies, malnutrition, growth retardation and delayed
psychomotor development. Infants should be referred to a paediatric
dietitian or paediatrician to assess the adequacy of the diet and
appropriate growth.
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11
4.5 Salt in food
Dietary salt is an inorganic compound consisting of sodium and chloride ions. It is found naturally
in many foods, but it is also added to many foods because of its preservative and flavouring
characteristics.
Recommended intake for sodium (1)
0 – 6 months
140 – 280 mg per day
7 – 12 months
320 – 580 mg per day
1 – 3 year olds
460 – 1730 mg per day
1000 mg sodium is contained in about 3 g of common salt, or just over half a teaspoon.
To achieve this intake, infants and children should consume fresh food, foods normally processed
without salt, and low salt or no added salt, and avoid adding salt to food (10).
For infants, ingestion of foods high in sodium can lead to death because the kidneys are not
fully developed until many months after birth. This is another reason why solids should not be
introduced until 6 months of age. The new food standards code for Australia and New Zealand
stipulates the total amount of sodium allowed in foods for infants is a maximum of 100 mg/100g in
flours, pasta and ready to eat foods. However, in biscuits it is 300 mg/100 g and 350 mg/100 g to
teething rusks. In comparison, the sodium content of breastmilk is 18 mg/100 g.
Food Standards Australia New Zealand defines a low salt food as a food with a sodium
concentration of up to 12 mg/100 g.
4.6 Sugar in food
Many foods in the Australian diet contain naturally occurring sugars. In other foods, sugars may
be added during processing to increase the food’s palatability and acceptability and sometimes
to add bulk. Sugars provide a readily absorbed source of energy and have an important role as
sweeteners and flavour enhancers.
The presence of high amount of sugars can dilute the nutrient density of the diet, and diets high in
added sugar have been associated with development of obesity and dental caries.
Taste buds detect four primary taste qualities: sweet, bitter, salt and sour. Children’s preference for
a majority of foods are influenced by learning and experience, they develop a preference in relation
to the frequency and exposure to particular tastes. The only innate preference is for sweet, and
even newborn infants will avidly consume sweet substances if given them. It is therefore important
not to introduce sugar in any concentrated form until the infant has a chance to experience and
develop a taste for other flavours, especially fruits and vegetables (5).
Parent handout
Food label poster
http://www.foodstandards.gov.au/_srcfiles/final%20FSANZPosterV2.pdf
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4.7 Useful websites and resources
Queensland
Child Health Fact Sheets www.health.qld.gov.au/child&youth/factsheets/
Community Child Health
www.health.qld.gov.au/cchs/nutrition.asp
Growing Strong: feeding you and your baby manual
www.health.qld.gov.au
Fun not Fuss with Food
■■
Order form for non QH staff
www.health.qld.gov.au/phs/Documents/sphun/27967.pdf
■■
Order form for QH staff
qheps.health.qld.gov.au/PHS/Documents/sphun/27966.pdf
Fact Sheets
qheps.health.qld.gov.au/PHS/Documents/sphun/27484.pdf
Royal Children’s Hospital Health Service District Department of Nutrition and Dietetics –
Infant and toddler feeding guide - Parent Information (2004). Hard copies available from
Nutrition and Dietetic Department ph 07 3636 8571.
Royal Children’s Hospital Health Service District – Community Child Health Service: Time
to Eat – baby’s first foods (2004). Heath promotion and prevention issues, education
document services cchs106, second edition. Ph 07 3250 8530 officer manager primary
care program cost $104.60 including GST plus postage.
Royal Children’s Hospital Health Service District – Community Child Health Service: First Steps
qheps.health.qld.gov.au/rch/cchs/Resources/first_steps.pdf
New South Wales
Teach your baby to drink from a cup.
www.mhcs.health.nsw.gov.au
South Australia
Foods for babies (solids)
www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=302&id=1487
Foods for babies (solids) questions and answers
www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=302&id=1927
Nutrition topics
www.cyh.com/HealthTopics/HealthTopicCategories.aspx?p=302
Tasmania
TuckerTalk Manual (2003). Department of Health and Human Services Tasmania. Ph 03 6222 7222
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13
National
Raising Children Network
www.raisingchildren.net.au/nutrition/babies_nutrition.html
NHMRC
www.health.gov.au/nhmrc/publications
Hillis, A and Stone, P (2003). Breast Bottle Bowl. HarperCollinsPublishers
International
WHO
http://www.who.int/child-adolescent-health/NUTRITION/infant.htm
International Association of Infant Food Manufactures
www.ifm.net/sitemap.htm
Ellyn Satter
http://www.ellynsatter.com/index.htm
References
1. National Health and Medical Research Council. Dietary Guidelines for Children and
Adolescents in Australia: Infant Feeding Guidelines for Health Workers, Canberra 2003
2. Queensland Health (2003). Optimal Infant Nutrition: Evidence Based Guidelines 2003-2008,
3. WHO (2002). Global Strategy for Infant and Young Child Feeding. Geneva: World Health
Organization.
4. Queensland Health (2005). Child and Youth Health Fact sheets [online] www.health.qld.gov.au/child&youth/factsheets
5. Infant and young child feeding: standard recommendations for the European Union 2006
[online] http://ilca.org/liasion/Infant-and-YoungChildFeeding/EUPolicy06English.pdf
6. Children, women’s and youth health service, SA government. Foods for babies – how and
when to start [online] www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=302&id=1487
7. Brown KH. (2000). WHO/UNICEF Review on complementary feeding and suggestions
for future research: WHO/UNICEF guidelines on complementary feeding. Pediatrics
106(5):1290
8. WHO (2001). Complementary Feeding Summary of guiding principals. Geneva
[online]http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/
Complementary_Feeding.pdf
9. Queensland Health. Infant and Child Nutrition in Queensland 2003. [online] http://www.health.qld.gov.au/hic/epidemiology/nutrition_report2005.pdf
10. McCarron DA. (2000) The dietary guideline for sodium: should we shake it up? Yes! Am J Clin Nutr 71: 1013-19
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5.0 Toddler nutrition
5.1Why is nutrition important in toddlers?
The toddler years of a child’s life, that is the ages between 1 and 3, present an exciting and busy
time for children as they begin to explore life independently. It is a time when children are learning
eating behaviours, skills, knowledge and attitude relating to food (1); a unique period, which instils
attitudes and practices that can form the basis for lifelong health-promoting eating patterns (1, 2, 3).
These years for caregivers can be quite daunting. Toddlers are exploring their independence,
whilst “for caregivers it is the time to teach their child to eat with the family and try a wide variety
of foods and tastes” (3). “The time between 18 months and 3 years can be difficult for both adults
and children alike. This is the period when infants begin to recognise themselves as separate from
the adults in their life... They enter into power struggles with their adult caregiver; at the same time,
they are fearful of new experiences. These behaviours are particularly evident in feeding situations”
(4).
An enormous shift occurs in the variety of an infant’s diet from the period of 6 to 12 months. By
the time a child is 12 months old, the reliance on the breast or formula as the sole food source
has decreased, and the toddler should be eating a variety of family foods, as well self feeding and
learning to drink from a cup. Healthy eating is important - it “provides the energy and nutrients
needed for growth and development; it develops a sense of taste and an acceptance and
enjoyment of different foods” (5).
Poor nutrition in children can lead to common childhood nutrition problems such as constipation
and iron deficiency anaemia (see respective sections). Also, if inadequate food is consumed,
children do not have enough energy to explore, discover and learn as they should. In addition they
may not progress optimally in the long term, in areas such as motor development (movement,
motor skills), physical development (height and muscle development) and cognitive development
(5). Developing healthy eating habits in childhood can reduce the risk of nutrition related chronic
disease in later life (8).
So, let’s take it back to basics. This chapter explores the ‘parent-child feeding relationship,’ (3, 4, 5, 7, 8) recognising the importance of both the parent and child in the complex process of
eating and mealtimes, particularly in the context of fussy eating.
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1
Understanding how children approach eating (5)
Developmental characteristics of toddlers
The toddler years bring:
■■ A time of exploration. Toddlers explore their surroundings by touching, seeing, listening,
smelling and tasting. Food is of immense interest to most of them—but not always to eat
■■ Greater autonomy but at the same time a fear of new experiences. Between 18 and 24
months most toddlers can handle a spoon and cup for feeding themselves, although spills
often occur. ‘No’ becomes a favourite word. Inconsistency is also a common feature: one
day they insist on feeding themselves and the next day they insist on being fed
■■ A need for a sense of security. The need for ritual and a sense of security is very strong in
toddlers. A desire for the familiar—a special toy or food—often dictates their daily routine.
This is an integral part of the normal transition from infancy to childhood
■■ A limited attention span. Easily distracted, toddlers may be unable to sit at the family table
for the normal duration of a meal
■■ An awareness of others. Although not skilled in cooperative play, 2- and 3-year-olds are
gradually developing social skills. They often imitate people close to them. Watching
other people who enjoy food is a powerful influence on the toddler’s acceptance of foods,
watching other children is especially powerful
Adapted from NHMRC: Dietary Guidelines for Children and Adolescents in Australia, 2003 (2)
Refer to child developmental milestones parent handout at www.health.qld.gov.au/child&youth/factsheets/default.asp
Toddlers and preschoolers are less accepting of new foods when they are rewarded or otherwise
pressured to eat them, but more accepting when they get social support at eating time
(as cited in 11)
Caregivers have an important role in fostering children’s preferences for healthy foods and promoting
acceptance for new foods’ (as cited in 12).
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TODDLER NUTRITION
Table 13
Typical physical and social/ personal characteristics related to eating
during the preschool years (5)
Age
Physical characteristics
Social/ personal
characteristics
12-18 months
Grasps and releases foods with fingers
Wants food that others are eating
Holds spoon but use poor
Loves performing
Turns spoon in mouth
Uses a cup but release poor
18 months – 2 years
Appetite decreases
Ritual becomes important
Likes eating with hands
Displays food preferences
Likes experimenting with textures
Distracts easily
Develops negative behaviour
2-3 years
Holds glass in hand
Definite likes and dislikes
Places spoon straight in mouth
Insists on ‘doing it myself’
Spills a lot
Ritualistic
Chews more foods, but choking still a
hazard
Dawdles
Food fads
Demands food in certain shapes and
whole foods
Likes to help in the kitchen
Adapted from NHMRC: Dietary Guidelines for Children and Adolescents in Australia, 2003 (2)
5.2 What should toddlers eat?
After 12 months of age, there are few foods a child cannot have. Children should be offered a
variety of different foods, flavours and textures for balanced nutrition and to help feel comfortable
with new tastes. Children will learn to eat what the family eats if they are given the same food and
encouraged to try it.
Exposure to new foods encourages adventurous eating habits and the child will be more confident
making food choices (5).
After 12 months of age, there are a few foods a child cannot have:
■■ Reduced fat milk – in Australia reduced fat milks are recommended for older children
and for all adults as part of a healthy diet. By the time children reach 2 years of age they can share in reduced fat dairy consumed by the rest of the family
■■ If there is a strong history of peanut allergy, peanut products (including peanut butter)
should be avoided until 3 years of age.
Low fat or restricted diets are not recommended for toddlers as they may result in
poor growth (7).
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What affects toddler’s daily intakes?
Children have an in-built hunger alert and satiety mechanism, so they know when they are hungry
and when they are full, and they eat accordingly. A healthy child will never starve itself, so encourage
caregivers to trust their child to eat enough.
The period between a child’s first and fifth birthdays is a time of rapid social, intellectual and
emotional growth. It is also characterised by a slowdown in the child’s growth rate, which may
be reflected in a less reliable appetite. In addition, at this age children are discovering their
independence and testing their choice in food selection, and this can lead in reduced interest
in eating when the rest of the family eats (5). Furthermore, children have small stomachs, so it is
difficult for them to achieve their daily nutritional requirements with only 3 meals per day. Grazing
and snacks are necessary (5).
•
Slower growth - From birth to 12 months a child’s weight triples, yet from 1 – 5 years the
weight gain on average is only 2 - 3 kg each year. As toddlers growth slows down, their
appetite decreases too. This means toddlers need less food. This change is normal and
doesn’t mean the child is being difficult or is unwell.
•
Grazing and snacking - toddlers rarely follow a traditional meal pattern. They tend to
need small and regular snacks. This suits small tummy sizes and provides the energy to
keep moving all day. The amount eaten at mealtimes, in particular the evening meal may be
smaller than caregivers would like. However, children can balance the amount of food eaten
with exactly how much they need if they are not forced to overeat or finish all the food on the
plate. This means that healthy snacks are important to help provide the energy and nutrition
your child needs during the day (3).
•
Independence – Showing independence is part of normal toddler development and this
often includes refusing to eat foods to see what will happen. Rejecting a food does not
always mean the child does not like it (3).
Clues for fullness cues
Children may clamp their mouth shut or turn their head away when offered food. They may also push
the bowl or food away from the table or highchair. Discuss these cues with families and encourage
them to recognise them in their child’s behaviour.
Encourage caregivers to recognise when their child is full
The Dietary Guidelines for Children and Adolescents in Australia
recommendation
Small, frequent, nutritious and energy dense feedings of a variety of foods from the
different food groups are important to meet nutrient and energy needs during the second
year of life. The regular family diet (see the Australian Guide to Healthy Eating) should be
the basis of the child’s meals.
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The National Health and Medical Research Council have not developed nationally endorsed food
group servings for 1‑3 year olds as it has for children 4 years and older. At this age there is marked
variability in how much individual children eat. How much food is eaten varies from child to child and
from day to day and is influenced by growth and activity levels.
Ensure the child has foods from all five core food groups and has a variety of foods from within each
food group. The emphasis is on healthy family foods and having an environment around eating that
encourages healthy food behaviours. Intake can be monitored by assessing the child’s growth and
development.
It is imperative that caregivers are made aware these suggestions are a guide only. The main
focus should be on the introduction of a healthy eating pattern and family meal acceptance
rather than on serves. A child’s intake should be determined by their appetite, which may
vary from day to day depending on their activity, age and growth.
Suggested meal plan for a toddler
Breakfast
Bowl of cereal with ½ cup milk
1 slice toast with polyunsaturated margarine with spread eg. Vegemite, jam, peanut butter, cheese, egg
Snack
Water
Fruit eg. slices banana, kiwi fruit, apricot, mandarin
Lunch
Meat, chicken, fish, cheese or egg with
¼ cup pasta/rice OR 1 slice of bread OR legumes
¼ cup cut up vegetables or ½ cup salad vegetables
½ cup custard or yoghurt
Water to drink
Snack
½ cup whole milk
1 slice raisin bread
Evening Meal
Family food
Chicken, meat, fish, cheese or egg eg. 1 small chop, slice roast meat,
piece of fish
1 potato and ¼ cup other vegetables
¾ cup pasta OR rice OR 1 piece of bread
½ cup custard/yoghurt with ½ cup diced fruit
Recipes can be found at
www.health.qld.gov.au/cchs/Infant_Toddler_Feeding/FS10_Recipes.pdf
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Extra foods
These are foods that do not fit into the five food groups. They are not essential to provide the
nutrients the body needs. NO more than one extra food per day is recommended for 1-3 year olds.
Some examples are:
1 (40g) donut
1 small packet (30g) potato crisps
4 plain sweet biscuits
12 hot chips
1 (40g) slice cake
1½ scoops of ice cream
1 tablespoon butter, margarine, oil
60g jam and honey (1 tablespoon)
1 (375mL) soft drink
25g (1 fun size or half a regular) chocolate bar
5.3 What should toddlers be offered to drink?
Water is the best drink for children.
Fluid requirements depend on body size. In the Australian climate very young children are at
particular risk of dehydration. A child’s fluid needs are best met by water, then milk.
Avoid fruit juices, cordials and soft drinks.
Excessive consumption of fruit juice and soft drinks should be discouraged: these liquids have a
high sugar and energy content, which may displace other nutrients in the diet and contribute to
dental caries.
Early childhood caries, a recognised problem in infants and toddlers, is characterised by extensive
and rapid tooth decay. Prolonged sessions of bottle feeding and liquids containing sucrose are
two potentially cariogenic practices.
Toddlers should be offered all drinks in a cup. Some children may fill up on drinks, particularly
sweet ones like juice and milk, this leaves little room for solid food, whilst providing limited
nutrients
Encourage caregivers to:
■■ offer 1 to 3 glasses (200 ml) of milk only per day (depending on other dairy foods
consumed), and water at other times
■■ give food before drinks at mealtimes, particularly for small and picky eater
■■ understand why juice and sweetened drinks are unnecessary
For a parent handout ‘teaching my child to drink from a cup’, www.health.nsw.gov.au/mhcs/publication_pdfs/7845/AHS-7845-ENG.pdf
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5.4Assessing whether their children are meeting
their dietary needs
The focus in feeding should not be on getting food into the child…Instead the focus should be on the
feeding relationship and on the achievable goal of helping the child learn eating skills and positive
eating behaviours (8)
Caregivers often appear to be more concerned with the amount of food consumed rather than
the type of food offered or even the feeding environment (4). But obviously a balance between the
amount, type and variety of foods is necessary. The nutritional quality of the diet is important to
ensure that the child receives the levels of nutrients specified in the recommended dietary intakes
(1,9)
Food diary
A tool to assess toddler intake is a food diary. Encourage caregivers to keep a record (a food
diary, see parent handout) of everything their child ate over a 2 to 4 week period.
Instruct them to:
■■ include all meals and snacks in and outside the home
■■ include any behaviour that accompanies eating
■■ after 2 to 4 weeks, check all food groups are covered in the sufficient amounts
■■ look for any areas in the diet that need attention and any links to fussy behaviour.
Growth monitoring
Encourage caregivers to have regular visits to the child health centre so weight and height can be
continuously monitored. For assessment of growth and interpretation of growth charts, refer to
growth charts section.
When to refer
No healthy child has ever starved from refusing food. If the child is growing normally,
and is busy and active, reassure families their child is getting enough.
Please note, some medical conditions result in decreased appetite (eg. iron deficiency anaemia).
It is important the underlying medical condition is corrected. Supplements (such as vitamins
and minerals) should only be prescribed based on clinical findings. In these instances referral is
essential.
Check
Encourage families to seek a referral to a paediatrician or dietitian if they have:
✔✔ concerns about child’s growth
✔✔ the child is unwell, tired and not eating
✔✔ mealtimes are causing a lot of stress and anxiety (3)
“Infants are currently exposed to a wide variety of ‘kid’ foods that tend to be high in fat and sugar,
including excess juice, juice-based sweetened beverages, French fries and nutrient poor snacks.
Usual food intakes of infants and young children may exceed estimated energy requirements… for
children aged 1 to 4 years; intakes exceed requirements by 20 to 35%” (12)
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7
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5.5 Tips for toddler eating (3, 8)
Children do not need special foods. By this age they should be eating the same sort of meals
as the rest of the family.
■■ Toddlers should be eating and enjoying healthy meals and meal times with the rest of
the family. As much as possible, offer ‘family meals’.
■■ Toddlers appetite and food intake can vary daily
■■ Toddlers need small meals and regular snacks. Regular meal and snack times, with
adequate time set aside: 20-30 minutes for mealtimes and 10-20 minutes for snacks
helps!
■■ Encourage caregivers to let their child identify when they are full, instead of forcing a
child to finish all food on the plate
■■ This is a great time for learning and exploring. New foods may be rejected at first, in fact
some foods won’t be well accepted until tasted 10-20 times.
Dishing up:
■■ Serve a new food with a favourite food.
■■ Serve an amount you know your child can finish.
■■ Give solids first - before fluids.
■■ Offer drinks in a cup
■■ Do not add sugar and salt to basic foods
Mealtimes should be relaxed and fun
■■ This is a time for learning the social skills of eating as a family and learning courtesy at
the meal table.
■■ Encourage caregivers to avoid distractions such as TV, toys and games.
■■ Keep mealtimes as calm and relaxed as possible. Avoid family arguments at mealtimes!
■■ Give plenty of positive encouragement. Do not bribe children with food.
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5.6 Safety tips
Chewing tips for kids
There are a few safety issues with small children that need to be addressed.
Firstly, children under 4 years have not fully developed their chewing skills so
extra care is required with hard foods such as popcorn, nuts, fruit and raw
vegetables.
How to help toddlers chew
✔✔ Encourage caregivers to serve food in bite-size pieces.
✔✔ Encourage children to bite through food. Start with soft foods such as
bananas, tinned fruit, macaroni, and progress to apples, raw carrot, dried
fruit and meat.
✔✔ As each food is mastered, try a new one.
✔✔ Encourage caregivers to praise their toddler as they attempts chewy food.
✔✔ Role model behaviour: there are always opportunities for familles and
friends to show children how to take small bites. Move the food to the side
of the mouth and chew (4).
Some tips to prevent choking
✔✔ Young children should always be supervised when eating.
✔✔ Encourage caregivers to make a rule that eating is to be a sit down activity,
to prevent accidents with food or unintentional swallowing of large pieces
of food.
✔✔ Try role modelling sitting and eating, so that your child will learn that eating
is a sit-down activity for all family members.
✔✔ It is best to leave hard foods such as popcorn, corn chips, hard lollies and
hard, raw fruit or vegetables until the child is 4 years of age as they may
cause choking.
✔✔ For safety reasons never give whole nuts under 5 years — always use
paste.
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5.7 Milk matters
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
Pasteurised whole cow’s milk may be introduced to a child’s diet at around 12 months
of age and be continued throughout the second year of life – and of course, beyond.
It is an excellent source of protein, calcium and other nutrients
Milk, whether it is from the breast or formula, is a child’s most important food in the first year of life
and still very important in the next few years. Breastmilk is the preferred milk for infants up to at
least 12 months of age and offers benefits beyond this time (5)
Follow-on formulas are not necessary. There have been no studies showing advantages over
infant formula (5). Compositional changes in protein, fat, carbohydrate, sodium and calcium have
no clearly established superiority over ordinary formula provided together with appropriate solid
foods.
Plain milk is a good drink for children over 1 year of age (8)
How much milk?
500 ml of milk (2 glasses of 250 mL) a day is plenty. It is only one part of what toddlers eat and drink.
Other foods and drinks are needed too.
How much fat? (5)
Reduced fat milk (skim milk and milk with 1 or 2 percent fat) is not recommended in the
first two years of life due to the extra kilojoules required for this period of rapid growth.
Table 14
Recommended fat content of milk for 1 to 5 year olds
1 to 2 years
Breastmilk and full cream milk is recommended to children between 1 and 2 years of age.
