MILK & MORE Helping children eat for a healthy life

Rosemary Brown CPHVA conference June 2013

What are we aiming for?

 Healthy, active child able to enjoy life – now & later

What are we aiming for?

 Happy, secure child through good relationships

What are we aiming for?

 Child who enjoys food… … without feeding becoming a battleground

What are we aiming for?

 Child who eats enough for their needs …but not too much

How can we achieve that?

 Encourage what will build positive relationships from the beginning  Harness a child’s inbuilt ability to regulate his/her own intake  Enhance parents’ knowledge, skills and confidence in enabling development of healthy eating habits

Government recommendations :



Breastfeed exclusively for 6 months, then



Continue to breastfeed until at least 1 year, whilst offering solid foods from around 6 months

How does breastfeeding help?

 Custom-made food and drink for baby, adapting to meet changing needs of baby

How does breastfeeding help?

Nucleotides F

Contains many ingredients not present or active in formula

White blood cells Viral fragments O Anti-inflammatory Bifidus factors Oligosaccharides

Antibodies

Enzymes R M Growth factors Transfer factors U

Vitamins/minerals Vitamins/minerals

L Fats

Carbohydrates

Fats

Carbohydrates

A Protein Water Protein Water B R E A S T I M L K

How does breastfeeding help?

 Breastmilk contains many protective factors, lowering the risk of infection & other diseases for babies and mothers:  reducing all common childhood infections     1/3 risk of SIDS reduced risk of breast and ovarian cancer for mum 15% fewer GP visits in first 6 months (McConnachie et al 2004) decreased hospital admissions (DH quarterly figures)

How does breastfeeding help?

 The hormones of breastfeeding (prolactin & oxytocin) and physical closeness facilitate:     connecting up helpful pathways in brain good bonding & protective instincts in mum stabilise baby’s heartrate, breathing, temperature, blood sugar calm the baby & help the mum relax & rest

How does breastfeeding help?

 Facilitates baby regulating intake to meet needs:  hunger cues enable responsive feeding  more control over flow and how much they take  leptin: hormone regulates appetite and energy metabolism  learn to recognise when they are full – need several weeks of breastfeeding before this begins (Brown & Lee 2012)  lower protein and energy in breastmilk reduces fat deposition -> lower risk of obesity (McCrory et al 2012)

Enabling breastfeeding

 Skin to skin contact at and after birth  Help to ensure effective attachment :

C

close to mum, chin indenting breast

H

head able to tip back – nipple protected, big mouthful more from underneath of breast

I

in line – head & body in line helps swallowing

N

nose to nipple – stimulates wide gape

S

sustainable & comfortable for mum

Recognising effective feeding

  Use breastfeeding assessment ourselves Empower mum feeding       to look for signs of effective deep suckles AND swallows baby calm at breast baby content after most feeds at least 6+ wet and 2+ dirty nappies a day pain-free for mum baby alert, when awake, with good colour and tone

How can we achieve that?



Bottle feeding

: intake depends on:    teat stimulating baby to suck, whether hungry or not size of teat expectations of mum/tin/society as to quantity and frequency   tends to be more mother-led can involve less interaction & closeness & more people

How can we achieve that?



Bottle feeding

: important to encourage responsive feeding  watch out for and follow hunger cues  let baby decide quantity  allow baby to draw teat into mouth  take bottle out from time to time  hold baby close with eye contact, smiles, talking  limit caregivers  use first stage milk

How can we achieve that?



Start offering solids when:

 they are developmentally ready to cope well & eagerly with solids   nutritional needs no longer met completely in breastmilk or formula usually around 6 months – not too early or too early or too late  Allows baby to continue to control own intake  Baby develops skills & good eating lifestyle

So why from around 6 months?

 Breastmilk, or formula, has all they need till then: energy for growth (Nielsen et al 2011; Wells et al 2012) for adequate iron stores (Jonsdottir et al 2013)  Giving anything else displaces breastmilk (Wells et al 2012)

So why from around 6 months?

