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If all UK infants were exclusively breastfed for six months, admissions to hospital due to diarrhoea would be halved

Recent dietary guidance emphasises why discussing infant nutrition can impact on the child’s health status later in life

Carbohydrates hit the headlines in July when a government body recommended free sugars should account for no more than 5 per cent of daily dietary intake. The press picked also up on proposals that the new term ‘free sugars’ be adopted to describe those added to food or those naturally present in honey, syrups and unsweetened fruit juices, but excluding lactose in milk and milk products. However, they failed to mention that the recommendations applied to adults and children above two years.

The reason given by the Scientific Advisory Committee on Nutrition, in its ‘Carbohydrates and Health’ report, was that there is insufficient data relating to dietary carbohydrates in infant nutrition.

The SACN report considers carbohydrates from a number of angles: classification, how the body processes them, dietary sources, health outcomes, and then various broad categories. It also reviews published studies, including data around infant nutrition. Among the findings are:

  • The mean intakes of total carbohydrate ranged from 93 to 126g/day and contributed 49-52 per cent of total dietary energy intake in children aged 4-18 months
  • Infant formula is the major contributor to total carbohydrate intake for children aged 4-11 months, providing 46 per cent of intake in the youngest children reducing to 28 per cent in those aged 10-11 months
  • Commercial infant foods are also major contributors to total carbohydrate intake for younger children, with milk and milk products at the older ages.

However, SACN concludes that “due to the absence of information” it cannot make any quantitative recommendations about how much dietary carbohydrate children aged under two years should consume, other than “from about six months of age, gradual diversification of the diet to provide increasing amounts of whole grains, pulses, fruits and vegetables is encouraged.”

A sweet education

Commenting on the SACN report, the Infant & Toddler Forum noted the call for a reduction in sugar in diets and said there should be better education on sugar, but at a much earlier stage. The ITF believes discouraging sugary drinks is an important step in protecting children’s health through helping to develop positive eating habits as early as possible.

The foods children learn to like in their early years can help shape eating habits that influence their health in later life, says the ITF. “A life begun, even in utero, with unhealthy food choices means setting up that child with a higher risk of child obesity before a child reaches pre-school age and also a risk of long term health problems.”

Judy More, paediatric dietitian and ITF member, explains: “High sugar and other unhealthy diets are related to the environment, where easy access to sugary and fatty foods is influencing food choices and overweight and obese parents influence a toddler’s later health outcomes.” This is where fiscal and education measures could work together, says Ms More.

“It’s clear we should act even earlier in improving outcomes, by having a conversation with women before, during and after pregnancy. Children born to women who begin pregnancy at a healthy weight and who eat a nutritious diet during pregnancy have the best long-term health outcomes.”

ITF’s own report, ‘Early Nutrition for Later Health; Time to Act Earlier’, published last autumn, stresses the need for healthcare professionals to advise families on developing healthy lifestyles. “We need to tailor our approach and act as early as possible. Families need consistent, practical advice from pre-conception through to pregnancy and beyond,” says Ms More.

NICE and nutritious

Shortly after the SACN report, NICE published quality standard QS98 ‘Nutrition: improving maternal and child nutrition’. It focuses on “improving nutrition before, during and after pregnancy (up to a year after birth) for women who may become pregnant, and for babies and pre-school children,” especially those in low-income and other disadvantaged households.

Its six quality statements include reiterating advice around breastfeeding, set out in July 2013 in QS37, which deals with post natal care (and which also includes advice on formula feeding). But QS98 also calls on healthcare professionals to give information about the Healthy Start scheme to pregnant women and the parents of young children who may be eligible. This will mean providing them with support to apply if necessary, “including having enough application forms for distribution.”

With regards introducing solids, it says: “It is important that babies aged around six months are started on solid food, with the introduction of suitable foods in addition to breast milk or formula milk to establish a healthy and varied diet.” And discussions with parents about starting solid food should take place at the 6-8 week health visitor appointment.

Almost three quarters of mothers initiate breastfeeding soon after birth, according to NHS England statistics. This figure has risen slightly in recent years, from around 71.7 per cent in 2008-09. But there is wide variation around the country, from 47 per cent in NHS Knowsley CCG to 93 per cent in NHS Lambeth and Wandsworth CCGs.

These figures decline significantly within a few weeks, however. The proportion of mums breastfeeding (either wholly or partially) at six to eight weeks was 43.8 per cent in 2014-15.

The Royal College of Paediatrics & Child Health strongly encourages mothers to breastfeed. Its position statement on the matter points out: “If all UK infants were exclusively breastfed for six months, admissions to hospital due to diarrhoea would be halved and those due to respiratory infections would fall by a quarter.”

Colic

A common misapprehension about infantile colic is that it is a digestive condition. Although the internationally-recognised Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders includes infant colic, there is nothing specifically gastrointestinal about the signs and symptoms. Rather, it is the age, the nature and lack of apparent cause of crying, and the baby continuing to thrive that describes colic. Colic will not stop a child from feeding, and it occurs equally in babies who are breast-fed or bottle-fed.

Several theories exist about possible causes of colic but there is very little solid evidence. As three quarters of babies do not experience colic, it could be one end of the crying spectrum, or an evolutionary advantage to get additional parental attention.

Excessive crying can lead to the baby swallowing air, and the trapped gas can cause flatulence and abdominal distension. Other ideas are that the baby’s digestive tract is not yet producing sufficient enzymes, triggering a (temporary) gut sensitivity, or the intestinal flora has not yet built up. In a minority of cases, colic may be secondary to a cow’s milk protein allergy and may respond to mum going on a hypoallergenic diet if breastfeeding, or using a hydrolysed formula if bottle-feeding.

NHS Choices says there is no best way to treat babies with colic but recommends trying the various colic preparations as some parents do find them useful. And it offers tips such as how to hold and comfort the baby. When it comes to feeding, it suggests sitting the baby upright to reduce the chances of swallowing air, to always burp a baby after feeding, and if bottle feeding, to try a teat with a different flow rate.

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