This is milk with 4% fat (4 g fat / 100 ml)
2 years and over Children over 2 years of age do not need full cream milk. Choice of reduced fat or full cream milk
Reduced fat milk has 1-2% fat (1-2 g fat / 100 ml)
5 years and over It is safe to introduce skim milk to children
This is milk with less than 1% fat (less than 1 g fat / 100 ml
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Milks
Homogenised and pasteurised milk:
■■ is milk sold from refrigeration at the shops
■■ has been homogenised (ie. mixed through and made into uniform consistency) and then
pasteurised (heated to kill any germs that could cause illnesses, such as tuberculosis) It is safest for young children to drink milk that has been treated in both these
ways
Long life and UHT milk:
■■ has been partially sterilised by heating it for a short time, around 1-2 seconds, at a
temperature exceeding 135ºC, which is the temperature required to kill spores in milk,
but maintain nutritient profile
■■ has the same food values as ordinary milk, it has just been treated differently so it lasts
longer
Untreated cow’s milk:
■■ is cow’s milk that comes straight from the farm
■■ requires boiling before it is given to toddlers
■■ needs to be stirred as it cools, to mix in the fat
Low lactose milk:
■■ Used when indicated (ie lactose intolerance), under the guidance of a suitable health
professional
■■ refer to lactose intolerance section
Goat’s milk:
■■ goat and sheep milks have overall nutrient profiles similar to cow’s milk
■■ goat’s milk must be pasteurised or boiled, as it can contain germs that could make a
young child very ill
■■ goat’s milk composition, when compared to cow’s milk is:
■■
higher in protein, potassium and chloride contributes to increased renal solute load
and risk of dehydration, particularly in infants
■■
contains inadequate amounts of folic acid and vitamin B12
■■
very low in Vitamin C, vitamin b6 and vitamin D
■■
it is very low in iron (7)
■■ its popularity comes in part from unsubstantiated claims that it is less allergenic and
more digestible than cow’s milk (7)
Parent handout available
www.cyh.com
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Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
Soy (except soy formula where specifically indicated), rice and other vegetarian
beverages – whether or not they are fortified - are inappropriate alternatives to
breastmilk, formula or pasteurised whole cow’s milk in the first 2 years of life.
Soy milk
■■ full fat fortified soy beverages are suitable for use after 2 years of age as part
of a mixed diet
■■ infants and children medically requiring a soy milk should continue to use a soy infant
formula for the first 12 months and possibly 2 years. After this time a fortified soy milk
should be used with a calcium content greater than 100 mg/100ml milk (7)
Rice milk
■■ not a suitable substitute for breastmilk or cow’s milk for young children (8)
■■ rice milk is made from filtered water, rice flour, oil and sea salt. It may also have added
calcium (7)
■■ toddlers could have an occasional drink of rice milk, as long as it doesn’t take the place
of other milks in their diet (8)
■■ compared to cow’s milk and soy milk, rice milk is higher in carbohydrates, lower in
protein and naturally lower in fat. It has a naturally sweeter taste due to the higher
carbohydrate content (7).
Coconut milk
■■ not an infant food and certainly cannot be used to replace other milks
■■ doesn’t provide the same nourishment as normal milks
■■ contains a lot of fat and little else of value to the diet
■■ can be used occasionally in meals
Condensed milk
■■ not an infant food and certainly cannot be used to replace other milks
■■ doesn’t provide the nourishment of normal milks
■■ is high in sugar and fat
Check
✔✔ Encourage breastfeeding to 12 months and beyond, as long as mutually
desired
✔✔ Full cream cow’s milk until 2 years of age
✔✔ From 2 years onwards
■■
Reduced fat milks can be introduced
■■
Soy, rice and other vegetarian beverages can be introduced
✔✔ Milk is limited to 2 glasses of 250ml per day from 12 months onwards
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5.8 Fussy eating
‘Fussy eating’ is common among toddlers and often worries caregivers. Usually it is a stage in
normal development, but it can be aggravated by parental response. When growth and development
are normal and a variety of foods are offered to the child, simple reassurance from the child’s
caregivers may be all that is needed. (5)
Many caregivers worry about their child’s eating at some stage, particularly in younger children
when food intake and appetite appear to change daily (3). Work with caregivers to understand the
principles behind fussing eating, and develop some strategies with them to tackle fussy eating.
Use the parent handouts included in this section from Fun not Fuss with Food.
Parent-child feeding relationship (2, 8)
The parent–child feeding relationship recognises the importance of both the parent and child
in the complex process of eating and mealtimes. Feeding requires a division of responsibility
between parent and child. The parent is responsible for what the child is offered to eat, the child is
responsible for how much (2, 7, 8, 10, 11).
Breastfeeding is an example of the parent-child feeding relationship ‘caregivers must provide an
appropriate feed….. but they must allow the infant to regulate the amounts’
Caregivers decide what to feed their child and when:
■■ choosing, preparing and presenting a wide variety of foods
■■ continuing to offer foods without a fuss, even when they are rejected
■■ avoiding ‘junk’ foods and sweet drinks, which may reduce their appetite for ‘healthier’
options
■■ providing foods in ways that children can easily handle (eg cut into small pieces)
■■ providing meals and snacks at regular times
■■ caregivers having meals and snacks with children whenever possible
■■ setting rules about behaviour at the meal table and sticking to them
Children decide whether to eat and how much to eat
■■ remember children eat when they are hungry and do no starve themselves
Remind caregivers to avoid feeling the need to encourage their child to eat a little more, even if
they have left most of their meal. The child will not starve! When caregivers try to control whether
their child eats and how much is eaten, they are providing opportunities for fussing and tantrums
(7).
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‘Parking foods’ (5)
‘Parking’ a new food, that is, placing the new food on the plate with no expectations that the food
will be eaten, is a concept to discuss with caregivers. Research suggests that some children need to
be offered new foods up to 30 times before they will accept them.
‘Parking foods’ provides children the opportunity to become familiar with colour, texture and
smells even before attempting to taste the new food.
Encourage caregivers to allow toddlers to touch, smell or manipulate the new foods. If caregivers
are concerned their child develops a sudden preference for only a limited range of foods, this is
normal. Encourage caregivers to continue to offer a variety of foods at each meal and the child’s
range of foods eaten should increase again with time.
Food refusal is not necessarily about the child disliking the taste of the food. Most children accept
most foods eventually.
Caregiver development
When discussing fussy eating it is essential to be mindful of how caregivers are approaching the
situation, and how they are feeling. Adults receive a variety of messages regarding their role in the
feeding situation (4)... And often adults receive conflicting information. Bombarded with a host of
expectations, caregivers and caregivers can become easily confused and unsure. Limited nutrition
knowledge and food preparation skills may negatively affect caregivers abilities to feed children
appropriately (4).
It is the responsibility of the health workers to assist caregivers in recognising the biological,
physical and social environments associated with feeding preschoolers and to enable caregivers
to develop personal feeding and food selection strategies without unwarranted feelings of guilt (4).
Use Fun not Fuss with Food handouts as a tool to discuss feeding and food selection strategies.
Use My child won’t… handout and Fussy eating checklist as tools for caregiver advice.
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My child won’t ...
Adapted from Fun not Fuss with Food, 2004 (5)
■■ Won’t eat vegetables – consider the flavours, are they too strong, would you eat them?
Try raw vegetables with healthy dips, or add to other foods that they enjoy such as
pizza, rissoles and spaghetti bolognaise. You may have more success if you let your
child help to prepare the vegetables. Allow your child to experiment with vegetables. A
taste does not always lead to a swallow. The ‘one bite’ policy is also a good technique
and the child will eventually realise that the vegetable is actually edible.
■■ Won’t drink water – encourage water and make sure it is easy to access, serve it cold
with interesting ice cube shapes added. Leave the cordial in the back of the cupboard or
on the supermarket shelf. As caregivers you need to role model water drinking yourself.
Evidence suggests that caregivers who drink water are more likely to have children who
drink water.
■■ Won’t drink milk – try other dairy foods such as cheeses and yoghurt. Children usually
like soft cheeses and flavoured yoghurts (usually without the fruit bits). You can also
make flavoured milk with Milo, Actavite or Ovaltine and smoothies with milk and fruit or
yoghurt.
■■ Won’t eat meat – Some cuts of meat may be too tough or dry for children to chew
properly. You can try softer cuts such as mince or thinly sliced meat in sandwiches.
Other foods can take the place of meat, so include eggs, peanut paste, nuts or
combinations of legumes and grains such as baked beans on toast, hommos with pita
bread, or kidney bean tacos or tortillas.
■■ Try to persevere when offering new foods to your child. Be comfortable with the concept
of parking the new food
■■ Eats too much at snack times – snack times are meal times for children. Ensure snacks
are nutritious, so serve fruits or vegetables with wholegrain breads or crackers. Snack
times such as afternoon tea may be when your child is at their hungriest. You can serve
a small meal (equivalent of a dinner) at this time if it is convenient.
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Fussy eating checklist
Take a moment to think about WHY your child may be refusing a meal
Check
■■ recent snacks: have these provided the child with enough energy?
■■ drinks: did they have a drink recently, which may have filled them up?
■■ family situation: what is the family doing – are you singling out the child for a special
meal?
■■ activity: what activity were they doing – was it new and interesting or a favourite that is
hard to drag them away from?
■■ time: is this normal time for a meal?
■■ illness: is your child ill?
Remember
■■ it’s OK for a child’s food intake to vary. Children are very good at judging their hunger
and fullness signs
■■ include a variety of foods to ensure your child is receiving all the nutrients he or she
needs
■■ a child’s intake will increase during growth or as activity levels increase
■■ children tend to eat less if they are tired
■■ children need to enjoy food and eating
■■ children should not be pressured about how much or how little they eat
■■ don’t use lollies, chocolates, biscuits, milk or desserts as bribes or rewards
Notes:
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17
Check
✔✔ Caregivers understand types and amounts of food and drinks suitable for
toddlers
■■
Check five food groups and extras. Discuss choking issues
✔✔ Toddler is being allowed to determine when they are hungry and when they
are full
■■
Question: what signs does your child show when they are hungry?
■■
Question: what signs does your child show when they are full?
✔✔ Toddler is consuming a wide variety of ‘family foods’
Question: Tell me about the food your child is eating at their main meal
✔✔ Toddler is drinking from a cup
■■
Check with toddler: Can you show me how you drink?
■■
Check content of cup / bottle
■■
Water is offered as a drink
✔✔ Appropriate milk and appropriate amount of milk
■■
18
Check toddler is consuming 1-3 glasses of milk / day
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5.9 Useful websites and resources
Key state and national documents for health workers
Dietary Guidelines for Children and Adolescents in Australia and Infant Feeding Guidelines
for Health Workers
Optimal Infant Nutrition: evidence based guidelines
Infant and Child Nutrition in Queensland 2003
Report of the Chief Health Officer Queensland, 2006
Further professional development reading:
Parent handouts
Child Health Information Fact Sheets www.health.qld.gov.au/child&youth/factsheets/
Guidelines for toddlers www.health.qld.gov.au/cchs/Infant_Toddler_Feeding/FS8_Guidelines_Todd.pdf
Recipe fact sheet
www.health.qld.gov.au/cchs/Infant_Toddler_Feeding/FS10_Recipes.pdf
Guidelines for fussy eaters
www.health.qld.gov.au/cchs/Infant_Toddler_Feeding/FussyEaters.pdf
Parent books
Jenny O’Dea. Doublebay, 2005. Positive Foods For Kids; Healthy Food, Healthy Children,
Healthy Life.
Yummy! Every Caregivers Nutrition Bible, Jane Clarke, 2006
Video / DVD
Websites
www.health.vic.gov.au/nutrition/child_nutrition/eat.htm
A note on Fun not Fuss with Food
Fun not Fuss with Food was developed in 2000 by a multidisciplinary team of health
professionals at the Gold Coast Health Service District, and is now distributed nationally
through Population Health Services.
It is a single session, two-and-a-half-hour workshop that covers nutrition for children
and behavioural management strategies. The workshop aims to increase the capacity
of caregivers with children aged 2–10 years in managing their child’s problem eating and
mealtime behaviours. There is a range of resources to support health professionals (child
health nurses, child psychologist/early intervention specialists, and nutritionists/dietitians)
to deliver the workshop. These include a facilitator’s manual, facilitator’s guide (video/DVD),
and parent resources. This package can be ordered from qheps.health.qld.gov.au/PHS/Documents/sphun/27966.pdf
Some parent handouts are included in the manual. And can also be accessed at
qheps.health.qld.gov.au/ahwac/docs/nutrition/fun_not_fuss.pdf
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References:
1. Queensland Public Health Forum (2002). Eat Well Queensland 2002–2012: Smart Eating
for a Healthier State. Brisbane, Queensland Public Health Forum.
2. Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant
Feeding Guidelines for Health Workers, NHMRC, Canberra 2003.
3. Department of Human Services (DHS), Public Health Division. ‘What’s there to eat? Food
& Nutrition, Melbourne [online] www.health.vic.gov.au/nutrition/downloads/whatstoeat/
29th March 2007
4. Sigman-Grant M., Feeding preschoolers: balancing nutritional and developmental needs.
Nutr Today 1992;27:13-17
5. Queensland Health; Fun not Fuss with Food. Brisbane 2004.
6. Queensland Health: Infant and Child Nutrition in Queensland 2003. Queensland Health.
Brisbane 2005
7. Community Population and Rural Health (2003). Tuckertalk (child nutrition) fully revised.
Tasmania,
8. Satter E., The Feeding Relationship. Zero to three Journal, June 1992
9. Queensland Health: Child & youth health fact sheets: Brisbane [online] www.health.qld.gov.au/child&youth/factsheets/ 13th March 2007
10. Evans Morris, S. & Dunn Klein, M. 2000, Pre-feeding Skills: A Comprehensive Resource
for Mealtime Development (2nd Edition), Therapy Skill Builders, San Antonia.
11. South Australia Child and youth health – health topics-milk for toddlers [online]
12. Dietary recommendations for Children and Adolescents: A Guide for Practitioners,
Paedatrics 2006:117;544-559
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6.0 Preschool nutrition
The years between a child’s 2nd and 5th birthdays represent a period of rapid social, intellectual
and emotional growth. At the same time, overall physical growth is decelerating while motor skills
are being fine-tuned. Preschoolers are busy exploring the environment (1). They have tested their
independence and are now ready to learn.
Preschoolers have two common preferences. Firstly, they have a preference for routine in daily
life. Most children need some structure and routine to their day. Generally, they prefer meals and
snacks at regular times, as governed by the family’s lifestyle.
Secondly, they have a preference for simplicity. Many children may like simply prepared, mild
tasting foods that they can easily identify. They prefer foods they can manage, for example, cut-up
vegetables they can eat with their fingers and soups they can drink from a cup (1).
In the preschool years, food takes on more complex meanings. Preschoolers have an association
with food of more than eating. Foods have specific meanings determined by a child’s associations
with them. For example, sweets may mean a reward for good behaviour in the supermarket.
Additionally, caregivers should be aware that early impressions associated with various uses of
food, affect food-related attitudes and practices that can last throughout life (1).
Food preferences can now be influenced; parents and friends as well as television advertising will
affect food consumed.
Acceptance of new foods, new textures and new tastes takes time and patience. Caregivers should
be encouraged to maintain their responsibility to provide preschoolers with adequate amounts of a
variety of nutritious foods and allow the children to select the amounts needed from these foods (1).
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1
6.1 Eating patterns
Once children commence child care, kindergarten or school, life takes on a new routine. A regular
intake of food is needed throughout the day to keep children active and to help their concentration
while learning.
Some children in this age group are still fussy, so encourage parents to offer a wide variety
of foods and regular meals and snacks, and allow children to eat to appetite without force or
arguments (3).
Developmental characteristics of preschoolers (2)
Generally in preschoolers there is:
■■ progressive acquisition of new skills. Preschoolers are striving for independence and
gaining competence in such activities as tying their shoelaces, brushing their teeth and
pouring milk. A preschooler’s oral motor development and manual dexterity should be
considered, so that foods of appropriate texture, consistency and ease of eating are
chosen for them
■■ energy. Sitting still for more than a few minutes might be difficult. Preschoolers need
plenty of time for active play and opportunities to develop gross motor coordination
■■ more effective communication. Language is important. Peers become increasingly
important. Most preschoolers enjoy sharing food with friends and carers
■■ a keen curiosity. ‘Why’ has usually replaced ‘no’ as the favourite spoken word. The kitchen
provides an opportunity for experiments, crafts, and participation in food preparation
■■ comfort with the familiar but willingness to try new challenges. Food fads are common at
this time. Preschoolers might insist on having a particular food prepared in a particular
way for several days then, once it has been experienced to the full, become infatuated with
another food. This has been called ‘fussiness’, but it is actually characteristic of normal
development. Although variety may be limited while the fad persists, the preschooler is
gradually expanding their food choices.
Preschoolers showed significant levels of nutrition knowledge…. They were able to identify foods of
higher nutrient density as being ones to use to make their doll ‘grow bigger and stronger’ (1).
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Table 15
Typical physical and social/personal characteristics related to eating
during the preschool years
Age
Physical characteristics
Social/ personal
characteristics
3 – 4 years
Holds handle on cup
Improved appetite and interest in food
Pours from a small jug
Favourite foods requested
Uses fork
Likes shapes, colours, ABCs
Chews most foods
Able to choose between 2 alternate foods
Influenced by television commercials
Likes to copy food preparer
Imaginative play
4 – 5 years
Uses knife and fork
Rather talk than eat
Good use of cup
Food fads continue
Good self-feeder
Motivated to eat by incentives
Likes to help
Interested in nature of food and where it
comes from
Peer influence increasing
5 – 6 years
Independent at feeding
Conforming
Less suspicious of mixtures but still
prefers plain foods
Social influence outside home increasing
Food an important part of special
occasions
Adapted from NHMRC: Dietary Guidelines for Children and Adolescents in Australia, 2003 (2)
6.2 Nutrition during preschool years
How much food is eaten at this age varies from child to child and from day to day and is
influenced by growth and activity levels. The following serving sizes and amounts can be used
as a guide to feeding 4 – 7 year old children each day. Some serve sizes are different to those
commonly used for adults.
These suggestions are a guide only.
Every child is different, and their activity and growth rate changes from day to day. The main focus
should be on the introduction of a healthy eating pattern and family meal acceptance rather than
on serves.
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3
Suggested sample servings for children aged 4 –7 years (4,5)
Food group
Serves per day
Bread and cereals, rice,
pasta and noodles
3-4
Fruit
2 slice of bread OR
1 medium bread roll OR
11/3 cup ready to eat cereal OR
1 cup cooked porridge OR
1 cup cooked rice, pasta or noodles
2
1 medium piece of fruit OR
2 small pieces of fruit OR
1 cup diced fruit OR
½ cup fruit juice
1 glass of fruit juice per day is enough.
Fresh fruit is best but frozen, canned and
dried are also good alternatives
4
½ cup cooked vegetables OR
1 cup salad vegetables OR
1 small potato
½ cup legumes
Vegetables, legumes
Meat, fish, poultry, eggs,
nuts and legumes
½-1
Dairy
3
Milk, yoghurt, cheese
1 serve
65-100g cooked meat or chicken
(2 small chops, ½ cup mince, 2 slices roast
meat) OR
80-120g cooked fish OR
1/2 cup legumes OR
40-60g cooked fish OR
2 eggs OR
1/3 cup nuts.
For safety reasons never give nuts to
children under 5 years of age – always use
paste
250ml (1 cup) milk OR
250ml (1 cup) custard OR
200g tub yoghurt OR
40g cheese
Extra foods:
These are foods that do not fit into the five food groups. They are not essential to provide the
nutrients the body needs. NO more than 1 – 2 extra foods per day for 4 – 7 year olds.
Some examples are:
1 (40g) donut
4 plain sweet biscuits
1 (40g) slice cake
1 tablespoon butter, margarine, oil
1 (375mL) soft drink
1 small packet (30g) potato crisps
12 hot chips
1½ scoops of ice cream
60g jam and honey (1 tablespoon)
25g (1 fun size or half a regular)
chocolate bar
A recent study in Queensland found less than 20% of 4 - 7 year olds consumed the recommended
number of serves of vegetables for their age group. (6)
Refer to My child won’t eat vegetables in the toddlers section.
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6.3 Suggested meal plan for a 4-7 year old
Breakfast
1 cup cereal with 1 cup milk
slice toast with polyunsaturated margarine with 1
spread eg. Vegemite, jam, peanut butter, cheese, egg
Snack
Water
ruit eg. 1 apple/banana, orange OR 2 apricots OR 1 cup canned fruit OR
F
4 dried apricot halves
Lunch
eat, chicken, fish, cheese or egg with
M
1 cup pasta/rice OR 2 slices of bread
½ cup cut up vegetables OR 1 cup salad vegetables
½ cup custard or yoghurt
Water to drink
Snack
1 cup milk
slice bread with baked beans OR
1
fruit and vegetable platter OR
savoury vegetable muffin
Evening meal
hicken, meat, fish, cheese or egg eg. 2 small chops, slice of roast meat,
C
piece of fish
1 potato and ½ cup other vegetables
½ cup pasta OR rice OR 1 piece of bread
½ cup custard/yoghurt with ½ cup diced fruit
6.4 Eating habits
A number of strategies can be adopted to encourage good eating habits and monitor food intake (2)
■■ Establish routines where the child and caregiver sit down together and talk during meal
times and snacks.
■■ Establish habits such as milk with a meal and water at bedtime that will help ensure
variety and nutritional adequacy.
■■ Keep a ‘snack-box’ in the fridge or on the kitchen bench containing healthy snack foods
such as pieces of fruit, vegetables, cheese and small sandwiches, that the child can
either use independently or have offered to them. This helps to monitor what the child is
eating between meals.
■■ Introduce the practice of having the child at the table for meal times as soon as he or
she is able to sit up and grasp foods.
■■ Do not give the child too large a serving. It is better to offer small amounts and have
more available if they want it.
■■ Provide foods the child likes, plus a new food to try. Be accepting if the child does not
like particular foods, but remember that likes and dislikes change over time. Do not avoid serving a food that the child dislikes but that the rest of the family likes:
continue to serve it, placing only a small amount on the child’s plate, and accept it if they do not eat it.
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5
6.5 Growth (1,3)
Children grow at a steady rate during the kindergarten and early school years. ‘This slower growth
rate is reflected in a decrease in appetite and less interest in food. Paradoxically, while parents
worry that their preschooler may not be eating enough, the incidence of childhood obesity
continues to rise’ (1). Strict or low fat diets are not recommended because children’s energy and
nutrient needs are high. For parents who are concerned about excessive weight gain, a good
approach to discuss with them is to:
■■ develop healthy eating habits for the whole family
■■ encourage regular physical activities for everyone
■■ limit television time.
See obesity section for further discussion
6.6 Appetite (2,3)
■■ There is considerable variation in children’s appetite, fluctuating from day to day,
depending on their rate of growth and level of physical activity.
