feeding guideline for infants and young children · web viewthere is currently insufficient...

Feeding Guideline for Infants and Young Children

CHHS18/213

Canberra Hospital and Health Services

Clinical Guideline

Feeding Guideline for Infants and Young Children

Contents

Contents1

Guideline Statement2

Scope2

Section 1 – Breastfeeding2

Section 2 – Infant Formula3

Section 3 – Other Fluids/Drinks3

Section 4 – When to Introduce Solids4

Section 5 – Establishing a Supported Feeding Position4

Section 6 – How to Introduce Solids5

Section 7 – What Solids to Introduce6

Section 8 – Oral Motor Development and Texture Progression7

Section 9 – Reducing the Risk of Food Allergies8

Section 10 – Management of Food Allergies9

Section 11 – Commercial Baby Foods10

Section 12 – Gagging10

Section 13 – Eating beyond 12 months10

Section 14 – Fussy Eating11

Section 15 – Food safety11

Section 16 – Nutrition Supplements12

Section 17 – Further resources and Training13

Implementation13

Related Policies, Procedures, Guidelines and Legislation13

References14

Search Terms15

Guideline Statement

Background

This clinical guideline has been developed to support health professionals to provide consistent advice regarding early childhood feeding.

Key Objective

The guideline will support provision of consistent, evidence-based advice and practice among Canberra Hospital and Health Services (CHHS) staff. It provides recommendations on breastfeeding, introducing solids, food allergy management, food safety and responsive feeding relationships.

Alerts

This guideline does not apply to infants and children with special health care needs. Infants and children with an existing medical condition or disability may require specialised assessment and advice.

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Scope

This guideline applies to healthy, term infants and young children aged 4 months to 2 years seeking healthcare at Canberra Hospital and Health Services.

This guideline applies to the following staff working within their scope of practice:

· Medical Officers

· Nurses and Midwives

· Allied Health Professionals

· Students working under direct supervision.


Section 1 – Breastfeeding

The World Health Organization (WHO) states that ‘breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants’. Breastfeeding is beneficial to infants, mothers, families and society, and is viewed as the biological and social norm for infant and young child feeding1.

The Baby Friendly Hospital Initiative (BFHI) aims to protect, promote and support breastfeeding under a Ten Steps to Successful Breastfeeding framework. In community facilities this initiative is referred to as the 7 Point Plan. CHHS is accredited as a BFHI organisation.

For further information on breastfeeding, refer to the National Health and Medical Research Council (NHMRC) Infant Feeding Guidelines, the Australian Breastfeeding Association (ABA) and the Breastfeeding Clinical Guideline on the policy register.


Section 2 – Infant Formula

If an infant is not breastfed or is partially breastfed, commercial infant formulas should be used as an alternative to breast milk until 12 months of age. Health workers should provide families with all of the information and support that they need to prepare, store and use feeds correctly1.

2.1 Regulations and Codes

Infant formula products are regulated under Standard 2.9.1 of the Australia New Zealand Food Standards Code. The Standard provides compositional and labelling requirements for infant formula products and specifically prohibits claims, images and symbols on product labels.

The MAIF Agreement (Marketing in Australia of Infant Formulas) aims to promote safe and adequate nutrition for infants through promotion of breastfeeding and ensuring proper use of infant formulas. It is a voluntary, self-regulatory code of conduct between manufacturers and importers of infant formula and gives effect to the WHO International Code of Marketing of Breastmilk Substitutes.


Section 3 – Other Fluids/Drinks

Exclusively breastfed infants do not require any additional fluids until 6 months of age2.

3.1 Transitioning from a Bottle to Cup

Infants may be offered an open cup from around 6 months of age to support development. Straw and sipper cups can be used occasionally. Support parents and carers to completely replace bottles with a cup by 12 months of age.

3.2 Water

Cooled boiled tap water can be offered to infants when solids are introduced. Tap water is recommended as it contains fluoride which helps reduce the incidence of dental caries. The NHMRC recommends that all water given to infants under 12 months of age is boiled and then cooled1. Water may be given from an open cup, or a straw or sipper cup. After 12 months of age tap water should be encouraged as a child’s main drink.

