Feeding young children

Question 1

What is ‘preconception’? (Stephenson et al. 2018)

Answer 1

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

Question 2

Why is preconception health important? (Stephenson et al. 2018)

Answer 2

“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)

Question 3

global policies

Answer 3

first 1000 days

every women, every child

Question 4

Importance of and increased focus on preconception health

Answer 4

being aware of screening
up to date with vaccinations
folic acid supliments
healthy diet
physically active
no smoking
less alcohol

Question 5

Dietary and lifestyle characteristics of UK women of childbearing age

Answer 5

‘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%

Question 6

Weight of UK women of childbearing age

Answer 6

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).

Question 7

Micronutrient intakes of adolescent girls and adult women in the UK

Answer 7

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

Question 8

Micronutrient status of adolescent girls and adult women in the UK

Answer 8

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

Question 9

Micronutrient status of adolescent girls and adult women in the UK – Vitamin D (PHE&FSA, 2019)

Answer 9

Adequate vitamin D levels important for fetal skeletal development and regulation of blood calcium levels; possible link with adverse pregnancy outcomes

Question 10

Summary of UK advice for women planning pregnancy (Stanner, 2018; NHS, 2020; NICE, 2010; NICE 2019)

Answer 10

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

Question 11

Energy requirements during pregnancy (SACN, 2011)

Answer 11

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

Question 12

Macronutrient requirements during pregnancy (COMA 1991; SACN, 2011)

Answer 12

Protein
RNI = 45g/day
+ 6 g/day Preg

Carbohydrate
~50% energy

Dietary fibre
30g/day

Fat
~35% energy

Question 13

Selected vitamin requirements during pregnancy (COMA 1991; SACN, 2011, Stanner 2018)

Answer 13

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
-

Question 14

Selected mineral requirements during pregnancy (COMA 1991, SACN 2011, SACN, 2016, Stanner 2018)

Answer 14

Calcium (mg)
700

Iron (mg)
14.8

Zinc (mg)
7.0

Iodine (µg)
140

Question 15

General dietary recommendations during pregnancy (PHE, 2016)

Answer 15

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

Question 16

The role and importance of folate during pregnancy

Answer 16

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

Question 17

Current UK approach: supplementation

Answer 17

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)

Question 18

Alternative approach – mandatory fortification of staple foods (Kancherla et al. 2022)

Answer 18

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

Question 19

Fortification of flour with folic acid in UK

Answer 19

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

Question 20

Weaning

Answer 20

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.

Question 21

complementary feeding

Answer 21

introduction of solid foods complements nutrients provided by breastmilk/formula, rather than replacing.

Question 22

An area of confusion for parents!

Answer 22

40% of parents feel unsure as to what age to start introducing solid foods

Question 23

When to introduce solid foods?

Answer 23

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

Question 24

Developmental readiness for solid foods (SACN, 2018)

Answer 24

‘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

Question 25

Developmental readiness for solid foods: UK public health guidance (PHE, 2019)

Answer 25

sit up and hold their hands steady

coordinate their hands and eyes and bring food to mouth

swallow food

Question 26

Evolving nutritional requirements: energy (SACN, 2011)

Answer 26

Energy from breastmilk/formula sufficient for requirements until 6 months of age

Additional energy required from complementary foods:
130kcal/day at 6-8m
310kcal/day at 9-11m
580kcal/day at 12-23m

Question 27

From around 6 months (NHS, 2021a; NHS,2021b; image from First Steps Nutrition Trust)

Answer 27

NHS/Start4life advice:
Start with small amounts of food once a day, with gradual increase in amount and variety (breast milk (or infant formula) will still provide most energy)
Introduce known allergens one at a time (from around 6 months – not as first food given)
Include a wide range of foods, including iron-containing foods
Introduce bitter vegetables (e.g. broccoli, courgette), not just sweet veg/fruit
No added salt or sugar to food

Progression in texture:
blended, mashed or soft cooked to start
move from purees/blended to mashed and finger foods as soon as ready
lumpy textures from 6-7 months
encourage self feeding – finger foods good for hand-eye co-ordination

Question 28

7-12 months (NHS, 2021a; NHS, 2021b; images from First Steps Nutrition Trust)

Answer 28

7-9 months:
Gradually move towards eating 3 meals a day (breakfast, lunch and tea – main course only)
Offer a wide variety of foods from all groups to help ensure good nutrient intake (especially iron)
Move onto mashed, lumpy and finger foods as soon as baby can manage them
Breastmilk/infant formula as main drink (~4 feeds/day)

10-12 months:
3 meals a day in addition to milk feeds
Lunch and tea including main course and dairy/fruit pudding
Mashed, lumpy, chopped and finger foods
Breastmilk/infant formula as main drink (~3 feeds/day)

Question 29

Foods to avoid during weaning(NHS 2021b)

Answer 29

Added salt/salty foods
Added sugars
Honey
Whole/chopped nuts
Raw jelly cubes/jelly sweets
Low-fat foods
Saturated fat
Certain cheeses
Shark, swordfish, marlin
Raw shellfish
Certain eggs
Rice drinks