■■ Children are able to decide how much food they need if allowed to eat to appetite,
encourage parents to allow this.
■■ Children commonly eat small amounts of foods, frequently, due to their small stomach
capacity.
■■ Many parents find their children eat better at certain times of the day.
■■ Forcing children to ‘clean the plate’ or giving sweets as rewards may lead to problems of
overeating later on.
Tiredness and irritability can prevent children from eating, especially at the evening meal (1)
6.7 Physical activity
Children should be encouraged to be physically active from a young age. Physical activity helps
children feel good and encourages a healthy appetite. Encourage parents to promote a family
setting that:
■■ plays games in the backyard
■■ goes for a walk in the park
■■ learns to swim
■■ participates in kindergarten and school activities
■■ watches less television
For more ideas check out Eat Well, Be Active website at
www.health.qld.gov.au/eatwellbeactive/funideas/active_fun.asp
www.health.qld.gov.au/eatwellbeactive/beactivetips/tips_for_families.asp
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6.8 Packing lunches for kindergarten
If children are away from home for 8 hours, they should eat about half of the food needed for the
day. The rest should be eaten at breakfast and at the evening meal (7).
Treats
By this age children can eat independently and enjoy the social aspects of eating. Having friends
means eating out of home more, and the occasional meal at a fast food restaurant or party filled
with high energy and fat snacks does no harm if good nutrition is continued most days.
Parent handout can be found at
www.health.qld.gov.au/cchs/Gen_Nutrition_Activity/lunches.pdf
Healthy snacks
Parent handout can be found at
www.health.qld.gov.au/cchs/Gen_Nutrition_Activity/lunches.pdf
Healthy drinks
An adequate intake of fluids is important at all ages. Children should be encouraged to drink as
much water as possible, in preference to other fluids. Milk is a good source of fluid, an important
source of calcium and, because it has a high protein content, it has a greater satiating effect than
other drinks. 1 - 3 glasses of 250 ml of milk a day (depending on other dairy consumption) is enough.
Sweet drinks such as juice, soft drink or cordial are unnecessary in a child’s diet.
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7
6.9 Food preferences
Children’s eating is not only influenced by family life but also by other children and messages from
television. Children can learn to make healthy food and lifestyle choices if given help from parents
and carers (3).
Parents and peers
Parental influences on food patterns are critical in the development of food preferences (1, 6)
■■ parental pressure, even if it is positive, can affect a child’s food acceptance (1).
■■ Using foods as rewards or presenting them paired with adult attention increases a child’s
preference for that food.
■■ frequency with which children see a particular food (1). It is important children are
presented new foods frequently; continued exposure promotes acceptance.
■■ role modelling: when children observe adults consuming a food, it is more likely the
children may consume the food (1)
Peer influence can also affect children’s food preferences as they age (1).
Children should like to eat and enjoy food, not see food as threatening or as a reward (9).
Television advertising
In addition to its effects on physical activity, television exposes children to numerous food
advertisements. Public health experts and nutrition educators have expressed concern that many
of the food advertisements on television directed at children are for a narrow range of products
that are high in fats, sugars and/or salt and low in dietary fibre (2).
There has been increasing evidence that television commercials influences child food preferences.
An American study found television commercials were important influences on the types of food
children ask their parents to buy and the foods they buy for themselves (1).
Sweetened breakfast cereals, candy, desserts, low-nutrient beverages, and salty snack foods
were the products most commonly advertised to children and are also the items most frequently
requested of parents. Kraak and Pelletier (2) suggest that building children’s and teenagers’ skills
in processing consumer information is one strategy—when combined with parental guidance
and environmental support (including government–industry partnerships)—that can help
young consumers make ‘healthful’ dietary choices before undesirable dietary behaviours have
developed.
Check
Food tips for growing children (3):
✔✔ a variety of foods should be offered every day
✔✔ encourage healthy eating for everyone in the family
✔✔ let children decide if they are full or hungry
✔✔ offer healthy snacks between meals
✔✔ encourage children to help prepare meals
✔✔ encourage water rather than sweet drinks
✔✔ encourage family mealtimes and activities to be enjoyed together
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6.10Useful websites and resources
Key state and national documents for health workers
Dietary Guidelines for Children and Adolescents in Australia and Infant Feeding Guidelines
for Health Workers
Optimal Infant Nutrition: evidence-based guidelines
Infant and Child Nutrition in Queensland 2003
Report of the Chief Health Officer Queensland, 2006
Further professional development reading
Parent handouts
Child Health Information Fact Sheets www.health.qld.gov.au/child&youth/factsheets/
Parent handout for lunch box and snack ideas
‘Great lunch and snack ideas for hungry kids’ (see brochure): To order contact Queensland Health Publications
GPO Box 48
Brisbane QLD 4001
Phone (07) 3234 1053
Fax (07) 3234 0659
www.health.qld.gov.au/cchs/Gen_Nutrition_Activity/lunches.pdf
A note on Fun not Fuss with Food
Fun not Fuss with Food was developed in 2000 by a multidisciplinary team of health
professionals at the Gold Coast Health Service District, and is now distributed nationally
through Population Health Services.
It is a single session, two-and-a-half-hour workshop that covers nutrition for children
and behavioural management strategies. The workshop aims to increase the capacity
of parents with children aged 2 – 10 years in managing their child’s problem eating and
mealtime behaviours. There is a range of resources to support health professionals (child
health nurses, child psychologists/early intervention specialists, and nutritionists/dietitians)
to deliver the workshop. These include a facilitator’s manual, facilitator’s guide (video/DVD),
and parent resources. This package can be ordered from qheps.health.qld.gov.au/PHS/Documents/sphun/27966.pdf
Some parent handouts are included in the manual and can also be accessed at
qheps.health.qld.gov.au/ahwac/docs/nutrition/fun_not_fuss.pdf
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9
References
1. Sigman-Grant M. Feeding preschoolers: balancing nutritional and developmental needs.
Nutr Today 1992;27:13-17.
2. Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant
Feeding Guidelines for Health Workers, NHMRC, Canberra 2003.
3. Vic Health. What’s there to eat? Food and nutrition: Part 2. Melbourne.
4. Queensland Health. Fun not Fuss with Food. Brisbane 2004.
5. Queensland Health: Child & youth health fact sheets: Brisbane [online] www.health.qld.gov.au/child&youth/factsheets/ 13th March 2007
6. Queensland Health. Infant and Child Nutrition in Queensland 2003. Queensland Health.
Brisbane 2005.
7. Queensland Health. What is Better Food? Brisbane 2002.
8. Gray G. Afferent signals regulating food intake. Proc Nut Soc 2000;59:373-84.
9. Klesges RC., Stein RJ., Eck RJ., Isbell TR., Klesges LM. Parental influence on food
selection in young children and its relationships to childhood obesity. American Journal of
Clinical Nutrition 53(4) 859-64, 1991 April.
10
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7.0 Clinical nutrition
7.1 Adverse food reactions
Food allergies and intolerances are examples of adverse food reactions and describe adverse
reactions to foods. Regardless of whether classified as either an allergy or intolerance, dietary
management should be handled by a qualified dietitian/nutritionist (in conjunction with an allergist
in the case of food allergies), since self imposed restrictions may lead to nutritional deficiencies.
The area of food allergies and intolerances is not at all clear-cut. Accurate diagnosis is essential,
and this usually requires a referral from a General Practitioner to an Allergist.
Understanding food allergies and intolerances
This section is kindly adapted from Friendly Food, Royal Prince Alfred Hospital Allergy Unit.
Understanding the difference between intolerance and other types of food reaction is an important
starting point because the approach to dealing with them is quite different. Unlike allergies and
coeliac disease, which are immune reactions to food proteins, intolerances don’t involve the
immune system at all. They are triggered by food chemicals which cause reactions by irritating
nerve endings in different parts of the body, rather in the way that certain drugs can cause sideeffects in sensitive people (2).
The chemicals involved in food intolerances are found in many different foods, so the approach
involves identifying them and reducing your intake of groups of foods, all of which contain the
same offending substances. By contrast protein allergens are unique to each food (for example,
egg, milk and peanut), and dealing with a food allergy involves identifying and avoiding all traces of
that particular food. Similarly gluten, the protein involved in coeliac disease, is only found in certain
grains (wheat, barley, rye) and their elimination is the basis of a gluten-free diet (2).
If food allergy is suspected, refer patient to an allergist or immunologist for
assessment.
Understanding food allergies
A food allergy is an abnormal immune reaction to a food that is harmless for most people.
Antibodies against the food are produced so that when the allergic individual eats the food,
histamine and other defensive chemicals are released causing inflammation. These chemicals
trigger allergic symptoms that can affect the respiratory system, gastrointestinal tract, skin or
cardiovascular system (5).
A rather short list of foods accounts for 85-90% of significant reactions, although any food can
provoke a reaction. Foods responsible for the majority of significant food allergy in infants, children
and adults are as follows:
■■ infants: cow’s milk, soy
■■ children: cow’s milk, egg, peanut, soy, wheat, tree nuts (walnuts, hazelnuts etc), fish,
shellfish
■■ adults: peanut, tree nuts, fish, shellfish (9)
Fortunately, most children grow out of their egg and milk allergies before they reach school age, or
during the early school years, but allergies to nuts and seafoods can persist. Wheat and soy can
cause allergies, but they tend to be mild and transient (2).
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1
Common food allergens (2, 3, 5)
■■ Peanut and other nuts
■■ Egg
■■ Milk
■■ Seafood
■■ Sesame
■■ Wheat
■■ Soy
Children born into atopic families are more likely to develop allergic diseases (50-80% risk)
compared to those with no family history of atopy (20% risk) The risk appears to be higher if both
parents are allergic.. and if the mother (rather than the father) has allergic disease (8)
Symptoms usually begin in the first 2 years of life, often after the first known exposure to the food…
It is estimated that up to 6% of children under 3 years of age are affected by food allergies (3).
For more information, the handouts below can be accessed at the Royal Prince Alfred Hospital
website: www.cs.nsw.gov.au/rpa/Allergy/default.htm
■■ Egg Allergy
■■ Frequently Asked Questions about Food Allergies (includes Advice for Schools)
■■ Latex Allergy
■■ Milk Allergy
■■ Peanut Allergy
■■ Food Allergy Prevention
■■ Upper Airway
■■ Wheat Allergy
Food allergy reactions (2)
Food allergy reactions vary in severity, depending on how sensitive the person is and how much of
the food they’ve eaten.
Food allergy is mainly a problem of infants, toddlers and young children. Over 90% of cases are
associated with atopic eczema - an intensely itchy chronic skin rash affecting the face, arms, legs,
and other parts of the body (2).
More severe reactions are usually obvious and occur consistently, every time the person has
the food. Contact with the mouth and tongue can cause an immediate burning sensation, with
hives and redness around the face and if the food is swallowed, an immediate feeling of being
unwell can be followed by vomiting, cramps and diarrhoea. The face, mouth and eyes can swell
dramatically, and hives on the body can join into large, rapidly spreading welts (2).
The most severe type of reaction – anaphylaxis - can progress rapidly with breathing difficulty
(from swelling of the throat or severe asthma), allergic shock and collapse, and can be lifethreatening if not treated immediately with adrenaline (epinephrine) by injection. In the most
sensitive people with a food allergy, tiny amounts of the food (pin-head sized) can be enough to
provoke a severe reaction (2).
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Minimising the risk of allergy in high-risk infants (1, 8)
Pregnancy
■■ Do not smoke during pregnancy, and provide a smoke-free environment for your child after
birth.
■■ Dietary restrictions in pregnancy are not recommended.
Breastfeeding, formula feeding
■■ Exclusively breastfeed your child for at least 6 months, and preferably longer.
■■ If breastfeeding is discontinued for any reason, seek professional advice: hydrolysed
protein formula may be recommended.
■■ Soy milk and goat’s milk formulas do not reduce allergies, and should not be used as an
alternative to cow’s milk formulas.
■■ Maternal dietary restrictions during breastfeeding are not recommended for prevention (8)
■■ If an infant is breastfeeding and showing signs of allergies, refer to local general
practitioner or specialist (eg paediatrician, allergist).
Introducing solids
■■ Solid foods should not be introduced until about 6 months of age.
■■ Start with low-allergenic foods such as rice and rice based cereals, followed by vegetables
(eg. potato, pumpkin) and fruits (pear, apple, banana), then meats.
■■ Add only one food at a time. Wait several days (ideally 5 to 10 days) before introducing a
new food.
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3
Management
Dietary Guidelines for Children and Adolescents in Australia
recommendation
Encourage exclusive breastfeeding for 6 months to decrease the risk of
allergy in infants with a positive family history.
If there is a strong family history of allergy, delay introducing some or all of the highly allergenic
foods during the first year; among these foods are cow’s milk and other dairy products, soy, eggs,
nuts, peanuts and fish.
It is best to continue avoiding eggs, nuts and shellfish until the age of 3 years.
When food choices are restricted, the advice of a dietitian should be sought to ensure that the
dietary intake continues to meet nutrient and energy needs.
Best Practice management is essential; refer to paediatrician or an allergist.
Dietary intervention
The main principle of food allergy management is avoidance of the offending antigen. An incorrect
diagnosis is likely to result in unnecessary dietary restrictions, which, if prolonged, may adversely
affect the child’s nutritional status and growth. For patients requiring prolonged restrictive diets, a
formal dietetic evaluation is recommended to ensure that nutritional requirements are met (3).
Food Intolerances
Food intolerances are an adverse reaction to a food or substance that does not involve the
immune system (5). Food intolerance reactions can be triggered by a range of natural substances
or additives present in many different foods.
Some people are born with a sensitive constitution and react more readily to food chemicals than
others. The tendency is probably inherited, but environmental triggers can bring on symptoms at
any age by altering the way the body reacts to food chemicals. These triggers may include:
■■ a sudden change of diet
■■ a bad food or drug reaction
■■ a nasty viral infection; for example, gastroenteritis or glandular fever (2).
Natural food chemicals
Natural chemicals are found in the foods we eat. Food is composed of protein, carbohydrate,
fat and various nutrients as well as a number of natural ‘chemicals’. These naturally occurring
molecules often add flavour and smell to food. Sometimes they will trigger symptoms in unlucky
individuals. These chemicals include (6):
■■ salicylates
■■ amines
■■ glutamate.
These natural substances are the ones common to many different foods, and therefore consumed
in greatest quantity in the daily diet. As a rule, the tastier a food is, the richer it’s likely to be in
natural chemicals.
It is important to realise that reactions to these substances are not due to allergy, and so allergy
testing is of little use in helping us to decide what to avoid (6).
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Chemical threshold
The small amounts of natural chemicals present in a particular food may not be enough to cause
a reaction straightaway. However, because one substance may be common to many different
foods it can accumulate in the body, causing a reaction when the threshold is finally exceeded (2).
Food intolerance reactions (2)
Symptoms triggered by food chemical intolerances vary from person to person. Common ones
include:
■■ recurrent hives and swellings
■■ headaches
■■ sinus trouble
■■ mouth ulcers
■■ nausea
■■ stomach pains
■■ bowel irritation.
Some people feel vaguely unwell, with flu-like aches and pains, or get unusually tired, run-down or
moody, often for no apparent reason.
Management of food intolerances
The chemicals involved in food intolerances are found in many different foods, so the approach
involves identifying them and reducing the intake of groups of foods, all of which contain the same
offending substances (2).
Elimination diets
Once a diagnosis is made, the history may help identify the role of dietary or other factors in
making symptoms worse. The only reliable way to sort out whether diet is playing a role is by
people being placed on a temporary elimination diet under the supervision of a skilled
dietitian and medical practitioner. If the diet helps, this is followed by challenges under
controlled conditions to identify dietary triggers so that they can be avoided in the future (6).
It is important to emphasise elimination diets must only be undertaken for a short term, under
strict medical supervision and only for very good reasons. Prolonged restricted diets can lead to
problems with nutrition, particularly in children (6).
Refer to a dietitian.
Parent handout can be found at
www.medeserv.com.au/ascia/aer/infobulletins/food_intolerence.htm
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5
Coeliac disease
This section is kindly adapted from Friendly Food, Royal Prince Alfred Hospital Allergy Unit.
Coeliac disease is caused by an immune react ion to gluten, a protein found in wheat, barley
and rye. The reaction causes inflammation and damage to the lining of the small bowel, which
impairs its ability to absorb nutrients. Typical symptoms include mouth ulcers, fatigue, bloating,
cramps and diarrhoea, but some people have no symptoms at all, and in others the only clue
may be anaemia (due to iron or folic acid deficiency) or an unusual chronic skin rash (dermatitis
herpetiformis). Coeliac disease should not be confused with wheat allergy, which rarely occurs
beyond infancy, or the stomach and bowel irritation that gluten can sometimes cause in people
with chemical intolerances.
Screening blood tests are available, but definite diagnosis requires a small bowel biopsy. These
tests can become negative after a few weeks of gluten avoidance. Untreated coeliac disease
carries a long-term risk of nutritional deficiency, osteoporosis and/or bowel malignancy. Currently,
a life-long gluten-free diet is the only known treatment.
Useful websites and resources
Dietary Guidelines for Children and Adolescents in Australia
Clinical guidelines
Katrina J Allen, David J Hill, Ralf G Heine. Food Allergy in Childhood.
MJA 185(7) 394-400.
www.mjw.public/issues/182_09_020505/pre10874_fm.html
Susan L Prescott and Mimi LK Tang (2005). The Australasian Society of Clinical
Immunology and Allergy position statement: summary of allergy prevention in children MJA 182(9) 464-467.
www.mja.com.au/public/issues/185_07_021006/all10609_fm.pdf
Parent books, DVDs
Friendly Food (Murdoch Books) by Anne Swain, Velencia Soutter and Robert Loblay, Royal Prince Alfred Hospital Allergy Unit.
Order form can be found at www.cs.nsw.gov.au/rpa/Allergy/default.htm
“Dealing with Food Allergy” DVD and booklet – available from Royal Prince Alfred Hospital.
Parent handouts regarding food allergy and intolerance can be found at
www.foodauthority.nsw.gov.au/consumer/c-allergies.html
including translated information sheets in eight different languages.
6
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A note on the Australasian Society of Clinical Immunology and Allergy
(ASCIA)
ASCIA is a professional non profit organisation, comprised predominantly of Clinical
Immunologists, Allergy Specialists and Immunology Scientists. The main roles of ASCIA are
to: promote the highest standards of scientific and medical practice and education amongst
its members….. and to coordinate education programmes for its members, other health
professionals and the public.
Contact information:
Executive Officer
The Australasian Society of Clinical Immunology and Allergy (ASCIA)
PO Box 450 Balgowlah NSW 2093
Email:
[email protected]
Website:
www.allergy.org.au
Patient education resources can be found at
www.allergy.org.au/aer/infobulletins/index.htm
A note on the Royal Prince Alfred Hospital (RPAH)
The RPAH Allergy Unit is attached to the Department of Clinical Immunology, Royal Prince Alfred
Hospital (RPAH), and is affiliated with the Discipline of Medicine at the University of Sydney. The staff at the Allergy Unit are committed to excellence in clinical care, research and teaching,
and act as a centre of national expertise providing information and resource materials for health
care providers as well as the wider community.
Contact information:
Email:
[email protected]
Website:
www.cs.nsw.gov.au/rpa/Allergy/default.htm
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7
References
1. Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant
Feeding Guidelines for Health Workers, NHMRC, Canberra 2003.
2. Friendly Food (Murdoch Books) by Anne Swain, Velencia Soutter and Robert Loblay,
Royal Prince Alfred Hospital Allergy Unit.
3. Allen KJ., Hill DJ., Heine RG., (2006) Food Allergy in Childhood. MJA Practice Essentials
185(7) 394-400
4. Food Allergy Prevention; RPA
www.cs.nsw.gov.au/rpa/Allergy/default.htm [online] 5th April, 2007
5. NSW Food Authority: Food Allergies ands Intolerances Fact Sheet: 25th August 2005.
[online 4th April] www.foodauthority.nsw.gov.au
6. www.medeserv.com.au/ascia/aer/infobulletins/food_intolerence.htm [online 10th April]
7. Bischoff S., Crowe S.E., (2005) Gastrointestinal Food Allergy: New Insights Into
Pathophysiology and Clinical Perspectives. Gastroenterology 2005;128:1089-1113
8. Susan L Prescott and Mimi LK Tang (2005) The Australasian Society of Clinical
Immunology and Allergy position statement: summary of allergy prevention in children
MJA 182(9) 464-467
9. American Gastroenterological Association medical position statement: guidelines for the
evaluation of food allergies, Gastroenterology 2001 Mar; 120(4) 1023-5
10. Prescott S.L., Tang M., (2004) The Australasian Society of Clinical Immunology and Allergy
position statement: Allergy prevention in children. [online] 10th April www.allergy.org.au/pospapers/Allergy_prevention.htm
8
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7.2 Colic
The word ‘colicky’ is used to describe a fussy baby who is otherwise a healthy, growing infant
younger than 4 months. Whether colic exists as a separate entity or as a symptom of a maternal
problem is often debated.
In a recent Australian study 60% of parents reported that their babies had suffered from colic.
Even though colic is common is can be very distressing for the parents and other family members.
Inconsolable, unexplained and incessant crying in a seemingly healthy infant gives rise to tired,
frustrated and concerned parents (1).
Normal patterns of crying
All infants, whether or not they have colic, cry more during the first 3 months of life than at any
other time. One study describes crying patterns – crying lasted approximately 2 hours per day
at 2 weeks of age, increased to a peak of 3 hours a day at 6 weeks, and gradually decreased to
about 1 hour by 3 months of age. The hypotheses for these findings were that the accumulated
excitement caused by environmental stimuli during the day was discharged in the form of crying
during late afternoon and evening (2).
Most of the features of crying in infants with colic also occur in normal infants but with less
frequency and shorter duration.
A commonly used criterion for defining colic is the Wessel’s rule of threes, which states that
infantile colic involves crying lasting for at least 3 hours a day, for at least 3 days in any week, for at
least 3 weeks in the first 3 or 4 months of life.
There have been many articles and research reports published, yet still little is known about
the cause or what to do about it. Some studies suggest colic can be caused by food allergies,
gastrointestinal problems, environmental and behavioural factors. Others suggest that it is normal
for infants to fuss and have increasingly longer bouts of crying from birth to about 6 weeks, after
which the crying decreases.
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
Changes in diets and restrictions on individual foods have had a very limited success in the
treatment of colic. Ensure dietary modification or pharmacological intervention is safe and does
not result in nutritional deficiencies.
Tips for practice
■■ Provide reassurance that the infant is healthy.
■■ A thorough examination and history should be conduced to eliminate other possible
physiological problems.