3.3 Cow’s milk and calcium fortified soy drink

Cow’s milk and calcium fortified soy drink should not be given as a drink before 12 months of age, but can be added to other foods such as cereal, mashed potato, scrambled eggs etc at around 6 months of age. Reduced fat or low fat milk is recommended for children over 2 years of age.

3.4 Other milk drinks

Rice, oat and almond milks are low in protein and energy and are not appropriate alternatives to breast milk or formula in the first 12 months1. If clinically required, they can be added to solid foods from 6 months of age under health professional guidance.

3.5 Fruit Juice

Fruit juice is not recommended for infants under 12 months of age. After 12 months, small amounts of diluted 100% fruit juice can be offered. This should be offered in an open cup, not a bottle1.


Section 4 – When to Introduce Solids

The NHMRC recommends introducing solids when the infant is physiologically and developmentally ready, at around 6 months, but not before 4 months1. Introducing complementary foods when the infant is developmentally ready supports development of long term food preferences.

Signs that an infant is ready to commence solids include the following:

Good head and neck control

Sits with limited support

Shows interest when others are eating

Reaches for food

Has a reduced tongue thrust reflex

Opens mouth when food is offered3.


Section 5 – Establishing a Supported Feeding Position

Infants are more likely to accept new foods if they feel supported and stable in their feeding chair. A stable posture ensures that the infant is able to focus on the task of eating, rather than trying to balance, and is required for effective and safe chewing and swallowing4,5.

Ideally, feeding chairs should have:

a high back that supports the infant in an upright position

an adjustable seat height so the infant can rest their arms comfortably on the chair tray

an adjustable foot rest to allow the infant’s feet to touch and rest on a firm surface.

The child’s hips, knees, ankles and elbows should ideally all be at 90 degrees, with their feet stable on a stable surface or ground4. Infants can be further supported using foam cushions or rolled up hand towels. An ideal position at mealtimes is illustrated in the diagram below.

Diagram sourced from: Child Development Service, ACT Government


Section 6 – How to Introduce Solids

Parental feeding practices are instrumental in shaping food preferences and eating behaviours among infants and children (Figure 1). An enjoyable meal environment provides the best opportunity for infants and young children to learn to eat a variety of healthy family foods. The practices outlined below support children to achieve ‘eating competence’6 and a trusting relationship with their carer.

Offering food when the child and parent are calm

Establishing consistent and predictable meal and snack times throughout the day

Eating shared food together without distraction and with the child sitting facing others

Responding to the infant’s/child’s appetite and satiety cues, interest in feeding, tiredness and emotional state

Providing a calm and pleasant time for eating without pressure to try or finish a food

Allowing a child to learn about food through exploration.

Figure 1. Daniels, L.A., Magarey, A., Battistutta, D. et al. BMC Public Health (2009) 9: 387. https://doi.org/10.1186/1471-2458-9-387,.

As per use under CreativeCommons license (http://creativecommons.org/licenses/by/2.0)7

Division of Responsibility

Division of Responsibility in feeding is an evidence-based approach where the parent is responsible for what, when, and where food is offered, and for keeping meal times calm and pleasant; and the infant/child is responsible for deciding whether to eat and how much to eat. The model is based on evidence that healthy infants are born with the ability to know how much they need to eat to grow. See Ellyn Satter Insititute website for more information.


Section 7 – What Solids to Introduce

7.1 Introduce solids in line with NHMRC recommendations

Introduce a variety of solid foods when developmentally ready, at around 6 months, but not before 4 months, starting with iron rich foods, and while continuing breastfeeding8

To prevent iron deficiency, include iron containing foods in the early stages, e.g. iron fortified infant rice cereal, pureed meat/chicken, cooked plain tofu, legumes/lentils

Foods can otherwise be introduced in any order provided the texture is appropriate for the infant’s developmental stage

Introduce foods according to what the family usually eats, regardless of whether the food is considered to be a common food allergen

Progress from puree to thicker, lumpier textures by 7-8 months, to soft chopped family foods by 9-12 months1

Texture progression is important for developing good oral motor skills. Smooth pureed textures should only be given in the short term while starting solids, e.g. the first 1-2 weeks

Encourage family foods from the five food groups (grain foods, vegetables, fruit, meat and alternatives, dairy and alternatives)

Infants should be eating the family meal (with minor modifications) by 12 months of age.

