Feeding young children Flashcards
What is ‘preconception’? (Stephenson et al. 2018)
Often defined as the time period 3 months before conception (as the average time to conceive for fertile couples)
But, can be thought of from several perspectives:
biological: critical period spanning weeks around conception (gametes mature, fertilisation, developing embryo)
individual: once a woman/couple decides they want to have a baby
public health: longer periods of months/years during which risk factors such as diet/obesity can be addressed
Why is preconception health important? (Stephenson et al. 2018)
“A woman who is healthy at the time of conception is more likely to have a successful pregnancy and a healthy child”
An estimated ~60% pregnancies are planned globally (~55% in England – PHE, 2018)
global policies
first 1000 days
every women, every child
Importance of and increased focus on preconception health
being aware of screening
up to date with vaccinations
folic acid supliments
healthy diet
physically active
no smoking
less alcohol
Dietary and lifestyle characteristics of UK women of childbearing age
‘The majority of women do little to change their lifestyle to prepare for pregnancy.’ (Davies, 2014)
BMI = 26
OVERWEIGHT/OBEASE = 50%
less than 5 portions of fruit n veg = 77%
current smoker = 26%
high risk alcohol = 22%
Weight of UK women of childbearing age
In the UK, around half of all women of childbearing age are overweight or obese
Almost 20% of women have a BMI >30kg/m² at the beginning of pregnancy (NICE, 2013)
Maternal obesity increases risk of adverse outcomes for the mother and fetus/offspring
Maternal pre-pregnancy obesity significantly associated with child obesity in offspring (Heslehurst et al., 2019).
Micronutrient intakes of adolescent girls and adult women in the UK
Intakes are worse amongst adolecance girls
Girls 11-18 years
Women 19-64 years
Vitamin A
G = 18
W = 8
Riboflavin
G = 22
W = 13
Folate
G = 10
W = 7 (6% including supplements)
Iron
G = 49
W = 25
Calcium
G = 16
W = 9
Magnesium
G = 47
W = 11
Potassium
G = 37
W = 24
Zinc
G = 16
W = 7
Selenium
G = 41
W = 46
Iodine
G = 28
W = 12
Micronutrient status of adolescent girls and adult women in the UK
Almost 90% had RBC folate concentration lower than the threshold for optimal avoidance of NTDs; lower levels seen in women 16-24 years
Mean RBC folate concentrations reduced by 34% over 9 years of NDNS data
Micronutrient status of adolescent girls and adult women in the UK – Vitamin D (PHE&FSA, 2019)
Adequate vitamin D levels important for fetal skeletal development and regulation of blood calcium levels; possible link with adverse pregnancy outcomes
Summary of UK advice for women planning pregnancy (Stanner, 2018; NHS, 2020; NICE, 2010; NICE 2019)
a varied and balanced diet
daily folic acid supplement
400µg/day until 12th week of pregnancy; higher dose of 5mg/day for women at higher risk of NTD)
vitamin D supplement to meet RNI of 10µg/day
Avoid supplements containing vitamin A/foods high in vitamin A
Avoid alcohol
Limit caffeine intake
Maintain/attain a healthy weight
Energy requirements during pregnancy (SACN, 2011)
Energy and nutrient supply need to be sufficient to meet usual needs, meet needs of the growing fetus and lay down stores for late pregnancy and lactation
total energy cost ~77,000 kcal
↑ requirements for some nutrients
But, physiological adaptations mean higher dietary intakes not always required
In UK, increment of 191kcal/day recommended during the final trimester only
not ‘eating for two’!