■■ Establish if the infant is crying for other reasons such as hunger, temperature, boredom.
■■ Establish the infant’s diet, indications of reflux, sleeping patterns, bowel and urination
patterns.
■■ Ask about the general well being of the parents and the social situation of the infant.
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9
Resources
www.raisingchildren.net.au/articles/colic:_what_to_do.html/context/255
www.raisingchildren.net.au/articles/colic:_what_is_it.html
www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=304&id=1735
www.gut.nsw.edu.au/pcinfo1.htm
www.gut.nsw.edu.au/free1.htm
www.healthinsite.gov.au/
www.healthinsite.gov.au/topics/Colic
References
1. JBI 2004, The Effectiveness of Interventions for Infant Colic, Best Practice 8(2) 1-6.
www.joannabriggs.edu.au/pdf/BPIScolic.pdf
2. Turner T.L., (2006) Clinical features and aetiology of colic: [online] 18th April 2007,
www.uptodateonline.com/utd/content/topic.do?topicKey=behaviour/2155
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7.3 Constipation – keeping things moving!
Recommendations from the Dietary Guidelines for Children and
Adolescents in Australia
To avoid unnecessary intervention, parents need to be educated about the wide variation in normal
bowel function in infants (particularly those who are breastfed) and toddlers.
There have been some recent changes in the way constipation is being managed. This section will
give you an overview of management plans, and provide some detailed advice on when referrals
are necessary.
A normal pattern of stool evacuation is thought to be a sign of health in children of all ages.
Especially during the first months of life, parents pay close attention to the frequency and the
characteristics of their children’s defecation. Any deviation from what is thought by any family
member to be normal for children may trigger a call to the nurse or a visit to the paediatrician (4).
Stool consistency and frequency can be very variable in infants and children. Healthy breast or
formula fed infants may pass stools as regularly as after every feed or as seldom as once a week.
As long as the stools are soft and easily passed and the infant is continuing to grow appropriately,
there is generally no cause for concern. Some foods will change stools to a different colour, for
example, spinach may cause dark green stools or beetroot may cause a reddish colour.
Chronic constipation is a source of anxiety for parents who worry that a serious disease may be
causing the symptoms (4).
Constipation in childhood is common, with a reported prevalence ranging from 0.3 – 28%. Faecal
soiling occurs in 1 – 3% of children aged 4 – 7 years (2).
Symptoms persist beyond puberty in about 30% of children with constipation and soiling (2)
Definition
An infant or child is considered constipated if there is pain associated with passing stools and
the stools are hard or dry. Infrequency is insufficient grounds upon which to make a diagnosis of
constipation. However, there is general acceptance that it is abnormal to have
■■ stool frequency of less than 3 times per week,
■■ hard painful defecation
■■ periodic passage of very large amounts of stool at least once every 7 – 30 days
■■ or a palpable abdominal or rectal mass on physical examination (2).
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13
Normal bowel function
What is striking is the variance of normal frequency of bowel movements, particularly in infants;
breastfed babies 0 – 3 months old, range from 5 – 40 bowel movements per week (4).
Normal bowel function (1, 2, 3)
■■ First bowel action consists of meconium, which is greenish-black
■■ 24 – 48 hours meconium changes; brown transitional stools
■■ Breastfed:
■■
3rd or 4th day, mustard coloured
■■
May also be green or orange
■■
Milk curds may be present
■■ 6 weeks to 3 months - number of bowel motions decrease; intervals of several days or
more are common
■■ Babies older than 2 months may normally have infrequent stools, sometimes up to 1 – 2 weeks apart (1)
■■ Formula fed babies pass fewer stools, once a day or every second day, khaki coloured
and plasticine like consistency
Meconium is passed within the first 24 hours in about 87% of infants and within 48 hours by 99%;
this is not influenced by whether the infant is receiving breastmilk or formula (2).
Subsequently, however, the method of feeding has a significant impact on stool frequency, colour
and consistency. Breast-fed infants pass softer, uniformly yellow stools up to 5 times a day. This
is more frequent than in bottle-fed infants. However, breast-fed infants may occasionally have no
bowel actions for 3 days or more, which is rare in bottle-fed infants. Within the first few weeks of
life, 64% of breast-fed, but only 30% of bottle-fed, infants are having more than 3 bowel actions a
day (2).
Stool frequency reduces progressively with age, so that by 16 weeks of age both breastfed and
bottlefed infants are passing on average 2 stools a day.
Hard, dry motions are more likely to occur after formula or solids are introduced (1).
Please note: continued passage of meconium in the first couple of months may be a sign of
inadequate milk intake and may be the first sign of an underfed baby (1). See Failure to Thrive section.
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Aetiology of constipation
The aetiology of constipation and soiling is multifactorial.
Functional constipation (2,4)
Constipation without objective evidence of a pathological condition. It is most commonly caused
by painful bowel movements with resultant voluntary withholding of faeces by a child who wants to
avoid unpleasant defecation (see Box 2). Withholding faeces can lead to prolonged faecal stasis in
the colon, with reabsorption of fluids and an increase in size and consistency of the stools.
p to 63% of children with constipation and faecal soiling will have a history of painful defecation
U
beginning before 3 years of age and secondary withholding behaviour (2).
Events leading to painful defecation (4)
■■ toilet training
■■ changes in routine or diet
■■ stressful events
■■ intercurrent illness
■■ unavailability of toilets
■■ the child’s postponing defecation because he or she is too busy.
Recognising the signs to prevent functional constipation: ‘withholding’
The passage of large hard stools that painfully stretch the anus may frighten the child, resulting in
a fearful determination to avoid all defecation. Such children respond to the urge to defecate by
(2,4):
■■ contracting their anal sphincter and gluteal muscles, attempting to withhold stool
■■ rising on their toes and rocking back and forth while stiffening their buttocks and legs
■■ wriggling or fidgeting
■■ assuming unusual postures
■■ crossing their thighs
■■ walking on tiptoes to clench their buttocks
■■ performing these actions often while hiding in a corner
Often parents believe this behaviour is the child attempting to defecate (4)
Eventually the rectum habituates to the stimulus of the enlarging faecal mass, and the urge to
defecate subsides. With time, such retentive behaviour becomes an automatic reaction. As the
rectal wall stretches, faecal soiling may occur (4), during spontaneous relaxation of sphincters
(2) angering the parents and frightening the child. After several days without a bowel movement
irritability, abdominal distension, cramps, and decreased oral intake may result (4).
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15
Fibre, fluid and exercise
Slowed colonic transit as a cause of constipation in childhood is also well recognised, as is the
association of low fibre intake with hard, infrequent stools (2).
There is a strong correlation between dietary fibre intake and mean daily stool weight. Cereal fibre
has been found to improve bowel function by increasing faecal bulk and reducing transit time,
resulting in softer, larger stools and more frequent bowel action.
For children aged 1-3 years the average intake of fibre is 14g/day and 18g/day for 4-8 year
olds. Diets rich in insoluble fibre—such as that present in wholegrain cereals and breads - are
associated with a low prevalence of constipation and diverticular disease (1).
For children aged 1-3 years the average intake of fluid is 1 litre/day and for 4-8 year olds it is 1.2 litres/day.
Fibre content of foods
Food Group
Bread, cereal, rice,
pasta, noodles
Food Item
Fibre (grams)
wholemeal bread (1 slice)
white bread (3 slices)
cooked rolled oats (½ cup)
2g
brown rice (1 cup) Bran Flakes (½ cup)
muesli (2 Tbsp)
4g
Weetbix/Vitabrits (2)
All Bran (≈ cup)
cooked wholemeal pasta (1 cup)
8g
Sultana Bran (1≈ cups)
Fruit and Vegetables
4-5 medium prunes
½ medium apple/pear/orange
1 medium banana
½ punnet strawberries
30 g sultanas
2-3g
½ cup tinned fruit
1 small potato, peeled
1 cup mushrooms
3 brussel sprouts
Legumes and Pulses
½ cup baked beans
≈ cup kidney beans
Nuts and Seeds
30 g almonds (shelled)
60 g peanuts (shelled)
2 Tbsp linseed
30 g sunflower seeds
16
8g
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5g
Cow’s milk protein allergy
It has recently been recognised that one of the manifestations of the spectrum of cow’s milk protein
allergy in early childhood is constipation (2).
In one study the “relationship between cow’s milk protein intolerance and chronic constipation
was observed. In 28% of the children, constipation disappeared during the CMP-free diet and
reappeared after the challenge” (5).
These results suggest cow’s milk protein intolerance must be considered in the differential diagnosis
of chronic constipation’ (5). ‘In children unresponsive to conventional medical and behavioural
management, consideration may be given to a time-limited trial of cow’s milk-free diet (6).
In children between 1 – 4 years of age, a history of allergy, anal fissure or abdominal discomfort may
suggest allergy to cow’s milk protein, justifying a 2 week trial of restriction of cow’s milk protein (2).
Refer to dietitian
Clinical presentation of constipation
Table 16
Clinical presentation of constipation (2)
First week of life
Delayed passage of meconium beyond the first 48 hours, suggests
either an anatomical obstruction, such as anal atresia or stenosis, or
Hirschsprung’s disease
Before introducing
solids
Formula fed infants pass harder stools
May present with difficult passage of hard stools, occasionally a
fissure
Breastfed infants unlikely to present with hard stools, but stools may
be infrequent. Breastmilk is so good there is nothing to waste (1)
Introducing solids
Common for both breast and bottle fed infants to change bowel
functioning. Constipation may first present here
Toilet training
May be associated with development of withholding behaviour and
functional faecal retention
Adapted from Catto-Smith et al (2005) (2)
Exclusively breastfed infants are rarely constipated. Many breastfed infants show signs of discomfort
or distress before passing a motion: this is a normal response to body sensations they are not used
to. It does not indicate pain or constipation (1)
Management of children with constipation
Evidence Based Practice tip: A combination of behavioural therapy and laxatives is more effective
than behavioural therapy used alone (2).
Education
Both parent and child need to understand that constipation and faecal soiling are common,
and are likely to improve with age and simple therapies. The easiest way to explain soiling is to
emphasise the loss of conscious awareness of the need to defecate that comes with chronic
rectal distension with faeces (2). The emphasis on ‘keeping the rectum empty’ is likely to alleviate
blame, and improve cooperation and compliance (2)
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17
Maintenance therapy (2)
■■ Establishing a regular toileting regime, generally about 2 to 3 times per day for 5-10 minutes at a time after meals.
■■ Ensure appropriate toileting posture and comfortable foot support with feet flat.
■■ If dietary fibre is deficient, it should then be optimised. Dietary changes are unlikely to be
helpful if the main mechanism of constipation is withholding behaviour.
■■ A diary is helpful, and can be linked to a reward chart. Encourage parents to record
toileting frequency, successful passage of stool in the toilet, soiling free days, daily
medications and episodes of soiling.
Stool reimpaction is less likely to occur if stools are being passed daily (2).
When to refer
Referral of a child for specialist advice should be considered when:
1 impaction is suspected – referral to general practitioner, hospital or paediatrician
2 symptoms of constipation do not respond to treatment in general practice after 3-6 months
3 there is frequent soiling and distress
4 in doubt about the cause of the symptoms
5 the condition is interfering with the child’s schooling or social relationships
Relapse
A significant proportion (30-50%) of children will relapse after being successfully treated for
constipation (2)
Long term relapse is more frequent in children under 4 years at the onset of symptoms and in
whom there is a history of faecal soiling associated with constipation (2).
Initial review should be after 1-2 weeks, then monthly, and eventually at 3 monthly intervals.
Maintenance therapy and follow up should be continued for at least 6 – 24 months. A trial of
weaning from the use of laxatives should be attempted at 6 monthly intervals (2). It is imperative
to stress to caregivers the importance of long term maintenance therapy, including the use of
laxatives.
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References
1. Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant
Feeding Guidelines for Health Workers, NHMRC, Canberra 2003.
2. Catto-Smith AG., (2005). Constipation and toilet issues in children. MJA Practice
essentials –Pediatrics 182 (5) 242-246
3. Breastfeeding management, Australian Breastfeeding Association. 3rd edition (2004).
Wendy Brodbirbb. Ligare
4. Baker SS, Liptak GS, Colletti RB., Croffie JM., Di Lorenze C., Ector W., Nurko S (1999)
Constipation in Infants and Children: Evaluation and Treatment. Journal of paediatric
gastroenterology vol 29(5) pp 612-626
5. Daher S., Tahan S., Sole D., Napitz CK., Patricio FRS., Fagundes-Neto U., Morris MB.
Cows milk intolerance and chronic constipation in children. Paedatric Allergy Immunology
2001: 12: 339-342
6. 2006. Clinical Practice Guideline: Evaluation and Treatment of Constipation in Children:
Summary of Updated Recommendation of the North American Society for Paediatric
Gastroenterology, Hepatology and Nutrition. Journal of Gastroenterology and Nutrition 43:
405-407
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19
7.4Failure to Thrive
(Slow weight gain and undernutrition)
Failure to Thrive (FTT) has been recognised as more of a clinical description of growth failure in
infants and children, rather than a stand alone diagnosis. FTT continues to be used as a blanket term
for children, especially infants with perceived growth abnormalities (1). Now it is accepted that FTT
has a predominantly nutritional cause, it has been suggested slow weight gain or undernutrition are
reasonable alternate terms.
The most serious consequences of an inappropriate food intake in infancy and early childhood
are underweight and failure to thrive. In Australia, in recent years, concern about the prevalence
of underweight and failure to thrive in infancy and childhood has largely focused on Indigenous
communities, where the aetiology of the problem rests in a complex mix of social and economic
factors (2).
Failure to thrive among other sections of the community is also most commonly a result of
psychosocial factors, including poor living conditions (2).
The literature provides evidence that from time to time cases of failure to thrive also occur in
more affluent sections of the community as a consequence of parents inappropriately restricting
the dietary intake of young children because of fears about obesity and atherosclerosis or the
development of ‘unhealthy’ dietary habits. Such cases are, however, relatively rare compared with
the problem of dietary restriction in older children and adolescents (2).
Although it is now accepted that FTT has a predominantly nutritional cause, the implication of an
association with emotional and physical deprivation persists (3).
There are a number of causes of failure to thrive and referral to a medical practitioner
is recommended. If undernutrition is diagnosed, a dietitian/nutritionist will help in the
management of this problem.
Definition
Failure to thrive is a condition characterised by failure of expected growth (usually weight)
(3,4,5). Onset often occurs within weeks of birth and with hindsight growth faltering is clearly
evident on growth charts by 6 months. Failure to thrive often persists up to the age of 5 years (5).
Currently, there are no nationally or internationally standardised guidelines for diagnosing FTT.
In studies reviewed, chronic poor weight gain is the most commonly used feature for diagnosis
failure to thrive. Chronic poor weight gain includes growth deviation from the expected weight
percentiles, a trend, which may also be reflected in the height percentiles (6).
Chronic poor weight gain may include:
■■ inadequate weight gain
■■ static weight
■■ intermittent periods of poor growth.
An adequate assessment must be based on a series of accurate measurements of both length
and weight. Long term length and weight changes are desirable (refer to growth chart section).
Head circumference should also be monitored (7).
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Growth
Normal growth (1)
Growth and development represent the end product of a multitude if factors both intrinsic and
extrinsic to the infant or child. Normal growth is as much dependant on the genome of a particular
individual as it is the external environment in which the individual thrives. Therefore, regular routine
monitoring of growth indexes represents one of the most important responsibilities facing health
professionals.
Although newborn size is dependant on intrauterine factors, growth during infancy is largely
nutritionally driven. There is transition from the nutrition based growth of infancy to the growth
hormone dependant childhood phase.
Factitious failure to thrive (1)
Normal growth is highly variable. Some physiological adjustments such as constitutional growth
delay, familial short stature and intrauterine growth retardation do not represent true failure to
thrive or paediatric undernutrition.
■■ Familial short stature:
■■
infants have a decreased growth velocity between 6 and 18 months pf age
■■
gradually these infants will fall into a new, genetically predetermined, percentile
■■
after this deceleration of growth, they have normal growth rate along their new
centiles
■■
characteristics include normal birth weight and length, but frequently a family history
of short stature
■■
infants with normal short stature have normal skeletal maturation
■■ Constitutional growth delay:
■■
deceleration in growth velocity that occurs before 2 years of age, and can begin
before 6 months of age
■■
also a decrease in weight for length caused by slow gaining of weight
■■
deceleration of growth usually ends by 3 years of age, followed by normalisation of
growth rate, albeit below the 3rd centile
■■
family history of growth delay characterised by features such as delayed puberty or
menarche in a parent
■■
boys are more commonly affected than girls
■■
increased growth potential during childhood
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21
■■ Intrauterine growth retardation (IUGR):
■■
infants who are small for their gestational age, and tend to have global growth
retardation
■■
catch up growth usually occurs before 2 years of age
■■
those infants that fail to display catch up growth, typically remained small, and
growth proceeds very slowly
■■
28% to 70% are believed to be constitutionally small, displaying their genetic
predisposition, with the remainder of the infants expressing IUGR caused by
underlying pathological processes, and overlapping problems such as malnutrition or
substance abuse are recognised contributors
■■
it is important to realise, by assessment of growth indexes, growth rate and history
that iugr infants may be growing normally while not achieving catch up growth
Causes of failure to thrive (3)
“Traditionally, FTT has been subdivided into organic or non-organic in nature. Studies have found
5% or less have major organic diseases, mostly diagnosable from other signs and symptoms”
(5).
■■ Abuse and neglect – Two studies have found that between 5 - 10% of children with
FTT have been registered for abuse or neglect. “However, the study of Skuse and
colleagues found that children with FTT were four times more likely to be abused than
controls” (3).
■■ Emotional – does not appear to be strongly linked to FTT (3,5)
■■ Undernutrition – Most children with FTT have been found to be substantially
underweight for height
“Simply, there are inadequate calories for growth and development. The undernourished state
occurs either by, or a combination of (1)
■■ inadequate supply of calories
■■ impaired or excessive utilisation of calories”
“It might seem puzzling that a healthy child in a loving affluent home can become undernourished.
This is less so when one recognises the high energy needs of infants: approximately three times
those of adults (for each kg body weight)” (3).
The fastest decline in weight gain occurs in the early weeks of life, when energy needs are the
highest and the highest proportion is required for growth.
Catch up growth may then not occur for some time, if subsequent intake is merely sufficient for
immediate needs. A wide range and combination of factors may contribute to either the decline or
the failure for catch up. For example, at the age of 14 months, children with FTT have a relatively
delayed progression on to solid foods, poorer appetites and eat a more narrow range of foods (3).
22
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Consequences (1,3)
■■ Growth – the natural history of FTT is gradual improvement
■■ Cognition – evidence suggests that although FTT probably influences development in
the short term, a permanent effect on head circumference and brain growth is
possible.
Primary care management
A home visit might reveal obvious dietary issues and this input alone often results in improvement.
It is crucial that parents are told at an early stage and in simple terms that under nutrition is the
likely cause, while emphasising what a common phenomenon it is.
Weighing
Routine weight monitoring at birth, at 6-8 weeks and at 8-12 months as part of routine clinical care
(3, 5). Weight monitoring (particularly if conducted frequently) can lead to parent anxiety if a baby
is seen not to be gaining weight fast enough or too fast… (5)
Dietary assessment
“A fifth of the children showed an improvement in their growth pattern immediately after dietary
advice” (3).
The purpose of the assessment is to identify potential areas for tailored intervention, not to
diagnose dietary insufficiency.
A firm grasp of the energy balance equation is essential for the successful management of FTT.
However much food a child appears to be consuming, if they are underweight for height and
failing to gain weight at the expected rate, or failing to catch up, they are not consuming sufficient
for their needs and advice on energy enhancement is required (3).
Toddlers with FTT often have a low intake of immature, low energy foods, with a high fluid intake.
Thus the aim of management is to expedite their progression on to more energy dense solid
foods. Liquid supplements or tube feeding merely delay this, whereas hospital admission exposes
children to the risk of infection and further disruption to routines. The dramatic gains that can be
made at home in response to advice and support alone are often not appreciated (3).
The role of the general practitioner / paediatrician
If medical causes are suspected, investigations should be undertaken. Most tests are undertaken
to exclude pathology rather than to arrive at a diagnosis.
Improvement in growth should be evident approximately 1-3 months following initiation of treatment (5)
See Table 18 on following page.
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23
Table 18
Possible strategies for increasing energy intake
Dietary
✔✔
Small, frequent meals: aim for three meals and two to three snacks each day
✔✔
Increase number and variety of foods offered
✔✔
Increase energy density of usual foods (for example, add cheese, margarine, and cream)
✔✔
Decrease fluid intake, particularly carbonated drinks
Behavioural
✔✔
Offer meals at regular times, eaten with other family members
✔✔
Praise when food is eaten
✔✔
Gently encourage child to eat, but avoid conflict
✔✔
Never force feed
Adapted from Wright, 2000 (3)
It must be stressed again that the introduction of solids and the rate at which acceptance and
progression of solids occurs, is very much moderated by the individual child and his/her particular
developmental patterns.
Checklist for failure to thrive (adapted from 6)
If the infant is breastfed
YES
Is he/she feeding well? (ie position and attachment)
Is he/she feeding frequently (8-12 feeds per day)
Is there adequate milk supply?
Does the infant have
■■ reflux
■■ vomiting
■■ diarrhoea
Does the infant have ‘normal’ bowel motions
Is the infant passing adequate urine?
(6-8 wet cloth nappies or 4 wet disposable nappies a day)?
Adapted from Tuckertalk 2003
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NO
If the infant is bottlefed
YES
NO
Is the infant formula being made up correctly?
Is the correct (adequate) volume of formula being given?
Does the infant have
■■ reflux
■■ vomiting
■■ diarrhoea
Does the infant have ‘normal’ bowel motions
Is the infant passing adequate urine?
(6-8 wet cloth nappies or 4 wet disposable nappies a day)?
Adapted from Tuckertalk 2003
If the infant is taking solids
(to be used in conjunction with either the breastfed or formula fed sections)
YES
NO
YES
NO
Have solids been introduced at an appropriate age (around 6 months)
Are the solids appropriate for the age of the infant
■■ Cereal products
■■ Meats
■■ Fruits
■■ Vegetables
Feeding schedule
Number of solid feeds / day
Solids offered before or after feeds
Additional fluids offered?
■■ Type __________________________
■■ Quantity _______________________
Adapted from Tuckertalk 2003
Older children
Are a variety of foods from the five food groups being eaten?
Is the child being offered regular meals at structured times?
Is food being displaced by cordials, fruit juices and carbonated drinks?
Does the child have abnormal bowel motions (diarrhoea, fatty stools)?
If yes, refer for a medical review
Is food high in fibre but low in energy displacing other foods?