7.2 Regular exposure and the development of food preferences

The early years are crucial for the development of long-term flavour preferences. Infants and young children may need to be offered family foods many times in a non-pressured environment before they can learn to like and accept them9. Regular exposure to food prepared at home provides children with the opportunity to experience and enjoy the taste of family foods.


Section 8 – Oral Motor Development and Texture Progression

8.1 Oral motor development

Initially babies have little or no voluntary control over feeding. They are born with reflexes such as the rooting reflex, and coughing and gagging reflexes. As infants grow, some reflexes such as sucking disappear and they gain voluntary control over their feeding. Eating is a learned process. From around the time solids are introduced to 12 months of age, infants will move from sucking food off a spoon to learned skills such as biting, munching and chewing10. The gradual development of these skills forms the basis for texture progression with solids (see Figure 2).

Figure 2: Food Texture Timeline

Around 6 months start with smooth, soft, pureed or finely mashed textures.

Around 7-8 months move towards mashed, grated, minced and finely chopped foods. Encourage soft finger foods that the infant can hold and chew such as rusks, soft vegetables and fruit.

Around 9-12 months include soft chopped foods. Encourage finger foods.

From 12 months offer family meals with a variety of textures. Avoid foods that may cause choking e.g. whole nuts and lollies.

8.2 Self Feeding and Exploring Food

Parents/carers should be encouraged to allow their infant to hold a spoon, pick up food with their hands and feed themselves. Playing with food helps infants to understand the properties of food (e.g. texture and temperature) and is often the first step to eating4. Infants also develop their hand skills during messy eating. Exploring food is a learning opportunity as well as a fun sensory experience for infants. It may be messy but it is important to allow infants to practise their eating skills in a supportive environment free from stress and distractions.

8.3 Baby Led Weaning

The Baby Led Weaning (BLW) approach involves the introduction of finger foods from six months of age. Pureed food and spoon feeding are avoided. Instead, the baby feeds themselves from the beginning, first with their hands and later with cutlery. There is an emphasis on parents giving finger foods that the infant can pick up and feed themselves11.

Alert:

ACT Health does not recommend BLW as the standard approach for introducing solids to infants as there is currently not enough evidence on its safety. More research is needed on the effect of BLW on an infant’s iron status, growth and choking risk. ACT Health endorses the NHMRC Infant Feeding Guidelines, which recommend offering finger foods alongside pureed or mashed food, to support optimal growth and nutrition.


Section 9 – Reducing the Risk of Food Allergies

The Australasian Society of Clinical Immunology and Allergy (ASCIA) has developed recommendations to reduce the risk of infants developing food allergies.

Recommendation Overview

Introduce solids when the infant is developmentally ready, at around 6 months but not before 4 months; whilst maintaining breastfeeding or formula feeding

There is no particular order in which to introduce solid foods. However, iron rich foods need to be included at around 6 months, e.g. iron enriched (fortified) cereals, meats, poultry, fish, cooked egg and legumes

There is insufficient evidence to delay the introduction of potentially allergenic foods to any infant, including those with a first degree relative with a proven food allergy (however, if the infant has confirmed food allergies, these foods need to be avoided)

Introduce foods according to what the family usually eats, regardless of whether the food is considered to be a common food allergen

Introduce foods one at a time, around 1-2 days apart, to help identify if any foods cause a reaction

If tolerated, continue to include these foods to build a diet that contains a wide variety of foods

Breast milk or an infant formula should remain the main source of milk until 12 months of age

If a food causes a reaction parents/carers should stop feeding that food to their infant and seek medical advice