 Their body systems are mature enough  Needed enzymes are present  Breastfeeding whilst whilst starting solids seems to reduce risk of allergies (Akobeng et al 2006)

So why from around 6 months?

 Can sit up with support  Safer  More able to reach out for food

So why from around 6 months?

 Interested in food – no coaxing needed!

 Start by watching people eat from 4-5 months

So why from around 6 months?

 Then reach out and grab objects, take to mouth & chew on them

So why from around 6 months?

  Eager to eat and feed themselves Encourages baby-led feeding & may reduce parental anxiety

So why from around 6 months?

 Good eye & hand coordination & motor skills (Wright et al 2011)  Feeding themselves develops skills

So why from around 6 months?

 Tongue able to move food around mouth  Munching action

So why from around 6 months?

 Able to swallow solid foods – learn to gum and gnaw before learning to swallow (Naylor & Morrow 2001)  Can cope with lumpier foods from beginning, so no need for purees & less work for mum  Breastfed babies accept new tastes more easily

So why from around 6 months?

 Able to take food off spoon without constantly pushing it out with tongue  Able to eat almost everything (e.g. fish, eggs, dairy foods)

So why from around 6 months?

 Reflex causing baby to gag moves further back, but still is safety mechanism

So why from around 6 months?

 Great sense of achievement!

Look for 3 signs together:

   Can sit and hold head steady Picks up food & puts it in mouth Swallows some – not pushing it all out again

How to start

 Start with 1 meal a day, after or between milk feeds – time when baby not too hungry or   Give baby finger foods to pick up in fists to (Baby-led weaning cookbook)  Offer softly cooked or mashed foods on a spoon – can add a little breastmilk or formula



How to start

Offer wide variety of food from all the food groups from the beginning  Increase lumpiness of foods quickly  Be prepared to offer new food many times (up to 20) – babies show they recognise new food by spitting it out!

 Baby’s tummy about the size of baby’s fist – use this as guide to portion sizes

Encourage good eating lifestyle

 Sit baby up to eat and stay with him/her  Let baby participate in family meals - and preparation when older  Avoid distractions during meals  Be prepared for messy eating – bib, food on clean highchair surface, plastic sheet on floor

Follow baby’s pace & cues

 Wait for baby to open mouth for spoon  Follow babies’ cues showing they have had enough – turning head away, pushing food away

Learning to drink from a cup

 Use open cup (or one with free flow spout) to give fluids – water, milk  Wean off any bottles & dummies by 1 year

Encourage a relaxed approach

 Praise good eating  Don’t use food as rewards  Look at what baby eats over a week rather than a day  If they are not interested, wait till next mealtime

So what do they need?

 Milk still major source of nutrients until 2 years - and protection, if breastfeeding  Food from all food groups:  raw or softly cooked vegetables and fruits starting once day, 4 times a day by 1 year   – starchy foods – potatoes, rice, pasta, plantain protein foods chicken, fish, eggs, meat, pulses and beans, dairy foods – soft well-cooked meat and 1-2 a day by 1 year

Just a few guidelines:

    Use whole milk – wait till 2 yrs to use semi-skimmed & 5 yrs for skimmed milk – young children need the fat content for calories without bulk and to carry vitamins Cut up any small round or coin-shaped food Make sure egg is well-cooked – yolk & white firm Avoid:        salt & sugar or salty/sugary snacks, including juices and squash. honey, in 1 st year – rare danger of botulism reduced calorie or low fat food very high fibre food – tea/coffee – fills stomach too quickly reduce absorption of vitamins whole nuts till 5 years – danger of inhaling rice or soya “milk” or goat’s milk – not suitable



Vitamin supplements

Vitamin drops A, C & D are From 6 months, if: - breastfed - taking less than 500ml formula per day For all children 1-5 years From 1 month if mother has not taken vitamin D in pregnancy

Why is Vitamin D needed?