Adapted from Tuckertalk 2003
It is often possible to troubleshoot and solve problems associated with nutrition by working through
the checklist as above.
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25
Tips for practice:
If an infant or child is not experiencing any difficulties with any of the previous checklist points and
there is no medical reason for the failure to thrive according to medical examinations, but is still not
gaining weight, it may simply be that the infant requires more food.
This is a special situation and requires additional thought. Extra energy can be added by offering a
high energy/high protein meal plan using the recommendations in the next section.
If unsure refer to dietitian for assessment and advice.
References
1. Jolley C.D., Failure to Thrive Curr Probl Pediatr Adolesc Health Care 2003;33:183-206
2. Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant
Feeding Guidelines for Health Workers, NHMRC, Canberra 2003
3. Wright C.M., Identification and management of failure to thrive: a community perspective.
Arch Dis Child 2000: 82:5-9
4. Olsen E.M., 2006 Failure to Thrive: Still a Problem of Definition. Clinical Paediatrics 45:1-6
5. Child Health Screening and Surveillance: 2002 A critical Review of the evidence. NHMRC
[online] 13th April 2007 www.nhmrc.gov.au/publications/synopses/_files/ch42.pdf
6. Community Population and Rural Health (2003). Tuckertalk (child nutrition) fully revised.
Tasmania,
7. Shaw V., Lawson M., Clinical Paediatric Dietetics, 1994. Blackwell Sciences, London
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7.5 Fluoride
Fluoride is a naturally occurring compound found in water, plants, rocks, soil, air and most foods.
It helps protect against tooth decay. Water fluoridation is the most effective way for everybody
to access the benefits of fluoride. Less than 5% of Queensland water is currently fluoridated.
Encourage parents/caregivers to check with their local council to determine if the water is
fluoridated.
Tooth decay occurs when acid destroys the outer surface of the tooth. The acid is produced from
sugar by bacteria in the mouth. Fluoride makes teeth more acid resistant and also helps repair
damage before it becomes permanent.
Tooth decay is the single most common chronic childhood disease. Queensland children have
significantly higher rates of tooth decay than the national average, not only higher than the national
average, but worse than any other state.
Fluoride and breastfeeding
Breastmilk naturally contains 5 – 10 micrograms of fluoride per litre of milk (optimally fluoridated
water contains 1000 micrograms per litre). The level of fluoride in breastmilk remains steady when
a nursing mother drinks fluoridated water.
Fluoride and formula feeding
Reconstitution of infant formula with fluoridated water may pose a slight risk of very mild or mild
dental fluorosis in children. Parents should weigh the balance between a child’s risk for dental
fluorosis and the benefit of fluoride for preventing tooth decay when making a decision on whether
or not to use fluoridated water for such purposes.
Fluoride guidelines
Fluoride supplements should only be used when prescribed by a dental professional and are not
recommended for general use. They do not provide the same benefit as fluoridated water and can
be harmful if taken inappropriately.
Fluoride toothpaste should be used for tooth cleaning as below:
Table 19
Fluoride is important to healthy teeth
Water supply
Not fluoridated
Fluoridated
Birth – 6 months
As soon as teeth appear, clean them twice a day with a wet, child sized
soft toothbrush without toothpaste.
6 – 18 months
Clean teeth twice a day with a low
fluoride paste.
18 months – 5 years
Clean teeth twice a day with low fluoride paste.
6 years and over
Clean teeth twice a day with standard fluoride paste.
Clean teeth twice a day with a wet,
child sized soft toothbrush without
toothpaste.
Adapted from Fluoride script pad. For copies contact QH Oral Health Unit [email protected]
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27
Useful websites and resources
Taking care of your baby’s teeth – child health fact sheet
www.health.qld.gov.au/phs/documents/cyhu/28096.pdf,
QH Water Fluoridation Questions and Answers
www.health.qld.gov.au/oralhealth/documents/30265.pdf
Information Bulletin for community. Fluoridation of water supplies and your Health, Queensland
Health: Oral Health Unit, 2005
www.health.qld.gov.au/phs/documents/ohu/30268.pdf
Queensland Health. Water fluoridation: helps protect teeth throughout life
Queensland Health: Oral Health Unit, 2005
www.health.qld.gov.au/oralhealth/documents/31293.pdf
Queensland Health Water fluoridation: information for health professionals. Queensland Health:
Oral Health Unit, 2005
www.health.qld.gov.au/fluoride/health_professionals.pdf.
QH fluoride fact sheet
www.health.qld.gov.au/phs/Documents/ohu/21922.pdf.
The health of Queenslanders CHO report 2006
www.health.qld.gov.au/cho_report/documents/32048.pdf
For more information please email [email protected]
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7.6 Gastroenteritis
Gastroenteritis is the term used to describe acute, infective diarrhoea and is commonly caused
by pathogens such as viruses, bacteria and parasites. The most common cause of gastroenteritis
in children less than 2 years is Rotavirus; however, it is rarely seen in infants less than 6
months of age. An infant or child with gastroenteritis most often presents with vomiting and
diarrhoea. Diarrhoea is defined as an increase in the frequency, fluidity and volume of stools. The
gastrointestinal loss of water and electrolytes accompanying this is the most common cause of
dehydration in infants and children. The more watery and frequent the diarrhoea, the greater the
risk of dehydration (particularly if vomiting is also associated).
Management
A child who has diarrhoea and/or vomiting is at risk of dehydration and should be seen by a
doctor. Do not give medicines to stop vomiting or diarrhoea.
Solely breastfed
■■ Continue breastfeeding (there is no need to cease feeding).
■■ Ensure fluid and electrolyte losses are recovered by either:
■■
Increasing the frequency of breast feeds
■■
Offering additional clear fluids such as cooled, boiled water between feeds
Formulafed
■■ Continue normal strength formula feeds.
■■ Ensure adequate hydration/rehydration by offering extra clear fluids.
■■ If formula feeding has been stopped reintroduce formula after 24 hours.
Solids
■■ Reintroduce food within 24 hours even if diarrhoea has not settled.
■■ Ensure adequate hydration/rehydration by offering extra clear fluids.
■■ Suitable foods include bread, potatoes, rice, noodles, vegetables, plain meats, fish and
eggs.
Consult a doctor if one or more of the following applies:
■■ the infant is less than 6 months of age
■■ diarrhoea is profuse eg 8 – 10 watery stools
■■ diarrhoea or vomiting lasts longer than 24 hours
■■ the infant or child is vomiting and cannot keep fluids down, will not drink, or has not
passed urine in 4 – 6 hours
■■ there is stomach pain or blood in the diarrhoea
■■ there is a persistent high fever > 39.5 o C.
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29
It is essential, when treating gastroenteritis to:
Ensure that the infant/child remains hydrated by correcting and preventing further losses of fluids
and electrolytes.
Reintroduce foods as soon as possible in order to prevent prolonged nutritional deficit.
Research has shown that refeeding, sooner rather than later, reduces the duration of diarrhoeal
disease.
Signs of dehydration (1)
Mild – 5% body weight loss, thirsty, alert, restless, otherwise normal
Moderate –6 –9% body weight loss, thirsty, restless, lethargic but irritable, rapid pulse normal
blood pressure, sunken eyes, sunken fontanelle, dry mucous membranes, absent tears, pinched
skin retracts slowly, decreased urine output
Severe – 10% or more body weight loss, drowsy, limp, cold, sweaty cyanotic limbs, comatose,
rapid feeble pulse, low blood pressure, sunken eyes and fontanelle, very dry mucous membranes,
pinched skin retracts slowly, no urine output.
Recommended hydration strategies for the dehydrated
child
If a child is dehydrated medical attention should be sought.
Oral Rehydration Solution (ORS):
Are the best clear drinks for babies (of any age) and children with gastroenteritis because:
■■ they have the right amounts of sugar, salt and water to be easily absorbed in the gut
■■ must be made exactly according to directions in the package
■■ include Gastrolyte, Gastrolyte-R, Pedialyte, Repalyte (New Formulation) and Hydralyte**
(ice blocks)
■■ available from chemists in Australia. Always ask the pharmacist which one would be
best
■■ these solutions are the fluid of choice for treating dehydration. The absorption of glucose
and sodium is linked together and acts as a pump, promoting the absorption of water.
They supply fluid, glucose, and help correct electrolyte imbalances. It is best to provide
ORS in small, frequent doses 10 – 20ml every 10 minutes
■■ review child after 24 hours for rehydration status.
Please refer to:
Queensland Health, Southern Zone paediatrics parent information – gastroenteritis in children qheps.health.qld.gov.au/twmba/Pdf/SZ_gastro_fact.pdf
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Recommended hydration strategies for the
non‑dehydrated child
Usual maintenance fluids per hour is on a sliding scale:
First 10 kg 4 ml/kg/hr. Next 10 kg 2 ml/kg/hr.
Every kg over 20 - 1 ml/kg/hr.
For example- for a 30 kg child (40 ml + 20 ml + 10 ml) = 70ml per hour.
Give small amounts frequently.
Full strength fruit juice, lemonade, cordial and sports drinks should not be used. The high sugar content draws water into the bowel and can make diarrhoea worse.
Do not give low joule drinks.
Dilution rates for fluids for use in non-dehydrated children
Cordial 15 ml in 235 ml water
Soft drinks (not low joule) 50 ml soft drink in 200 ml water
Unsweetened fruit juice 50 ml fruit juice in 200 ml water
ORS reconstituted as directed
Sample meal plan
Breakfast
Cereal
Apple juice
White toast with scrape of margarine and Vegemite
Lunch
1 slice white bread with Vegemite
Tinned/stewed fruit
Jelly
Dinner
Lean meat
Mashed potato (no butter or milk added)
Mashed pumpkin (no butter or milk added)
Gravy
Tinned/stewed fruit
Jelly
Adapted from Westmead Children’s Hospital, 2004 (2)
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31
Useful webstes and resources
Fact sheets
When your child is sick – child health fact sheet [accessed 2007 April 27] www.health.qld.gov.au/child&youth/factsheets/
Gastro fact sheet CYH SA [accessed 2007 April 27]
www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=303&id=1845#6
Gastro fact sheet Children’s Hospital Westmead [accessed 2007 April 27]
www.chw.edu.au/parents/factsheets/gastroj.htm
Websites
Australian Gastroenterology Institute website [accessed 2007 April 27]
www.gesa.org.au/
References
1. Department of Health and Human Services. TuckerTalk Manual: keeping abreast of
nutrition. Tasmania; 2003.
2. Westmead Children’s Hospital; James Fairfax Institute of Paediatric Nutrition. The feeding
guide: a handbook on the nutritional composition of infant formula. Sydney: Westmead
Children’s Hospital; 2001.
3. Department of Nutrition and Dietetics; Mater Children’s Hospital. Gastro children’s
guidelines. Brisbane.
4. Gut Foundation. Diarrhoea in children. Randwick, Sydney: The Foundation.
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7.7 Growth charts
Growth has been used as a tool to assess the health status of populations and individuals. Growth
is a common measure of physical development and nutritional intake, and a change in growth may
lead to nutritional intervention. The growth of an individual is compared with ‘expected growth’
and conclusions are drawn about the individual and interventions consequently planned.
Understanding the applicability and interpretation of the growth charts is essential in accurately
assessing growth. This is important because the pattern of growth is different between a
breastfed infant and a formula fed infant.
In the first 6 months breastfed babies are typically heavier than formula fed babies. Compared to
breastfed babies of the same percentile, formula fed babies are lighter in the first 6 months and
become increasingly heavier from 6 months to approximately 18 months. Because formula fed
infants are heavier after 6 months, it is a common mistake to misdiagnose breastfed infants as
having compromised growth.
Types of charts
There are currently a number of growth charts available for use in Australia. The table below
describes them. At the time of printing, Queensland Health is reviewing the growth charts to be
used. Currently the CDC 2000 charts are published in the personal health record.
Table 20
Comparison of CDC2000 and WHO growth charts
Chart
Presentation
Data source
Endorsement
CDC
2000
In Personal Health
Record. Purple ‘Pfizer’
chart. Available for clinical
chart or at www.cdc.
gov/growthcharts/
A range of US studies
including 3 cycles of
NHANES from 1966 –
1994. All subjects from
US but mix of race and
ethnicity, breastfed and
formulafed. For children
0 – 2 years.
Currently recommended
for use.
Released April 2006.
Multicentre Growth
Reference Study 1997
– 2003. Children from
Brazil, Ghana, India,
Norway, Oman and US.
All exclusively breastfed
for 4 – 6 months with
continued breastfeeding
to at least 12 months.
WHO
WHO
Available at www.who.int/
childgrowth/standards/
en/
For children 0 – 5 years,
then use of CDC 2000
recommended.
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Endorsed by NHMRC,
Australian Paediatric
Endocrinology Group,
Australian College of
Paediatric and Child
Health Nurses
International Pediatric
Association
Australian Medical
Association
International Lactation
Consultants Association
Australian Breastfeeding
Association
33
Using growth charts
Regular and consistent growth monitoring is more important than the
chart used.
■■ The pattern of growth is more important than a single plot. It should follow the line of the
curve, irrespective of its centile.
■■ Growth measurements must be accurately recorded on the growth chart.
■■ Refer children who, over a series of readings are not following the shape of the curve.
Note the difference in patterns of growth between breastfed and formula fed infants.
■■ Ensure the correct stature chart is used. ‘Length’ refers to a child lying down. ‘Height’ refers to a child standing up. These values will differ.
■■ When taking weight measurements, ensure the same scales are used wherever
possible, they are routinely calibrated and the infant is wearing minimal clothing.
■■ Encourage parents/caregivers to understand and interpret growth charts.
■■ Allowance for gestational age is made for children born under 37 weeks. Generally the
allowance should be made until the child is 2 years of age and up to 5 years of age for
extreme prematurity, for example, less than 28 weeks.
■■ For example, if an infant born at 32 weeks gestation visits the Child Health Centre at 8 weeks of age the weight will be plotted at the age of 40 weeks gestation.
Weight and length/height
Length/height is a mandatory component of the growth assessment; weight is meaningless unless
a corresponding length/height is done simultaneously.
Action
For infants under 12 months of age, action will be required if the weight differs by 2 percentile lines
or greater compared to the length.
Poor growth
While there is no standard ‘cut off’ for defining short or tall stature, traditionally it has been
recommended that children falling below the 3rd centile be referred for further assessment.
FTT is often defined as an absolute weight criterion, for example, a drop below the 3rd centile for
weight or the 5th centile or when growth deviates from an established growth curve for 3 consecutive months. This approach is likely to identify false positives, for example, naturally
small children, while missing naturally tall children with a FTT issue. A judgement should be made
according to a fall on a centile chart over a period of time/visits or where children’s weight is 2 centile lines less, compared with their height.
NB: Weight gains in infants are often step-wise rather than a constant process; therefore the trend
over time is more important than individual weights.
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Overweight and obesity
Children less than 2 years
Young children whose weight is greater by 2 centile lines or more compared to their length may
require intervention and referral.
Children over 2 years
BMI
To determine whether an older child is overweight or obese it is necessary to calculate Body Mass
Index (BMI) and plot the result on an appropriate BMI percentile chart for the child’s age and sex.
Calculation of BMI
BMI = weight (kg)
height (m)2
For example :
A 2 year old child who was 87cm tall and weighed 13kg would have a BMI of 17
BMI = 13 / (0.87 x 0.87kg/m2)
BMI = 17
This would put the child just above the 50th percentile for BMI.
A child is overweight if their BMI is at or above the 85th percentile.
Such a child requires intervention and referral.
A child is obese if their BMI is at or above the 95th percentile.
Such a child requires intervention and referral.
It is important to note that discussion of children’s weight and associated food and activity patterns
can be a sensitive issue. Carers should understand that the growth chart is a screening tool. It is
intended to be a guide of when to take small steps to make changes and when to seek further
guidance from a doctor or a dietitian.
Head circumference
The child should be seen by a medical officer if the head circumference is:
■■ above the 95th percentile
■■ below the 5th percentile
■■ crossing the percentile lines, either upward or downwards, after measurement on two
separate occasions
■■ small anterior fontanelle
■■ anterior fontanelle not closed.
Closure of the anterior fontanelle is variable but usually complete by 18 months.
Any suspected small anterior fontanelle with bossing of sutures, or split and separated sutures or
anterior fontanelle that is not closed by 2 years should be seen by a medical officer.
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35
References
1. CDC Growth Charts
www.cdc.gov/growthcharts
2. WHO Growth Standards
www.who.int/childgrowth/standards/en/
3. Victorian Health Department
www.health.vic.gov.au/childhealthrecord/growth_details/index.htm
4. NHMRC “Clinical Practice Guidelines for the Management of Overweight and Obesity in
Children and Adolescents” and “Overweight and Obesity in Adults and in Children and
Adolescents: A Guide for General Practitioners”.
www.dhac.gov.au/internet/wcms/Publishing.nsf/Content/obesityguidelines-guidelineschildren.htm
5. NHMRC “Child Health Screening and Surveillance: A critical review of the evidence”
(2002)
www.nhmrc.gov.au/publications/synopses/_files/ch42.pdf
6. For anthropometry technique standards:
depts.washington.edu/growth/module5/text/page5a.htm
7. Standard methods for the collection and collation of anthropometric data in children. PSW Davies, R Roodveldt and G Marks (2001) Commonwealth of Australia
8. Olsen EM. Failure to thrive: still a problem of definition. Clin Pediatr (Phila). 2006 Jan-Feb;
45 (1):1-6.
9. Batchelor JA. Has recognition of failure to thrive changed? Child Care Health Dev. 1996
Jul; 22 (4):235-240.
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7.8 Healthy weight
Keeping Kids on Track
The wiry sun-bronzed Aussie is becoming a figure of the past. We are becoming a nation of fat
couch potatoes. Obesity is bringing us lifelong health problems. A lifestyle disease requires a
lifestyle solution. Fortunately, this is within the capabilities of all Australians (1).
This chapter explores tools you can use in your practice to help combat the rising epidemic of
childhood obesity.
Overweight and obesity is already a serious problem in Queensland. While recent data is not
available for Queensland, in Australia between 1985 and 1997 the population prevalence of
overweight increased by 60-70%, obesity increased 2-4 fold (2). The problem has continued to
worsen. There are now an estimated 1.5 million young people under the age of 18 in Australia who
are overweight or obese (3).
“New data indicates that an additional 1% of children in Australia are becoming overweight each
year, which is amongst the highest rates of increase in the world” (4).
Childhood overweight is associated with increased risk factors for heart disease such as raised
blood pressure, blood cholesterol and blood sugar. Of great concern is the appearance of Type 2
diabetes in adolescents—even primary school children—with its potential for complications such
as heart disease, stroke, limb amputation, kidney failure and blindness (3).
The most significant long term consequence of obesity in childhood is its persistence into
adulthood. Overweight young people have a 50% chance of being overweight adults, and
perhaps not surprisingly children of overweight parents have twice the risk of being overweight
than those with healthy weight parents. Obese adults who were overweight as adolescents have
higher levels of weight-related ill health and a higher risk of early death than those adults who only
became obese in adulthood (3).
WHO has identified the underlying causes of the global obesity epidemic as (5):
■■ sedentary lifestyles
■■ high intake of energy-dense, micro-nutrient poor foods
■■ heavy marketing of fast food outlets and energy-dense, micronutrient-poor foods and
beverages
■■ a high intake of sugar-sweetened drinks
■■ large portion sizes
Obese children are at increased risk of:
■■ hyperlipidemia
■■ hypertension
■■ abnormal glucose tolerance
■■ psychosocial problems
■■ adult obesity (6)
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The 1995 Australian Nutrition Survey indicated that children aged 4-7 years had excessively high fat
intakes, one third ate no fruit and one fifth ate no vegetables on the day of the survey (2)
One study found “consensus amongst parents that obesity prevention strategies needed to
begin early in a child’s life, long before they reached the school setting. Parents recognized
that behaviors are shaped early in life and were largely already entrenched by the time children
reached school age” (8).
Defining overweight and obesity in children
An Australian expert working group identified body mass index (BMI) as the most appropriate clinical
measure of excessive weight in children (9)
It is essential for height and weight to be accurately measured to determine if a child is
overweight or obese. Visual assessment should be avoided.
About the BMI for children
BMI = weight (kg)
height (m)2
Although the BMI number is calculated the same way for children and adults, the criteria used to
interpret the meaning of the BMI number for children and teens are different from those used for
adults. For children and teens, BMI age- and sex-specific percentiles are used for two reasons:
■■ the amount of body fat changes with age
■■ the amount of body fat differs between girls and boys
The CDC BMI-for-age growth charts take into account these differences and allow translation of
a BMI number into a percentile for a child’s sex and age. For adults, on the other hand, BMI is
interpreted through categories that do not take into account sex or age (11).
Table 21
NHMRC current classifications for BMI percentile ranges (13)
Weight status category
Percentile range
Overweight
85th to less than the 95th percentile
Obese
Equal to or greater than the 95th percentile
How is BMI calculated and interpreted for children and teens?
(adapted from Centers for Disease Control and Prevention)
Calculating and interpreting BMI involves the following steps:
1 Before calculating BMI, obtain accurate height and weight measurements.
2 Calculate the BMI; weight (kg) / [height (m)]2
3 Plot the BMI on the appropriate chart to determine the percentile
4 Review the calculated BMI-for-age percentile and results
5 Find the weight status category for the calculated BMI-for-age percentile as shown in BMI
table (see table 1). These categories are based on expert committee recommendations
A BMI calculator can be found at apps.nccd.cdc.gov/dnpabmi/Calculator.aspx
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Nutrition strategies
Food language: everyday vs sometime foods
The language we use when communicating about food is very important. Often we describe
high calorie food as very negative. Words like “junk’/‘bad” can be guilt inducing and may bring
up feelings of negativity and failure. A more positive and helpful approach is to use terms such
as “sometimes” foods and “everyday/always” foods. This describes foods more accurately and
provides a basis for language around food choices (1). Encourage parents to use this form of
language when discussing food choices with their family.
Energy balance
Offering a simple concept to explain energy imbalance as the cause of overweight is often ignored
as more glamorous/novel ideas capture people’s attention and their money. Unfortunately, these
explanations are often scientifically unfounded and cause considerably confusion but do sell a lot
of books. We all know someone who is overweight. Upon reflection, this person may not seem to
eat excessively. Many children we see for management of obesity eat only slightly in excess of
their daily requirements.
So why is it that they are very obese when they only eat a small amount of extra calories per
day? The answer is like getting interest in a bank account. Small amounts over time add up to
large amounts in the end. For example, imagine if someone ate 2 level teaspoons of extra fat per
day (10g). Over a year this adds up to 3.5 kg of excess weight (10g X 365 days). Keep this up for
5 years and all of a sudden you have a child who is 17.5kg over their expected weight. Obesity
results from small amounts of excess energy each day. Even if children lead very active lives, it is
easier for them to collect more energy than they expend through exercise (1).