There is good evidence for infants with severe eczema and/or egg allergy, that regular peanut intake before 12 months of age can reduce the risk of developing peanut allergy

There is moderate evidence that introducing cooked egg into an infant’s diet before 8 months of age, where there is a family history of allergy, can reduce the risk of the infant developing egg allergy

Foods should not be ‘tested’ on an infants skin prior to eating. The facial skin of infants is very sensitive and many foods (e.g. citrus, tomatoes, berries, other fruit and Vegemite) can irritate the skin and cause redness on contact – this is not food allergy.12

The ASCIA website contains up-to-date, evidence-based information on introduction to solids and allergy prevention and management:

ASCIA Guidelines – Infant feeding and allergy prevention (2016)

ASCIA Information for Patients, Consumers and Carers – Information on how to introduce solid foods to infants (2017)

ASCIA Guide for introduction of peanut to infants with severe eczema and/or food allergy (2017).


Section 10 – Management of Food Allergies

Some infants will develop food allergies. Symptoms may be mild, moderate or severe and range from vomiting, diarrhoea, hives, facial swelling and eczema to anaphylaxis. If an adverse food reaction occurs:

The suspected food should be avoided until the infant is reviewed by their general practitioner or paediatrician

Other new foods should continue to be offered

Consider referral to an allergy specialist13

Alert:

Infants and children with severe food allergy symptoms should seek immediate medical attention.


Section 11 – Commercial Baby Foods

Commercially prepared baby foods are nutritious; the ingredients used are of high quality and have been hygienically prepared. Commercial baby foods, including ‘squeezy pouches’, are best used as a convenience food when travelling or on outings rather than as an everyday choice. It is important to offer these products to an infant using a spoon. Infants should not suck on the squeezy pouch as it may contribute to dental caries, and can cause bacterial contamination of the food pouch. A variety of flavours should be chosen and a texture appropriate for the infant’s stage of development. If used regularly, infants may develop a preference for the taste and textures of commercial baby foods and become more likely to refuse home prepared family foods.


Section 12 – Gagging

Gagging is a natural reflex that helps prevent choking. Occasional gagging is a normal response when an infant is learning to chew and swallow new foods, textures or liquids. The transition to new solids or liquids is best managed by providing gradual changes to match the infants oral motor skill development. The gag reflex naturally diminishes with age and with repeated exposure to a variety of foods and fluids. If the infant continues to gag each time they eat or drink over several months, they may need an assessement by a Speech Pathologist14.


Section 13 – Eating beyond 12 months

Healthy eating in the second year of life builds on nutritionally sound practices established in infancy. By 12 months of age infants should be well established on solid foods as their major source of nutrition. Continuing to offer a variety of nutritious family foods provides the basis for lifelong healthy eating habits and will assist in meeting the needs for most nutrients1.

It is normal for toddlers to be less interested in food after 12 months of age. Toddlers grow more slowly than babies, have small appetites and stomachs and their appetite is variable from day-to-day. They are also developing independence15. Encouraging parents/caregivers to offer a variety of family foods at planned meals and snacks without pressure to eat will ensure adequate nutrition for growth; assist in development of taste preferences and enjoyment of family foods; and positively influence their child’s attitude and habits towards food and eating2.

13.1 Fluids/Drinks

Tap water and small amounts of pasteurised full cream milk are the best drinks for children until 2 years of age. Toddler milks or formulas are not necessary if the child is eating a varied diet and growing well. Encourage parents/caregivers to completely replace their child’s bottle with an open cup by one year of age.

Refer to Tuckatalks consumer handouts: Food for 1-3 year olds, Setting Healthy Habits and Drink up for Good Health available on the ACT Health website for further information.


Section 14 – Fussy Eating

Fussy eating is a normal part of development for most toddlers. It varies in severity and duration, but usually peaks from 12 months to 5 years of age. Young children are neophobic and often fear anything new16. It can take many exposures to a food before a child will taste it, and many more before they learn to like it. Increasing a child’s food variety is best supported by parents/caregivers maintaining a consistent meal and snack routine based on a variety of nutritious family foods.