Question 30

Drinks – milk for infants 0-6m/6-12m

Answer 30

Breast milk, infant formula and water should be the only drinks offered between 6-12 months of age. Unmodified cows’ milk should not be given as a main drink to infants under 12 months of age’ [but can be used in cooking from around 6 months]. (SACN, 2018)

Question 31

UK practices for introducing solids

why early intro

deter of early weaning

Answer 31

Infant feeding survey 2010 (McAndrew et al., 2012)
75% of babies had received solid foods by 5 months of age (94% by 6 months)
Most common reasons given for early introduction of solids:
perception that baby was not satisfied with milk
experience from previous child(ren)
baby able to sit up and hold food in hand
baby waking during the night

Determinants of early weaning (Wijndaele et al. 2009) strong evidence for:
Young maternal age
Low maternal education
Low socio-economic status
Absence/short duration of breastfeeding
Maternal smoking
Lack of information/advice from healthcare provider

Question 32

What is baby-led weaning? (Rapley, 2011)

Answer 32

Infant self-feeds from the outset: no spoon feeding/purees

Key features of baby-led weaning:
Not started until developmental signs of readiness appear (sits upright, able to co-ordinate to put food in mouth, eager to participate!)
The baby eats with the family at mealtimes
The baby is offered the same (healthy) food as everyone else, in pieces appropriate to their developmental level (large at first, then smaller)
The baby feeds themselves from the beginning, first with their hands and later with cutlery
Milk feeding (breastmilk/formula) continues on demand, unconnected with mealtimes

Question 33

BLW: rationale

Answer 33

natural progression from breastfeeding
at 6 months, it is appropriate for babies to self feed
pace of complementary feeding can be determined by the infant’s acquisition of gross and fine motor skills
less coercive
enables infants to regulate their energy intake more effectively (respond to appetite and satiety cues)
may lead to improved body weight and reduced fussiness?

Question 34

BLW: Concerns

Answer 34

Concerns:
do infants eat enough? can iron requirements be met?
is there a higher risk of choking?
not suitable for all babies (e.g. pre-term babies/babies with developmental delay)?

Question 35

Who uses this approach of BLW?

Answer 35

Brown (2016) survey of n=604 mothers of 6-12m infants
Women who reported following a BLW approach differed in personality eating behaviour and well-being
↓ restrained eating, anxiety and introspection, anxiety and obsessive-compulsive symptoms
May impact on feeding style chosen and indirectly affect outcomes

Question 36

How does BLW compare to traditional weaning: cross-sectional research

Answer 36

BLW babies:
more likely to be breastfed
consumed more foods also consumed by their mother
fed less purees at 6-8 months
bias towards self-report of BLW weaning style – social desirability?

Differences in nutrient intake between BLW and TW?
At 6-8m, higher intakes (food + milk) of iron, zinc, iodine, vitamin B12, vitamin D in TW babies
No difference in nutrient intake at 9-12 months
Few differences in exposure to different food groups

Question 37

How does BLW compare to traditional weaning: RCT evidence on nutrient intake

Answer 37

Overall conclusion: BLISS trial appeared to result in a diet that is as nutritionally complete as traditional weaning, and may address some concerns, but salt/sugar intakes of both groups concerning

Question 38

How does BLW compare to traditional weaning: RCT evidence on micronutrients

Answer 38

Zinc (Daniels et al., 2018a)
No sig. difference in
zinc intakes at 7 or 12mo
plasma zinc concentration
At 7mo TW babies more likely to be getting most zinc from veg Vs breads and cereals for BLW babies
At 12m, TW & BLW babies most zinc from dairy
But, caution in applying results to all BLW babies, as RCT included advice on iron intakes

Iron (Daniels et al, 2018b)
No sig. difference in
iron intakes at 7 or 12mo
plasma ferritin concentration, body iron or prevalence of depleted iron stores, early functional iron deficiency or iron deficiency anaemia at 12 mo.
N.B parents given advice to offer ‘high iron’ foods as part of each meal during RCT

Question 39

BLW and risk of choking (Fangupo et al. 2016)

Answer 39

“Infants following a baby-led approach to feeding that includes advice on minimising choking risk do not appear to be more likely to choke than infants following more traditional feeding practices”

N.B. Concern was that large numbers of infants in both groups were offered food posing a choking risk at 7 and 12 months (94% at 12 months!)

Question 40

Is BLW suitable for all?

Answer 40

Data from Gateshead Millennium Study
Reaching out for food, n=602
56% by 6mo but 6% still not done so by 8mo
Infants not reaching out for food by 6mo less likely to be walking at 12mo
First finger foods, n=447
40% before 6mo, 90% before 8mo

Babies born before 37 weeks (premature) should weaned in close consultation with a health visitor (somewhere between 5 and 8 months).
Weaning will likely be onto smooth purées
Weaning will probably take longer and should be approached more slowly

Question 41

Is BLW recommended in UK guidance?

Answer 41

SACN (2018) Feeding in the first year of life:
“There is limited evidence on the BLW approach to complementary feeding.

BLW approach promotes self-feeding and results in a positive attitude to food (more enjoyment and less fussiness) and earlier exposure to family food.

longer duration of exclusive breastfeeding and later introduction to solid foods