Sometimes the aim for children is to maintain their weight so that when they grow taller they will
then be in proportion. However at times losing some excess weight is necessary. The quality of
food we consume can have a large impact on our weight. It is important to understand that the
building blocks of food, fat, protein and carbohydrate contain different amounts of kilojoules (1).
These are:
■■ Fat: 37 kilojoules per gram
■■ Protein: 17 kilojoules per gram
■■ Carbohydrate: 16 kilojoules per gram
Satisfying appetite
Research has shown that the above nutrients do not satisfy our hunger in the same way. Fatty
foods have only a weak effect on satisfying our appetite. In comparison, certain carbohydrate
foods have been shown to have a more satisfying effect on the appetite (1). For more information,
contact your local dietitian.
NB: It is important to remember that children do need some fats in their diet for good nutrition.
The Australian Guide to Healthy Eating has been developed to provide people with practical
applications to achieve daily energy balances. Additionally, it maximises the amount of vitamins
and minerals consumed. Use this as your evidence based tool when providing nutrition
information to parents.
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39
Energy in
Portion sizes
It is important to emphasise the correct portion sizes when discussing with parents healthy eating.
Portion sizes have been increasing over the past decades, driven in part, by companies profiting
from a person ‘upsizing’. Plates, bowls and glasses are now bigger, requiring more food to fill
them. Snack foods are available in a variety of increasing sizes. Utilise The Australian Guide to
Health Eating as your evidence based tool to advise parents of correct portion sizes.
Every little bit extra contributes to energy in. Being more concise with portion sizes is a good place
to start when looking at improving a child’s diet.
Energy dense foods
Many foods are pre-packaged, ready to eat and loaded with calories for convenience and taste.
Compare yourself to someone who may have lived many years ago. They might have had to work
the field with a horse drawn plough, sow seeds by hand, harvest the seeds with a scythe, thresh
the seeds by hand, mill the seeds into flour and then bake them in a wood fired oven. They would
also have to chop and transport the wood and do other tasks in their spare time (1).
This person could eat 20 loaves of calorie dense bread in a day and still not become overweight
because they burned more energy than they consumed. This energy balance has changed for
us and produced an epidemic of obesity. We are now paying the price for the imbalance with our
health (1).
92% of children less than five years of age consume takeaway food regularly (6).
One study found many Australian children “were generally well informed about the health value
of different foods, could identify the healthy and unhealthy foods pictured, and were aware of the
nutrients contributing to their perception of foods being more or less healthy” (8).
“Parents believed their children knew which foods were healthy, but suspected they did not fully
comprehend the consequences of eating unhealthy foods…. They postulated that the inconsistent
messages about unhealthy energy-dense foods, including attractive marketing and advertising
strategies, confused children” (8).
Parents themselves, although generally well informed, requested more parent education… they
did not feel well equipped to distinguish between more and less healthy pre-packaged snacks
in light of the huge array available and marketed to children. “There’s so much deception in
marketing, it’s hard to know which snacks are healthy” (8).
Food labels
By law, food labels in Australia must contain a nutrition information panel and an ingredients list.
You can encourage families to do their own investigating when trying to ascertain whether foods
are everyday foods or sometimes foods, by using the following information sheets.
Ingredient list
This lists the amount of ingredients by weight in descending order (highest to lowest). So if the first
few ingredients listed are fat or sugar (see below for other names for these), then it is one of the
major ingredients in the product and therefore likely to be high in energy.
Nutrition information panels
All manufactured foods need to carry a nutrition information panel. This shows the amount of
energy (in kilojoules), and nutrient content including protein, total fat, saturated fat, carbohydrate
and sugars, as well as any other nutrient that a claim has been made about (eg: iron, calcium,
fibre) in measurements per serve and per 100 grams.
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When comparing nutrition information panels it may be helpful to consider (1):
■■ Overall energy
■■ Fat content:
■■
low fat means 3 g per 100 g solid food or <
< 1.5 g per 100 ml liquid food.
■■ Sugar content:
■■
aim for
< 10 g sugar per 100 g
■■ Fibre:
■■
aim for the highest fibre content.
It may be useful to compare products by using the “per 100 g” column as serve sizes can vary
between products.
Parent fact sheets available
www.health.qld.gov.au/eatwellbeactive/documents/fact/reading_food_labels_fact_sheet.
doc
High fat
Most children do not need low fat diets. However, snacks that are high in fat and low in other
nutrients tend to take away children’s appetites for the more nutritious foods they need.
In some cases however, a high fat food will contain other nutrients essential for growth. These
foods should still be included in children’s diets, eg. cheese, peanut butter and avocados.
The fat contents of various popular children’s foods are shown in the table below.
Table 22
Comparison of fat content of various foods
High fat food
Approx fat
content (%)
Lower fat alternative
Approx fat
content (%)
Potato crisps
30
Vegemite on crackers
Chocolate
30
Bread, bread roll, bun loaf, fruit
toast
3-4
Most small savoury biscuits
25
Rice snacks, corn thins
3-4
Shortbreads, cream filled biscuits
20-25
English muffins
3
4
Cheerios, frankfurts, salami
sticks
20
Lean mince, chicken breast, leg
ham
Chocolate coated muesli bar
20
Wholemeal fruit bar
8
Fruit muesli bar
15
Fruit
0
Plain sweet biscuits
15
Scone, pikelet
2-7
10
Adapted from What is Better Food? 2002.
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High sugar
Foods high in sugar can take away children’s appetites for more nutritious foods and can
contribute to tooth decay. It is not only the amount of sugar in foods that should be looked at
when considering children’s teeth. Foods that are sticky or that will cling to children’s teeth are
much more likely to contribute to tooth decay.
‘No added sugar’ does not indicate that a food is low in sugar. It just means no extra sugar is
added to the product. It may be naturally high in sugar such as in no added sugar, 100 per cent
fruit juice.
Table 23
Comparison of sugar content of various foods and drinks
Food or drink
Actual serve
size
Approximate amount of
sugar consumed
Soft drink
1 can
40g = 10 teaspoons
(375 ml)
Cordial
1 cup
20g = 5 teaspoons
Drink
(250 ml)
100% fruit juice, no added
sugar
1 cup
Water
1 cup
18g = 4½ teaspoons
(250 ml)
0
(250 ml)
20g
13-15g = 3-4 teaspoons
Muesli bars
35g bar
7-10g = 2 – 2½ teaspoons
Chocolate
60g bar
33g = 8¼ teaspoons
Fruit loaf
2 slices
9g = 2 teaspoons
Bread
2 slices
2g = ½ teaspoon
Dried fruit bars
Food
Processed fruit straps
Note 1 teaspoon sugar = 4 g
Adapted from What is Better Food?
The Infant and Child Nutrition in Queensland Report found “over half (55%) of all children under two
years of age had ever been given sweet drinks regularly. In children less than one year, 15% had been
given sweet drinks regularly” (6).
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Snack food dilemmas
Adapted from What is Better Food?
Below is some nutrition information about food products that often appear in lunchboxes, or used
as snacks. We generally know that foods such as chocolate and potato chips are not suitable to
be regularly included in children’s lunchboxes. However, there are many foods that children bring
where it is harder to decide.
Dried fruit bars and fruit straps
These do contain some dried fruit but are generally very high in added sugar, low in fibre and cling
to children’s teeth. They are not comparable to fresh fruit, despite the advertising claims. They may
reduce children’s fruit intake, take away their appetites and contribute to tooth decay.
Recommendation: Not recommended.
Dried fruit
Dried fruit contains similar nutrient levels and fibre to fresh fruit. However, because water has
been removed, dried fruit has more concentrated sugar and will cling to teeth. Dried fruit is
recommended, but is best eaten just prior to brushing teeth or at meal times when other foods
are being eaten. Giving dried fruit alone for morning tea means it will remain on children’s teeth for
some time before it is removed by brushing or by eating other foods.
Recommendation: Recommended at mealtimes or with other food.
Small oven baked savoury biscuits
Companies are now targeting children with these snacks and are providing these biscuits in small,
convenient packets. Many parents think that small savoury biscuits are a healthier option than
potato chips for their child. However they are often as high in fat and salt as regular potato chips
and can easily take away children’s appetites for the more nutritious foods they need.
Recommendation: Not recommended.
Noodle snacks
Two-minute are very high in fat as the noodles are usually deep fried in oil prior to packaging. The
flavouring is also very high in salt.
Recommendation: Better alternatives include fat-free Asian or oriental noodles. These are very
tasty when added to stirfry meat and vegetables, ie. leftovers. Check the ingredient list for fat or
oil.
Muesli bars and breakfast bars
Muesli bars are popular with children and are often found in children’s lunchboxes. They vary in
flavour, texture and nutritional content. In general, chocolate coated or chocolate chip muesli bars
are very high in fat and sugar. Chewy muesli bars cling to children’s teeth and can contribute to
tooth decay. Snack bars made from children’s breakfast cereals are also very high in sugar and
will cling to teeth.
Recommendation: Chocolate coated, chocolate chip and chewy muesli bars are not
recommended. Children’s breakfast cereal bars should also be limited. Adult breakfast cereal bars
are a better alternative. If these foods are brought along they should be eaten with other foods and
teeth brushed after eating.
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Flavoured milk
Dairy foods have properties that help protect teeth against tooth decay. Flavoured milk has added
sugar but is still desirable, as it is an important source of calcium. Some children will not drink
plain milk. Children enjoy the variety that flavoured milk provides. It is important that children
receive an adequate calcium intake and drinking milk is one of the easiest ways to achieve this.
Recommendation: All milk is recommended.
■■ For toddlers over 12 months of age plain, full cream milk is preferred and for children two
to five years of age reduced fat milks (1.5 - 2.5 % fat) should be used.
■■ Skim milk (less than 0.5 % fat) should not be used until children are over five years. It is
fine to have flavoured milk occasionally.
■■ Make sure milk consumption does not exceed recommendations for age.
Flavoured dairy desserts
Yoghurt is the ideal dairy dessert for children. It is moderate in sugar and fat and high in calcium
and protein. Reduced fat varieties are recommended for children once they are over two years
of age. There are many flavoured dairy desserts marketed for young children. These vary in their
fat, sugar and calcium contents. Compared to yoghurt, desserts which have ‘mix-ins’ are, in
general, much higher in sugar and sometimes higher in fat. This is also the case with the majority
of chocolate mousse and crème caramel desserts. Popular custard based flavoured desserts are
generally higher in sugar than yoghurt and they vary in their calcium content. These are not a bad
choice if children will not eat yoghurt and can be a valuable way of improving calcium intakes.
Recommendation:
■■ encourage full cream flavoured or unflavoured yoghurt in preference to other products
■■ use the nutrition panel of yoghurt to compare the various products that appear in
children’s lunchboxes
■■ discourage yoghurt with mix-in lollies and high fat desserts, like chocolate mousse.
Cheese and biscuit snacks
These are popular in children’s lunchboxes and are a good source of calcium. Rather than the
pre-packaged varieties, wrapping up some crackers and a slice of cheese in plastic wrap for the
lunchbox reduces cost and packaging.
Recommendation: Recommended.
Biscuit and dip packs
Many different types of biscuit and dip packs exist for children. Some dips are cheese-based and
are a good source of calcium. The sweet flavoured dip snack packs are very high in sugar.
Recommendation: Cheese or cheddar dip packs are recommended but sweet flavoured dip
snack packs are better left out.
Jam, honey or chocolate paste sandwiches
The bread is a healthy choice but jam, honey and chocolate paste provide sugar with few other
nutrients. Children need a good source of iron each day. The filling on sandwiches is usually the
easiest way to provide this.
Recommendation: Jam and honey are OK to have occasionally, but try to encourage high iron
foods eg. roast meat, chicken, ham, tuna, egg, peanut butter or baked beans
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Energy out
Kids sport and technology
Energy expenditure through physical activity is an important part of the energy balance equation
that determines body weight. A decrease in energy expenditure through decreased physical
activity is likely to be one of the major factors contributing to the global epidemic of overweight
and obesity (5). Refer to physical activity section.
Children aged 5-12 years spend an average of 2.5 hours per day watching television (2).
How much physical activity is sufficient for children?
New physical activity guidelines from the Department of Health and Ageing 2004 (4):
1 Children and youth should participate in at least 60 minutes (and up to several hours) of
moderate – to vigorous intensity physical activity every day
2 Children and youth should not spend more than 2 hours per day using electronic media for
entertainment (eg television, computer games, internet), particularly during daylight hours.
Physical activity has decreased markedly over the last century (especially in the last 20 years). The
advent of technology has encouraged children to pursue more sedentary activities such as playing
video games, computers, VCRs, DVDs, CDs, and MP3s. Concerns about safety have discouraged
parents from allowing their children to play unsupervised in parks, streets and neighbourhoods.
Children don’t ride or walk to school (1).
Young children spend more than 50% of their time in sedentary play (13).
One study found some children view any amount of body movement constituted physical activity;
“playing piano or computer is a bit healthy because you’re moving your fingers” (Grade Two) (8).
Media and peer conformity
Peer pressure and what other children are eating/doing directly impacts upon our thinking and
expectations. Advertising companies have become very cunning in promoting their products. For
example, product placement now occurs in movies where companies will pay to have their brand
exclusively used in a movie. This is a sneaky and hidden way to promote and influence people to
buy the product (1).
In the simplest terms, obesity results from an imbalance between calories eaten and calories
expended through activity and exercise. Television (and media behaviour) upsets this balance
through:
■■ reduced metabolic rate when watching TV and other media activities
■■ reduced activity because of what they are not doing whilst they are interacting with the
media (children who watch more TV do less sport)
■■ increased food and calorie consumption (from advertising and snacking).
Children are vulnerable to food messages portrayed through television advertisements, with food
advertising affecting the choices and amounts of foods consumed (17).
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One Australian study found “Confectionery’ and ‘fast food restaurants’ were the most advertised
food categories during children’s TV viewing hours. Confectionery advertisements were three
times as likely, and fast food restaurant advertisements twice as likely, to be broadcast during
children’s programs than adults’ programs (17).
“Foods most advertised during children’s viewing hours are not those foods that contribute to
a healthy diet for children. Confectionery and fast food restaurant advertising appears to target
children’ (17).
It is well recognized that childhood obesity is a worldwide problem. The heavy marketing of energydense, nutrient-poor foods influences food choices and contributes to the incidence of overweight
and obesity in children (14).
Check
✔✔ reduce TV viewing for children and set specific limits
✔✔ remove TVs from bedrooms
✔✔ limit mobile phone usage
✔✔ cease cable TV
✔✔ reduce computer time especially chat rooms, emails, videos, video games
✔✔ remove electronic toys
✔✔ reduce and limit dvd’s movies
✔✔ look for product placements in media with your children ie turn sound off
and guess what products have been placed in TV-movies
Adapted from Kids on Track, 2004
Meal time tips
✔✔ use smaller plates/ bowls
✔✔ do not over fill plate
✔✔ have water available with all meals
✔✔ allow children to leave food on their plates
✔✔ minimise distractions eg TV off
✔✔ encourage your children to eat slowly
✔✔ encourage mealtime conversation
✔✔ eat together as a family
✔✔ model all the above tips yourself during the meal
✔✔ try these during at least one meal per day
✔✔ a small amount of sugar and salt per day
✔✔ increase plant based unprocessed foods
✔✔ increase high fibre foods
✔✔ reduce family grazing between meals and limit it to fruit and water
Adapted from Kids on Track, 2004
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Table 24
Possible causes of a child being above their natural body weight
Action
Concerns with eating
patterns?
✔✔ Encourage parents to accept their child’s
Are foods high in fat and
sugar being consumed
in large amounts or often
throughout the day?
✔✔ Restrictive diets are not recommended
ENERGY IN
Question
ability to regulate energy intake
✔✔ Promote the intake of fruit and vegetables
✔✔ Restrict the intake of energy-dense,
micronutrient-poor foods (eg. packaged
snacks)
✔✔ Restrict the intake of sugars-sweetened
soft drinks
✔✔ Assure the appropriate micronutrient intake
needed to promote optimal linear growth
What is the child drinking? ✔✔ Limit juice to ½ cup per day
(eg cordials, soft drinks, fruit
juices)
✔✔ Provide milk in sufficient amounts for age
✔✔ Meet additional fluid requirements with
ENERGY OUT
water
Physical activity
✔✔ Promote an active lifestyle
Is the child active?
✔✔ Encourage planned exercise that the child
enjoys as well as an increase in activities
that involve more movement
Sedentary behaviour
How much TV and computer
games does the child watch?
✔✔ Limit television viewing
✔✔ Discuss the number of hours TV is watched
as it can reduce exercise levels and
exposes the child to considerable food
advertising
Adapted from WHO (2002), Tuckertalk (2003)
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Useful websites and resources
Further reading
1. The Queensland Strategic Policy Framework for Children’s and Young People’s Health
2002 – 2007. Queensland Health 2002
2. Eat Well Queensland 2002-2012, Smart Eating for a Healthier State, Queensland Public
Health Forum. June 2002
3. Eat Well, Be Active – Healthy Kids for Life: 2005-2008. Queensland Government 2005
4. Healthy Weight 2008, the National Action Agenda for Children and Young People and
Their Families, Commonwealth of Australia. 2003.
5. Queensland Health, Enhanced Child Health Model of Care for Community Health Services
(0-12 years)
6. Strategic Policy Framework for Aboriginal and Torres Strait Islander Children and Young
People’s Health 2005- 2010
Growth charts
Centres for Disease Control and Prevention www.cdc.gov/
World Health Organisation www.who.int/childgrowth/en/
Parent resources
Eat Well, Be Active www.health.qld.gov.au/eatwellbeactive
A note on Kids on Track
Kids on Track targets children three to ten years who do not have any medical conditions
that might cause overweight. Its purpose is to examine the effect of a group parent
intervention on the course and severity of overweight. It helps parents address their
children’s health problems via three key areas of nutrition, physical activity and family
behaviour change. It also investigates if positive health outcomes can be maintained. These programs are currently being run on the Gold and Sunshine Coasts as well as
Bayside.
For further information please contact
The Receptionist
Bundall Community Child Health
PO Box 5699
GCMC Bundall QLD 9726
Phone: 07 5570 8553
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References
1. Queensland Health: ‘Kids on Track,’ Gold Coast, 2004
2. Booth, M. L., Wake, M., Armstrong, T., Chey, T., Hesketh, K., & Mathur, S. (2001). The
epidemiology of overweight and obesity among Australian children and adolescents,
1995-97. Australian and New Zealand Journal of Public Health, 25(2), 162-169.
3. Commonwealth of Australia 2003 Healthy Weight 2008, Australia’s Future, Canberra
[online] 29th April www.healthyactive.gov.au/publications.htm
4. Queensland Government. Smart State healthy weight for children and young people.
Eat well, be active – healthy kids for life. The Queensland Government’s first action plan
2005-2008.
5. Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic
Diseases (2002 : Geneva, Switzerland) Diet, nutrition and the prevention of chronic
diseases: report of a joint WHO/FAO expert consultation, Geneva, 28 January -- 1
February 2002. [online] 29th April www.who.int/hpr/NPH/docs/who_fao_expert_report.pdf
6. Queensland Health: Infant and Child Nutrition in Queensland 2003
7. Best Practice Dietetic Management of Overweight and Obese Children and Adolescents.
Australian Centre for Evidence Based Nutrition and Dietetics. The Joanna Briggs Institute
[online] 26th April
8. Healthy eating, activity and obesity prevention: a qualitative study of parent and child
perceptions in Australia K. HESKETH, E. WATERS, J. GREEN, L. SALMON and J.
WILLIAMS Health Promotion International, 2005, Vol. 20 No. 1 pp 19-26
9. Batch, J. A., & Baur, L. A. (2005). Management and prevention of obesity and its
complications in children and adolescents. MJA, 182, 130-135.
10. National Health and Medical Research Council: Dietary Guidelines for Children and
Adolescents in Australia incorporating the Infant Feeding Guidelines for Health Workers,
Canberra 2003.
11. Centres for Disease Control and Prevention www.cdc.gov/nccdphp/dnpa/bmi/childrens_
BMI/about_childrens_BMI.htm [online] 2nd May, 2007
12. Queensland Health: What is better food? Brisbane 2002
13. Clinical Practice Guidelines for the Management of Overweight and Obesity in Children
and Adolescents, NHMRC. Canberra, 2003
14. How much food advertising is there on Australian television? Kathy Chapman, Penny
Nicholas and Rajah Supramaniam. Health Promotion International 2006 21(3):172-180;
doi:10.1093/heapro/dal021
15. Community Population and Rural Health Tuckertalk, Tasmania, 2003
16. online [2nd May] www.culturaldata.gov.au/publications/statistics_working_group/
australias_culture_pamphlets/10_childrens_participation
17. Neville L., Thomas M., Bauman T., Food advertising on Australian television: the extent of
children’s exposure Health Promotion International 2005, Vol. 20 No. 2. pp 105-112
18. Borushek, A. Pocket calorie, fat & carbohydrate counter, 2007, Family Health Publications,
Western Australia
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7.9 Iron deficiency
Iron deficiency is the most common nutritional deficiency in children and adults in both developed
and developing countries (1)
Those most at risk of Iron deficiency are:
■■ children particularly aged between 9-18 months
■■ women of child bearing age (1).
As many as 10% of Australian toddlers are iron deficient (2).
Iron deficiency in childhood differs in many ways from that in adults. In children, the most likely
cause is an inadequate amount of iron in the diet, coupled with the extra requirement for iron
because of growth (2).
The effects of anaemia and iron deficiency on brain development in infancy and very early childhood
are well documented: “infancy is the critical period for brain growth, and nutrient deficiencies during
this time may affect psychomotor development and neurocognition” (3). “There is some disturbing
evidence which suggests that the intellectual and psychomotor impairment caused by iron deficiency
may not always be completely reversible when iron status is corrected” (as cited in 2).
For these reasons, the Australian Iron Status Advisory panel strongly believes that iron
deficiency should be regarded as a serious illness in the first years of life’ (2)
Iron deficiency is common, but it is preventable if suitable feeding choices are made. Exclusive
breastfeeding to the age of 6 months will ensure that breastmilk is not replaced by food of lower
nutrient density and will minimise the risk of iron deficiency (8). If formula feeding, it is imperative
parents or caregivers choose an iron fortified cow’s milk formula.
The RDI for infants aged between 7 and 12 months is 11mg/day; for children 1- 3 years of age
9mg/day, and children aged 4-8 years is 10mg per day. Pregnancy and breastfeeding to 27mg/
day and 9-10mg per day respectively.