Refer to the Ellyn Satter Institute website and the Tuckatalk Setting Healthy Habits handout on the ACT Health website for more information.

Women, Youth and Children’s Dietitians deliver regular Fussy Eating groups for parents/carers of 1-5 year olds. Refer to the Fussy Eating Group information on the ACT Health website for further details.


Section 15 – Food safety

15.1 Food hygiene and food poisoning

Attention to food hygiene is very important when preparing foods for infants and children.2

To reduce the risk of salmonella poisoning, eggs should be well cooked, i.e. until the white is completely set and yolk begins to thicken. Uncooked egg products such as home-made ice cream or mayonnaise are not recommended

Honey should not be given to infants under 12 months of age due to risk of botulism

Unpasteurised milk should not be given to infants and young children1.

If commercial baby foods, including ‘squeezy pouches’, are not used immediately upon opening, the remaining contents should be discarded or emptied into a clean plastic or glass container, covered and stored in the refrigerator17.

15.2 Choking risks

Infants and young children are at higher risk of inhalation and choking on food. Parents and carers should:

Always stay with their child and supervise them while they eat

Always sit their child down to eat

Encourage their child to eat slowly and chew well

Never force their child to eat18.

To make eating safer for young children:

Do not give any foods that can break off into hard pieces

Do not give popcorn, nuts (whole or crushed), hard lollies, corn chips or other similar foods

Avoid raw carrot, celery sticks and apple pieces. These foods should be grated, cooked or mashed

Remove tough skins from fruit, e.g. grapes, and chop into quarters or halves

Cut meat, chicken, sausages and frankfurts into small pieces. Remove tough skins on frankfurts and other sausages

Check fish carefully for bones and remove if present1.

15.3 Mercury

Some fish contains higher levels of mercury and should be limited in a child’s diet. Food Standards Australia and New Zealand advise that children up to 6 years of age can safely eat:

75 grams of Orange Roughy or Catfish and no other fish that week OR

75 grams of Shark or Billfish (e.g. swordfish) and no other fish that fortnight OR

225 grams per week of any other type of fish or seafood (including tinned tuna, salmon and fish fingers) 19.

For more information about fish and mercury visit www.foodstandards.gov.au


Section 16 – Nutrition Supplements

Vitamin and mineral supplements and probiotics are not routinely required for infants and young children and should only be recommended on an individual basis. There is currently insufficient evidence to support the broad recommendation of nutrition supplements for infants unless their diet is limited (e.g. food allergy, food intolerance, vegan) or a nutrient deficiency has been medically diagnosed (e.g. low vitamin D, iron deficiency).

There may be a role for particular species and strains of probiotics for infants and children with gastrointestinal disorders including gastroenteritis, antibiotic-associated diarrhoea, Clostridium difficile induced diarrhoea, nosocomial diarrhoea and infantile colic. There is insufficient evidence for their use in other conditions20. Probiotics for these conditions are best used under medical supervision.


Section 17 – Further resources and Training

ACT Health WYC Nutrition service Tuckatalk Factsheets available on the ACT Health website

ASCIA Food Allergy e-training for GP’s, Paediatricians and Nurses available on the ASCIA website

ASCIA Allergy Resources available on the ASCIA website

Infant Nutrition: From Breastfeeding to Baby's First Solids. Deakin University, online course via FutureLearn.


Implementation

This guideline will be communicated to CHHS staff via communication with key stakeholders, the Tier 3 Quality and Safety meetings, Women, Youth and Children Community Health Programs orientation guidelines and training.

The guideline will be available to staff on the policy register.


Related Policies, Procedures, Guidelines and Legislation

Procedure

Maternal and Child Health Procedures in the ACT

Guidelines

Maternal and Child Health Services in the ACT

Breastfeeding Clinical Guideline

National Guidelines

NHMRC Infant Feeding Guidelines

Legislation

· Food Standards Australia New Zealand Standard 2.9.1 – Infant Formula

Health Records (Privacy and Access) Act 1997

Human Rights Act 2004

Work Health and Safety Act 2011


References

1. Australian Government. Eat for Health Infant Feeding Guidelines Information for health workers. National Health and Medical Research Council: Department of Health and Ageing; 2012.