         Healthy diet is not enough: 90% of our vitamin D comes from sunlight Sunlight not enough Oct-March 1 in 4 people in UK have low vitamin D Darker skins take longer to absorb enough from sunlight Hijabs etc -> less sunlight exposure Safe sun messages – only a short time of exposure needed Increased indoor pursuits Obesity: affects production & use Deficiency -> rickets, seizures in babies, smaller pelvis, lower immunity

Make mealtimes fun… & eat together!

Many thanks to Maya Tammam & the Goodinge support group for being wonderful visual aids! (Maya photos ©Jonathan Tammam)

Resources

•

Leaflets (Start4Life - DH):

    ‘Introducing Solid Foods’ ‘Building blocks for a better life’ ‘Off to the best start’ (breastfeeding) ‘Guide to bottle feeding’ Islington (PDF in English & 7 other languages):  ‘Milk & More: starting your baby on solid foods’  ‘ Drinks for children up to 5’  ‘ Snacking for children under 5’  ‘ Vitamins and minerals for children 1-5 years old’ • ‘

Milk and More’ training pack and recipe book

Resources

• Websites: 

www.firststepsnutrition.org



‘Infant Milks in the UK’: independent info re formula milks



Eating well in the first years of life’ – for parents and carers – coming in 2013



www.chew.org.uk



Breastfeeding and starting on solids:



www.babyfriendly.org.uk

– research & resources



www.nhs.uk/conditions/pregnancy-and-baby

•

The Baby-led weaning cookbook (Rapley & Murkett)

References:

Akobeng A.K et al (2006) Effect of breastfeeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies, Archives of Disease in Childhood, 2006(91), 39-43 Brown, A. & Lee, M. (2012) Breastfeeding during the first year promotes satiety responsiveness in children aged 18 24 months. Pediatric Obesity.2012, 7, 382-390 Cameron, S., Heath, A-LM.., & Taylor, R.W (2012) How feasible is baby-led weaning as an approach to infant feeding? A Review of the evidence, Nutrients 2012, 4, 1575-1609 Cameron, S, Heath, A-L.M. & Taylor, R.W (2012) Healthcare professionals’ and mothers’ knowledge of, attitudes to and experiences with, Baby-led Weaning: a content analysis study, BMJ Open 2010:2:e001542 DH quarterly figures, including comparison between breastfeeding prevalence and prevalence of hospital admissions DH (2013) Diet and Nutrition Survey of Infants and Young Children, 2011 (available on DH website) Jonsdottir O.H. et al (2012) Timing of the introduction of complementary foods: a randomized trial, Pediatrics, 2012:130:1038-1045 McConnachie A. et al (2004) Modelling consultation rates in infancy: influence of maternal and infant characteristics, feeding type and consultation history, British Journal of General Practice, 2004, 54, 598-603 McCrory C. & Layte, R.(2012) Breastfeeding and the risk of overweight and obesity at nine-years of age, Social Science and Mediecine 2012:Jul:75(2):323-30 Naylor, A.J. & Morrow, A.J (2001) Devclopmental readiness of normal full term infants to progress from exclusive breastfeeding to the introduction of complementary foods, Wellstart International and the LINKAGES project Nielsen S.B. et al (2011) Adequacy of milk intake during exclusive breastfeeding: a longtitudinal study, Pediatrics 2011:128:e907 Rapley G. & Murkett T. ( 2011) The Baby-led Weaning Cookbook UNICEF (2012) Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates Wells, J.C.K et al (2012) Randomized controlled trial of 4 compared with 6 mo of exclusive breastfeeding in Iceland: differences in breast-milk intake by stable-isotope probe, American Journal of Clinical Nutrition, May 16, 2012 WHO (1998) Complementary feeding of young children in developing countries: a review of current scientific knowledge, WHO Wright, C.M. et al (2010) Is baby-led weaning feasible? When do babies first reach out for and eat finger foods? Maternal and Child Nutrition

Contact

• For more information: Rosemary Brown Infant Feeding Coordinator, Islington 0203 316 8441 [email protected]