An important aspect of prevention is educating parents about the changing dietary needs of their
growing child and the types of foods that are rich in iron or which encourage iron absorption and
also those that restrict iron absorption.
Informing parents of the two most common factors associated with iron deficiency may also be a
useful preventative activity. These two factors are (1) being fed on cows’ milk prior to 12 months of
age, and (2) continuing solely on milk (either breast or cows’ milk) after 12 months of age, without the introduction of solids.
If unsure of iron intake – refer to a dietitian for assessment and advice.
The Dietary Guidelines for Children and Adolescents in Australia
recommendations
■■ Continue exclusive breastfeeding for about 6 months
■■ Introduce complementary foods containing iron at about 6 months of age
■■ Choose iron-containing formula for infants who are not breastfeed and for
infants receiving formulas as well as breastmilk
■■ Delay the introduction of whole cow’s milk until 12 months of age
■■ Continue to offer iron-fortified and meat containing foods beyond
12 months of age
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What is iron deficiency?
“Iron is present in all cells in the human body. Its functions include the transportation of oxygen
around the body, the facilitation of oxygen use and storage in the muscles…. Most iron is found in
the red blood cells as haemoglobin” (1).
Newborns receive their iron stores in the womb. “6 months of age has been identified as a time
when iron stores are falling in both breast and formula fed infants” (4). “However, once newborn
iron stores are depleted, the child must meet the body’s iron needs through dietary intake” (1).
The body’s ability to absorb iron from the diet is dependant on:
■■ the amount of iron already stored in the body (more iron is absorbed when the iron
stores are low)
■■ the rate of red blood cell production
■■ the amount and kind of iron eaten in the diet eg iron in meat is more readily absorbed
than iron in vegetables.
■■ the presence of absorption enhancers and inhibitors in the diet
“If there is insufficient iron in the diet or if other problems prevent dietary iron from being absorbed
into the body, a child’s iron stores will become depleted” (1).
Iron deficiency occurs across a spectrum from iron depletion to
anaemia.
Table 25
Definitions of impaired iron status
Iron depletion
■■ Plasma ferritin level <10µg/L
■■ No functional deficit (3)
■■ Normal haemoglobin
Iron deficiency
■■ Iron depletion plus
■■ Mean corpuscular volume <70fL (age, 12-23 months) or <73fL (age, 24-38 months) plus
■■ Mean corpuscular haemoglobin <22 pg
■■ Functional deficit (3)
■■ Normal haemoglobin (3)
Iron-deficiency anaemia
■■ Iron deficiency plus
■■ Haemoglobin level <110 g/L
■■ Normal functions compromised (1)
Adapted from Couper R et al (2001) (3)
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Figure 6
Continuum of changes in iron stores and distribution in the presence
of increased or decreased body iron content
Adapted from Herbert V: Anemias. In Paige DM [ed]: Clinical Nutrition. St. Louis, CV Mosby, 1988,
p 593, with permission.
Symptoms of iron deficiency and iron deficiency
anaemia (1)
Iron deficiency in children can be asymptomatic. Clinical indictors may include:
■■ behavioural changes (lethargy, irritability, lack of concentration)
■■ cognitive and psychomotor deficits,
■■ decreased immune function (recurrent infections)
■■ loss of appetite
■■ pica (the eating of dirt, clay or other strange ‘foods’)
■■ FTT, although not specific to iron deficiency, should always prompt consideration of iron
status
Clinical indictors of anaemia include the above and
■■ pallor
■■ in extreme cases, heart failure
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What causes iron deficiency?
Infants
The infant year is one of rapid growth. Dietary inadequacies during this period place the
infant at risk of developing iron deficiency.
Risk factors for iron deficiency:
■■ uncorrected maternal iron deficiency during pregnancy
■■ prematurity, leading to inadequate accumulation of iron in the newborn’s stores
■■ age less than 2 years
■■ introduction of cow’s milk as the main source before 12 months of age
■■ cow’s milk intake exceeding 600 ml per day (6)
Common feeding practices contributing to iron deficiency
Infants may be developing iron deficiency if any of the following feeding practices occur (6):
■■ use of cow’s milk instead of infant formula or breastmilk, in infants under 12 months of age
■■ delayed introduction of solids
■■ displacement of solid food intake by milk
■■ prolonged bottle feeding with cow’s milk
■■ low meat or haem iron intake
■■ bottle use in children over 12 months of age encourages excessive fluid intake that may
displace other more nutritious solid foods
NB: Cow’s milk not only has a low concentration of iron, but the iron is poorly absorbed (refer to
toddler section).
NHMRC states health professionals should be vigilant with their clients and assess iron status
based on the above risk factors (6)
Recommendation: Commercial infant cereal is the preferred first solid food because it is iron
fortified (6).
Rice cereal was the first food given to the majority (70%) of children in the findings in the Infant and
Child Nutrition in Queensland Report, 2003 (7).
Toddlers and preschoolers
The same basic scenario applies in the second year of life. The main problem with toddlers
is the over reliance on milk: unfortunately, this low iron food ends up forming a large part of
the total food intake. These comments apply to all forms of milk, not just cow’s milk. Goat’s
milk is a particularly poor source of iron and soy milk is not satisfactory either (see toddler
section).
Vegetarianism in infants and children
A vegetarian diet that is adequate for adults is not necessarily suitable for infants and
young children, who face constraints such as limited stomach capacity and higher needs
for nutrients per unit weight. Each diet must be assessed separately for its suitability for
children; if the regimen is very restrictive in terms of the type and amount of animal proteins
consumed, it is essential to plan a diet carefully so as to avoid deficiencies.
In general, lacto-vegetarian and lacto-ovovegetarian diets provide adequate nutrition if they
are properly planned. Vegan diets pose a risk if care is not taken to ensure that the diet
provides adequate energy, vitamin B12, protein and iron (8). Referral to dietitian for assessment and advice
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All ages:
Iron deficiency results from one or a combination of factors, which include:
■■ inadequate oral intake
■■ impaired absorption
■■ blood loss – including menstrual bleeding
■■ pregnancy (without adequate intake/oral supplementation)
Treatment
A dietary assessment is the first component of management. Following this, the health
professional can advise parents on ways to increase their child’s consumption of foods rich in iron
and those that enhance iron absorption, whilst decreasing the consumption of foods that hamper
iron absorption.
Initially children may be also be prescribed iron supplements to replete their iron stores (1). Parents
should be warned that bowel motions are often black and that this does not denote ill health.
Too much iron can be harmful
The body stores iron very efficiently, and too much iron can be toxic.
Haemochromatosis is a condition characterised by excessive iron stores (9)
Supplementation must never be given, unless under the supervision of a medical practitioner.
“Once children become iron deficient, they become very restricted in the range of foods they will
accept. Appetite and tolerance of new or previously discarded foods improves with iron repletion”
(3).
Referral to general practitioner / paediatrician and dietitian
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Bioavailability of iron
Dietary iron comes in two forms:
Haem iron
is found in flesh foods such as red meat, chicken and fish.
Non-haem iron is found in plant foods such as wholegrain breads and cereals and some vegetables.
The body absorbs:
■■ Just under one quarter of the iron contained in animal foods.
■■ Less than one tenth of the iron from plant sources
What are the best sources of iron? (10)
Foods which contain haem iron include:
■■ lean red meats such as beef, lamb and veal.
■■ offal meats such as liver and kidney.
■■ chicken, pork (including ham), fish and shellfish.
■■ pate or fish paste.
Foods which contain non-haem iron include:
■■ Iron-fortified breakfast cereals (check the label to see if iron is added).
■■ Wholemeal/wholegrain breads and cereals.
■■ Dried peas, beans and legumes eg. lentils, baked beans, soybeans, kidney beans, tofu.
■■ Leafy green vegetables eg. spinach, parsley, broccoli.
■■ Eggs.
■■ Dried fruit.
■■ Peanut butter and nuts (whole nuts are not recommended for children under 5).
■■ Tahini and hommus.
Dietary factors that boost iron absorption (9)
Certain foods and drinks help your body to absorb greater amounts of iron, including:
■■ Vitamin C (found in fruits and vegetables such as: citrus fruits, red capsicum, kiwi fruit)
increase iron absorption from both haem and no haem iron sources.
Dietary factors that reduce iron absorption (9)
Certain foods and drinks reduce your body’s ability to absorb iron, including:
■■ Tannins from tea, coffee and wine reduce iron absorption by binding to the iron and
carrying it out of the body.
■■ The phytates and fibres in wholegrains such as bran can reduce the absorption of iron
and other minerals.
Check
✔✔ eat foods high in haem iron
✔✔ eat foods high in non-haem iron, and where possible combine with haem
iron to help absorption
✔✔ eat vitamin C rich foods (citrus and berry fruits, tomato, broccoli and
capsicum) at each meal as this further increase iron absorption
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55
Assessing the diet – asking about iron consumption for
infants and toddlers
Adapted from the Australian Iron Status Advisory Panel 2,6
First year
■■ Was the child breastfed or formula fed (iron-fortified)?
■■ What age did you cease breastfeeding
■■ What drinks did you introduce? (iron-fortified formula or cow’s milk)?
Solids
■■ At what age did you introduce solids?
■■ Were the foods iron fortified (or were supplements given)?
■■ When did the child start to eat red meat, chicken and fish? How much?
Current diet
■■ What does your child eat now?
■■ What about flesh foods (red meat, chicken, fish) and plant sources of iron (grains,
legumes).
■■ How many vitamin C rich foods are eaten at the same time (eg. citrus fruits, cauliflower,
broccoli, strawberries, melon)?
Cow’s milk
■■ At what age did your child start on cow’s milk and how much is consumed?
Other fluids
■■ What about the volume of other fluids - other animal milks, juices, cordials and soft
drinks, tea and coffee? (Tannin inhibits iron absorption, juices displace iron rich foods
from the child’s diet)
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Suggestions to prevent or treat iron deficiency in
pregnant and breastfeeding mums (4, 9)
One and a half serves of meat, fish, poultry or alternatives each day are recommended in pregnancy
and 2 during lactation. The Australian Guide to Healthy Eating recommends that red meat be eaten 3
to 4 times a week; less than this and high-iron replacement foods will be required.
Pregnancy
■■ Eat an iron-rich diet during pregnancy. Red meat is the best source of iron (see antenatal
section). Choose iron-fortified breakfast cereals and breads.
■■ Tests to check for anaemia should be conducted during pregnancy. If your doctor
prescribes iron supplements, take them according to instructions.
■■ Discuss any side effects causing concern with your doctor. It is normal to see changes
in stools.
Breastfeeding
■■ When breastfeeding, ensure a healthy diet is consumed, with adequate amounts of iron
(see breastfeeding section)
■■ Cut back on the amount of tea and coffee you drink, especially around mealtimes, since
the tannins in tea and coffee bind to the iron and interfere with absorption.
Pregnancy / breastfeeding checklist
Mum includes red meat 3-4 times a week
Iron levels have been checked whilst pregnant, and mum is aware of her iron
status
If iron supplement is required, it is taken as directed
Encourage foods high in non haem iron to be eaten with haem iron foods
Encourage foods high in vitamin C to be consumed with iron containing foods
Limit intake of tea and coffee (around 3 a day)
Limit excessive intake of bran
If mum is a vegetarian refer to dietitian
Suggestions to prevent or treat iron deficiency in
infants (4,9)
Introducing solids
■■ Don’t give your baby cow’s milk or other fluids that may displace iron-rich solid foods
before 12 months of age.
■■ Start giving your baby pureed foods when they are around 6 months of age. Fortified
baby cereal made with iron-fortified formula or breastmilk, at first along with pureed
vegetables and fruit. Gradually include finely minced meat at one mealtime from 6 months onwards.
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57
Introducing solids with appropriate iron checklist (adapted from 4)
Babies are exclusively breastfed until 6 months of age
If formula fed, iron fortified milk formula is chosen
Iron fortified cereals have been introduced around 6 months
Haem iron foods (eg red meat, chicken and fish) have been introduced around 7
months
Cow’s milk is delayed as the main milk drink until 12 months
Once a variety of foods have been introduced, vitamin C rich foods (eg citrus,
berries, tomatoes etc) are eaten with haem and non haem iron foods
If mother and/or child are vegetarians refer to dietitian
Suggestions to prevent or treat iron deficiency in
toddlers and preschoolers (4,9)
■■ meat, poultry and fish are important sources of iron in your child’s daily diet. include red
meat 3 to 4 times per week (8)
■■ vitamin C helps the body to absorb more iron, so make sure your child has plenty of fruit
and vegetables
■■ watch your child’s fluid consumption; lots of milk and juice can take the edge off an
already small appetite and therefore limit intake of iron rich foods
■■ chronic diarrhoea can deplete your child’s iron stores, while intestinal parasites such as
worms can cause iron deficiency. Referal to doctor for prompt diagnosis and treatment.
Practical ways to increase iron in the diet for young children
■■ include nutrient dense finger foods such as slices of roast meat, leftover mini meatballs,
sandwiches with cold meat, cold cooked sausages, cold platter with cooked meat and
raw vegetables with a dip
■■ offer meat alternatives including dried beans, lentils, chickpeas, canned beans, fish,
eggs and small amounts of nuts and nut pastes.
■■ include foods rich in vitamin c like oranges, mandarins, berries and tomatoes.
■■ encourage young children, toddlers or fussy eaters to try minced meats, fortified
breakfast cereals, eggs and smooth nut pastes.
Iron in toddlers and children checklist (adapted from 4)
Small portions of a variety of foods from all food groups are offered regularly
Toddlers consuming up to 600ml milk per day (no more)
Toddler consuming up to ½cup of juice per day (no more)
High iron, nutrient dense finger foods are encouraged
If concerns with fussy eating, refer to dietitian
If mother and/or child are vegetarians refer to dietitian
Adapted from Tuckertalk, 2003
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Useful websites and resources
Key state and national documents for health workers:
Dietary Guidelines for Children and Adolescents in Australia and Infant Feeding Guidelines
for Health Workers
Optimal Infant Nutrition: evidence based guidelines
Infant and Child Nutrition in Queensland 2003
National Breastfeeding Strategy
Report of the Chief Health Officer Queensland, 2006
Australian iron Status Advisory Panel
www.ironpanel.org.au/AIS/AISdocs/childdocs/Ccontents.html
Further professional development reading:
Sandoval C., Jayabose S., Eden A.N., (2004): Trends in diagnosis and management of iron
deficiency during infancy and early childhood. Haematology Oncol Clin N Am 18 (2004)
1423-1438
Parent handouts:
Child Health Information Fact Sheets www.health.qld.gov.au/child&youth/factsheets/
www.health.qld.gov.au/cchs/Gen_Nutrition_Activity/whyiron.PDF
Better health Channel; Victorian Government
www.chw.edu.au/parents/factsheets/iron.htm
Growing Strong: Feeding you and your baby
References
1. Child Health Screening and Surveillance: 2002 A critical Review of the evidence. NHMRC
[online] 13th April 2007
www.nhmrc.gov.au/publications/synopses/_files/ch42.pdf
2. [online April 2007] www.ironpanel.org.au/AIS/AISdocs/childdocs/Ccontents.html
3. Couper R., and Simmer K. Iron deficiency in children: Food for thought. MJA 2001;
174:162
4. Tuckertalk: The Family Nutrition Education Manual. Department of Health and Community
Services, Tasmania. 2004
5. Couper R., and Simmer K. Iron deficiency in children: Food for thought. MJA 2001;
174:162
6. Kruske S., Norberg M., Stewart L., Millen L. 2004. ‘Feeding Practices and Iron Deficiency
in Children under 2 years of age: Centre for Family Health and Midwifery, Sydney
7. Queensland Health: Ros Gabriel, Gayle Pollard, Ghazala Suleman, Terry Coyne and Helen
Vidgen. Infant and Child Nutrition in Queensland 2003. Queensland Health. Brisbane
2005.
8. National Health and Medical Research Council: Dietary Guidelines for Children and
Adolescents in Australia incorporating the Infant Feeding Guidelines for Health Workers,
Canberra www.health.gov.au/pubhlth/strateg/childnutirtion/index.htm
9. [online April 2007] www.betterhealthchannel.vic.gov.au/bhcv2/bhcarticles.nsf/pages/
Iron_explained?open
10. [online April 2007] www.chw.edu.au/parents/factsheets/iron.htm
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59
7.10Lactose intolerance
Lactose intolerance is a condition which results in an inability to digest lactose. Lactose is a sugar
found in milk. Lactose must be broken down in the body in the small intestine by an enzyme called
lactase, into its individual components - glucose and galactose - before it can be absorbed. An
inability to digest lactose due to a decreased or absent lactase activity can result in symptoms of:
■■ diarrhoea
■■ nausea
■■ flatulence
■■ abdominal discomfort and distension after the ingestion of lactose
Dietary lactose elimination or clinical tests are available to detect lactose intolerance and it is
important to have this correctly diagnosed by a doctor. These tests can include non-invasive
hydrogen breath testing, stool acidity test or invasive intestinal biopsy determination of lactase
concentrations (1).
Lactose intolerance is a distinct entity from cow’s milk sensitivity, which involves the immune
system and causes varying degrees of injury to the intestinal surface. Cow’s milk protein
intolerance is reported in 2% - 5% of infants within the first 1 to 3 months of life, typically resolves
by 1 year of age (1).
Frequent runny stools do not mean a breastfed infant has diarrhoea or lactose intolerance: they
are simply viewed ad evidence of sufficient milk. Diarrhoea entails very frequent watery stools (2).
Causes of lactose intolerance
Congenital alactasia or hypolactasia
This condition is seen in infants from birth and results in the enzyme lactase either being absent or
present in low levels. This condition is rare.
Primary lactose intolerance
This condition results in an absent or low lactase activity. It is rare before the age of 3 years.
Decreased lactase activity is genetically inherited and is more common amongst near East and
Mediterranean, Asian, African and North and South American ethnic groups. This condition
generally persists throughout life and requires life-long adherence to a low lactose diet, at a level of
restriction that eliminates symptoms.
Secondary lactose intolerance
This is usually only temporary and occurs as a result of damage to the intestinal mucosa, for
example, coeliac disease, inflammatory bowel disease or gut surgery. It may also occur after
gastroenteritis. Treatment requires a low lactose diet to be followed for a short period of time.
Developmental lactase deficiency
Relative lactase deficiency observed among pre term infants of less than 34 weeks of gestation.
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Management
Breastfed Infants
Lactose is the sugar in all mammalian milks, it is produced in the breast and is independent of the
mother’s consumption of lactose (3). Breastmilk contains around 7% lactose.
It is uncommon for breastfed infants to exhibit signs of primary or secondary lactose intolerance.
Breastmilk is usually well tolerated despite it containing lactose. Breastfed infants should be
continued on human milk in all cases.
Ensuring the infant’s correct attachment to the breast in order to allow effective drainage is
important. Encouraging the infant to finish suckling one breast before offering the second may
also be helpful for infants suffering from lactose intolerance. This results in the infant receiving
a higher fat feed and tends to delay gastric emptying. It also slows the rate at which lactose is
presented to the small intestine.
Although lactose free cow’s milk protein based formulas are readily available no studies have
documented that these formulas have any clinical impact on infant outcomes measure including
colic, growth or development (4).
Lactase drops are an option in expressed breastmilk – but these are not always helpful.
In special cases breastfed infants may be required to change to a low lactose formula.
Breastfeeding should only be ceased due to lactose intolerance after receiving medical advice.
Formula fed Infants
In developed countries enough lactose digestion and absorption are preserved so that low-lactose
and lactose free formulas have no clinical advantages compared with standard lactose containing
formulas. Infants with secondary lactose intolerance should only be given lactose free formulas for
a short period of time as prescribed by a doctor.
Note A
lthough soy milk formulae are low in lactose, they are not the feed of choice for the
treatment of lactose intolerance. For infants, a cow’s milk based low lactose formula should
be recommended.
Low lactose solids
It is rare for young children less than 3 years of age to have primary lactose intolerance. Lactose
intolerance in this age group usually exists due to an injury to the intestinal mucosa. Low lactose
diets should usually only be required for short periods of time.
For children requiring long term adherence to a low lactose diet, advice from a dietitian should be
sought. It is important that meals remain balanced and that nutrient requirements such as calcium
are met. A more extensive list of low lactose foods can then be provided.
Children vary in the level of lactose they can tolerate and it is often not necessary to eliminate all
dairy foods from the diet. Often levels of lactose equivalent to the amount in 1 glass of milk are
tolerated each day. Some milk products such as yoghurt, buttermilk and hard cheeses (eg. swiss,
cheddar) contain only small amounts of lactose and are usually well tolerated.
It is important to test a child’s level of tolerance and provide the maximum amount of dairy food
possible to ensure adequate calcium intakes. A calcium supplement may be required if intakes of
low lactose milk or calcium fortified soy milk are low.
For secondary lactose intolerance, low lactose foods and fluids should be provided for 1-4 weeks
depending on the severity of the symptoms. A normal diet should then be gradually introduced.
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61
Table 26
Lactose content of common foods
Food
Lactose content (g)
Regular milk, 200 ml
9.4
Cheese, 35g slice (Edam, Swiss, Brie, Cheddar)
0.0
Processed cheddar, fetta
0.1
Cottage cheese, 100g
1.4
Cream cheese
3.2
Ice cream, 50g
2.8
Yoghurt, 200g*
7.8
* The lactose content in yoghurt decreases each day, even while it sits in the fridge, because its
natural bacteria use lactose for energy.
Hidden sources of lactose
■■ Breads, biscuits, cakes and other baked goods
■■ Processed breakfast cereals
■■ Mixes for pancakes, biscuits and cookies
■■ Margarine
■■ Cheese studies, cream soups
■■ Custard
■■ Milk chocolate
■■ Salad dressings
Dairy foods are an important source of calcium. If these foods are eliminated from the diet it is
essential to replace them with other calcium rich foods eg calcium fortified soy products.
Useful websites
www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Lactose_intolerance?open
www.breastfeeding.asn.au/bfinfo/lactose.html
www.lactose.com.au/
www.mayoclinic.com/health/lactose-intolerance/DS00530
www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=302&id=1787
www.chw.edu.au/parents/factsheets/pdf/low_lactose_diet.pdf
References
1. Heyman M 2006 Lactose Intolerance in Infants, Children and Adolescents Paediatrics 118
(3) 1279-86.
2. Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant
Feeding Guidelines for Health Workers, NHMRC, Canberra 2003.
3. 3. Anderson J (2006) Lactose intolerance and the breastfed baby. Essence magazine
35(1).