2. Australian Government. Eat for Health Infant Feeding Guidelines Summary. National Health and Medical Research Council: Department of Health and Ageing; 2013.

3. Perez-Escamilla R, Segura-Perez S, Lott M. Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach. Healthy Eating Research: Building evidence to prevent childhood obesity; 2017.

4. Toomey KA and Ross E 2014. Picky Eaters vs. Problem Feeders: The SOS Approach to Feeding Workshop handbook.

5. Redstone F and West JF. The Importance of Postural Control of Feeding. Paediatric Nursing 2004; 30:97-100.

6. Satter E. The Satter Feeding Dynamics Model of child overweight definition, prevention and intervention. Paediatric and Adolescent Obesity Treatment: A Comprehensive Handbook. New York: Taylor and Francis; 2007. p. 287-314.

7. Daniels LA, Magarey A, Battistutta D, Nicholson JM, Farrell A, Davidson G and Cleghorn G. The NOURISH randomised control trial: Positive feeding practices and food preferences in early childhood – a primary prevention program for childhood obesity. BMC Public Health. 2009: 9:387.

8. Murdoch Childrens Research Institute. Great result for Infant Feeding Guidelines Consensus. Media Release. 18 May 2016.

9. Australian Government. Giving your baby the best start The best foods for infants. National Health and Medical Research Council: Department of Health; 2015.

10. Morris SE and Klein MD (2000) Pre-Feeding skills (Second Edition). Harcourt Health Sciences, USA.

11. Brown A, Wyn Jones S and Rowan H. Baby-Led Weaning: The Evidence to Date. Curr Nutr Rep. 2017: 6:148-156.

12. Australasian Society of Clinical Immunology and Allergy. How to introduce solids foods to babies for allergy prevention. 2017. Retrieved from

https://www.allergy.org.au/images/pcc/ASCIA_PCC_How_to_introduce_solid_foods_2017.pdf

13. Australasian Society of Clinical Immunology and Allergy. Infant feeding and allergy prevention. 2016. Retrieved from

https://www.allergy.org.au/images/pcc/ASCIA_Guidelines_infant_feeding_and_allergy_prevention.pdf

14. Royal Childrens Hospital Melbourne. Feeding Difficulties Case Scenarios.

https://www.rch.org.au/feedingdifficulties/casescenarios/Ava/

15. Department of Health, Government of South Australia. Women’s and Children’s Health

Network Nutrition Department. Tucker for Toddlers A guide to healthy eating for 1-3 year olds. October 2011.

16. Satter E (1987) How to get your kid to eat…but not too much From birth to adolescence.

Bull Publishing Company.

17. Food Standards Australian and New Zealand. Canned foods: purchasing and storing

http://www.foodstandards.gov.au/consumer/safety/cannedfoods/Pages/default.aspx 2017

18. Department of Health, Government of South Australia. Information for families and

carers Preventing choking on food Children under 4 years of age. August 2011.

19. Food Standards Australia and New Zealand. Mercury in Fish

http://www.foodstandards.gov.au/consumer/chemicals/mercury/Pages/default.aspx 2011

20. Cameron D, Hock QS, Kadim M, Mohan N, Ryoo E, Sandhu B, Yamashiro Y, Jie C,

Hoekstra H and Guarino A. Probiotics for gastroinstetinal disorders: Proposed

recommnedations for children of the Asia-Pacific region. World Journal of

Gastroenterology. 2017; 23(45):7952-7964.


Search Terms

Feeding, introduction to solids, food allergy, fussy eating, food safety

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:

Date Amended

Section Amended

Divisional Approval

Final Approval

15 Aug 2018

New Document

Liz Chatham, ED WY&C

CHHS Policy Committee

This document supersedes the following:

Document Number

Document Name

Doc Number

Version

Issued

Review Date

Area Responsible

Page

CHHS18/213

1

20/08/2018

01/09/2022

WY&C - CHP

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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