underweight/very active women may need more; women who are overweight entering pregnancy may not need this, but specific recommendations not given
Macronutrient requirements during pregnancy (COMA 1991; SACN, 2011)
Protein
RNI = 45g/day
+ 6 g/day Preg
Carbohydrate
~50% energy
Dietary fibre
30g/day
Fat
~35% energy
Selected vitamin requirements during pregnancy (COMA 1991; SACN, 2011, Stanner 2018)
Vitamin A (µg)
600
+100 preg
Folate (µg)
200
+ 100 (+400µg supplement until 12wk) preg
Vitamin C (mg)
40
+10 (3rd trimester only) preg
Vitamin D (µg)
10
-
Selected mineral requirements during pregnancy (COMA 1991, SACN 2011, SACN, 2016, Stanner 2018)
Calcium (mg)
700
Iron (mg)
14.8
Zinc (mg)
7.0
Iodine (µg)
140
General dietary recommendations during pregnancy (PHE, 2016)
Balanced, varied diet including:
Plenty of fruit and vegetables
Wholegrain starchy carbohydrates
Varied protein sources (including oily fish)
Foods providing good dietary sources of folate, ß carotene, iron, calcium and zinc
Limited amounts of foods high in fat and/or sugars
The role and importance of folate during pregnancy
Folate plays an important role in cell division – high demand during early fetal development particularly around the time of the closure of the neural tube (~4 weeks gestation) to form the brain and spinal cord
Low maternal intake of folate is a risk factor for neural tube defects (NTDs) such as spina bifida and anencephaly caused by failure of the neural tube to completely close
Estimated 214,000-322,000 NTD affected pregnancies globally each year
Affect around 1,000 pregnancies annually in the UK
Current UK approach: supplementation
Dietary advice: UK RNI for folate = 200µg/day, plus additional 100µg/day during pregnancy from folate rich foods such as green vegetables, oranges, fortified cereals, chickpeas, pulses
Supplement advice: Women who could become pregnant advised to take daily 400µg/day folic acid supplement before conception until 12 weeks gestation (higher amount for at risk groups)
Free vitamin supplements available for women with lowest income (Healthy Start scheme)
Alternative approach – mandatory fortification of staple foods (Kancherla et al. 2022)
Mandatory fortification of staple foods (e.g. flour) was in place in ~80 countries by 2020
Considerations:
A more equitable approach – doesn’t just benefit those aware of or able to access supplements
Cost-effective option, with economic benefit with reduced mortality/morbidity
Need to carefully consider appropriate foods to fortify (staple foods, widely used within population)
Need to consider amount of folic acid required as fortificant – need to increase intakes sufficiently to ↓ NTD risk, but limit intakes above safe levels in high consumers of the fortified foods
Unintended consequences e.g. concerns around risk of masking vitamin B12 deficiency in older people?
Ongoing requirement for monitoring of population folate status and relevant health outcomes
Potentially unpopular with some groups as a loss of freedom of choice
Fortification of flour with folic acid in UK
1998 Bread and Flour Regulations already require fortification of white flour with iron, calcium, thiamin and niacin
Sep 2021: UK Government announced introduction of mandatory fortification of non-wholemeal wheat flour with folic acid (expected to lead to 20% fall in NTD affected pregnancies)
Currently running: Consultation on amending UK bread and flour regulations to require 250µg folic acid/100g flour to non-wholemeal flour
~99% households buy bread, quarter of groceries contain flour
Excludes wholemeal four and gluten-free flour
Weaning
traditional term used to describe foods introduced alongside breastmilk/formula
But, can be interpreted as cessation of breast/milk feeding
NHS uses the term ‘weaning’ as felt more easily understood by parents
meet evolving nutritional requirements;
acceptance of taste and texture;
develop chewing and eating skills.
complementary feeding
introduction of solid foods complements nutrients provided by breastmilk/formula, rather than replacing.
An area of confusion for parents!
40% of parents feel unsure as to what age to start introducing solid foods
When to introduce solid foods?
WHO Global Strategy for Infant and Young Child Feeding (WHO, 2003)
wherever possible infants should be fed exclusively on breastmilk from birth until 6 months of age
thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond
exclusive breastfeeding from birth is possible except for a few medical conditions, and unrestricted exclusive breastfeeding results in ample milk production
Developmental readiness for solid foods (SACN, 2018)
‘Achieving developmental readiness’ involves maturation of:
Neurological system
maintain posture (average age = 5.9 months, but wide variation!)
learning to ‘munch’ (4-7 months; with movement of gag reflex towards back of the mouth)
learning to chew (from about 7 months)
Gastrointestinal function
capacity to absorb macronutrients and micronutrients from solid food
development of the gut microbiota
Renal system
matures rapidly during first 6 months of life