4. Heubi J et al (2000) Randomised multicenter trial documenting the efficacy and safety of a
lactose free and lactose containing formula for term infants J Am Diet Assoc 100; 212-217
5. The GUT Foundation: [online: May2007 ] www.gut.nsw.edu.au/free3.htm
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7.11Regurgitation and gastro-oesophageal reflux
The passage of gastric contents into the oesophagus is a normal physiological process that
occurs in healthy infants and children. In fact, in healthy infants, gastric fluids may frequently erupt
into the oesophagus, anywhere from 10 to 50 times a day (1). Many, but not all of these episodes
result in regurgitation. Regurgitation describes reflux into the oropharynx. Regurgitation is most
frequently reported between 1 and 3 months (50%) to around 4 months (61%). By the time the
infant is 10 to 12 months old, only 5% of parents still report it as a problem (1).
Gastro-oesophageal reflux (GOR) is a condition of frequent regurgitation or vomiting, often
beginning between 2 and 6 weeks of age (2).
The symptoms in young infants differ from those seen in older children and include:
■■ excessive crying
■■ irritability
■■ back arching
■■ breast refusal
■■ feeding difficulties (1,2)
Most infants with regurgitation or reflux remain healthy and thrive, and the symptoms settle down
between 6 and 10 months of age, when the infant begins to spend more of the day in an upright
posture (2). If severe, it can lead to gastro-oesophageal reflux disease (GORD), when reflux leads
to pathological consequences such as, oesophagitis (inflammation of the oesophagus) failure to
thrive, recurrent aspiration (which may be associated with apnoea) and pneumonia.
Gastro-oesophageal reflux is significantly less common in breastfed infants than in those fed
formula. This finding is unrelated to feed volume (2).
Diagnosis
The diagnosis of gastro-oesophageal reflux is made on clinical grounds. It is important to
determine if symptoms are caused by an underlying pathological condition, or if there is evidence
reflux is causing secondary complications such as failure to thrive.
In most cases reflux is uncomplicated and little intervention is required.
Investigation is required only when complications are present or if the infant does not respond to
simple management measures (2).
Some warning signs of underlying pathology (1)
Does the infant have:
■■ Bilious and/ forceful vomiting
■■ Onset of vomiting after 6 months*
■■ GI bleeding*
■■ Constipation
■■ Diarrhoea
■■ Abdominal tenderness, distension
■■ Fever
■■ Lethargy
■■ Failure to thrive*
* may also be a symptom of GORD
Refer for medical intervention if the infant has one or more of these symptoms
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63
Reflux and poor weight gain
Infants with recurrent vomiting and poor weight gain should undergo evaluation for the adequacy
of caloric intake and the effectiveness of swallowing.
Poor weight gain despite an adequate intake of calories should prompt evaluation for causes of
vomiting and weight loss other than GORD.
Referral to dietitian
Management
Reassurance
The majority of infants will have physiological regurgitation and will settle spontaneously. Provided
the infant is thriving, no investigation or intervention is required. It is important not to label these
children as having a condition such as gastro-oesophageal reflux (2).
Posture (2)
■■ Placing the infant in a more upright feeding position can be helpful for regurgitation.
■■ Keeping the infant upright for 15 to 30 minutes after feeding also helps; a baby sling is
useful in this setting.
■■ The best position for reducing reflux is prone but, because this position has been
associated with an increased incidence of sudden infant death syndrome, it is not
generally recommended.
■■ No other lying position has been shown to be effective.
Food thickening
■■ When breastfeeding, liquid Gaviscon is sometimes effective, although it can cause
constipation (2).
■■ Recently infant formulas containing a thickening agent (AR formulas) have become
widely available….. They should be considered only for reducing regurgitation; they are
not an anti-reflux formula (2).
■■ Thickening solid feeds with rice cereal can assist in regurgitation.
If an infant is placed on a thickened feed or is using a thickener, this should only occur under
appropriate medical supervision.
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Milk free diet
Some studies report up to 40% of infants with GOR has a cow’s milk protein intolerance.
This is important to investigate, particularly if the infant has poor weight gain, irritability and
feeding refusal (3).
Referral to dietitian for assessment and advice
Drug therapy
Drug therapy should be given only under medical supervision.
There are two possible therapies: acid reduction and use of prokinetic agents. At present
there is no drug available that is truly anti-reflux (2). In most cases they are not valuable
treatment of infants with regurgitation (1).
Outcome
Active medical management controls symptoms leading to:
■■ 50 % of children needing no further therapy beyond 8 to 10 months of age
■■ 30 % beyond 18 months of age.
However, 17% of patients have ongoing symptoms or complications requiring anti-reflux surgery (2)
Surgical intervention
Surgical intervention is restricted to infants for whom medical management has failed and/or who
have potentially life-threatening complications such as apnoea or aspiration. This is rare.
References
1. Winter H.S. (2007) Gastroesophageal reflux in Infants, www.uptodate.com/udt/content/
topic.do?topicKey=pedigast/16818 [online] 18th April, 2007
2. Dietary Guidelines for Children and Adolescents in Australia incorporating the Infant
Feeding Guidelines for Health Workers, NHMRC, Canberra 2003.
3. Salvatore S., Vandenplas Y., (2002) Gastroesophageal reflux and cow’s milk allergy: Is
there a link? Pedatrics Nov 2002. 110(5):972
4. Huang R-C., Forbes DA., Davies MW., (2003) Feed thickener for newborn infants with
gastroesophageal reflux. Cochrane Review Abstracts
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65
Resource list
Useful phone numbers
Australian Breastfeeding Association
Brisbane
13HEALTH 13 43 25 84
Lifeline
13 11 14
Child Health Information Service
Brisbane
Freecall
(07) 3844 6488
7-day Breastfeeding Helpline (07) 3844 8166
(07) 3862 2333
1800 177 135
Kids Help Line 1800 55 1800
Parentline
1300 301 300
Poisons Information Centre 13 11 26
TravelSmart
(07) 3253 4006
Sport and Recreation Queensland
1300 656 191
Women’s Health
Brisbane
Freecall
(07) 3839 9988
1800 017 676
Useful websites
The following websites contain a wide range of useful information on health, nutrition, and physical
activity:
Australian Breastfeeding Association (ABA)
The Australian Breastfeeding Association is Australia’s leading source of breastfeeding information
and support to all sectors of the community. ABA is supported by health authorities and
specialists in infant and child health and nutrition. ABA operates a 7-day Breastfeeding Helpline,
where callers can contact volunteer breastfeeding counsellors to assist them with breastfeeding
issues. ABA provides an electric breast pump hire service as well as mother-to-mother support
through more than 75 Queensland groups.
Website: www.breastfeeding.asn.au
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1
Australian Council for Health and Physical Education
and Recreation (ACHPER) Queensland
ACHPER Queensland is a national, not-for-profit professional association representing people
who work in the areas of health education, physical education, recreation, sport, dance,
community fitness or movement science. The mission of the Council is to promote healthy
lifestyles for all Australians and to study and promote its areas of focus. The ACHPER QLD website includes information about:
■■ events, such as the ACHPER QLD Women in Sport breakfast
■■ programs, such as Schools Network
■■ conferences, such as the ACHPER QLD State HPE Conference
■■ resources, such as the ACHPER Advocacy Kit.
Website: www.achper.org.au/
Australian Dental Association Queensland (ADAQ)
In Queensland, ADAQ is regarded as the recognised voice of dentistry. With around 90 per cent
of registered dentists and dental specialists across the private and public sectors as members, the
Association provides a most effective representative body. ADAQ strives to promote the art and science of dentistry, to represent the profession and to
provide services which promote the highest level of oral health in the community.
Website: www.ada.org.au/default.aspx
Australian Medical Association (AMA) Queensland
AMA Queensland is the peak medical body for doctors in Queensland and is committed
to bettering public health in the State through a range of different initiatives. One of these is
AMA Queensland’s Kids GP campaign, which is aimed at providing an effective public health
contribution towards the spiralling rates of overweight and obese children in Queensland. For more information about AMA Queensland’s Kids GP campaign please visit Kids GP website.
Website: www.kidsgp.com.au/
Australian Indigenous Health InfoNet
The Australian Indigenous Health InfoNet is an innovative web resource that makes knowledge
and information on Indigenous health easily accessible to inform practice and policy.
The web resource is a ‘one-stop info-shop’ for people interested in improving the health of
Indigenous Australians. We provide quality, up-to-date knowledge and information about many
aspects of Indigenous health, and support ‘yarning places’ (electronic networks) that encourage
information-sharing and collaboration among people working in health and related sectors
Website: http://www.healthinfonet.ecu.edu.au/
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Brisbane Markets
Brisbane Markets Limited is involved in a range of activities to promote health and nutrition,
support the fruit and vegetable industry and interact with our local community.
These include:
■■ The Queensland Kids Fresh-Net - a central information and materials resource for
schools
■■ The Fresh for Kids program - multifaceted program to encourage school children
to make healthy eating choices
■■ Fresh Tastes - a multifaceted program to provide support and reward excellence
amongst independent fruit and vegetable retailers
■■ Local community and school sponsorships
■■ Sponsorship of Life Education Queensland
Website: www.brisbanemarkets.com.au/
The Cancer Council Queensland
The Cancer Council Queensland was established in 1961 and is the State’s foremost anticancer organisation. It is an independent, community-based charity and is not government
funded. The Cancer Council aims to reduce the impact of cancer - particularly the suffering it
causes - and ultimately to eliminate the disease, by raising funds to advance cancer research;
improve cancer treatment; support people with cancer, their family and friends; and increase
community awareness of cancer, its prevention and early detection.
Website: www.cancerqld.org.au/default.asp
The Coeliac Society of Australia
The State Societies aim to give information and support to medically diagnosed coeliacs and
their families, sufferers of dermatitis herpetiformis and those medically diagnosed as requiring a
gluten free diet. Advice and information is given about the gluten free diet, ingredients, where to
buy, recipes and cooking, overseas travel, educational material, as well as research information.
Support groups have been set up throughout the States and Territories where members can meet
to give support and exchange ideas and information.
Website: qld.coeliacsociety.com.au
Diabetes Australia Queensland
Diabetes Australia - Queensland is a not-for-profit organisation dedicated to improving the
lives of people with diabetes. Diabetes Australia Queensland is a member-based association and
is part of the national organisation, Diabetes Australia Ltd. Diabetes Australia Queensland was
formed in 1968 and currently has over 44,000 members. The organisation’s vision is an Australian
community free from diabetes and its impacts.
Website: www.daq.org.au/
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3
Dietitians Association of Australia (DAA)
DAA is the largest professional nutrition organisation in Australia with over 3000 members.
Accredited practising dietitians (APDs) are university-qualified professionals committed to quality
service and the DAA Code of Professional Practice. The DAA website gives practical, up-to-date
information on nutrition and healthy eating and provides an online ‘find an APD’ service.
Website: www.daa.asn.au/
Eat Well Be Active
The Eat Well Be Active website is a goldmine of fact sheets, downloads, information, recipes and
advice.
Website: www.health.qld.gov.au/eatwellbeactive/default.asp
Food Standards Australia and New Zealand
Food Standards Australia New Zealand (FSANZ) is an independent statutory agency established
by the Food Standards Australia New Zealand Act 1991. Working within an integrated food
regulatory system involving the governments of Australia and the New Zealand Governments, we
set food standards for the two countries. FSANZ is part of the Australian Government’s Health and
Ageing portfolio.
The ultimate goal is: A safe food supply and well-informed consumers. FSANZ develops food
standards, and joint codes of practice with industry, covering the content and labelling of food
sold in Australia and New Zealand. In addition, we develop Australia-only food standards that
address food safety issues – including requirements for primary production - and maximum
residue limits for agricultural and veterinary drug residues.
Using our skills, knowledge, and scientific capabilities, we develop food standards for
composition, labelling and contaminants, including microbiological limits, that apply to all foods
produced or imported for sale in Australia and New Zealand.
Website: www.foodstandards.gov.au
Formula for Life
Formula for Life is one of Australia’s most comprehensive dietary and analysis websites. In
addition to nutrition information, Formula for Life also gives you free access to more than 140
recipes and healthy eating tips as well as lifestyle tips, information on food groups, nutrients,
vitamins, minerals, vegetables, diet related diseases and more.
The site is consistent with contemporary Australian standards and has applied recognised
government agency standards. However, given recent changes to the National Health and Medical
Research Council’s Nutrient Reference Values (2006), nutrient-specific analysis may not provide
up-to-date information. The website is free to use. It is developed and supported by Queensland
vegetable growers and Growcom, Queensland’s peak horticulture body.
Website: www.formulaforlife.com.au/
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Gut Foundation
The Gut Foundation provides professional and public education and promotes research into
digestive disorders to improve gastrointestinal health. Information provided explores both a)
terms of understanding the process of digestion and absorption and b) how that might affect the
development of subsequent diseases.
There is also information on how to manage common problems, including the very common
irritable bowel syndrome and dyspepsia, together with other more serious diseases, such
as colorectal cancer. website features interactive presentations on anatomy, endoscopy,
colonoscopy, sigmoidoscopy, wireless video capsule endoscopy, etc.
Website: www.gut.nsw.edu.au/
The Heart Foundation
The Heart Foundation, Australia’s leading heart health organisation, has developed the Walk of Life
- for all walks of life campaign and a booklet called Losing Weight the Healthy Way, with easy and
clear tips to help you achieve and maintain a healthy weight and a healthy lifestyle.
The Heart Foundation saves lives by funding world-class research, guidelines for health
professionals, informing the public and assisting people with cardiovascular disease. As a charity,
the Heart Foundation relies on donations and gifts in wills to continue its lifesaving research,
education and health promotion work.
For further information visit Heart Foundation or call 1300 36 27 87.
Website: www.heartfoundation.com.au/
International Lactation Consultants Association
The International Lactation Consultant Association (ILCA) is the professional association for
International Board Certified Lactation Consultants (IBCLCs) and other health care professionals
who care for breastfeeding families.
The vision is a worldwide network of lactation professionals. Their mission is to advance
the profession of lactation consulting worldwide through leadership, advocacy, professional
development, and research.
Website: www.ilca.org/
Lactation Resource Centre
Australian Breastfeeding Association’s Melbourne-based Lactation Resource Centre specialises
in providing comprehensive information and resources on all aspects of human lactation. Study
modules and the latest research articles on breastfeeding are available for a fee.
Website: www.breastfeeding.asn.au/lrc/lrc.html
National Health and Medical Research Council
(NHMRC)
NHMRC is Australia’s peak body for supporting health and medical research; for developing health
advice for the Australian community, health professionals and governments; and for providing
advice on ethical behaviour in health care and in the conduct of health and medical research.
Clinical Pratice Publications are also available.
Website: www.nhmrc.gov.au/
Nutrition publications www.nhmrc.gov.au/publications/subjects/nutrition.htm
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Nutrition Australia
Nutrition Australia (the registered business name for the Australian Nutrition Foundation Inc.) is
a non-government, non-profit community-based organisation that aims to provide scientifically
based nutrition information to encourage all Australians to achieve optimal health through food
variety and physical activity.
Website: www.nutritionaustralia.com.au/
Queensland Divisions of General Practice (QDGP)
The QDGP is the peak representative body for divisions of general practice in Queensland.
QDGP promotes the central role of general practice in primary health care by ensuring that key
stakeholders and general practice work together in a supported environment.
Established in 1997 and representing 18 Divisions in Queensland, QDGP aims to influence and
implement primary health care reform in Queensland.
Website: www.qdgp.org.au/
Queensland Health: Health Information Directory
The Health Information Directory provides access to online health and wellbeing information. The fact sheets and other resources on this site are constantly expanded and regularly reviewed.
Website: www.health.qld.gov.au/healthtopics/result.asp?browseaz=N
Sport and Recreation New Zealand (SPARC)
The SPARC website is dedicated to getting New Zealanders moving. It features some great ways
to help people get more active, including the Online Activator, which helps individuals to choose
physical activities to suit their lifestyle; and Action Packs for Kids, which has loads of fun ideas to
get kids active.
Website: www.sparc.org.nz/getting-active
Sport and Recreation Queensland
Sport, Recreation and Racing is proactively working towards helping Queenslanders become
more active.
As the lead agency responsible for implementing the Queensland Government’s sport and
recreation policies, we work with sporting organisations, councils, schools, Indigenous
organisations and the wider community to increase participation, develop better skills in the
industry and create better places and opportunities for sport and recreation.
Website: www.sportrec.qld.gov.au/
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Queensland Government programs
10,000 Steps
The 10,000 Steps program aims to increase the day-to-day activity of Queenslanders and
Australians by encouraging the accumulation of ‘incidental’ physical activity as part of everyday
living. The program used the 10,000 Steps per day message as a way to help people to increase
their activity levels.
The Queensland Government supported the initial 10,000 Steps Rockhampton project and then
the further development of the 10,000 Steps program and 10,000 Steps website so that others
can implement program activities and promote physical activity in their local communities. It is free for community groups and organisations to become a registered provider of 10,000 Steps
activities.
The 10,000 Steps website has a range of physical activity resources and information, including an
online Steplog, a workplace challenge, a pedometer library loan scheme and walkway signage;
plus information packages for GPs and other health professionals. Website: www.10000steps.org.au/
Easy Steps
Easy Steps is a toolkit for planning, designing and promoting safe walking is a resource that has
been prepared by Queensland Transport to assist local local governments through the provision of
a range of tools to help them improve walking environments in Queensland through the provision
of through a range of tools, information and encouragement. The series of Easy Steps modules
are designed to assist council managers, planners and engineers plan for, promote and provide
for increased walking levels in their local area.
Website: www.transport.qld.gov.au/Home/Safety/Road/Pedestrians/Pedestrian_easy_steps
Go for 2&5® fruit and vegetable campaign
Queensland Health launched the Go for 2&5® fruit and vegetable campaign in October 2005
to increase awareness of the need to eat more fruit and vegetables; and to encourage all
Queenslanders to increase their intake of fruit and vegetables by 1 serve per day.
The Australian Guide to Healthy Eating recommends eating at least 5 serves of vegetables and 2 serves of fruit per day. Prior to the campaign, Queensland adults were only eating 2.1 serves of
vegetables and 1.4 serves of fruit each day.
Since the Go for 2&5® fruit and vegetable campaign was introduced there have already been
improvements in Queenslanders’ intake of fruit and vegetables. Phase 1 campaign results from
a survey conducted in 2006 shows an increase in fruit intake by 0.1 serve per person a day, and
an increase in vegetable intake by 0.3 per person per day. This amounts to an overall reported
increase in consumption by 0.4 per person per serve, which is well on the way to achieving the
campaign target.
The Phase 1 results show that the creative approach using the ‘Vege Man’ character has been
successful in encouraging Queenslanders to eat more fruit and vegetables every day. Phase 2 of the 4.5 year campaign introduced the colourful ‘Dame Edna’ character and included
the launch of the Go for 2&5® website in August 2006.
The website includes a large range of recipe ideas and helpful hints to include more serves of fruit
and vegetables every day. Website: www.qheps.health.qld.gov.au/gofor2and5/default.htm
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Growing Strong, feeding you and your baby resources
Growing Strong resources have been developed by Queensland Health staff to provide evidencebased information about eating well during pregnancy as well as suggestions for dealing with
some common food and nutrition related problems. Information is also provided about common
breastfeeding issues including how to know when a baby gets enough breastmilk and correct
positioning and attachment. The resources help to dispel myths and misinformation about
feeding young children.
Currently the Growing Strong resources are designed for health workers to use with Aboriginal
and Torres Strait Islander families. Fact sheets for community members are currently being
developed. Website: www.health.qld.gov.au and search ‘Growing Strong’
Healthy Food Access Basket (HFAB) Surveys
HFAB surveys are conducted regularly to monitor the cost and availability of food throughout
Queensland. The survey assesses the variability in costs and availability of a standard basket of
basic healthy food items from nearly 100 stores in geographical locations across Queensland. The foods that are in the standard basket represent commonly available and popular foods. As the HFAB survey has been repeated over time, the latest survey findings can be compared to
survey findings from previous years. Reports from the 2000, 2001 and 2004 HFAB surveys are
available on the Queensland Health website. A report from the latest HFAB survey, conducted in
2006, is currently under preparation. This will be available later in 2007.
Website: www.health.qld.gov.au and search ‘Healthy Food Access Basket’
Lighten Up to a Healthy Lifestyle Program
Lighten Up to a Healthy Lifestyle is a group-based healthy lifestyle support program delivered by
trained facilitators (community health nurses or allied health professionals) in selected community
health centres in 27 Health Service Districts of Queensland Health. All Queenslanders who are
either overweight or at risk of chronic diseases are eligible to participate in this community-based
program.
Lighten Up to a Healthy Lifestyle does not focus on dieting or scales, but emphasises making
healthy food choices, being physically active, setting realistic goals, modest weight loss,
increasing self esteem and managing stress. The program is supported by a participant workbook
which includes seven workshops covering increasing everyday physical activity, making better
food choices, skills in reading food labels, shopping and adapting recipes, stress management
and problem-solving.
Contact your local Community Health Centre (check the White Pages) to find out if the program is
available in your area.
To order the Lighten Up workbook, phone 1800 679 778 or visit the Queensland Government
Publications website, then choose ‘Search catalogue’ from the menu and enter LIGHTEN UP
then SEARCH.
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Smart Choices - healthy food and drink supply strategy
for Queensland schools
Smart Choices, a major element of the Safe and Healthy Schools initiatives, is all about offering
healthy food and drink choices to students in Queensland school settings. It applies to any place
or event where food and drink is supplied in Queensland state schools, including tuckshops,
fundraising, vending machines, excursions, camps, classroom rewards, sports days and
curriculum activities. Smart Choices is mandatory for all Queensland state schools from January 2007.
The Smart Choices website contains a resource package and tool kit that has been developed to
help schools implement the strategy.
Website: www.education.qld.gov.au/schools/healthy/food-drink-strategy.html
TravelSmart
The TravelSmart program encourages and supports voluntary change in the behaviour of
individuals and organisations to increase the use of environmentally-friendly transport such as
walking, cycling and public transport. TravelSmart raises awareness through campaigns, improves
access to information and promotes alternatives to car use. See the TravelSmart website for
more information.
Website: www.transport.qld.gov.au/Home/General_information/Travelsmart/
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A Healthy Start in Life ‐ a nutrition manual for health professionals ORDER FORM Your name: __________________________________________________
Position:
__________________________________________________
Organisation: _________________________________________________
Address:
__________________________________________________
_____________________________Postcode_____________
Telephone: ________________________
Email:
Fax: ___________________
___________________________________________________
Number of manuals required (maximum of 2)
PLEASE FAX TO:
Gold Coast Population Health Unit
5561 1851
Please note:
Hard copies of the manual are only available for distribution within
Queensland for health professionals only.
If you are interstate please view the manual online at:
www.health.qld.gov.au/healthieryou/healthystartinlife.asp

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